Ultrasound guided Injections

Patient experience of hydrodistention injection for frozen shoulder

Pain and discomfort from a frozen shoulder is one of the most common reasons patients get in touch with us, so I thought it might be helpful for people to hear directly from a patient what it is like to receive a hydrodistension injection for a frozen shoulder.

If you would like to know more about this condition, please visit our frozen shoulder treatment page.

I performed a hydrodistension procedure for Rebecca’s frozen shoulder approximately 6 weeks ago. The total volume injected was 20ml before capsular rupture.

I recently asked her to describe what it is like to have a frozen shoulder injected with a high volume. I also wanted to know her progress.

Below is her account:

WHAT WAS THE REASON THAT YOU WERE GIVEN A HYDRODISTENSION INJECTION?

A three-month-old frozen shoulder

CAN YOU DESCRIBE THE PROCEDURE? (WHATEVER YOU CAN REMEMBER OF IT).

After explaining what he had seen on the ultrasound scan, Robert inserted the needle into the back of my shoulder and talked me through the procedure as he inserted 5ml fluid into the joint space, I felt a fullness in the shoulder joint/capsule, and Robert then asked if I felt he could inject more fluid in after I agreed he was able to inject another few ml before I felt a pop as the capsule released.

 

WAS IT PAINFUL?

It was uncomfortable, however, the main feeling was a fullness of the shoulder, it felt as though the joint was going to burst

WERE YOU ADVERSELY AFFECTED IN YOUR DAY-TO-DAY ACTIVITIES IMMEDIATELY AFTER THE INJECTION?

No adverse effects at all.

 

HOW LONG AFTER THE INJECTION DID YOU FIRST FEEL THE BENEFIT?

Pain reduction over the first week and movement increased over the following 5-6 weeks.

 

HAS THE INJECTION MADE A DIFFERENCE IN YOUR DAY-TO-DAY ACTIVITIES?

A significant functional improvement would not have been possible without the intervention.

HAS YOUR SHOULDER IMPROVED FURTHER  OVER THE WEEKS /MONTHS SINCE THE INJECTION? PLEASE DESCRIBE IN WHAT WAY:

Increased range of movement, strength and function over the following 5 weeks.


Ultrasound guided injections

Steroid hyaluronic acid or hydrodisension injection - Which is the best?

Many will have heard of steroid injections, often in relation to musculoskeletal disorders. Many people know someone who has received a steroid injection for a frozen shoulder, an osteoarthritic knee or for any other musculoskeletal condition.

Fewer people might have heard of Hyaluronic Acid injections, and maybe still fewer might have heard of Hydrodistension injections.

In this blog, I will try to give a brief summary of the differences between these injection options and indicate when they are likely to be most beneficial.

Steroid Injection therapy

Often times patients are referred by their GP for a steroid injection when their shoulder, knee or whatever other joint or soft tissue problem they might be suffering with, is persistent,  causing a lot of pain and is not responding to the usual first-line treatments such as relative rest, Non-steroidal Anti-inflammatory Drugs (NSAIDs) and or exercise therapy +/- physiotherapy.

Steroid injections when given appropriately are generally very safe and cause very few side effects. Please see our steroid information leaflet for some more information on steroid injections and their risks and side effects.

Steroid injections for musculoskeletal conditions should not be confused with oral steroid (steroid pills) treatment.

Usually, the adverse reports one hears about steroids refer to the side effects associated with long term (typically oral) systemic steroid therapy (steroid pills). This tends to be for chronic conditions. For doctors to decide that the benefits outweigh the significant risks and side effects associated with long term steroid therapy, it usually reflects the seriousness of the conditions that these people might be taking it for.

In what situation is steroid Injection therapy most beneficial?

Corticosteroids are synthetic drugs that resemble cortisol, a hormone that you produce in your adrenal glands. Corticosteroids have powerful anti-inflammatory effects. As a rule, steroid injections are most useful for conditions where the pain, caused by a musculoskeletal condition, is a dominating feature and where there is a significant impact on functional activities. Injections allow for an optimum dosage to a specific area of the body. Steroid injections tend to give pain relief relatively quickly, usually within one week following administration. Note that these are not the same drugs that some athletes use (illegally) to gain muscle strength.

