Cortisone injections have gotten a bad rap in recent years as a treatment for arthritis pain, because steroids are known to damage cartilage and could potentially cause the joint to further deteriorate.
But a new study suggests that if used wisely, cortisone shots are as safe as another type of injection used to treat knee arthritis.
Occasional cortisone shots don’t appear to cause knees to deteriorate any faster than injections of hyaluronic acid, a substance injected to lubricate joints stiffened by arthritis, the researchers said.
“Knee replacement rates were, if anything, a little bit less in the group that got the cortisone injections,” said senior researcher Dr. David Felson, a professor of medicine and epidemiology at Boston University School of Medicine.
However, Felson added that the study only looked at people who’d gotten infrequent cortisone shots to their knee, and shouldn’t be interpreted as giving the green light to regular injections for years to come.
“What we know from the study that we can trust is that a few cortisone injections won’t really cause much trouble,” Felson said. “It’s conceivable that repeated injections every three months for years won’t cause any trouble, but you can’t say that.”
Steroids are known to be toxic to cartilage, the connective tissue that keeps your bones from rubbing against each other, explained Dr. Melissa Leber, director of the Emergency Department’s Division of Sports Medicine in the Icahn School of Medicine at Mount Sinai in New York City.
“If you use it enough, it will damage the cartilage,” said Leber, who had no role in the study.
A 2019 study reported a threefold increased risk of knee arthritis progression in people who’d received repeated cortisone injections, compared with people who’d never gotten the shot, Felson and his colleagues said in background notes.
Comparing two types of shots
However, no clinical trials had ever compared the two most common types of knee arthritis injections, cortisone jabs and hyaluronic acid shots, Felson said.
The two types of shots do different things in the joint, and are sometimes used in combination, Leber said.
Cortisone shots are anti-inflammatory and help reduce pain, while hyaluronic acid injections are like a gel that provides lubrication in the ailing joint.
“You’re injecting WD40 almost into the knee. That acts to allow smoother gliding in the joint,” Leber explained.
The latest study looked at nearly 800 people with knee arthritis, of whom 4 out of 5 reported getting cortisone shots for their knee pain. The rest had reported receiving hyaluronic acid injections.
After seven years of follow-up, researchers found that those who got steroid injections had no greater cartilage loss than those treated with hyaluronic acid.
In fact, people who got cortisone shots were about 25% less likely to need a total knee replacement than those who got hyaluronic acid.
The message to knee arthritis patients regarding cortisone shots is simple, Felson said: “Don’t be scared.”
“There’s nothing bad that’s going to happen with one shot or even a few shots,” Felson said. “People should be reassured. They shouldn’t avoid getting an effective treatment.”
Wise use is crucial
The findings bolster the approach orthopedic specialists already take in handing out cortisone shots to treat knee arthritis, Leber said.
“If someone already has a ton of damage to the cartilage in their knee, a lot of arthritis, then we don’t worry as much about using a steroid to help with pain control because they already have a lot of arthritis in the knee,” Leber said. “Damaging it a touch more just to give them good pain control is a very minor thing. It’s not as risky.
“In someone who’s young, in their 20s to 40s, who has very little cartilage damage but has pain, we try to use it sparingly,” she continued. “Would you use them on occasion in a young person? Yes. That’s only as a one-time thing. You don’t want to use it repetitively.
“Steroid is bad for cartilage, but that doesn’t mean it’s bad for every patient,” Leber concluded. “It’s a case-by-case situation.”
Regardless, you wouldn’t expect any patient to receive frequent cortisone injections, whatever their condition, added Dr. Jeffrey Schildhorn, an orthopedic surgeon with Lenox Hill Hospital in New York City.
“If you give someone a shot in January and they come back in April saying they want another one, and they come back in August and want another one, how well are they working?” said Schildhorn, who was not part of the study. “They’re not working, if you’re only getting two or three months of relief.”
SOURCES: David Felson, MD, professor, medicine and epidemiology, Boston University; Melissa Leber, MD, director, Emergency Department’s Division of Sports Medicine, Icahn School of Medicine at Mount Sinai, New York City; Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, New York City; Arthritis and Rheumatology, Dec. 1, 2021
Dr. Kim Huffman, an avid runner, gets a fair amount of guff from friends about the impact that her favorite exercise has on her body.
