December 9, 2018
corticosteroid injections of the hip and knee

Evidence Behind Corticosteroid Injections of the Hip and Knee

Previously, we have reviewed CSI of the shoulder region and elbow, wrist and hand. Next in the series, we will continue to discuss the evidence related to corticosteroid injections by moving distally to the hips and knees.  As with others, we will cover randomized controlled trials and systematic reviews on corticosteroid injections for issues common to orthopedics such as trochanteric bursitis, hip osteoarthritis and knee osteoarthritis.
Greater trochanteric pain syndrome, commonly known as greater trochanteric bursitis, is common among the general population, affecting 8.5 % of women and 6.6 % of men in a large observational study 1 and hip pain affects more than 14 percent of the population in another 2.  The greater trochanter is associated with bursae that provide protection for the surrounding tendons, namely, the gluteus medius and minimus, ITB, and tensor fascia lata. The most superior bursa, the subgluteus medius bursa, sits superior to the greater trochanter under the gluteus medius tendon. The subgluteus maximus bursa sits between the tendons of the gluteus medius and maximus and lateral to the greater trochanter. The deep subgluteus maximus bursa is a division sometimes referred to as the trochanteric bursa 3.
Patients with greater trochanter pain syndrome will commonly complain of lateral hip pain that is worse with pressure, such as while lying down on the affected side. They often complain of pain with walking and may admit that pain is worse while standing on the affected leg. There may be associated lateral thigh pain radiation but rarely below the knee 3,4.
greater trochanter bursa hip bursitis corticosteroid injection

Image 1. Illustration of greater trochanteric bursa corticosteroid injection (courtesy of AAOS)

Local injections in the lateral hip region were shown to be favorable and have long term benefit up to 2 years in multiple studies in the starting in the 1960s until the 1980s 5, 6, 7.  The longevity of these injections has come into question over the past two decades, however.  It has been shown that corticosteroid injections were superior to physical therapy treatment alone at 3 months (55% fully recovered vs. 34% recovered), but the effect was not evident at 12 months 8.  Another study showed pain relief that was greatest at one week but still effective in 61 percent of patients at 26 weeks 9.  One other randomized trial with more than 200 patients concluded that corticosteroid injection was superior to home therapy and shock wave therapy at 1 month, but corticosteroid injections had worse outcomes compared to shock wave therapy at fifteen months 10.
More recent studies have shown ultrasound guided injections into the subgluteus maximus bursa provide more pain relief compared to injections into the subgluteus medius bursa 11.  One randomized controlled trial showed no benefit but a greater perceived benefit when comparing blinded injections versus ultrasound guided injections 12.  Another trial showed 72 % of patients with significant improvement at 3 months following an ultrasound guided injection 13.
hip corticosteroid injection under ultrasound guidance

Image 2. Demonstration of hip corticosteroid injection under ultrasound guidance (courtesy of highlandultrasound.com)

Hip osteoarthritis has a reported prevalence of 4-12 % of the population.  It can affect up to one third of patients over 85 and falls under the category of degenerative joint disease 14. Most people with hip osteoarthritis have pain with daily activities and is progressive in nature.  Many will have pain that radiates into their groin region that is increased with walking, stairs or tying their shoes and relieved with rest.  X-rays are typically done to aid in diagnosis and monitor progression.
Injections for hip osteoarthritis were almost always done with fluoroscopic guidance until the emergence of musculoskeletal ultrasound in sports medicine in the last decade.  Dosages were compared in a randomized trial that showed 80 mg of methylprednisolone was superior to 40 mg for hip stiffness at 12 weeks, but both provided relief for hip pain and stiffness at 6 weeks 15.  Ultrasound guided hip injections were shown to significantly reduce hip pain while walking and synovial hypertrophy at one and three months in patients that failed to respond to conservative therapy 16.  Other studies have also provided similar results with pain relief, function and range of motion up to 6 months, but most studies show an effect lasting around 3 months 17, 18, 19, including one double blind randomized controlled trial 20.  
The American Society of Sports Medicine evaluated hip injections in 2015 and compared landmark guided injections to ultrasound guided injections.  They concluded that the accuracy and efficacy was superior with ultrasound guidance and preliminary data showed it is also more cost-effective 21.  There are no long term data regarding safety or cartilage loss with hip injections, but the consensus among providers falls to limiting injections to every 3 months.
iliopsoas bursitis corticosteroid injection under ultrasound guidance