Hyaluronic acid injections

Hyaluronic acid injections are also called visco supplementation injections.  Hyaluronic acid injections are most commonly used to treat symptoms of knee osteoarthritis.

Hyaluronic acid is an essential component of the joint fluid in healthy joints but is found in lower concentrations in osteoarthritic joints.

By adding hyaluronic acid to the existing joint fluid the aim is to facilitate better joint movement, reduce pain and maybe slow down the progression of osteoarthritis.

In what situation is a hyaluronic Injection therapy most beneficial?

Often good candidates for viscosupplementation are those with osteoarthritis who have failed to improve with other non-surgical treatments, including steroid injections. Steroid injections can only be repeated a limited number of times due to their potential side effects. So regardless of the benefits of steroid injections, the hyaluronic acid injection might be a more suitable alternative in these circumstances.

Generally, people who benefit from hyaluronic acid injections are active people for whom good movement in their joints is important. They should not be in severe acute pain as hyaluronic acid does not have the strong anti-inflammatory effects of a steroid injection and therefore might not provide enough pain relief in these more acute states.

Hyaluronic acid gives the joint fluid its viscous, slippery quality, enabling the bones’ cartilage-covered surfaces to glide against each other, thereby reducing joint friction. It adds cushion to protect joints during impact (e.g. weight-bearing activity).

Joints have lower concentrations of hyaluronic acid in their joint fluid than healthy joints, and therefore have less protection against joint friction and impact.

By injecting a synthetically made hyaluronic acid into the knee, the aim is to temporarily lubricate the knee joint, thereby decreasing pain improving function and hopefully slowing the degeneration process.

Hydrodistension Injections

Hydrodistension or High Volume injections are performed under ultrasound guidance with the aim of precisely depositing anti-inflammatory steroids, local anaesthetic and saline to give pain relief whilst also deliberately stretching the lining of the joint (joint capsule). This procedure is increasingly used in the treatment of ‘frozen shoulder’ (adhesive capsulitis) and has been shown to be effective in the majority of patients by giving pain relief and also helping them to regain movement. These injections can provide a rapid and effective reduction in pain and inflammation; however, improvements are usually temporary. As with all medicines, some people may experience side effects.

When is a hydrodistension Injection therapy most beneficial?

Clinically, hydrodistension are most useful in frozen shoulders where restriction rather than pain is the most dominant feature. As the injected volume is higher, the procedure is likely to be slightly more uncomfortable when compared with a “normal” steroid injection under ultrasound guidance. This makes the procedure a good choice in “stiffness dominated” frozen shoulders.

Some research (Yoon et al. 2016) appears to support the above notion. Their study showed that hydrodistension plus steroids resulted in a more significant reduction in pain and a more remarkable improvement of shoulder movement compared to steroid injection alone in the first 3 months post-injection. However, patients in this study due to the inclusion criteria were more likely to be in the more chronic stage  (froze stage) of the frozen shoulder when pain levels are reduced and the dominant problem is a restriction of movement.

No such differences have been shown in other studies which included patients in the more acute earlier stages of frozen shoulder (Sharma, 2016; Lee, 2016). This might suggest that hydrodistension is more effective in those with significant shoulder stiffness but who are not in severe pain. More research is needed to evaluate this further.

 

References:

Lee, D.H., Yoon, S.H., Lee, M.Y., Kwack, K.S. and Rah, U.W., 2017. Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial. Archives of physical medicine and rehabilitation, 98(5), pp.815-821.

 

Sharma, S.P., Bærheim, A., Moe-Nilssen, R. and Kvåle, A., 2016. Adhesive capsulitis of the shoulder, treatment with a corticosteroid, a corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care. BMC musculoskeletal disorders, 17(1), p.232.

 

Yoon, J.P., Chung, S.W., Kim, J.E., Kim, H.S., Lee, H.J., Jeong, W.J., Oh, K.S., Lee, D.O., Seo, A. and Kim, Y., 2016. Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial. Journal of shoulder and elbow surgery, 25(3), pp.376-383.

