Posted on 06/10/2025 9:35:33 AM PDT by Red Badger
In a nutshell
* Steroid injections were associated with faster arthritis progression compared to no treatment or hyaluronic acid injections
* Hyaluronic acid injections showed signs of slowing disease progression while still providing pain relief
* Both treatments reduced pain, but only steroid shots were linked to concerning structural changes on MRI scans
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SAN FRANCISCO — Getting a cortisone shot for knee arthritis might provide quick pain relief, but new research reveals a troubling association: those steroid injections may be linked to faster joint damage over time. A surprising study found that patients who received corticosteroid injections showed more signs of arthritis progression compared to those who got no treatment at all, or even a different type of injection.
The findings raise important questions about a common medical practice. More than 10% of knee arthritis patients receive these steroid shots, yet the study suggests they may be trading short-term comfort for potential long-term harm. By contrast, patients who received hyaluronic acid injections — a gel-like lubricant for joints — not only avoided signs of worsening arthritis, but actually showed reduced disease progression on MRI scans.
How Researchers Conducted the Investigation
The study, published in Radiology, analyzed data from 210 people participating in the Osteoarthritis Initiative, a large-scale project tracking Americans with knee problems from 2004 to 2015. The average participant was 64 years old, and around 60% were women—characteristics typical of the knee arthritis population.
What set this study apart was its use of detailed MRI scans to assess joint health. Researchers evaluated images from two years before the injection, at the time of injection, and again two years afterward using the Whole-Organ MRI Score (WORMS). This scoring system provides a comprehensive assessment of cartilage, bone marrow, meniscus, ligaments, and joint effusion.
Participants were grouped into three categories: 44 received corticosteroid injections, 26 received hyaluronic acid, and 140 were matched controls who had no injections. The control group was carefully selected using propensity-score matching to ensure they were comparable in age, sex, body mass index, arthritis severity, pain levels, and physical activity.
Clear Differences Emerged Between Treatments
Those who received steroid injections showed significantly more arthritis progression than both the control group and the hyaluronic acid group. The researchers found clear statistical evidence that steroid shots were linked to faster joint deterioration. The damage was especially evident in cartilage—the smooth tissue that cushions the knee joint.
By contrast, hyaluronic acid injections appeared to slow down arthritis progression. Patients in this group actually showed less joint damage after their injection compared to before they received it, suggesting these treatments may help protect the joint structure.
Both types of injections helped with pain relief. Steroid shots provided more dramatic pain reduction — cutting pain scores roughly in half — while hyaluronic acid injections offered more modest but still meaningful pain relief. However, only steroid shots came with the concerning side effect of potentially faster joint deterioration.
MRI images helped visualize the contrast. In a 58-year-old woman who received a steroid injection, follow-up scans showed new full-thickness cartilage lesions and bone marrow damage. In a 57-year-old man who received hyaluronic acid, the same cartilage remained intact and unchanged over four years.
Knee MRI scans in a 57-year-old male participant in the Osteoarthritis Initiative who was administered a hyaluronic acid (HA) injection. Coronal intermediate-weighted knee MRI scans obtained (A) 2 years before injection, (B) at the time of injection, and (C) 2 years after injection show a well-preserved medial femoral cartilage, indicating a stable medial femoral cartilage through the pre- and postinjection time points. The medial femoral cartilage appears well-preserved across all three time points, suggesting no structural deterioration following the HA injection. These findings indicate stable cartilage morphologic structure during the 4-year observation period. (Credit: Radiological Society of North America (RSNA))
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What This Means for Your Healthcare Decisions
These findings don’t mean patients should avoid knee injections altogether. Managing arthritis pain is important for maintaining mobility and quality of life. But the results highlight the need for deeper conversations between patients and healthcare providers about treatment trade-offs.
