Wednesday 17 May 2017

Steroid injections in the knee

Corticosteroid injections in the knee are VERY commonly performed for any knee pain, but particularly for osteoarthritis. They don’t provide significant benefit to people, and they cause harm.

1. They don’t help
This Cochrane review from 2015 used data from 27 trials. The quality of studies was generally low, there was evidence of publication bias, and yet the effect on pain and function (compared to doing nothing or placebo) was smaller than the minimum important difference for pain and for function. And the maximum effect was in the first two weeks, trailing off after that. At best, these injections might help 10% of patients a little bit, for a few weeks. Given the likely biases present in the studies, the real effect is likely to be even less.

2. They harm
Studies show increased risk of infection after knee replacement if the patient has had steroid injections previously (here). A randomised trial just out from the US (here) showed no difference in pain but greater cartilage loss over two years in patients treated with repeated injections of steroids into the knee.

The bottom line

Steroid injections are widely used but either not effective or so marginally effective that they are probably not worth the bother. This is the case in the spine (see previous post) and for the knee and very likely for everywhere else they are used.


  1. How does medicare justify paying for them?

    Medicare Coverage Determination Process
    Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation.

    We may consider an older National Coverage Deternimation for removal if, among other things, any of the following circumstances apply:
    We believe that allowing local contractor discretion better serves the needs of the Medicare program and its beneficiaries.
    The technology is generally acknowledged to be obsolete and is no longer marketed.
    In the case of a noncoverage NCD based on the experimental status of an item or service, the item or service in the NCD is no longer considered experimental
    The NCD has been superseded by subsequent Medicare policy.
    The national policy does not meet the definition of an “NCD” as defined in sections 1862(l) or 1869(f) of the Act.
    The benefit category determination is no longer consistent with a category in the Act.

    Somehow removal never seems to happen- too many vested interests- politics trumps evidence.

  2. Viscosupplementation is now a multibillion dollar "business." I suspect, based on the literature, it also a placebo. DO you agree?

    1. Largely. Any effect is small and short lived.


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