Hazards of steroid injection: Suppurative extensor tendon ruptureLocal corticosteroid injection in steroir The risks steroid injection in bum pregnancy benefits of local injection therapy of overuse sports injuries with corticosteroids are reviewed. Injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned. There exists no reliable risk of tendon rupture with steroid injection of the deleterious effects of peritendinous injections. Too many conclusions in the literature are based on rupturee scientific evidence and it is just the reiteration of a dogma if all steroid injections are abandoned.
corticosteroid(whole-article) - SportNetDoc
Local corticosteroid injection in sport: The risks and benefits of local injection therapy of overuse sports injuries with corticosteroids are reviewed.
Injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned. There exists no reliable proof of the deleterious effects of peritendinous injections. Too many conclusions in the literature are based on poor scientific evidence and it is just the reiteration of a dogma if all steroid injections are abandoned.
The corticosteroids represent an adjuvant treatment in the overall management of sports injuries: Basic treatment is "active" rest and graduated rehabilitation with the limits of pain. With proper indications there are only few and trivial complications that may occur with corticosteroid injections. Guidelines for the proper local injection therapy with corticosteroids are given. Since Hench and co-workers won the Nobel prize for medicine in for reporting the effect of the steroid hormone on the rheumatoid joint and Hollander in elucidated how steroids could be used locally with reduction of systemic side effects, the use of steroids has been one of the greatest advances in medicine in suppressing inflammation.
Steroids inhibit the early aspects of the inflammatory process, i. In addition, steroids inhibit the later manifestations of the inflammatory process, i. Few years later came the first evidence that steroids injected locally also had adverse effects. Candler reported rapidly progressive degenerative arthritis following intraarticular hydrocortisone injections and Mankin 4 showed diminished synthesis of articular cartilage.
These initial reports were followed by many others condemning steroids and also holding them responsible for conditions such as tendon ruptures. The last 20 years have seen an explosion of interest in sport and exercise, and consequently there has been an epidemic of sports-related injuries.
Soft tissue injuries are the most common problem. To day there is generally a rather good understanding of injury, healing mechanisms and rehabilitation, replacing the previous inadequate response of "bandage and rest for three weeks". Noyes documented the beneficial effects of physical activity compared with the deterioration in the physical properties of ligaments caused by immobilization. Other reseachers have subsequently shown that immobilization is detrimental and activity beneficial in the management of injuries to ligaments 6.
Inflammatory reactions that are very common in sport are often caused by overuse. These inflammatory reactions include bursitis, arthritis, tendinitis, tenosynovitis and peritendinitis. It is well known that footballers, for example, may develop symphysitis through chronic loading and radiologically there may be apparent erosive changes 7,8. Local injections of steroid in sport are used to reduce the inflammatory reactions, prevent and treat lesions with inflammation and prevent ruptures of the inflamed tendons so the athletes can return to sports before immobilization has reduced the physical properties of the soft tissues seriously.
Many investigators have reported case examples of tendon ruptures, especially among athletes, from injections of corticosteroids. The question remains whether these ruptures are the effect of steroids or merely an additional manifestation of the disease for which the steroids were used.
The aim of this study is to review the literature concerning the effects and adverse effects of corticosteroids and give guidelines for the injection of local corticosteroid in athletes. Cortocosteroid injections, tendon degeneration and tendon rupture. Spontaneous partial or total ruptures of the tendons are common in sport.
While the risk of tendon rupture following intratendinous inside the tendon or peritendinous around the tendon injection of corticosteroid is controversial, it is well known that inflammation and degeneration can predispose to tendon ruptures. Tendon rupture in patients with inflammatory diseases as rheumatoid arthritis or systemic lupus erythematosus is a well-regnognized entity. While Vaughan-Jackson attributed tendon ruptures in patients with rheumatoid arthritis to abrasion or attrition over bony prominence, Moore in showed that direct synovial invasion and degeneration coupled with devascularization and loss of nutrition probably account for many of the tendon ruptures in rheumatoid arthritis.
He did not found previous steroid injections to be causally related, although such a possibility can not be ruled out.
They did not found steroid-induced lesions in the spontaneously ruptured tendons. Ljungqvist found no histological difference in tendon ruptures between those having received local corticosteroid injection and those without any history of corticosteroid injection. In patients with systemic inflammatory diseases, Ippolito did find degenerative changes.
Many authors have, with animals, evaluated and described the effect of injection of corticosteroids into the tendon. Some authors have shown that the intratendinous injections result in collagen necrosis, followed by a decrease in tensile strength: No tendon necrosis occurred in rats injected intratendinously with an identical volume of physiologic serum. Similar results were found by Balasubramanian. In his study, necrosis was seen as early as forty-five minutes after intratendinous injection of hydrocortisone, and after eight weeks, the healing process was still incomplete.
The necrosis of collagen was seen to be continuous with normal collagen fibres at the periphery of the lesion. No necrosis was seen in any of the control tendons injected with saline solution. Noyes 30 showed that a single injection into the anterior cruciate ligament of Rhesus monkeys substantially decreased the tensile strength up to one year after the injection.
In monkeys which received intraarticular injections there were no changes in tensile strength or histology. Kennedy showed a decrease in tensile strength in the Achilles tendons of rabbit two and seven days after a single injection of betamethasone, but no difference in controls after two weeks. Kapetanos showed, in turn, in a group of rabbits that injection of repeated doses of local corticosteroid intratendinously significant decreased the formation of adhesions, but also decreased the tendon weight, load to failure and energy to failure, when compared to the saline-injected group.
