This can be thought of as a fire extinguisher for your body.
This is often known as a steroid or cortisone injection. It is a powerful, anti-inflammatory medication, that has been used in modern medicine for over 50 years. The premise for a steroid injection comes from cortisone, our body’s own natural “stress” hormone. Cortisone, which is a form of glucocorticosteroid, acts in the body’s immune (“defence”) system. It has many effects, one of which is to decrease the body’s inflammation (“fire”) and the pain (“alarm bells”) that are associated with it.
When a synthetic glucocorticosteroid is injected into a joint or body space, its suspension properties allow it to act locally, initiating an anti-inflammatory cascade to reduce pain. Ultrasound-guidance ensures accurate placement of the medication to its intended area, to maximize efficacy. This method of medication delivery is different from medication taken by mouth.
The exact choice of steroid, dose, and volume injected, varies upon the reason for injection, the body structure being targeted, and your prior medical history. Your physician will explain which option is best for you.
What are the benefits?
Pain control is the main benefit. It is sometimes hard to gauge the exact change in your pain levels, and so in our clinic we like to focus more on your function and quality of life. If after treatment, you can now tie your shoes, play with your kids, participate in your usual activities for daily living, and even recreational activities for maintenance and improvement of health, we consider this a huge success.
How long will my pain be reduced?
Unfortunately, this is very variable and difficult to predict. It depends your body’s overall pain pathways, the degree of degeneration with your joint or body structure, and the amount of active therapy you engage in afterwards. In general, the clinical effect of any steroid injection can last from weeks to months.
How often can I have this done?
Soft tissue (ligament, tendon, bursa): No more than 1 in a lifetime, for any area, unless being done for exceptional reasons.
Joint: No more than 3 in a lifetime (spread apart by 3-4 months), for any joint, unless being done for exceptional reasons.
Who can’t have this done?
Any patient who is scheduled for joint replacement surgery:
Steroid injections are known to reduce inflammation. During and after surgery, however, the body is at greater risk of infection. This is because the body’s protective structures have been disrupted (e.g. skin). If the body (joint) cannot produce inflammation, it cannot protect itself from infection. Therefore, most surgeons prefer at least a 3-month window from injection to surgery, but this varies depending on several factors. Overall, we ask that your surgeon be informed of any plans of an interventional procedure, whether it be steroid or some other medication.
Any patient who may appear to have:
- Infection within the body, near the site of administration, or the actual joint itself
- Bone fracture or loss near the joint or structure of interest
What are the side effects?
- Pain after injection: A post-injection flare occurs anywhere from 1 to 10% of patients. The pain that occurs is oftentimes more severe than before, but it usually settles within 2 days. Application of ice and simple pain medications (e.g. Tylenol, Advil) can help, if desired. The reason for this occurring is thought to be as a result of crystallization of the steroid solution, causing a local reaction.
- Pain during the procedure: The skin is the most sensitive part when it comes to any injection. We minimize this by using local anesthetic and/or a vapocoolant spray on the skin. Pain associated with the injection is usually brief and well-tolerated.
- Facial flushing: This occurs in up to 15% of patients and is particularly common in women. It can begin within a few hours of injection, lasting up to 4 days.
- Fat atrophy: This can occur just under the skin, leaving a skin dimple, or in deeper tissues, where fat pads act as protective structures. There is greater risk of this with less soluble steroid formulations. To minimize this risk, we offer different steroid formulations, avoid injecting steroid near the skin, and use ultrasound guidance to visualize and avoid deeper fatty structures.
- Hypopigmentation of the skin: There is greater risk of this with small joint procedures, as the deposit of steroid can lie closer to the skin surface. This is minimized by ensuring that the complete steroid is injected before beginning to withdraw the needle. The presence of hypopigmentation appears greater in darker-skinned individuals.
- Fainting/light-headedness: Some patients have an increased physiological response to the needle itself. Whether you have a known history of fainting or not, we minimize the harm from this potential event by performing injections in well-supported and safe positions.
- Infection: When a needle is passed through the skin into the body, there is a very small chance of introducing a joint infection. The chance of this occurring is extremely low, less than 0.002%, or equivalent to being struck by a car as a pedestrian and experiencing a catastrophic event. To minimize this risk, we not only follow the WHO minimum best practice standards for injections, but use sterile gloves, sterile ultrasound probe covers, and sterile ultrasound gel.
- Allergy: A swelling reaction to the local injectate can occur at the site of administration, or even rarer a whole-body reaction (case reports only). We ask all patients to remain in the clinic waiting room afterwards for a minimum of 15 minutes to observe for any adverse reactions to the medication.
- Bleeding: This is a greater risk if you have a known bleeding disorder or are taking blood thinners. By using ultrasound guidance, there is less “poking” around to get to the target tissue of interest, and thus less theoretical risk of bleeding. Pressure is maintained over the skin afterwards to reduce bleeding.
- Tendon injury: This occurs if steroid is inadvertently placed in an already weakened tendon, causing further injury and/or rupture. Ultrasound guidance minimizes this, as tendons can be visualized. Nonetheless, we typically limit soft-tissue injections to no more than 1 in a lifetime, for any area, unless being done for exceptional reasons.
- Cartilage loss: Repeated steroid injections into a joint is known to accelerate cartilage loss. The degree to which this occurs depends on several factors. At our clinic, we limit intraarticular steroid injections to no more than 3 in a lifetime (spread apart by 3-4 months), for any joint, unless being done for exceptional reasons.
Systemic Side Effects
This depends of the formulation used, dose, frequency, and number of joints injected. Diabetics may see an increase in their blood sugars afterwards, but overall corticosteroid injections cause little-to-no systemic effects.
Can I drive afterwards?
We recommend bringing a driver with you if you’re scheduled for an ankle or foot injection. Otherwise, most people can drive afterwards. Nonetheless, we ask all patients to remain in the clinic waiting room for a minimum of 15 minutes afterwards to observe for any adverse reactions to the medication.
Can I play sports afterwards?
This depends on the type of sport and intensity, but we generally recommend taking it easy for 2 days as post-injection flares may occur. The local anesthetic will decrease the pain in the area for a few hours afterwards, but this wears off. You do not want to aggravate it with increased activity. The steroid begins to take effect after day 2. Overall, please be mindful with anything you do, as this injection should be seen as a temporizing measure for pain control and function.