Usage of Corticosteroids in Musculoskletal Disorders

Abstract

Corticosteroids are one of the most important anti-inflammatory substances that are used for many conditions. Although oral form of corticosteroids has many side effects, they are used to cure systemic diseases. Local injection of corticosteroids can be beneficial in many conditions such as mononeuropathies, degenerative joint diseases (DJD), tenosynovitis, and canal stenosis with fewer side effects and better efficacy in site of pathology.

1. Introduction

We normally know corticosteroids as steroids that are one of the most important anti-inflammatory medications that are used to manage a broad variety of diseases.

This substance normally secrets by adrenal glands in response to different modules of stress and plays a very important role in humans daily life.

Different forms of this medicine such as prednisone, methylprednisolone, triamcinolone, hydrocortisone, and cortisone are used to manage a broad variety of musculoskeletal diseases. For example, the oral form of corticosteroids is used to cure systemic diseases like rheumatoid arthritis (RA) [1]. In chronic use of oral corticosteroids, the side effects are common and serious from time to time, like high blood pressure, edema as a reason of fluid retention, mood changes, weight gain, and facial features changes (moon face), ophthalmic problems like glaucoma and cataract, and high blood sugar that can exacerbate the existing diabetes and also cause overt diabetes and insulin-resistant patients, increased incidence of opportunistic fungal infections like Candida albicans and mucormycosis and serious infections like tuberculosis and also common bacterial, viral, and fungal infections and sometimes causes some skin conditions like frequent bruising and delayed wound healing [2].

Most of the patients who suffer from joint degenerative diseases like osteoarthritis (OA) and complain from severe pain and decreased quality of life are middle-aged and old people, and the side effects of corticosteroids intake are severally dangerous for them.

One of the very important side effects of prolonged oral corticosteroid intake is osteoporosis that limits the use of the medicine for old people. On account of this, patients already experience some diminished bone tissue mineralization due to various reasons like malnutrition and systemic diseases. In these patients that include a large number of musculoskeletal patients to allocate pain and inflammatory joint conditions, the local injection of corticosteroids can be beneficial [1, 2].

In this treatment, there are no such side effects as the systemic use, and on the other hand the medicine can act on the problematic area, like injecting the injectable form of triamcinolone in the joint space. Usually to eliminate patient’s pain in this treatment, corticosteroid is mixed with local anesthetic agents like lidocaine and is injected directly in the joint space either landmark-guided or sonographic-guided [3, 4, 5, 6, 7, 8, 9, 10, 11, 12].

Although this injection is way easier in large- and medium-sized joints for the operator to perform, it can also be used in smaller joints like metacarpophalangeal (MCP) and shows significant improvements in discomfort and swelling.

In this chapter, the types of intra-articular injections and their clinical application are discussed.

2. Corticosteroids application in musculoskeletal diseases

2.1 Corticosteroids application in carpal tunnel syndrome

The carpal tunnel syndrome (CTS) is referred to a condition in which the median nerve (that enters from forearm to the wrist) is stuck in the carpal tunnel. This nerve is responsible for innervation parts of thenar muscles and provide sensation for 3½ of the lateral fingers of the hand. After the nerve trap and pressure upon it, patient experiences symptoms like numbness in 3½ of the lateral fingers and in severe cases feeling of weakness and sometimes hand muscles atrophy; for example, the thenar prominence atrophy is initiated.

This condition is found in 5% of the population mostly in middle-aged women (F to M ratio: 3 to 1) and is related to age, weight, hypothyroidism, diabetes, repetitive wrist flexion, and pregnancy. This condition is divided to three different forms based on clinical presentation, electromyography, and nerve conduction velocity (EMG-NCV) and sonographic findings to mid, moderate, or severe [3, 4].

In mild and moderate form, the application of injectable corticosteroid can be used to decrease pain and adhesion on the nerve and tendon sheath around the nerve. This results in pressure sensation on the nerve and mends the patient’s signs and symptoms. In severe form, the noninvasive treatment is used first and if it was not successful or thenar atrophy (the medial prominence of the palm) is present, the invasive treatment is recommended which is surgery to cut the transverse ligament on the nerve and suture it on a higher distance [3, 4].