Physiotherapy

Meet Rob - Our lead physiotherapist

Rob is a specialist extended scope Physiotherapist who has over 20 years’ experience in managing complex musculoskeletal conditions.

Also make sure you check out our Facebook and Youtube channels to keep up to speed with our latest news

Meet Rob

Contact

info@sonoscope.co.uk

+44787 0304523

Clinics

With 2 practices Sonoscope can help identify and treat your pain in either location.  Click on the buttons below to find out about each practice location and service.


Ultrasound Coronavirus Clinic

Having a steroid injection during the Coronavirus pandemic. What are the additional risks?

Getting treatment during the Coronavirus pandemic.

Can steroids suppress the immune system during the Coronavirus pandemic?

One way in which steroids affect inflammation is by a by suppressing it. As the immune system plays a major role in your body’s ability to fight infections steroids will therefore also potentially affect your body’s ability to fight infections. There is very little research or data to guide on this matter in terms of the exact increase in risk. It is important that any patients considering a corticosteroid injection are aware of the fact that corticosteroids could theoretically

  • Increase the likelihood of contracting the Coronavirus due to its immune-suppressant effect
  • Inhibit their body’s ability to fight the COVID-19 virus if contracted.
  • Could potentially make the patients more contagious to people around them, following a corticosteroid injection.

The British Orthopaedic Association (BOA) , The British Society for Surgery of the Hand (BSSH), British elbow and Shoulder Society (BESS) have recently published (23.10.2020) A patient information leaflet discussing the additional risks of having steroid injections during the COVID pandemic.

The information in this leaflet can be downloaded by clicking on the leaflet. The contents are also applicable to anyone considering steroid injections for the lower extremity (Hip, knee ankle and foot).

If you have any questions about any of our treatments or require advice on any pain you may be suffering during the Coronavirus outbreak please do not hesitate to give you a call or contact us through our booking form.


ultrasound guided hip injection

Hip injections. Is there a need for Ultrasound Guidance?

Many will have heard of steroid injections often in relation to musculoskeletal disorders. Many people know someone who has received a steroid injection for an osteoarthritic knee a frozen shoulder or for any other musculokeletal condition.

Fewer people might have heard of Hyaluronic Acid injections and maybe still fewer might have heard of Hydrodistension injections. In this blog I will try to to give a brief summary of the differences between these injection options and indicate when they are likely to be most beneficial.

STEROID INJECTIONS

Often times patients are referred by their GP for a steroid injection when their shoulder, knee or whatever other joint or soft tissue problem they might be suffering with, is peristent,  causing a lot of pain and is not responding to the usual first line treatments such as: relative rest, Non steroidal Antinflamatory drugs (NSAIDs) and or exercise therapy +/- physiotherapy.

Steroid injections when given appropriately are generally very safe and cause very litle side effects. Please see our steroid information leaflet  for some more information on steroid injections and their risks and side effects.

Steroid injections for musculoskeletal conditions should not to be confused with oral steroid (steroid pills) treatment. Usually the negative reports one hears about steroids refer to the side-effects associated with long term (usually oral) systemic steroid therapy (steroid pills). This tends to be for chronic conditions. For doctors to decide that the benefits outweigh the significant risks and side effects associated with long term steroid therapy it usually reflects the seriousness of the conditions that these people might be taking it for.

IN WHAT SITUATION IS A STEROID INJECTION MOST BENEFICIAL ?

Corticosteroids are synthetic drugs that resemble cortisol, a hormone that you produce in your adrenal glands. Corticosteroids have powerful anti-inflammatory effects. As a rule steroid injections are most useful for conditions where the pain, caused by a musculoskeletal condition, is a dominating feature and where there is a big impact on functional activities. Injections allow for an optimum dosage to a specific area of the body. Steroid injections tend to give pain relief relatively quickly, usually within one week following administration. Note that these are not the same drugs that some athletes use (illegally) to gain muscle strength.