“People all the time tell me, ‘Oh, you wait until you’re 60. Your knees are going to hate you for it’,” Huffman said. “And I’m like, ‘That’s ridiculous’.”
Next time the topic comes up, Huffman is well-armed: An extensive British analysis of prior study data has found no link between a person’s amount of exercise and their risk for knee arthritis.
The research team combined the results of six clinical trials conducted at different places around the globe, creating a pool of more than 5,000 people who were followed for 5 to 12 years for signs of knee arthritis.
In each clinical trial, researchers tracked participants’ daily activities and estimated the amount of energy they expended in physical exertion.
Neither the amount of energy burned during exercise nor the amount of time spent in physical activity had anything to do with knee pain or arthritis symptoms, the researchers concluded.
“This helps dispel a myth that I’ve been trying to dispel for quite a while,” said Huffman, an associate professor at the Duke University Medical Center’s division of rheumatology.
“If you add up the amounts of activity that people do and also the duration of activity, neither of those is associated with knee arthritis,” added Huffman, who wasn’t involved in the analysis.
Dr. Bert Mandelbaum is chief medical officer of the Los Angeles Galaxy soccer club and team physician for the U.S. Soccer Men’s National Team.
He agreed the study “further corroborates the fact that levels of exercise in one’s personal life do not increase the risk, the onset or progression of osteoarthritis.”
So where did this misconception come from?
Huffman thinks it’s because people mistake exercise-related injuries for the effect that exercise itself has on your joints.
“Right now, the clear risks for knee arthritis are genetics, injuries and female sex,” Huffman said. “People who exercise more may be more likely to injure their knee. That’s where I think the myth comes from.”
In fact, exercise can help ward off knee arthritis in several ways, Huffman said:
Flexing and extending the knee during exercise promotes the diffusion of fluid into the joint, promoting better nutrition.
An elevated metabolism created by exercise helps control inflammation in the knee joint.
Weight loss reduces the amount of load placed on the knee.
Exercise strengthens the muscles surrounding the knee, stabilizing it and reducing the risk of injury.
“I don’t think we’re finding that simple overuse or using your joint is a problem. It’s more an association with injuries and perhaps in the setting of obesity or high genetic risk,” Huffman said.
Your best bet is to choose an exercise that poses the least risk of a knee injury, Huffman said.
“If you want to go snow skiing, I don’t think that’s a huge problem but you’re probably going to be more likely to injure yourself downhill skiing than, say, walking in your neighborhood or training for a marathon,” Huffman said. “It’s not soccer or football or skiing itself. It’s just the risk for injury during those activities.”
On the other hand, exercise provides benefits that go far beyond healthy joints, said Mandelbaum, co-chair of medical affairs at Cedars-Sinai Kerlan-Jobe Institute at Santa Monica, Calif. He played no role in the research review.
“Physical activity is essential to optimize both physical and mental health and plays a central role in facilitating life’s quality and quantity,” Mandelbaum said. “The list of benefits includes decreased anxiety, better mood, decreased levels of coronary disease, hypertension, diabetes and obesity, and therefore a longer life.”
The analysis was published recently in the journal Arthritis and Rheumatology.
The Arthritis Foundation has more about knee osteoarthritis.
SOURCES: Kim Huffman, MD, PhD, associate professor, Duke University Medical Center, division of rheumatology; Bert Mandelbaum, MD, co-chair, medical affairs, Cedars-Sinai Kerlan-Jobe Institute, Santa Monica, Calif.; Arthritis and Rheumatology, Nov. 3, 2021
It may look like bad news, but a new study says it’s not: The number of people younger than 21 who had total hip replacement surgery in the United States jumped from 347 in 2000 to 551 in 2016.
The increase wasn’t due to a rise in the number of children with inflammatory arthritis, which often prompts a hip replacement in the very young. That suggests that non-surgical treatments to control that painful condition are effective, said senior study author Dr. Bella Mehta, a rheumatologist at the Hospital for Special Surgery in New York City.
For the study, the researchers analyzed data on total hip replacement in U.S. patients younger than 21 from about 4,200 hospitals in 46 states. The mean age of patients was 17.
Osteonecrosis (the death of bone cells due to lack of blood supply), osteoarthritis and juvenile idiopathic arthritis (JIA)/inflammatory arthritis were the most common reasons for total hip replacement.
