Intra-articular steroid injections appear to provide 2 to 6 weeks of pain relief for patients with knee osteoarthritis (strength of recommendation [SOR]: A). Higher-dose steroids with or without joint lavage can provide pain relief up to 24 weeks (SOR: A). Steroid injections may be an appropriate adjunct in the treatment of osteoarthritis, which includes nonpharmacologic treatments (education, weight loss, physical therapy) and pharmacologic therapy (nonsteroidal anti-inflammatory drugs [NSAIDs], topical and opioid analgesics)

Jones, Wanwisa Y.

Mayo, Helen G.

Palacios, Luis C.

University of Missouri: MOspace

C L I N I C A L  I N Q U I R I E SNOVEMBER 2004 / VOL 53, NO 11 · The Journal of Family Practice 921C O N T I N U E D7. American College of Radiology (ACR), Expert Panel onMusculoskeletal Imaging.  ACR Appropriateness Criteriafor Acute Trauma to the Knee. Updated October 1, 2002. Reston, Va: American College of Radiology; 2001. Available at: http://www.acr.org/cgi-bin/fr?tmpl:appcrit,pdf:0365374_acute_trauma_to_knee.ac.pdf. Accessed on September 30, 2004.Do steroid injections help with osteoarthritis of the knee?■ EVIDENCE-BASED ANSWER Intra-articular steroid injections appear to provide2 to 6 weeks of pain relief for patients with kneeosteoarthritis (strength of recommendation [SOR]:A). Higher-dose steroids with or without jointlavage can provide pain relief up to 24 weeks(SOR: A). Steroid injections may be an appropriateadjunct in the treatment of osteoarthritis, whichincludes nonpharmacologic treatments (education,weight loss, physical therapy) and pharmacologictherapy (nonsteroidal anti-inflammatory drugs[NSAIDs], topical and opioid analgesics).1,2■ EVIDENCE SUMMARYOsteoarthritis, also known as degenerative joint dis-ease, is the most prevalent form of arthritis in theUnited States.3 For the elderly, it is a common causeof pain and disability, affecting patients’ ability toperform activities of daily living. Common causes ofosteoarthritis include past and present biomechani-cal stresses affecting the articular cartilage, sub-chondral bone changes, and biochemical changes inthe articular cartilage and synovial membrane.3Treatment of patients with osteoarthritis of theknee should be individualized to the severity ofsymptoms for each patient. A treatment plan caninclude patient education, physical and occupa-tional therapy, non-opioid oral and topical agents,NSAIDs, intra-articular corticosteroid injections,viscosupplementation injections, arthroscopiclavage, and total knee replacements. Our knowledge of the long-term safety and effi-cacy of intra-articular knee corticosteroid injec-tion is based on limited data. In a randomized,double-blind, placebo-controlled crossover study,investigators randomized 59 patients aged 51 to89 years to receive either an intra-articular injec-tion of 1 mL of 40 mg methylprednisolone or 1 mLof 0.9% saline. After 3 weeks, patients receivingsteroid injection had a minimal change in baselinevisual analogue score for pain compared withthose receiving saline (median change: –2.0 mmvs 0 mm on a 100-mm scale).4A randomized, single-blinded study involving84 patients demonstrated significant self-report-ed “overall improvement” for patients givenintra-articular triamcinolone hexacetonide(78%) compared with placebo (49%) after 1week (P<.05).5 It also confirmed reports thatvisual analogue score for pain and distancewalked in 1 minute improves significantly forboth steroid- and placebo-treated groups up to 6weeks. Only the steroid-treated patients exhibit-ed improved walking distance at 1 week com-pared with baseline (P<.001).A recent randomized, double-blind, placebo-con-trolled trial studied the long-term safety and effica-cy of treatment of knee osteoarthritis with repeat-ed steroid injections.6 These investigators studied66 patients aged 40 to 80 years recruited fromrheumatology clinics. One half (n=33) receivedinjections of triamcinolone acetonide 40 mg, andthe other half received saline injections every 3months for 2 years. At 1- and 2-year interval follow-ups, no statistically significant difference was seenbetween the 2 groups in loss of joint space and noprogression of degenerative disease, as demon-strated by measurements of joint space widths bystandardized fluoroscopically guided radiographs.Although the primary outcome measure of thisstudy was to assess radiologic joint space narrow-ing with repeated injections, knee pain and stiff-ness appeared to improve after 2 years, althoughthese results were not well quantified.A limitation of most studies testing intra-articular therapy has been sample size.Combining studies may allow the ability todetect