HYALURONIC ACID INJECTIONS

Hyaluronic acid injections are also called viscosupplementation injections.  Hyaluronic acid injections are most commonly used to treat symptoms of symptoms of knee osteoarthritis. Hyaluronic acid is an important component of the joint fluid in healthy joints, but is found in lower concentrations in osteoarthritic joints. By adding hyaluronic acid to the existing joint fluid the aim is to facilitate better joint movement, reduce pain and maybe slow down the progression of osteoarthritis.

IN WHAT SITUATION IS A HYALURONIC INJECTION MOST BENEFICIAL ?

Often good candidates for viscosupplementation are those with osteoarthritis who have failed to improve with other non-surgical treatments including steroid injections. Steroid injections can only be repeated for a limited number of times due to their potential side-effects. So regardless of the benefits of steroid injections hyaluronic acid injection might be a more suitable alternative in these circumstances.

Generally people who benefit from hyaluronic acid injections are active people for whom good movement in their joints is important. They should not be in severe acute pain as hyaluronic acid does not have the strong anti-inflammatory effects of a steroid injection and therefore might not provide enough pain relief in these more acute states.

Hyaluronic acid gives the joint fluid its viscous, slippery quality, which enables the bones’ cartilage-covered surfaces to glide against each other, thereby reducing joint friction. It adds cushion to protect joints during impact (e.g. weight-bearing activity).

joints have lower concentrations of hyaluronic acid in their joint fluid than healthy joints, and therefore have less protection against joint friction and impact.

By injecting a synthetically made hyaluronanic acid into the knee the aim is to temporarily lubricate the knee joint, thereby decreasing pain improving function and hopefully slowing the degeneration process.

HYDRODISTENSION INJECTIONS

Hydrodistension or High Volume injections are performed under ultrasound guidance with the aim of precisely depositing anti-inflammatory steroid, local anaesthetic and saline to give pain relief whilst also deliberately stretching the lining of the joint (joint capsule). This procedure is increasingly used in the treatment of ‘frozen shoulder’ (adhesive capsulitis) and has been shown to be effective in the majority of patients by giving pain relief and also helping them to regain movement. These injections can give rapid and effective reduction in pain and inflammation; however, improvements are usually temporary. As with all medicines, some people may experience side effects.

IN WHAT SITUATION IS A HYDRODISTENSION INJECTION MOST BENEFICIAL ?

Clinically hydrodistension appears to be most useful in frozen shoulders where restriction rather than pain is the most dominant feature. As the injected volume is higher the procedure is likely to be slightly more uncomfortable  when compared  with a “normal” steroid injection under ultrasound guidance. This makes the procedure a good choice in “stiffness dominated” frozen shoulders.

Some research (Yoon et al. 2016) appears to support the above notion. Their study showed that hydrodistension plus steroid resulted in a bigger reduction in pain and a greater improvement of shoulder movement when compared to steroid injection alone in the first 3 months post injection. However patients in this study due to inclusion citeria were more likely to be in the more chronic stage  (froze stage) of frozen shoulder when pain levels are reduced and the dominant problem is restriction of movement.

No such differences have been shown in other studies which included patients in the more acute earlier stages of frozen shoulder (Sharma, 2016; Lee, 2016). This might suggest that hydrodistension is more effective in those with significant shoulder stiffness but who are not in severe pain. More research is needed to evaluate this further.

 

References:

Lee, D.H., Yoon, S.H., Lee, M.Y., Kwack, K.S. and Rah, U.W., 2017. Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial. Archives of physical medicine and rehabilitation, 98(5), pp.815-821.

 

Sharma, S.P., Bærheim, A., Moe-Nilssen, R. and Kvåle, A., 2016. Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care. BMC musculoskeletal disorders, 17(1), p.232.

 

Yoon, J.P., Chung, S.W., Kim, J.E., Kim, H.S., Lee, H.J., Jeong, W.J., Oh, K.S., Lee, D.O., Seo, A. and Kim, Y., 2016. Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial. Journal of shoulder and elbow surgery, 25(3), pp.376-383.

Physiotherapy

Meet Rob - Our lead physiotherapist

Rob is a specialist extended scope Physiotherapist who has over 20 years’ experience in managing complex musculoskeletal conditions.

