1. Treatment with local
steroids in MSK disease
Gabrielle Kingsley
Lewisham and Greenwich NHS Trust
and Kings College London

2. Educational Objectives
• Why are injectable steroids used in MSK
disease?
• Preparations and doses
• Indications and benefits
• Adverse events
• What if I want to start doing injections?
To review the use and abuse of local
steroids in musculoskeletal disease

3. Why are injectable steroids
used in MSK disease?
• Reducing joint inflammation
− Inflamed joints eg rheumatoid arthritis
− Joints damaged by osteoarthritis with possible
inflammation
• Reducing soft tissue inflammation or swelling
− Inflamed soft tissue eg epicondylitis
− Reduction in tendon swelling eg shoulder tendinitis
− Reduction in nerve swelling eg compressive
neuropathies like carpal tunnel syndrome

4. Preparations and doses
Depomedrone-depot methylprednisolone
• Crystal suspension, commonly used and fairly cheap
Triamcinolone (kenalog)
• More expensive but some studies suggest longer-lasting
especially the hexacetonide preparation
• Interaction with ritonavir (also interacts with systemic and
inhaled steroids)
Hydrocortisone
• Aqueous preparation with no crystals
• Cheap but currently not easily available; effect short-lived
Dose varies with agent and size of site injected; can add local
anaesthetic

5. Indications and
benefits:
Soft Tissue
• Soft tissue inflammatory lesions
− epicondylitis (elbows)
− bursitis (shoulders, olecranon, greater trochanter, knees)
− Steroids, usually with local anaesthetic, injected into
relevant bursa/site leading to reduced pain and swelling
− To avoid recurrence, activity change/use a support/physio
• Inflamed tendons
− Rotator cuff tendons eg supraspinatus (shoulder)
− De Quervain’s tenosynovitis (wrist)/hands
− NOT Achilles tendon
− Steroids, with local anaesthetic, between tendon and
tendon sheath to reduce swelling of tendon; reduces pain
but also allows tendon to move through small spaces

6. Indications and
benefits:
Soft Tissue
• Trigger fingers and thumbs
− Inject between tendon and tendon sheath
− Restores free tendon movement
• Compression neuropathy
− Carpal tunnel syndrome
− Rarely other sites eg tarsal tunnel
− Inject non-crystalline steroid without local anaesthetic into
space around nerve (eg carpal tunnel)
− Reduces swelling of nerve avoiding its compression in the

7. Indications and
benefits:
Joints - OA
• Osteoarthritis (OA)
− Inject into joint (ensure no infection)
− Improves pain and thus function
− Most commonly used for

OA base of thumb (where effect may be prolonged)

OA where degeneration associated with inflammation eg knee
• NICE Guidance: intra-articular therapy in
OA
• 1.5.12 Intra-articular corticosteroid injections should be
considered as an adjunct to core treatments for the relief of
moderate to severe pain in people with OA. [2008]
• 1.5.13 Do not offer intra-articular hyaluronan injections for

8. Indications and benefits:
Joints – Inflammatory arthritis
• Inflammatory arthritis
− Rheumatoid arthritis, spondyloarthropathy, crystal arthritis
(gout and pseudogout)
− If multiple joints are involved consider systemic steroids
(intra-muscular or possibly oral)
− Must be certain that joint is not infected!
− If there is significant fluid, may need to aspirate joint first
before injecting steroid into synovial space
− Reduces synovitis (pain and swelling) improving function
− Not usually a long term effect - in general, improvement
will not be sustained unless other treatment is amended
(except where underlying problem is self-limiting eg gout)

9. Adverse
events
• What is the link with infection?
• Other adverse events
− Injections, especially into small spaces, can be painful
(finger joints, epicondyles)
− Soft tissue injections (especially into small spaces like
epicondylitis) may lead to tissue atrophy and loss of
pigmentation (problematic in ethnic minorities)
− Tendon injections can cause tendon rupture (don’t inject
into the tendon itself and avoid more than two injections)
− Injection of crystal preparations can lead to flares (eg
crystal synovitis)
− Repeated intra-articular steroid may worsen joint damage

10. Summary
• Why are injectable steroids used in MSK
disease?
• Preparations and doses
• Indications and benefits
• Adverse events
What if I want to start doing
injections?
• Learn from someone already competent
• Know your anatomy
• Preferably use plastic models and/or
cadavers before real patients
Treatment with local steroids in MSK disease