Long-time TOBI (The Orthobiologic Institute) Faculty, Dr. Gerald Malanga, and colleagues reviewed hundreds of published articles in this narrative study that highlights the history of corticosteroids, its use to treat joint pain, and its associated effects. Cortisone is both a natural hormone and a synthesized anti-inflammatory medication that is commonly used to treat symptoms related to chronic inflammation and joint conditions. Discovered over seventy years ago at the Mayo Clinic, it took nearly fifteen years for a group of doctors in collaboration with BigPharma to uncover the chemical compounds that contribute to the effects of this versatile hormone. Five compounds (Compound A-E) were originally isolated and synthesized; Compound E was further studied to determine its effects in the treatment of rheumatoid arthritis. This compound is known today as Cortisone, and Dr. Edward C. Kendall, who led this research, was awarded the Nobel Prize in Physiology and Medicine in 1950.
Corticosteroids is a class of synthetically derived chemical compounds isolated from the adrenal gland that mimic the effects of cortisone as an anti-inflammatory medication. These anti-inflammatory actions are attributed to slowing down the innate function of the immune system by controlling the release of chemicals in the body that cause inflammation and swelling. Throughout the decades since the discovery of cortisone in the 1920’s, researchers have sought to better understand the distinct ways in which corticosteroids work and determine the clinical significance of their therapeutic applications. Conversely, researchers and clinicians have detailed the relative risks associated with prolonged use of these compounds, since they inherently suppress immune function and reduce chemical signaling to other organs that are vital to maintaining hormonal balance and brain function. Since hormones are chemical compounds that are released into the bloodstream and elicit their widespread effects throughout the body, there are a myriad of conditions that contribute to the use of corticosteroids; however, this paper provides a summary of research that focuses on their use for joint pain.
Although corticosteroids have multiple functions, their anti-inflammatory effects are the main focus of this narrative review of published scientific papers. Researchers have identified two major modes of action, which (i) involves blocking the release of chemical signals that attract immune function cells to the site of inflammation and tissue damage in the body, and (ii) counteracts the expression of certain genes that facilitate increased blood flow, increased temperature, and swelling, which are characteristic signs of inflammation. Specifically, corticosteroids cause increased circulation of white blood cells (ie. neutrophils) that ingest damaged tissue particles in response to injury, but these cells cannot squeeze through the lining of blood vessels to get to the site of injury in order to clean-up the debris. Ultimately, osteoarthritis is the most studied and most targeted area of research concerning the use of corticosteroids. It was once suggested that the use of corticosteroids provided a protective mechanism against osteoarthritis, although this mechanism is unclear. Numerous studies echo the benefits of intra-articular corticosteroid injections for short-term relief, but recommend other modalities for long-term management of joint pain and dysfunction. The American Academy of Orthopedic Surgeons concluded that the evidence is unclear, and thereby, has published guidelines that neither strongly recommend for nor against the use of corticosteroid injections. Additionally, a consensus among published literature remains unclear whether there are clinically significant benefits one to six weeks after corticosteroid injection has been administered.
There is expressed concern throughout published literature reviews pertaining to adverse effects attributed to the use of corticosteroids. Minor adverse effects include skin discoloration at the injection site, and the unsightly breakdown of fatty tissue under the skin (ie. subcutaneous fat atrophy), in addition to characteristic redness, pain and irritation, and risk of infection at the injection site. Considering the effects on immune function, infection by the flu virus is of increased concern for patients prescribed or receiving corticosteroid injections, especially during a global pandemic with COVID-19. Other moderate to severe adverse effects related to corticosteroid injections involves increased incidence of soft tissue damage, bone decay due to lack of blood supply (ie. non-traumatic avascular necrosis) and erratic blood sugar elevations in diabetic patients. A majority of studies identify insulin dependence as the greatest predictor for having a more robust and a longer duration of elevated glucose levels following cortisone injections. Additionally, corticosteroids have been found to specifically decrease collagen production and increase protein breakdown, thereby predisposing tendons to weakening.
In conclusion, Dr. Malanga and colleagues provide a vast overview of the history, uses, and risks associated with corticosteroids in controlling joint pain. Referencing hundreds of published articles, this narrative review suggests that the use of corticosteroids provides short-term benefit in controlling pain, but provides limited evidence for maintaining pain control and improving function in the long-term. Corticosteroid injections are associated with multiple risks of varying degrees of severity, most emphatically concerning the suppression of immune function during the current COVID-19 global pandemic. For more details, access the article here.