Over the study period, total hip replacement for osteonecrosis rose from 24% to 38% of patients, but it fell from 27% to 4% for arthritis, likely due to recent improvements in drug treatments for arthritis, according to the study.
The findings were scheduled for presentation Tuesday at the American College of Rheumatology annual meeting and recently published in The Journal of Arthroplasty.
“Our study shows that although THA [total hip arthroplasty] procedures are increasingly being performed in young people, we aren’t seeing more of these patients seeking surgery for inflammatory arthritis,” Mehta said in a hospital news release.
“We’re doing a better job at treating these individuals so they don’t develop end-stage joint damage,” Mehta added. “Twenty years ago, we didn’t have access to effective pharmacologic treatments for these conditions, and now we’re using them well and helping these patients live a better life.”
Improvements in implant technology and materials have also made them far more durable than they were 20 years ago, so surgeons now feel more comfortable offering hip replacement surgery to young patients because their implants are likely to hold up under the wear and tear of decades of activity, noted study co-author Dr. Mark Figgie, chief emeritus of the surgical arthritis service at the hospital.
Mehta said the findings could be of value both to clinicians and young patients.
“I would use these results to say to a young person: ‘There are a lot of people who get these procedures; you’re not alone,'” Mehta said. “I find that, especially for young patients, knowing they’re not the only ones to experience something really helps. And it’s a life-changing procedure for them.”
Many American arthritis sufferers aren’t getting any exercise despite its benefits for reducing pain and improving their quality of life, new research shows.
Sixty-seven percent of U.S. adults with arthritis engaged in physical activity in the past month, most often walking, according to a new data analysis by the U.S. Centers for Disease Control and Prevention. The findings were drawn from national health surveys from 2016 through 2018.
“With 33% of U.S. adults with arthritis who are not physically active, there is still room for public health action,” said lead researcher Dana Guglielmo of the CDC’s National Center for Chronic Disease Prevention and Health Promotion.
And that action starts with frank talk between arthritis patients and their health care providers, she said.
Guglielmo suggested patients ask their doctors about arthritis-friendly physical activities and self-management programs to help ease symptoms such as joint pain.
“Providers should check in with patients about their physical activity levels and talk to them about physical activity and arthritis self-management programs,” she added.
Arthritis is the most often reported cause of disability among Americans over age 15.
U.S. National Health Interview Survey data showed that 71% of respondents got their exercise through walking, 13% from gardening and 7% by lifting weights.
Guglielmo urged anyone with arthritis to walk.
“Walking is an ideal physical activity for adults living with arthritis, because it is low-cost, convenient and adaptable to various settings,” she said.
To get the most benefit, however, adults with arthritis should engage in an activity that combines aerobic, muscle-strengthening and balance exercises, Guglielmo said.
“Any activity is better than none,” she added. “Evidence-based physical activity programs can support adults with arthritis in getting and staying active by helping them overcome common barriers to physical activity. These programs can even improve their mental and physical health and quality of life.”
Dr. Jeffrey Schildhorn, an orthopedic surgeon at Lenox Hill Hospital in New York City, said everyone with arthritis pain should be encouraged to be active.
“People with arthritis ask me what can I do, and I tell them … you want to move your body,” he said. “When people stop moving their bodies, they get stiffer, they start quitting, they get fat.”
The best way to prevent these consequences is to be active, Schildhorn said. Even people who suffer the most pain can benefit from walking. Being physically active helps keep joints lubricated, he explained.
“Most people with arthritis wake up stiff, and sometimes they wake up in more pain, and as they get going, joints tend to lubricate, they get more mobile and the pain is less,” he noted. “So, walking or anything that gets your body moving actually helps.”
Schildhorn emphasized that he’s not talking about deep squats, but about keeping the body going. Plus, getting outside, getting sunshine and socializing can keep people healthy, he said.
Being inactive can become its own self-defeating loop, Schildhorn said: If you aren’t active, you feel worse, and feeling worse makes it less likely that you’ll exercise.
“People stop working out, they get stiffer because they spend so much time sitting on a chair with a pillow behind them because it feels better. To me, that is the opposite of health,” he said.
Being active can extend the time before a knee or hip replacement is needed.
“What people don’t understand is just how valuable physical activity is,” Schildhorn said. “It’s good for your immune system, it’s good for your attitude, it won’t wear out the joints faster, and you can cope with the symptoms longer.”