levels of pain relief not found in individualJFP_1104_CI.final  10/18/04  11:06 AM  Page 921C L I N I C A L  I N Q U I R I E S922 NOVEMBER 2004 / VOL 53, NO 11 · The Journal of Family Practicestudies. A recent meta-analysis of 6 randomizedcontrolled trials using intra-articular corticos-teroid knee injections found short-term relief ofpain for 2 weeks (relative risk [RR]=1.66; 95%confidence interval [CI], 1.37–2.01).7 The num-ber needed to treat (NNT) range for these stud-ies is 1.3 to 3.5. Two additional studies includedin this study using higher-dose steroids (pred-nisone equivalent dose of 37.5 to 80 mg), with orwithout joint lavage, assessed improvement at16 to 24 weeks. Although neither individualstudy showed statistically significant differ-ences, the pooled data from the 2 studies favoredsymptom improvement at 16 to 24 weeks(RR=2.09; 95% CI, 1.2–3.7; NNT=4.4).7■ RECOMMENDATIONS FROM OTHERSGuidelines for the treatment of kneeosteoarthritis were outlined by a task force forthe European League Against Rheumatism(EULAR) Standing Committee for ClinicalTrials. The task force recommended intra-artic-ular steroid injection for acute exacerbation ofknee pain. This task force performed an evi-dence-based review and concluded at least 1randomized control trial recommended intra-articular steroid for patients with osteoarthritis.It was noted that intra-articular steroid injec-tions were effective for only short-term painrelief and that there are no predictors of successof treatment, such as the presence or absence ofsuch factors as joint effusion, degree of radio-logic change, age, or obesity.2The American College of RheumatologySubcommittee on Osteoarthritis Guidelines devel-oped both nonpharmacological and pharmacologi-cal recommendations for the treatment ofosteoarthritis of the knee.8 These recommenda-tions include: use of intra-articular steroid injec-tion for patients with acute exacerbations whohad evidence for joint inflammation, and jointaspiration accompanying the intra-articular injec-tion for “short-term relief.” Luis C. Palacios, MD, Wanwisa Y. Jones, MD, HelenG. Mayo, MLS, University of Texas Southwestern, Dallas■ CLINICAL COMMENTARYIntra-articular steroids provide extra relieffor patients with acute exacerbationsThis well-constructed review demonstratesthat intra-articular steroid injections provideup to 3 weeks of pain relief for patients withosteoarthritis of the knee. While this may notseem like much, in practice it can be quite help-ful in some situations. It provides supplemen-tal pain relief for patients with acute exacerba-tions of their disease. It is also useful as a temporizing measure for patients who are can-didates for total knee replacement but are notquite ready for it psychologically.Wail Malaty, MD, Hendersonville Family PracticeResidency Program, Hendersonville, NCREFERENCES1. Rozental TD, Sculco TP. Intra-articular corticosteroids: anupdated overview. Am J Orthop 2000; 29:18–23. 2. Pendleton A, Arden N, Dougados M, et al. EULAR recom-mendations for the management of knee osteoarthritis:report of a task force of the Standing Committee forInternational Clinical Studies Including Therapeutic Trials(ESCISIT). Ann Rheum Dis 2000; 59:936–944. 3. Hochberg MC, Altman RD, Brandt KD, et al. Guidelinesfor the medical management of osteoarthritis. Part II.Osteoarthritis of the knee.  American College ofRheumatology. Arthritis Rheum 1995; 38:1541–1546. 4. Jones A, Doherty M. Intra-articular corticosteroids areeffective in osteoarthritis but there are no clinical predic-tors of response. Ann Rheum Dis 1996; 55:829–832. 5. Gaffney K, Ledingham J, Perry JD. Intra-articular triamci-nolone hexacetonide in knee osteoarthritis: factors influ-encing the clinical response. Ann Rheum Dis 1995;54:379–381. 6. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety andefficacy of long-term intraarticular steroid injections inosteoarthritis of the knee: a randomized, double-blind,placebo-controlled trial. Arthritis Rheum 2003; 48: 370–377. 7. Arroll B, Goodyear-Smith F. Corticosteroid injections forosteoarthritis of the knee: meta-analysis. BMJ 2004; 328:869–870.8. Altman RD, Hochberg HC, Moskowitz RW, Schnitzer TJ.Recommendations for the medical management ofosteoarthritis of the hip and knee 2000 update: AmericanCollege of Rheumatology Subcommittee on OsteoarthritisGuidelines. Arthritis Rheum 2000; 43:1905–1915.Intra-articular steroids are useful forcandidates for total knee replacementwho are not ready psychologicallyJFP_1104_CI.final  10/18/04  11:06 AM  Page 922

Do steroid injections help with osteoarthritis of the knee?

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