Also make sure you check out our Facebook and Youtube channels to keep up to speed with our latest news

Meet Rob

Contact

info@sonoscope.co.uk

+44787 0304523

Clinics

With 2 practices Sonoscope can help identify and treat your pain in either location.  Click on the buttons below to find out about each practice location and service.


Can steroid injections help with frozen shoulder?

What are steroid injections?

Ultrasound-guided steroid injections for frozen shoulder have been used for many years. There is good evidence that they are beneficial when used for frozen shoulders.
A Systematic Review and Meta-analysis of Randomized Controlled Trials by Sun et al (2016) demonstrated the benefit of steroid injections versus no injection or placebo injections.
In the last 10 years or so, hydrodistension procedures for frozen shoulders have become more and more popular. They have mainly been touted as an effective way of treating frozen shoulder. But what is the evidence for its effectiveness?

WHAT IS HYDRODISTENSION?

 Hydrodilatation, or hydrodistension, is an injection performed under ultrasound (or X-ray) guidance that aims to stretch the tightened joint capsule. Local anaesthetic and steroid, as well as saline, are injected into the shoulder under pressure in an attempt to stretch the capsule and allow movement.
Hydrodistension was first described by Andren and Lundberg (1965) who described the injection into the glenohumeral joint under X-ray guidance.

EVIDENCE FOR EFFICACY AND SAFETY OF HYDRODISTENSION INJECTIONS

Three systematic reviews on the efficacy of hydrodistention injections vs normal steroid injections have been published in the last two years.
Catapano (2017) et al in their systemic review concluded that combining hydrodilatation with corticosteroid injection potentially expedites recovery of pain-free ROM. The most significant benefit is experienced within the first 3 months of intervention.
Meng-Ting Lin et al (2018) in their systematic review concluded that intra articular steroid injection was as effective as distension in shoulder function improvement, pain reduction, and increasing ER of the shoulder. Distension yielded better ER improvement in the medium term but to a minor extent in the long term. For patients with predominant ER limitation, early distension could be considered the primary choice of treatment.
Wei-Ting Wu (2017) in their systematic review concluded that distension of the glenohumeral joint provides a similar long-term efficacy to all reference treatments. A single dose of a corticosteroid-contained regimen introduced through the ultrasound-guided posterior approach is preferable practice of capsular distension for the management of frozen shoulder.

CAPSULE RUPTURE VS CAPSULE PRESERVATION

Currently, in many clinics it is an established standard of care to distend the joint capsule with saline solution and corticosteroid until rupture (Koh et al. 2012). Many researchers and clinicians believed that increasing intra-articular pressure could lead to capsular rupture at the tightest point.
However capsular rupture mostly occurs at the weakest and thinnest areas of the joint capsule such as the subacromial bursa, subscapularis recess or the long biceps tendon sheath (Rizk et al,1994) rather then the stronger and thicker parts of the capsule which are the main dysfunctional areas in adhesive capsulitis.
Capsular preservation provides continual dilatation whilst ensuring that injected corticosteroid stays within the joint capsule, where  the thinking is that it can provide maximal anti-inflammatory effects. With capsular rupture fluid will leak into the surrounding soft tissues carrying away the corticosteroid from the joint capsule which is its intended target.
One RCT (Kim et al 2011) found that in a head to head comparision of those those in whom the joint capsule was preserved (n=20) vs those injected until capsular rupture (n=26) the capsule preserved group showed a significant better range of movement and pain reduction in the short term (3  days post procedure and at 1 month post procedure). This study also monitored intra-articular pressures throughout the procedures which  is likely to have ensured the accuracy of the procedures.
A recent slide share from Mr. Lennard Funk (Shoulder Doc) (McBride) shows a retrospective analysis of hydrodistension (n=58) for capsular rupture and seemed to indicate that whether there had been capsular rupture or not it made no difference to clinical outcomes.