When you reach a point when you can’t walk as far as you once did because of the pain, then it might be time for surgery, he added.
The study was published Oct. 8 in the CDC’s Morbidity and Mortality Weekly Report.
SOURCES: Dana Guglielmo, MPH, National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention; Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, New York City; Morbidity and Mortality Weekly Report, Oct. 8, 2021
Many types of arthritis can be managed effectively without surgery. Try these six at-home methods first.
Arthritis symptoms range from an occasional mild ache to debilitating pain. Osteoarthritis, the most common type of arthritis, develops when the cushion of cartilage between the bones in a joint wears away, leading to pain (particularly after exercise), stiffness, a cracking noise during movement, and decreased mobility.
A degenerative disease, osteoarthritis usually occurs later in life. However, injuries such as a dislocation or fracture can make a joint more susceptible to arthritis. Fortunately, managing arthritis pain doesn’t always mean surgery. You can reduce the pain and stiffness of arthritis with several proven at-home, non-surgical therapies.
6 Ways to Manage Arthritis Pain Without Surgery
Whether it’s your hip, knee, or shoulder, first-line treatment for arthritis typically entails non-surgical methods to alleviate pain and increase range of motion. Try these at-home remedies for arthritis pain:
Exercise. Low-impact aerobic exercises such as walking, swimming, biking, and using an elliptical strengthen the muscles surrounding your joints. These activities also get your heart rate up without putting too much stress on your body. However, strenuous exercises that involve jumping, twisting, or deep bending should be avoided. A physical therapist can model effective ways to exercise or perform routine daily tasks like walking up and down stairs so you don’t strain your joints.
Lose Weight. Extra weight increases pressure on your joints, particularly your knees. For example, when you walk, your knees bear nearly two times your body weight. The more you weigh, the more stress you put on your knees. Exercise is one way to lose weight and reduce joint pain, but your diet plays a role, too. A plant-based diet of fruits and vegetables is helpful in fighting arthritis-related inflammation. On the other hand, processed foods, red meat, saturated fats, sugar, and salt contribute to inflammation and weight gain.
Hot & Cold Therapy.To ease stiffness, take a warm shower or bath or wrap yourself in a heated blanket. To reduce pain and swelling, apply a cold compress of ice covered by a towel or a gel ice pack to the aching joint. Just make sure the ice doesn’t directly touch your skin.
Anti-inflammatories. NSAIDs (non-steroidal anti-inflammatory drugs) are available either over-the-counter (ibuprofen and naproxen) or by prescription (celecoxib and meloxicam). Each one is an effective pain reliever and can be taken before you start an activity that causes discomfort. NSAIDs are generally safe, especially if used for a short period of time. But check with your doctor before taking an NSAID to make sure the medication doesn’t interfere with other drugs you may be prescribed.
Assistive Devices. Supportive devices, such as a walker or brace, alleviate pain by lifting the pressure off the affected joints. Assistive devices can also help you more easily accomplish everyday activities. If the pain is centered in your hands, for example, toothbrushes and brushes with larger handles are easier to maneuver.
Reduce Stress. Dealing with a painful chronic condition like arthritis can cause stress and anxiety, which only increases the intensity of your pain. Meditation, yoga, and other relaxation techniques calm the mind and help you cope with stress and pain.
If these at-home remedies or physical therapy fail to relieve your pain, your arthritis may have progressed to a point where surgery or joint replacement is advisable. Fortunately, today’s minimally invasive arthroscopic procedures allow you to regain use of your joint after a brief recovery period.
Let Us Heal You
The physicians at Comprehensive Orthopaedics treat arthritis with a combination of surgical and non-surgical methods. Our goal is to relieve your pain and get you moving freely again. Contact us today for a consultation.
WEDNESDAY, Jan. 13, 2021 (HealthDay News) — Lots of Americans suffer from painful arthritic knees, but a new study finds that wearing the right type of shoe may help ease discomfort.
Patients with knee arthritis will achieve greater pain relief by opting for sturdy and supportive shoes rather than flat flexible footwear, researchers in Australia found.
“A ‘sturdy supportive shoe’ is a shoe that gives stability to the foot, via motion control features such as arch support,” explained study author Rana Hinman, a professor of physiotherapy at the University of Melbourne. “It also has a thick, cushioned heel and a rigid sole that does not bend easily.”
