Steroid Injections
Why Steroid Injections?
Corticosteroid injections can often give rapid and effective reduction in pain and inflammation; however, as with all injection treatments relief is not permanent unless the reason for the inflammation is dealt with. Although steroid injections are deemed very safe and have been used for over 50 years medically, some people may experience side effects to treatment. Below is some useful information and frequently asked questions asked in respect to these injections.
What are Corticosteroids?
Corticosteroids are naturally occurring in the human body. The medical industry also produces man-made steroids that act like natural steroids to reduce pain and inflammation. These are very different from the anabolic steroids used illegally to enhance muscle by some body builders and other sport athletes wishing to increase muscle mass. Steroids can be taken as tablets or given as an injection. We use targeted steroids injections as this allows for a very small dose delivered precisely to the area of pain. In a joint for example the vast majority of the steroid would stay at the target site with very little leakage throughout the rest of the system. Tablets are a scatter gun action taking very high doses that reach everywhere.
Who Uses These Injections and What for?
Steroids are often used by people with inflammatory conditions such as inflammatory arthritis by rheumatologists. In orthopaedic and musculoskeletal (MSK) medicine they can also be used in degenerative diseases such as osteoarthritis and a range of other conditions which also involved pain and/or inflammation.
Different steroids exist but Tony and Keith only use longer acting steroids such as those used for injections whose action can last for several months after treatment. This can create a window of opportunity to enhance function, increase strength, relieve pain and to change habit.
What Will Happen After the Injection?
As we nearly always use a local anaesthetic at the time of steroid delivery, you will feel an immediate improvement. This initial numbing or pain reduced state will usually wear off after a couple of hours, but is a vital part of the diagnostic process. It will usually takes 2-10 days before the full effect of the steroid can be felt and we expect pain to be significantly reduced typically within 2 weeks after the injection.
We will ask you to wait 20 minutes post injection in the clinic to ensure your recovery is as expected and if you are driving home we would ask you to wait as long as required to ensure you are safe to drive. Ideally have someone else pick you up post injection if in a vehicle. We suggest relative rest to the area injected for 7-10 days and expect you to use common sense around this. Tony/Keith will discuss return to activity and activity with you on the day of the treatment.
Will I Need Further Injections?
If you find the injection helpful with your pain at times we would consider injecting the region again but both Keith and Tony are extremely experienced rehabilitation specialists and would encourage you to use the window of pain reduced or pain free movement to rehab the region to optimise the steroid effect and hopefully negate the requirement for continual injections. We do however realise this is not always possible and will offer repeat injections when this is appropriate and safe to do so. We will happily discuss this at appointment.
Potential Risks/Side-effects from Steroid Injections?
While there are side effects to steroids, these are usually in much long term courses of tablets and not a one off injection . We generally use long acting steroids that ideally work in your body for 3-4 months increasing the chance of a beneficial effect. Side effects include a temporary flare up of your pain after the injection for 24-48 hours, possible redness/ facial flushing. People with diabetes may notice some change to their blood sugar control, but this is usually short term and does not usually need to be adjusted for. Some female patients may notice a change to their menstrual cycle, with some spotting, but this is uncommon and nothing to be concerned about. If we inject around a superficial area the skin may depigment, ie lose colour, though this is purely a cosmetic side effect and will not affect the function of the tissues. Certain injections around fat pads also have the risk of fat pad atrophy but these would all be discussed and explained prior to any injection. These risks listed above will be broken down and expanded on below.
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Steroid is an auto immune drug and can dampen the immune response so has to be used with caution where immunity is already weaker. Any injection also has the potential to introduce infection but this is exceptionally rare. This has become a priority for many people during the Covid-19 pandemic, but Tony and Keith both practice under the current Covid-19 Injection Guidelines to ensure their patients are as safe as possible. It is generally recommended not to have a steroid injection within 2 weeks of any vaccination, in order to make sure that the vaccination is fully absorbed and able to work as intended.
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Generally the risk of side effects is thought to increase in line with higher dosages, and the clinical guidelines are to only use the lowest possible dose to achieve the desired clinical outcomes. Using Ultrasound guidance for your injections allows us to use the minimum effective dose in treatment.
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RARE SIDE EFFECTS
Skin Depigmentation
Steroid injections can in rare circumstances cause some local thinning and lightening in colour of the skin at the site of the injection, though this is purely a cosmetic effect and will not usually have any significant effect on the tissues themselves. Even more rare is fat pad atrophy (thinning) but these are risks we will discuss with you at the time of injection. This only relates to a few niche, usually superficial injections where we have fat pads in the first place.