BIOMECHANICAL PROPERTIES OF JOINT CAPSULES AND THE EFFECT OF REPEAT CAPSULE PRESERVED HYDRODISTENSION INJECTIONS

A very interesting study by Koh et al (2010) showed that repeated (3) Capsule-preserving hydrodistension injections changed the biomechanical properties of the glenohumeral joint capsule, lessening the stiffness and enlarging the volume capacity. these changes were accompanied by improved range of motion and relief of pain. Three hydrodistension distensions with saline solution and corticosteroid were performed with 1-month intervals.
This study would suggest that the pressure effect is responsible for the increase in range of motion and reduction in pain and that these improvements were accumulative.

SUMMARY OF THE EVIDENCE:

At least in terms of increase in range of movement hydrodistension appears better than steroid injection alone in the short and medium term. Despite the trend demonstrated in the literature, there remains a lack of robust data on the effect of hydrodilatation with corti-costeroid injection via this optimized technique, as only a few studies have combined these factors.

CAPSULE PRESERVED VS CAPSULE RUPTURING HYDRODISTENSION

Kim et al 2011 showed a significant better range of movement and pain reduction in the short term with capsule preserved hydrodistension when compared with capsule rupturing hydrodistension.
Koh et al (2010) showed that there is evidence suggesting that repeat hydrodistension injections (3) up to maximum pressure without capsular rupture can lead to reduced capsular stiffness and enlarged volume capacity resulting in improved range of movement and reduced pain levels. However In clinical practice without pressure monitoring equipment it might not be possible to avoid capsular rupture in every case.
What is now required is a large RCT to evaluate capsular preserved hydrodistension vs capsular rupturing hydrodistension. In the clinical situation it will remain a challenge to achieve maximum capsular distension whilst avoiding capsular rupture without using pressure monitoring equipment.

REFERENCES:

Andrén, L. and Lundberg, B.J., 1965. Treatment of rigid shoulders by joint distension during arthrography. Acta Orthopaedica Scandinavica, 36(1), pp.45-53.
Catapano, M., Mittal, N., Adamich, J., Kumbhare, D. and Sangha, H., 2017. Hydrodilatation With Corticosteroid for the Treatment of Adhesive Capsulitis: A Systematic Review. PM&R.
Kim, K., Lee, K.J., Kim, H.C., Lee, K.J., Kim, D.K. and Chung, S.G., 2011. Capsule preservation improves short‐term outcome of hydraulic distension in painful stiff shoulder. Journal of Orthopaedic Research, 29(11), pp.1688-1694.
Lin, M.T., Hsiao, M.Y., Tu, Y.K. and Wang, T.G., 2018. Comparative efficacy of intra-articular steroid injection and distension in patients with frozen shoulder: a systematic review and network meta-analysis. Archives of physical medicine and rehabilitation, 99(7), pp.1383-1394.
Sun, Y., Zhang, P., Liu, S., Li, H., Jiang, J., Chen, S. and Chen, J., 2017. Intra-articular steroid injection for frozen shoulder: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. The American journal of sports medicine, 45(9), pp.2171-2179.
Wu, W.T., Chang, K.V., Han, D.S., Chang, C.H., Yang, F.S. and Lin, C.P., 2017. Effectiveness of glenohumeral joint dilatation for treatment of frozen shoulder: a systematic review and meta-analysis of randomized controlled trials. Scientific reports, 7(1), p.10507.
Koh, E.S., Chung, S.G., Kim, T.U. and Kim, H.C., 2012. Changes in biomechanical properties of glenohumeral joint capsules with adhesive capsulitis by repeated capsule-preserving hydraulic distensions with saline solution and corticosteroid. PM&R, 4(12), pp.976-984.


Cortisone Injection knee

Could regular use of steroids injections reduce hyaline cartilage in osteoarthritic knees?

A recent study by McAlindon et al (2017) wanted to determine the effects of intra-articular injection of 40 mg of triamcinoloneacetonide every 3 months for 2 years on the progression of cartilage loss and knee pain.

 

Design: Two-year, randomized, placebo-controlled, double-blind trial of intra-articular triamcinolone vs saline for symptomatic knee osteoarthritis with ultrasonic features of synovitis in 140 patients.