Image 3. Labeled ultrasound image of needle advancing to the iliopsoas bursa (courtesy of http://mskultrasoundprocedures.com)

Iliopsoas tendinopathy or iliopsoas bursitis is another common problem in sports practice that can affect both young athletes and the aging population.  Anatomically, the iliopsoas musculotendinous unit is located directly anterior to the hip joint and is composed of the iliacus, psoas major, and psoas minor 22.  Iliopsoas injuries account for up to 25 percent of soccer groin injuries 23.  Common mechanisms include kicking, sprinting, and changes of direction in sports such as soccer, basketball, and handball, as well as activities such as dancing.  Patients can present with pain in the anterior hip and can have weakness of discomfort with hip flexion.
Similar to hip osteoarthritis, most injections in the iliopsoas region before the last decade were done via fluoroscopic guidance.  It is currently used for both diagnostic (intra-articular vs extra-articular hip pain) and therapeutic purposes. In 39 patients with suspected iliopsoas tendinopathy, 49 % of patients reported improvement at one month after a fluoroscopic guided iliopsoas bursa injection 24.  Other studies are very limited in sample size, but have shown to be effective in patients with iliopsoas tendinitis following total hip arthroplasty 25 and in dancers with recalcitrant iliopsoas tendinitis 26.  A 2018 study showed improved symptoms, pain, function in sports, quality of life and decreased pain with activities of daily living in patients with iliopsoas tendinopathy at 6 weeks.  This was true whether or not the patient had concomitant intra-articular hip abnormalities such as FAI, labral tears, hip dysplasia, etc 27. This study also had many more female than male participants (154 female vs. 24 male 27).  More long term trials are needed to draw stronger conclusions on effectiveness and safety.
example of corticosteroid injection of the knee

Image 4. Clinical demonstration of corticosteroid injection of the knee (courtesy of spring loaded technology)

Knee osteoarthritis is the most common cause of chronic knee pain and affects more than 27 million people across the United States 28.  Its prevalence increases with each decade of life and has been shown to be more common in women.  Many go on for decades after being diagnosed with knee osteoarthritis and more than half of the individuals diagnosed with knee osteoarthritis progress to the stage where they are candidates for a knee replacement 28.  The etiology is multifactorial but age, BMI, prior injury, socioeconomic and psychosocial factors all seem to play a role.  The medial compartment is the most common compartment affected and many will complain of pain with weight bearing, getting up from a seated position, going up and down inclines.  They may also complain of swelling, stiffness and crepitus. It is largely a clinical diagnosis but physical exam findings that are common include joint line tenderness, decreased range of motion and crepitus.  X-rays are normally sufficient for diagnosis.
The earliest studies done with corticosteroid injections starting in the 1950s started with trials involving efficacy of knee injections.  It is still commonly used in most orthopedic practices and the general guideline between injections is waiting at least three months. A recent Cochrane review in 2015 included 27 trials and 1767 patients concluded that the overall body of evidence was poor, pain and function improved up to 6 weeks and there was no benefit shown at 6 months 29.  This review also stated there was no effect on joint space narrowing or quality of life 29.  One meta-analysis showed some people having a response up to 24 weeks 30.  A recent paper also showed that people with more narrow joint space and more meniscus damage had lower response rates overall 31.
Recent comparisons between landmark guided injections and ultrasound guided injections have shown increased accuracy and improved clinical outcomes with the use of ultrasound guidance (96% vs. 78%) 32. Another 2012 study with patients made a similar comparison with ultrasound guided injections/arthrocentesis having significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes 33.  Ultrasound guided injections were also found to be cost effective and again reported decreased pain during the procedure and better clinical outcomes 34. It also was shown to be an effective in an obese patient with four prior landmark guided injections that yielded minimal response 35.  
Recent comparisons between landmark guided injections and ultrasound guided injections have shown increased accuracy and improved clinical outcomes with the use of ultrasound guidance (96% vs. 78%) 32. Another 2012 study with patients made a similar comparison with ultrasound guided injections/arthrocentesis having significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes 33.  Ultrasound guided injections were also found to be cost effective and again reported decreased pain during the procedure and better clinical outcomes 34. It also was shown to be an effective in an obese patient with four prior landmark guided injections that yielded minimal response 35.  

References

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34. Sibbitt WL, Band PA, Kettwich LG, et al. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol. 2011;17(8):409–415
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