There were no significant differences in healing and strain-elongation of the tendons in the two groups. Pelps, Mackie and Matthews found no alterations in the mechanical properties in tendons of rabbit injected intratendinously with corticosteroid.
Concerning peritendinous injection of corticosteroid, McWhorter described a study, where he injected hydrocortisone acetate around injured Achilles tendons of rats and found no significant difference in the mean separation forces for the damaged Achilles tendons whether given 0, 1, 3 or 5 injections at weekly intervals from one week after trauma and onwards.
There was no lightmicroscopic evidence that hydrocortisone was associated with consistent reduction of cells recognized as part of the healing process when compared with control groups. He concluded that hydrocortisone acetate has no deleterious effect on the rat Achilles tendon as measured biomechanically or histologically. Regarding systemic treatment with corticosteroid studies by Francis and Randall showed that treatment with hydrocortisone acetate does not have effect on the "tension to failure" of the normal Achilles tendon in the adult male rat.
Vogel 38 showed an increase in the tensile strength of tendons after corticosteroid administration. However, the repetition of the injections progressively weakened the tendons. Oxlund found rat tendons to be stronger and stiffer after 24 and 55 days of the steroid treatment. He suggested this was due to steroid action on the elastic component and that the viscous properties remained unchanged, an opionion in agreement with Vogels findings.
The corticosteroid treated group were compared to a group who received similar surgical and medical therapy but no steroids. No differences were noted between groups in incidence of postoperative problems in a one year follow-up.
Wrenn published an experimental study showing a decrease in the tensile strength of tendons after corticosteroid therapy.
Concerning the histological changes after corticosteroid injections, Guttu evaluated the changes that occur in rat skeletal muscle injected with local anaesthetic and steroid.
Rats injected with saline, steroid or procaine showed minimal reaction. Rats injected with the procaine and steroid combination had focal areas of inflammation at twenty-four hours but none on subsequent evaluations. The bupivacaine injected rats showed moderate localized necrosis of muscle fibres for less than tree weeks. The rats injected with the bupivacaine and steroid combination showed extensive localized necrosis of muscle fibres for more than four weeks.
He concluded that steroids injected intramuscularly do no harm, but when it is injected in combination with bupivacaine it increases the tissue damage of bupivacaine and prolongs the healing phase. In very large series of histological examinations of spontaneously ruptured tendons steroid-induced lesions were very rare giving evidence that steroid-induced tendon ruptures are not a major problem in a population rupturing their tendons.
In conclusion, it is documented that corticosteroid injection can indeed reduce the inflammatory process. It is well known that patients with inflammatory diseases have spontaneous tendon ruptures, and tendon ruptures are the end stage of many chronic sports injuries Jumper s knee, Achilles tendinitis. Post mortem studies indicate that degenerative changes in tendons are part of a normal aging process.
Most animal studies indicate that intratendinous injection of corticosteroid results in collagen necrosis of the tendon.
No studies indicate the same risk in peritendinous injection of corticosteroid. Despite the large use of corticosteroid injection, prospective, randomised studies are lacking. Other possible adverse effects of corticosteroids. Introducing an infection is a possible adverse effect when using local steroid injection therapy. Not only the millions of tiny corticosteroid micro-crystals physically protect bacteria from the body defence, but also the local immune inflammatory response to infections is suppressed by the antiinflammatory action of the corticosteroid itself.
However, this risk can be virtually completely eliminated by a meticulous aseptic, no-touch technique, and by avoiding injections in areas with suspected infection. Atrophy of the overlying skin with telangiectasia and increased hyperesthesia or hypoesthesia, and transparency can be caused if some injected material may leak back along the needle track.
This seems to do little harm and recedes with time 49? Subcutaneous fat necrosis is also described following corticosteroid injections.
Systemic effect of the corticosteroid is a possible risk. Although locally injected corticosteroids are designed to be most effective where they are injected, a proportion of the substance penetrates to the blood stream, especially if injections are repeated too frequently, and may cause adrenal cortical suppression, depression of osteoblastic activity or hypoglycemia. The latter can be dangerous for diabetic patients, as is the case with hyperglycemia.
Signs of inflammation, causing concerns of possible secondary infection can occasionally be seen after corticosteroid injection. It is usually transient and disappears within 24 hours. Penetration of minor blood vessels or nerves causing hematoma or sensibility disturbances is, as in any other injections, a possibility, too. Certainly, if the doctor that performs the injection is inexperienced, unintentional damage to other structures is possible. Corticosteroid injected into larger nerves can cause postinjection neuritis.
The risk of this complication is negligible if the doctor is familiar with the ease by which the injection should be done. A sudden paresthesia suggests instantaneously end of the injection. Anaphylactic shock is a theoretical complication, which doctors must be prepared to treat since cortison allergy is a rare but possible form of allergy. A much more common injection-induced problem is the transient faintness of the patient, but this has nothing to do with corticosteroids as a substance.
Progressive degenerative arthritis following intraarticular steroid injection was found by Chandler. Despite such reports, evidence for steroid arthropathy remains anecdotal, with scattered case reports, and confused by variables such as antecedent trauma or gross ligamentous instability.
However, in and Pelletier called this observation in question. Pelletier examined the effect of intraarticular injections of corticosteroid in the knees of dogs in which the anterior cruciate ligament had been sectioned. Four groups were used: Injections with corticosteroid significantly reduced the size of osteophytes in group three p0. He concluded that corticosteroid injections on osteoarthritis cartilage lesions not only had a protective effect but also a therapeutic effect.