Current guidelines from the American Academy of Orthopaedic Surgeons moderately recommend corticosteroids for short-term pain relief and advise against the routine use of hyaluronic acid. The new study doesn’t overturn those guidelines, but it suggests they may merit reevaluation if future research supports these results.
Knee MRI scans in a 58-year-old female participant in the Osteoarthritis Initiative who was administered a corticosteroid injection. Sagittal intermediate-weighted images obtained (A) 2 years before injection, (B) at the time of injection, and (C) 2 years after injection show a focus on the medial femoral cartilage and trochlea. (C) The postinjection scan shows a new full-thickness cartilage lesion in the medial femoral cartilage (arrowhead), whereas images from the preinjection time points show a well-preserved medial femoral cartilage (A, B). The postinjection scan (C) also shows the development of a new full-thickness cartilage lesion in the medial femoral cartilage and a new bone marrow lesion in the trochlea (arrow), both of which were absent in the preinjection scans. These findings suggest structural deterioration following the corticosteroid injection. (Credit: Radiological Society of North America (RSNA))
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Importantly, this study cannot prove that steroid injections directly cause faster arthritis progression. It was observational in nature, meaning that unmeasured differences between patients could account for some of the outcomes. Still, the consistent patterns seen on MRI raise important questions that warrant further investigation in randomized controlled trials.
For the millions of Americans living with knee arthritis, this study offers both a note of caution and a reason for hope. Cortisone shots may still help with intense pain episodes, but patients should understand the potential risks to long-term joint health. Meanwhile, hyaluronic acid injections, often overlooked, may offer pain relief without the same structural downsides.
“This study could lead to more judicious use of corticosteroid injections, especially for patients with mild to moderate osteoarthritis who are not yet surgical candidates,” said lead author Dr. Upasana Upadhyay Bharadwaj, who was a research fellow in the Department of Radiology at University of California, San Francisco, at the time of the research, in a statement.
“Given their widespread use, these findings could influence clinical guidelines and patient care decisions, encouraging more cautious use and stronger consideration of alternatives like hyaluronic acid,” she added. “The public impact is significant, as osteoarthritis is a major global cause of disability, and millions receive such injections annually.”
Paper Summary
Methodology
Researchers conducted a secondary analysis of data from the Osteoarthritis Initiative, following 210 participants (mean age 64 years, 60% female) over multiple years. They used detailed 3-T MRI scans taken at three time points: two years before injection (T-2), at the time of injection (T0), and two years after injection (T+2). The study compared three groups—those who received corticosteroid injections (44 people), hyaluronic acid injections (26 people), and propensity-score matched controls who received no injections (140 people). Joint health was measured using the comprehensive Whole-Organ MRI Score (WORMS) system rather than simple X-rays. Only participants with a single injection during the study period were included.
Results
Corticosteroid injections were associated with greater WORMS progression compared to both controls (mean difference, 0.39; 95% CI: 0.05, 0.75; P = .02) and hyaluronic acid injections (0.42; 95% CI: 0.01, 0.84; P = .04) over the two-year follow-up period. Hyaluronic acid injections showed decreased progression compared to the pre-injection period (mean difference, −0.42; 95% CI: −1.34, −0.28; P = .003). Both injection types delivered pain relief, with corticosteroid injections reducing WOMAC pain scores by 5.20 points (P = .001) and hyaluronic acid by 2.15 points (P = .04). The differences were particularly notable in cartilage deterioration.
Limitations
As an observational study, it cannot establish direct causation between injections and arthritis progression. The researchers noted potential confounding factors and selection bias, as people who choose different treatments may differ in unmeasured ways. The study only included participants who reported receiving a single injection, which may limit generalizability to those receiving multiple treatments. Additionally, the study relied on participant reporting of injections, with potential gaps of 2 or more years between questions about injections when follow-up appointments were missed.