 

Key findings: The 2-year change in the index compartment cartilage thickness was greater in the triamcinolone group with a between-group difference of −0.11 (95% CI, −0.20 to −0.03), which corresponds to a moderate effect size of 0.46 mm. Increased progression was not detected in other osteoarthritis features, structurally or clinically. These results contrast with a previous smaller trial that tested a similar regimen and found no difference in the rate of radiographic joint space loss and detected a benefit on knee pain in some secondary (but not primary) endpoints, Wernecke et al (2015). In this study, x-rays were used to determine cartilage loss rather than MRI. Guermazi (2011) showed that X-rays do not image cartilage directly and are insensitive to change. MRI used in this study enabled direct quantitation of cartilage.

 

CONCLUSIONS Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain.

 

Potential Implications for the clinical practice:

In Previous In vivo and clinical evidence, Wernecke (2012) showed the catabolic effects of corticosteroids. Eckstein (2014) showed that rates of cartilage loss are associated with higher rates of arthroplasty.

 

McAlindon’s study seems to indicate that cartilage loss does occur with 40mg Triamcinolone Acetonide given every three months for 2 years, which amounts to 8 steroid injections in total over this period of time.  Anecdotally, In my area of work, many practitioners would stop repeating steroid injections after 3 or 4 injections. In many cases, due to the concern of the potential for detrimental effects on the joint. In addition to that, there is also a notion that repeat steroid injections often appear to have shorter-lasting benefits after each subsequent injection. This personal experience does not seem to be supported though by a research study (Raynauld, 2003) which showed long-term clinical benefits from steroid injections over a two-year period.

In any case, for me, the objective evidence that cartilage volume was significantly reduced in the steroid group compared with a saline control group would make me more cautious still to continue with repeat injections beyond 3. I can think of clinical justifications to continue injecting (i.e. an Older person with severe and severely painful OA who is unsuitable for surgery and who has had significant benefit from steroid injection (which in this scenario often times in my experience is not the case) then perhaps there is an argument to continue with injections.

However, in younger patients, particularly those who are active and involved in high impact activities. In this category of patients, I would very early on (after as few as 1 or 2 steroid injections)  be thinking of alternatives such as Hyaluronic Acid injections in order to avoid progression of cartilage loss.

 

References:

Eckstein, F., Boudreau, R.M., Wang, Z., Hannon, M.J., Wirth, W., Cotofana, S., Guermazi, A., Roemer, F., Nevitt, M., John, M.R. and Ladel, C., 2014. Trajectory of cartilage loss within 4 years of knee replacement–a nested case–control study from the Osteoarthritis Initiative. Osteoarthritis and cartilage, 22(10), pp.1542-1549.

Guermazi, A., Roemer, F.W., Burstein, D. and Hayashi, D., 2011. Why radiography should no longer be considered a surrogate outcome measure for longitudinal assessment of cartilage in knee osteoarthritis. Arthritis research & therapy, 13(6), p.247.

McAlindon, T.E., LaValley, M.P., Harvey, W.F., Price, L.L., Driban, J.B., Zhang, M. and Ward, R.J., 2017. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. Jama, 317(19), pp.1967-1975.

Raynauld, J.P., Buckland‐Wright, C., Ward, R., Choquette, D., Haraoui, B., Martel‐Pelletier, J., Uthman, I., Khy, V., Tremblay, J.L., Bertrand, C. and Pelletier, J.P., 2003. Safety and efficacy of long‐term intraarticular steroid injections in osteoarthritis of the knee: A randomized, double‐blind, placebo‐controlled trial. Arthritis & Rheumatology, 48(2), pp.370-377.

Wernecke, C., Braun, H.J. and Dragoo, J.L., 2015. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthopaedic journal of sports medicine, 3(5), p.2325967115581163.

Physiotherapy

Meet Rob - Our lead physiotherapist

Rob is a specialist extended scope Physiotherapist who has over 20 years’ experience in managing complex musculoskeletal conditions.

Also make sure you check out our Facebook and Youtube channels to keep up to speed with our latest news

Meet Rob

Contact

info@sonoscope.co.uk

+44787 0304523

Clinics

With 2 practices Sonoscope can help identify and treat your pain in either location.  Click on the buttons below to find out about each practice location and service.