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What Happens if I get an Infection?
Infection following a steroid injection is rare. Several studies have looked into this and the risk would appear to be somewhere between 1 in ten to 1 in 60,000 cases. We take your health extremely seriously and will taken every step to reduce the risk of infection. Both Keith and Tony inject within their NHS practice and adopt the same procedures and steps to ensure we adhere to a strict set of hygiene control and infection control measures. If after the injection the region injected became painful, red , warn and swollen and or you feel feverish and unwell, you are advised to seek medical attention immediately via 111, GP or A&E if you are unable to contact Tony or Keith.
Can I Safely Take Other Medicines Along with the Steroid Injection?
We are generally not concerned about pain killers as they will not interact with steroid but prior to injection we would carefully discuss all your medication to ensure there are no interactions that would concern us. Steroid is exceptionally safe and only contraindicated in very rare circumstances in respect to other medications. Usually the contraindications are about your medical history ie an active cancer, uncontrolled diabetes, epilepsy we would not be happy to inject. We would need to know if you are on anticoagulants ie blood thinners, before we inject, though many of the newer drugs do not interact with injected steroids. Warfarin is one of the older, blood thinning drugs that need careful consideration before deciding to offer injection therapy, but Tony and Keith are well practiced in helping you to consider all the relevant issue around this and can support you if you decide to proceed.
Is it Safe to Have Steroid Injections Whilst Pregnant or Breastfeeding?
The simple answer is that we have no proof of harm but do everything we can to avoid any potential risk to the unborn child or breast feeding baby. Steroids are used to mature the lungs of unborn babies if we know they will be born early and thus have been used safely for decades, but unless you are in significant pain and unable to cope, it is unlikely that either you or we will want to take any risks. We do however realise that there are a few very unique cases where this is appropriate. You should discuss with your GP and us if you are in severe pain and feel it is appropriate i.e. a severe carpal tunnel related to pregnancy that surgery is inappropriate for but starting to cause nerve damage, or de Quervain's Tenosynovitis which a lot of pregnant ladies and new mums find very debilitating. As per all of our care its case by case so get in touch if this is you.
Will The Steroid Injection Make me put on Weight?
Injected small dose steroids that we use will not make you gain weight as the dose is too small to effect the metabolism. These weight gains are only linked to longer term steroid use.
Is there Post injection pain or Flare?
A slight flare up in pain within the first 24-48 hours after their injection is common in around 20% of procedures but will ease after this. It will often feel like your pain has just gotten a little worse, but this is a temporary issue that will pass. We advise taking simple over the counter pain medication or continue with the medication you were taking before until the steroid kicks in which is usually between 2-10 days post injection. Ice or heat to the area may help as well.
I am on the Waiting list for a Knee/Hip Replacement. Can I still have a Steroid Injection?
Although it may seem an obvious choice to have a steroid injection to reduce pain while waiting for a knee or hip joint replacement, it is not recommended. Many Orthopaedic surgeons will not operate within 3-6 months of someone having a steroid injection into the same joint, as there is some research suggesting it may increase the risk of post op joint infection, which is a serious complication for joint replacement surgery. If this is your current situation, it may be worth considering a Hyaluronic Acid injection instead as there is no associated risk of post op infection and indeed some of the local orthopaedic services will recommend their patients seek a Hyaluronic Acid injection to reduce pain and ease movement while waiting for the new joint for this very reason.
Do you offer injections into the back (spine) or for sciatica?
Currently we do not offer spinal, or "nerve root" injections for sciatica/leg pain. These are highly specialised injection that usually need to be carried out under x-ray guidance and are currently rarely performed outside of a hospital setting. Tony and Keith see many patients in their practices who have back and leg pain and are happy to help you manage those conditions with more traditional physiotherapy options and discuss when these advanced techniques may be of benefit to you.
How can it affect Menstruation, Diabetes and Immunity?
Steroid is a hormone and therefore can effect other hormonal activities in the body. Once injected or ingested this can potentially alter other hormonal regulation effects. Other hormonal aspects within the body i.e. female hormones linked to menstruation, and Insulin as a hormone linked to insulin resistance i.e. Diabetes can be effected. If you have poorly controlled diabetes we would usually require your GP's agreement to inject. Your immune system is also altered by hormonal activity hence the reason long term large dose steroids weaken the immune system. COVID19 has made us all extremely careful about using steroid injections but thankfully we have no evidence this small dose has had any negative side effects on immunity.