In contrast, Hinman noted, “a ‘flat flexible shoe’ is more lightweight, contains no arch support or motion control features, has a low heel (i.e., flat) with minimal/no cushioning and has a flexible sole that bends easily.”
Roughly 1 in 4 adults over the age of 45 has arthritic knees, Hinman noted.
One U.S. expert unconnected to the study agreed that “bum knees” will probably feel better with special footwear.
“I think it’s pretty intuitive that a structured shoe will be more stable and better for arthritis patients,” said Dr. Jeffrey Schildhorn, an orthopedic surgeon at Lenox Hill Hospital in New York City. “I’ve found that to be true in my practice and in my life. But this study is the first to really look at this in a rigorous way, and to show with good science that this isn’t just anecdotal.”
Foot support matters
As the Australian team noted, people with creaky, painful knees are often advised to wear shoes with support. But there’s also a school of thought that flat flexible shoes may deliver greater benefit because they provide more of a “barefoot” experience.
The latter theory didn’t win out in the new study. After working with 164 knee arthritis patients in the Melbourne area, Hinman’s team found that “58% of people who wore sturdy supportive shoes experienced a meaningful reduction in knee pain on walking, compared to only 40% of the people who wore flat flexible shoes.”
Study participants were 50 years old and older. Prior to the study’s launch, all had experienced near constant knee pain in the prior month (rated at a 4 or greater on a pain scale of 11), and most had worn shoes that featured a mix of sturdy and flat characteristics.
Between 2017 and 2019, half were randomly assigned to wear a flat flexible shoe for at least six hours a day over six months, while the other half was assigned stable supportive footwear. (The team did not compare shoes distributed in the study with the ones patients regularly wore.)
All footwear was commercially available. For the flat variety, the brands included: Merrell Bare Access (for men and women); Vivobarefoot Primus Lite (men and women); Vivobarefoot Mata Canvas (men); Converse Dainty Low (women); and Lacoste Marice.
Stable variety brands included ASICS Kayano (for men and women); Merrell Jungle Moc (men); Nike Air Max 90 Ultra (women); Rockport Edge Hill (men); and New Balance 624 (women).
Each patient was able to switch between two brands throughout the trial. Investigators kept track of reported knee pain levels while walking, functional ability, overall quality of life indicators and overall physical activity levels.
In the end, the team determined that while stable supportive shoes did not restore greater mobility to patients than flat flexible shoes, they did offer a leg up on knee and hip pain reduction and improved quality of life.
‘A Rolls-Royce over potholes’
As well, Hinman noted that “sturdy supportive shoes were much less likely to cause adverse effects at the knee and other joints, such as ankle/foot pain [or] knee swelling.” Moreover, people who wore flat flexible shoes reported twice as many adverse effects as people who wore sturdy supportive shoes, she said.
The upshot: “Shoes are an easy option that can help people self-manage their knee osteoarthritis pain,” Hinman said. “Patients with knee osteoarthritis should think carefully about their footwear and choose shoes that are most likely to reduce their knee pain.”
“For someone with knee arthritis,” he said, “a structured shoe is almost like a Rolls-Royce going over potholes. Because the problem with an arthritic knee is that the joints aren’t aligned correctly, and aren’t nearly as supple anymore. And it has cartilage with gaps, like cobblestones, which wear away.”
A structured shoe can absorb those issues, said Schildhorn. But an unstructured shoe or a bare foot “relies on all of the joints of the body to work just as they were designed. They all have to be aligned correctly, the ligaments have to be functional, and the joints have to be supple in order to absorb loads when walking in uneven areas. Because you need your body to be able to adjust to variances.”
The U.S.-based Arthritis Foundation agrees that patients should pay attention to the style and fit of the shoes they wear. But it cites mixed findings as to best practices.
For example, foundation experts acknowledge that stable shoes and boots (without heels) can indeed be helpful for some.
However, they also highlight prior knee research indicating that some flat shoes — such as flip-flops — may trigger less knee stress than more stable shoes. Others, however, such as loosely strapped sandals and so-called “foot gloves,” may prove problematic.
But the foundation has one piece of overriding advice: Never favor style over function and comfort.
The results were published Jan. 11 in the Annals of Internal Medicine.
SOURCES: Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, Northwell Health, New York City; Rana Hinman, PhD, professor, department of physiotherapy, University of Melbourne, Australia; Annals of Internal Medicine, Jan. 11, 2021