In light of last month's posting, Plantar Fasciitis vs. Fasciosis, and the treaments thereof, including injectable steroids w/ local anesthetic or local anesthetic alone (with or without the needling technique), I thought it prudent to post this review article:

Let me first say that many sources in the literature still cite that we do not yet fully and completely understand ALL of the mechanisms by which catabolic, medicinal steroids function in the body when introduced either orally or by injection.  We undertand many of the pathways by which they work, but experts still state that some of the chemical processes and interactions are yet to be elucidated.  I have searched, scoured, and read over the years; I have queried top clinicians, professors, and pharmacological gurus, but at the end of the day, most still say we are still feeling our way around in the dark with these 'roids things.  That boggles me.  This may be one of those, as in the other post: I don't need to know all about how it works just as long as I can get reproducible results.

One interesting note: the article discusses treating the pathway of pain and not just of inflammation with steroids; now that I have indeed read about in the literature over the past 12 years in my quest to better understand steroids. 

And again, I credit some of my earliest understanding of injectable steroid therapeutics to the good Dr. Markinson with whom I had the good fortune to corrsepond with (via PM-News) when I was a young practitioner out of residency some 11 years ago.  Because of his writings (monographs in emails), my views changed on this seemingly shrouded topic, and suddenly I was enlightened.  I then became truly inspired to learn everything I could about this important pod med topic.  As a result, I improved my practice patterns and helped countless more patients over the years.  Why someone hasn't written at least a small paperback dedicated solely to all things foot and ankle injections as of yet is a mystery to me.

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Steroid Injections: Can They Actually Make Things Worse?

By Steven A. King, MD, MS | March 29, 2013
Dr King is in the private practice of pain medicine in New York, and he is Clinical Professor of Psychiatry at
the New York University School of Medicine, New York.

Steriod injections have long been the go-to treatment for common musculoskeletal ailments like low back pain and tennis elbow. Here, the conventional wisdom gets a closer look.

I recently wrote here about (ESI) and the dearth of research to support this epidural steroid injections modality in the treatment of low back pain. Since then, 2 studies have been published that indicate that ESI may not only be of limited efficacy but actually might impede improvement.
 
ESI for lumbar spinal stenosis
The first study involved ESI for patients with lumbar spinal stenosis (LSS).
The multisite study compared 69 patients with LSS who underwent ESI with 207 who also had LSS
but did not receive ESI. All subjects had symptoms considered secondary to LSS consisting of
either neurogenic claudication or radicular leg pain
with associated neurologic signs that had persisted for at least 12 weeks. There were no relevant significant
differences between the groups at baseline.The subjects were followed for 4 years.
Patients who had received ESI and subsequently underwent surgery for their LSS were found to have an
average 26 minute increase in operative time and nearly 1 full additional inpatient day compared with those
who had surgery but did not undergo ESI at the outset of the study.
 
Also it was found that those who had ESI were more likely to undergo surgery than those who hadn't.
For those patients who did not undergo surgery, those who had ESI had less improvement on scales
measuring pain and physical function than the non-ESI group at the end of the 4-year study period.
 
The study authors provide several possible explanations for these results. ESI might actually exacerbate
stenosis by introducing additional material (ie, steroid, anesthetic) into an already compromised site or in
some other way damage nerve roots. ESI may also provide some temporary relief that might allow patients to
participate in activity that might lead to an increase in pain.
 
The additional surgical and recovery time required by patients who had received ESI, the authors suggest,
may be the result of adhesions or scarring caused by the original injection procedure that made the surgery
more difficult, which, in turn, necessitated an extended recovery period.

Steroid injections for lateral epicondylalgia

The second study examined the use of corticosteroid injections for lateral epicondylalgia, more popularly referred to as “tennis elbow.”

A group of 165 patients who had the condition for at least 6 months was  divided into 4 experimental groups:
steroid or placebo injection alone or one of these injections plus physicaltherapy. The physical therapy
consisted of 8 weekly sessions of local elbow manipulation and exercise and home exercises the
participants were to perform daily.
 
At 4-week follow-up, the groups receiving the steroid injections were more likely to report complete
recovery or much improvement compared to those who received the placebo injection.
 
At the 26-week and 1-year follow-ups, however, it was found that those who underwent the steroid injection
were less likely to have complete recovery or much improvement and more likely to have recurrence of the
pain compared with those who underwent the placebo injection. Whether or not the patients underwent
physical therapy had little effect on the outcomes at 26 weeks and 1 year.
 
There was at least one apparent benefit to physical therapy: patients who received it were less likely to use analgesic medications including nonsteroidal anti-inflammatory drugs.
 
This study indicates that while steroid injections may provide some short-term benefit for tennis elbow, in the
long run they not only have limited benefit but may actually have a negative effect. Also, the results fail to
support the conventional view that steroid injections make benefits from physical therapy more likely
because the injections make it easier (less painful) for patients to participate.
 
The failure of steroid injections to provide long-term relief indicates that the pain in tennis elbow is not
primarily related to an inflammatory process. Why did patients who received these injections not fare as well
as those who didn't? The study authors conjecture that the steroid might actually exacerbate the underlying
condition or that the short-term relief received from the injections might result in excessive use of the
affected arm before there is any actual improvement in this condition.
 
Although physical therapy didn't affect the outcome measures utilized by the study, the fact that it did reduce
the use of analgesic medications suggests that it did actually have an impact.  Conventional wisdom?
 
Both of these studies call into question the still widespread belief that steroid injections are a first-line
treatment for the management of low back pain and other pain conditions presumed to be caused by
inflammation even where there is little evidence that this is the etiology of the pain. The limited efficacy of
the injections observed in these 2 studies is not that surprising in light of similar findings in previous studies.
 
What is new is that steroid injections may not only provide relief but may actually exacerbate certain
not disorders and the associated pain. 
 
Obviously findings from a pair studies are not sufficient to make any final statements about any therapy.
However, these 2 in particular should at least make us continue to critically evaluate the appropriateness of
using steroid injections. And we certainly need to refrain from suggesting to patients suffering pain that the
possible benefit they may gain from steroid injections is well supported by research.
 
References
1. Radcliff K, Kepler C, Hilibrand A, et al. Epidural steroid injections are associated with less improvement
in patients with lumbar spinal stenosis. (Abstract). 2013;38:279-29. Spine
2. Coombes BK, Bisset L, Brooks P. Effect of corticosteroid injection, physiotherapy, or both on clinical
outcomes in patients with unilateral lateral epicondylalgia. (Abstract) 2013;309:461-469. JAMA.
 
ConsultantLive.com. Vol. No. March 29, 2013
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WG
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