Corticosteroid Injections in Primary Care: Benefits, Risks, and Considerations

Introduction

The use of corticosteroid injections in primary care has been steadily increasing, offering pain relief and inflammation control for various musculoskeletal conditions. With an aging population and rising incidence of conditions like osteoarthritis, tendinopathy, and bursitis, these injections have become a widely used treatment option. However, alongside their benefits, they also carry risks that both clinicians and patients must consider. This article explores the reasons for their increased use, the benefits, and the potential risks associated with corticosteroid injections.

Why is Corticosteroid Injection Use Increasing?

1. Rising Prevalence of Musculoskeletal Conditions

The demand for corticosteroid injections has grown due to the higher prevalence of musculoskeletal conditions, particularly osteoarthritis, tendinopathy, and bursitis. These conditions are more common in older adults, and as the global population ages, so does the incidence of these issues.

2. Proven Effectiveness in Pain Management

Corticosteroid injections are known for their quick and effective pain relief, making them a valuable tool for patients who do not respond well to first-line treatments such as physiotherapy or analgesics. They allow patients to engage in rehabilitation exercises, which is crucial in conditions like osteoarthritis, where a combination of exercise and injection therapy has been shown to be particularly beneficial.

3. Non-Surgical Alternative

For many patients, corticosteroid injections offer a way to delay or avoid surgery, especially for those with comorbidities or those who are not suitable surgical candidates. Additionally, they are often used as a bridging intervention to manage symptoms while awaiting surgical procedures such as joint replacements.

Benefits of Corticosteroid Injections

1. Rapid Pain Relief

Many patients experience relief within days of the injection, helping them regain function and return to daily activities. This is particularly beneficial for individuals in manual jobs or self-employed roles who need to resume work quickly.

2. Reduction in Inflammation

Corticosteroid injections reduce inflammation, improving mobility and function. While beneficial for conditions like rheumatoid arthritis and tendinopathy, their long-term impact on tendon health is debated, with some studies suggesting negative effects over time.

3. Delaying or Avoiding Surgery

Effective symptom relief from corticosteroid injections can sometimes delay or prevent surgery. This can be a significant advantage for patients looking to avoid the risks and recovery time associated with surgery. In many cases, they are used as a temporary measure while patients remain on long surgical waiting lists, particularly in the management of osteoarthritis.

Risks of Corticosteroid Injections

Like any medical intervention, corticosteroid injections have potential side effects. Below are the most common local and systemic risks, including their incidence rates where available. The main references for the incidence rates are Risk Management in Soft Tissue and Joint Injections document from the CSP and Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications from the American Journal of Roentgenology

Local Side Effects

Immediate Onset (Within 48 Hours)

Post-Injection Flare: Temporary worsening of pain after injection, common with particulate corticosteroids (Incidence: 8%).

Delayed Onset (After 48 Hours)

Skin Hypopigmentation & Atrophy: More common with superficial injections; usually resolves within a year (Incidence: 9%).
Soft-Tissue Calcification: Rare but can lead to increased pain.
Infection: Rare but possible, with an increased risk if surgery follows soon after (Incidence: <0.001%).
Tendon Rupture: Higher risk in tendons under stress, such as the Achilles tendon (Incidence: 0.1%).
Accelerated Osteoarthritis Progression: Some studies indicate increased joint space loss and faster radiographic progression.
Osseous Injury: Includes insufficiency fractures, osteonecrosis, and rapid joint destruction (Incidence: 1%).

Systemic Side Effects

Immediate Onset

Facial Flushing: More common in women, typically self-limiting (Incidence: 40%).
Hypertension & Hyperglycemia: Temporary spikes in blood pressure and blood sugar (Incidence: common).
Hypersensitivity Reactions: Rare but includes potential anaphylaxis (Incidence: 0.3–0.5%).
Ophthalmic Conditions: Can exacerbate glaucoma or cause chorioretinopathy.

Delayed Onset

Osteoporosis: Repeated injections may decrease bone mineral density and increase fracture risk. (Incidence: Common)
Irregular Menstruation: Can cause hormonal disturbances (Incidence: 51%. Early or delayed menstruation).

Special Considerations

Premenopausal Women: May experience hormonal suppression and menstrual irregularities. (Incidence: 51%)
Diabetic Patients: Blood sugar levels can spike, requiring careful monitoring. (Incidence: Common)
Athletes: Increased risk of tendon weakening and adrenal insufficiency; high-impact activities should be avoided post-injection.
Paediatric Patients: Limited data, but potential for significant side effects like Cushing’s syndrome (Incidence: 2.6%. skin hypopigmentation and atrophy).
Patients on Anticoagulants: Risk of bleeding is low, and most guidelines do not recommend discontinuing anticoagulation therapy. (Incidence: Low)
Patients on Ritonavir: High risk of adrenal insufficiency due to drug interactions.

Conclusion

Corticosteroid injections play a valuable role in primary care musculoskeletal management, offering effective short-term pain relief. However, their risks and benefits must be carefully weighed, and shared decision-making is essential. Patients should be informed about the potential side effects, and injections should rarely be a standalone treatment. Instead, they should be integrated into a comprehensive management plan that includes exercise, physiotherapy, and lifestyle modifications.

Check out the rest of Andy's work here: https://blog.andyhubbert.co.uk

References

Cleveland Clinic (no date) Cortisone Shots: How They Work and Side Effects, Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/treatments/cortisone-shots-steroid-injections (Accessed: 31 January 2025).

Dr Graeme Wilkes (N.D.) Risk Management in Soft Tissue and Joint Injections. Available at: https://www.csp.org.uk/system/files/documents/2019-04/risk_management_in_soft_tisse_and_joint_injections_-_presentation.pdf (Accessed: 31 January 2025).

Foster, Z.J. et al. (2015) ‘Corticosteroid Injections for Common Musculoskeletal Conditions’, American Family Physician, 92(8), pp. 694–699. Available at: https://www.aafp.org/pubs/afp/issues/2015/1015/p694.html (Accessed: 31 January 2025).

Holt, T.A. et al. (2013) ‘Corticosteroid injection for shoulder pain: single-blind randomized pilot trial in primary care’, Trials, 14(1), p. 425. Available at: https://doi.org/10.1186/1745-6215-14-425.

Kamel, S.I., Rosas, H.G. and Gorbachova, T. (2024) ‘Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications’, American Journal of Roentgenology, 222(3), p. e2330458. Available at: https://doi.org/10.2214/AJR.23.30458.

Kjeken, I. and Sundin, U. (2023) ‘Management of carpal tunnel syndrome in primary care’, Rheumatology, 62(2), pp. 495–496. Available at: https://doi.org/10.1093/rheumatology/keac396.

Moore, A.J. et al. (2024) ‘Intra-articular corticosteroid injections for osteoarthritis: A qualitative study of patients’ and clinicians’ experiences’, PLOS ONE. Edited by D. Tarantino, 19(10), p. e0311668. Available at: https://doi.org/10.1371/journal.pone.0311668.