Funding and Disclosures
The study was supported by multiple National Institutes of Health grants (R01 AR064771, R01 AR078917, R01 AG070647). The data came from the Osteoarthritis Initiative, a public-private partnership funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases with additional private funding from pharmaceutical companies including Merck Research Laboratories, Novartis Pharmaceuticals, GlaxoSmithKline, and Pfizer. Most authors reported no relevant financial relationships, though some had consulting relationships with various companies.
Publication Information
The study was published in Radiology, Volume 315, Number 2, May 2025, by Bharadwaj et al. The research was a secondary analysis of data from the Osteoarthritis Initiative study conducted from February 2004 to January 2015, with the clinical trial identifier NCT00080171.
One cortisone shot sure helped me when I tore my meniscus. Never needed surgery that time.
Yes, it’s good for injuries from sports or work accidents. I’ve had a few shots myself over the years.
But this article is about arthritic degradation and the progress of the disease................
This was known to many, 20 years ago. Nice to see the medical establishment is catching up.
Wonder why I should buy what a study by one alleged Dr. Upasana Upadhyay Bharadwaj at UCSF says . . .
But this article is about arthritic degradation and the progress of the disease
******
Oh, ok. I see.
If you just treat the inflammation and let the joint continue to grind of course it will get worse.
I get both injections. The gel doesn’t seem to do much but the cortisone works great - for about a week.
There should be a substance that is injectable to act as a ‘lubricant’ until the joint heals.....something like silicone grease that’s used in the electronics industry as a thermal conductive compound...........
Bkmk
Thanks
BFL
Ditto here.
As a physician (DO, Family Medicine) myself, I find that, lately, the effectiveness has mostly worn off within 1-2 weeks and I’m munching percocet around noon where about a decade ago I could get through the day, skip some days, mostly starting late evening/bedtime just so I could GET to sleep.
I wake up with knee pain. Haven’t broken stride more than twice in the past ten years where before I WAS running 7 minute miles (SEAL type runs, 4 miles under 30 minutes) but the last arthroscopy left me with Complex Regional Pain Syndrome (RSD) and I get knee cortisone shots maybe twice a year. I got my last one 6 weeks ago. My LAST one. I’m going to push for knee replacement.
Synvisc? The other one too, tried for two years with no noticeable effect.
Oh, and Garlic, Turmeric, Ginger, Curry, CBD, Relief Factor, Kratom, bad jokes, all.
The “RSD” is controlled, mostly, just annoying at this point.
The knee pain is a real show stopper.
There is the alternative of killing the nerves that transfer the pain. Done by a long needle and radio frequency ablation.
Your body gets used to the cortisone...which is why it stops working
Arthritis doesn’t matter when you have bone on bone in both knees, and cortisone shots give you relief.
Yeah. About a year ago the insurance companies decided that was "experimental", after all it had only been used for a decade, and that it would no longer be covered.
Just got my first cortisone shot end of May. Pain went away for about a week but starting to return along with popping sensations. PT says my knees are shot.
Cortisone injections worked wonderfully for me when my knees were ruined by too many standing parachute landings and too many hundreds of miles carrying 100 pound + backpacks up and down mountains.
But I gotta keep swallowing glucosamine pills daily if I want to keep them working well and painlessly without regular cortisone injections.
Many moons ago, after 15 years at a large supermarket chain, my lower back decided it had had enough. After some significant physical therapy, the orthopedist suggested a steroid injection into the problem area of the spine. They used, back then, a black & white monitor (xray? ultrasound?) to see and put the steroid where it will do the most good. So.....they numb the skin area, and then put the needle in. Once they believe they are in the right spot, they put a saline solution to see if the medicine will go into the spine, or just around the outside of the spine. The first attempt failed, the second attempt was successful, and they put in the steroids.
For three days, not only did my back feel much better, I felt like Superman. I started singing “here I come to save the day!”
The steroids wore off, and my back still needed A LOT of work. Later on, the doctor asked if I wanted another steroid injection. I stated that physical therapy results in slow, steady, real improvement.
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