Do Steroid Shots Help Joint Pain or Cause Cartilage Loss?
As a naturopath, acupuncturist and all around holistic practitioner I don’t use cortisone, primarily because there is a toxicity component to it. The main one is that it destroys cartilage, or does it? As I will allude to later on the amount is extremely negligible in the knee where there is more cartilage than in other areas of the body. However, in other joints such as the back where the cartilage is much less, the negligible amount then becomes more concerning with repetitive injections.
Regarding cartilage loss, if you ask nearly all of the medical practitioners who are holistic and even many Western practitioners how much cartilage is destroyed they will not have an answer. The notion of cartilage loss is basically just something that is parroted but no one really seems to understand how much.
Some people are vehemently opposed to the use of cortisone. But lets see if their vehemence is justified.
From an article published by Medscape written by Tara Haelle and titled: Steroid Injections Increased Cartilage Loss in Knee Arthritis it is reported that:
“From February 2013 to January 2015, patients in one group received 40 mg triamcinolone in intra-articular injections, and those in the other group received placebo saline injections every 12 weeks for 2 years.
Patients underwent magnetic resonance imaging at the beginning and end of the study to provide data on cartilage volume and soft-tissue structures. Among the 119 patients who completed the study, those receiving triamcinolone lost about twice as much cartilage as those in the placebo group.
Specifically, the intervention group lost an average 0.21 mm in index compartment cartilage thickness compared with 0.10 mm in the control group (for a mean difference of −0.11 mm: 95% confidence interval, −0.20 to −0.03 mm).”
From an article published in the Ann Rheum Dis 1999;58:27–34 written by D E T Shepherd, B B Seedhom and titled: Thickness of human articular cartilage in joints of the lower limb, it was stated that:
“The ankles and knees had mean cartilage thickness in the ranges 1.0 to 1.62 mm and 1.69 to 2.55 mm respectively, while the hips had mean cartilage thickness in the range 1.35 to 2.0 mm.”
Based on the evidence above, getting an injection of cortisone every 3 months over 2 years equates to 8 injections. That would be considered a lot (as in too much) by most people in modern medicine, and certainly a naturopath. With 8 total injections the loss of cartilage was an average of 0.10 mm when the average knee contains 1.69 mm cartilage on average. That is 1/16 loss of cartilage. Hypothetically speaking, that would equal 0.1 mm of wear and tear each 5 years for an average knee at an 80 year old death assuming that a person was losing cartilage at this rate. And one can safely assume that cartilage loss is not occurring early in life unless some rare circumstance so this assessment is flawed in favor of losing less cartilage over time.
A crude analysis of getting 3 of these injections in total, a more common experience than getting 8, would be 1/48 of your knee cartilage. When working as Western practitioner I rarely did more than 2 in year, or 3 for the patient in total. Usually by the third one the benefits were extremely short lived that it was never worth doing anyhow, although, every case is different and some did in fact still get benefits.
Lastly, there are are more joints than just the knee. Other joints that are comparable are the shoulders and knees when speaking of articular cartilage thickness in the healthy adult. However, there are smaller joints in the body such as facet joints located within the spine. These joints measure at most 1 mm of thickness . Other studies have its thickness at 0.8 mm . This is far less than other joins such as major weight bearing joints like the knee that average 1.69 to 2.55 mm thickness. Therefore, if you are a patient who already has degenerative changes within your spine, you would have less than the maximum measurement of 1 mm. You could very well have only 0.5 mm left of cartilage, or possibly less. 8 injections as previously stated was slated to cause 0.1 mm loss of articular cartilage. Even in the facet joint with an average of 50% less articular cartilage there is still room for “loss” by iatrogenic means via a cortisone injection. Iatrogenic means caused by a health care provider in case you were wondering.
While cortisone is not my choice of how to address problems, I do think it is important to put this medicine and approach into context because there are significant numbers of medical providers that really don’t understand what they are telling patients. And it further illustrates the beehive mind where people just parrot what they have been taught by their teachers who maybe didn’t get the correct or updated memo either. The reality is that for many people cortisone is the only option because this is what their insurance covers. And it doesn’t do anyone any good by putting out incorrect information that their joint is going to be destroyed by having 3 cortisone injections much less one.
In my experience, acupuncture is superior than cortisone in many cases over time. Thus, I would never use cortisone in my own practice as my primary approach to joint pain. But if a patient wanted it and the situation was such that it was warranted, I don’t see why exceptions to my own guidelines and ethics of practice should prevent me from giving it. As mentioned, a patient should not feel that their knee is going to be destroyed because they got 1 or 3 injections of cortisone. Education is key.