Cortisone Shots Do More Harm Than Good? Knee Injections Could Actually Make Arthritis Worse, Major Study Suggests

* 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

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.

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.

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))

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))

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.”

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.

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.

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.

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.

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.

I keep gel ice packs in the freezer; use them almost daily.

Ortho says I need a new knee, didn’t want to take a chance on another post-op neurological complication. As a doctor, I get it.

The handicapped parking is nice though….

Your experience sounds like my knee double. Constant pain except for the week I get after a cortisone shot.

I, too, have tried turmeric, etc., for naught. For drugs all I get is Celebrex. The VA refuses to give me anything stronger.

Care to be my primary? :)

If it were up to me I’d deregulate ALL opioids. All other class II drugs as well.
Let adults make their own health decisions and let the bodies hit the floor.

I have a VERY small panel of patients at this time, mostly friends and family since moving to Tennessee.

I still work as a clinical consultant and supervisor for a couple dozen physician assistants but that’s about it.

I can’t tell you how many patients I prescribed opioids for while in civil service. It’s the right thing to do.

Pain, despite all the touchy-feely psych models is NOT just in our heads. Meditation doesn’t transcend dental medication. Dentists - despite 6 months of anesthesia training - are the WORST at underprescribing for pain.

DEA under the last handful of presidential regimes have put the fear of God - and 4 AM home invasion by DEA SWATZI teams - into doctors who AREN’T selling prescriptions or defrauding medicare to the point most of us leave prescribing adequate analgesia to pain specialists.

And even THEY are skittish and somehow being convinced that ordinary folks can learn to “manage” or “tolerate” pain with “alternatives.” For WAY too many people “managing” is done with overdosing or other methods of suicide, especially among former military.

I’ve had the exact same prescription for Percocet for 10 years now and the VA - after deciding my conditions were 100% disabling 5 years ago - has kept the prescription going thank God.

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