2.2 Joint arthritis

Osteoarthritis is a degenerative joint problem that occurs with aging, wrong lifestyle, persistent and unsuitable use of joints, obesity, sports, and traumatic injury.

In this condition, the joint cartilage which has no nerve innervation and plays a very important role in easing movement and prohibiting the head of the bones from erosion is damaged and absorbed. After the initiation of arthritis process, patient experiences a progressive pain which gets worse by time and highly affects patient’s quality of life [13]. Recently, joint replacement which is aggressive but very effective method to manage arthritis is widely used for big joints like hip and knee. In this method, the joint and the heads of bones are cut and replaced with an artificial metal joint that can eliminate the pain and stiffness and other symptoms of arthritis.

This surgery like other surgical methods requires post-op care and use of other medications to avoid infection and clot accumulation due to motionlessness [14].

After the operation, strengthening of involved muscles in joint movement by routine workouts is highly recommended.

In mild and moderate and some major forms that patients cannot undergo surgery (like patients with decompensated heart failure, pulmonary edema, and other underlying conditions), arthritis in a joint that there is no proper way to replace it yet or when patient does not accept surgery, intra-articular injections can be beneficial. Various medicines can serve this purpose like hyaluronic acid gel (to improve joint surfaces to slide on each other and reduce erosion on bone ends), Botox, and platelet-rich plasma (PRP).

One of the very common medications which can work alone or mixed with hyaluronic acid is corticosteroid.

Corticosteroid is very helpful in mending arthritis symptoms, and patient is pain-free for about 2–3 months.

Compared to corticosteroids, hyaluronic acid takes longer to effect but reduces the pain for about 6 months, while PRP does it for 12 months [13]. In this time, patient can strength the muscles around the joint and have normal daily activities pain-free. Side effects of this kind of injections are septic arthritis (due to bacterial infiltration from skin while performing the injection) and bleeding (in coagulopathic patients) which can be prevented with a good medical history taking before starting the procedure and proper disinfection of the injection area.

In severe and progressive cases, the injection needs to repeat every 3–6 months, and because the side effects are few and preventable, intra-articular injections with corticosteroid seem to be harmless and beneficial. This injection with corticosteroid is permitted three times a year [5].

2.3 Tenosynovitis

Tenosynovitis is referred to a group of condition that causes tendonitis and synovitis. De Quervain is one of this conditions that causes inflammation on tendons of extensor tendon of fingers (abductor pollicis longus and extensor pollicis brevis). Patients experience pain while grabbing on objects, fisting, and rotating the hand. To mend this inflammatory condition, first-line treatment is local corticosteroid injection in problematic tendon sheath. In different studies, it was proved that this injection clearly makes the symptoms better compared to placebo in short term [6].

2.4 Adhesive capsulitis

In this condition, severe stiffness in shoulder joint with pain and reduced range of motion (ROM) is present. There are three phases to this condition: first, the pain is dominant and local intra-articular corticosteroid injection can be beneficial. Then in the second phase, the pain decreases and ROM is reduced. In this step, greater volume of local intra-articular volume injection (attenuated corticosteroid with normal salin) can be useful. In third phase, there is a significant improvement in ROM. This condition is referred to as self-limited, and with physiotherapy and over the counter (OTC) analgesics the symptoms are improved to some extent.

Sometimes, patients complain from severe continuous pain; in this case, the intra-articular and sub-acromial corticosteroid injections are useful. If symptoms do not improve over the use of injectable corticosteroid, surgical methods are indicated to cut the fibrous bundles [7, 8].

2.5 Medial and lateral epicondylitis

In lateral epicondylitis (tennis elbow), the origin of wrist extensor muscles in elbow area is inflamed due to continuous use. Most of the patients recover after time pass and physiotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs), other anti-inflammatory medication, and resting the muscles of the area.

In case of severe pain and limited daily activities, local injections, especially steroids, are a potent and valid anti-inflammatory agent that can help, although relapse happens in 50% of the cases after injection [9].

Medial epicondylitis (Golf elbow) is persistent pain in medial epicondyle. In this condition, like the lateral epicodylitis, the use of corticosteroid injection can help, but relapsing is common and the use of dextrose prolotherapy and PRP can benefit the patient for a longer period [10].

2.6 Trigger finger

In this condition, finger Pulley A1 that reasons smooth tendon movements in flexor digitorum superficialis and profound muscles is inflamed and holds the finger back while moving. Treatment can either involve surgery to cut pulley or local corticosteroid injection. Corticosteroid injection shows a significant improvement in patient’s symptoms, so it is recommended in most of the patients suffering this condition [11].

2.7 Greater trochanter bursitis

One of the very important differential diagnoses in lateral hip discomforts is inflammation of the burse on the greater trochanter. To cure it NSAIDs, physiotherapy and corticosteroid injection is recommended, the later can benefit the patient faster and better [12].

2.8 Facet joints injection

Facet joints are on both sides of each vertebrae and connect each thoracic, cervical, and lumbar vertebrae to its upper and lower. Arthritis or inflammation in this joint causes pain in spine. Corticosteroid accompanied by anesthetic agents’ injection in this joint is an easy procedure which is usually done by sonography or fluoroscopy guidance. The injection itself means no harm, and patient experiences the least convalescence period [15, 16].

Corticosteroid onset of effect in this type of injection is commonly 3–7 days and remains for couple of months. This treatment becomes so popular lately, since it is both noninvasive and effective in reducing pain and symptoms. This injection is advantageous on the other hand. If patient feels a significant improvement, the other techniques that have constant effects are recommended such as facet neurolysis injection and rhizolysis [15, 16].

2.9 Epidural injection to treat disk herniation and canal constriction

In cases like herniated disk, slipped vertebrae, listhesis, joint synovial cyst, spinal ligaments thickening due to spinal arthritis, epidural corticosteroid injection is useful.

In this method, the medication is injected by interlaminar on the fatty layer on the spine or transforaminal or caudal (with a greater volume). This method is very popular between clinicians and patients and provides a good improvement in patents’ pain. Side effects include steroid flush as profuse heat sensation for couple of days, sleep disorders, anxiety, edema, and rarely an increase in pain for the few first days. From time to time, patient experiences a provisional paralysis in lower organs after the injection which goes away after the lidocaine or other anesthetic agents effects wear off. To increase the effect of injection, rehabilitation after performing the injection is very important [17]. Two days after the injection, patient needs complete rest, and 2 weeks later relative rest is recommended. After corticosteroid injection to prevent the joints pain, cryotherapy is indicated.

3. Conclusions

Corticosteroids are used in a wide range of disorders, and local injection is curative in mononeuropathies and inflammatory conditions such as de Quervain tenosynovitis and has temporary pain relief in DJDs and spinal canal stenosis.

Conflict of interest

The authors declare no conflict of interest.

Appendices and nomenclature

Adrenal gland

two glands which are located above kidneys and secrete lots of essential hormones including Aldosterone, corticosteroid, sex hormones, and epinephrine

Glaucoma

an eye disease that can cause serious visual impairment like blindness and decreased vision acuity

Cataract

when the lens of the eye becomes cloudy

Candida albicans

a form of fungal infection that can cause mild skin infection to severe life-threatening systemic infection in case of immunocompromised patients

Mucormycosis

an invasive fungal infection than produce serious life-threatening infection in form of severe respiratory infection and black scars around the mouth and nose (skin involvement)

EMG-NCV

a noninvasive diagnostic procedure that the physician can check the electrical activity of muscles and nerves

Platelet-rich plasma (PRP)

a concentration of patient’s own platelet that is excluded from complete blood

Synovium (synovial membrane)

it is a connective tissue membrane that covers the inner surface of joint capsule. When the synovium is inflamed, the term of synovitis is used

Sub-acromial place

acromion is a bony process in upper outer of the scapula

Dextrose prolotherapy

local injection of dextrose works as an irritant and provokes the body immune system to relive the inflammation