Plus, there are definite risks.
This is the basis, or foundation, for using steroid injections for knee pain. The idea is to reduce the swelling and improve pain. So there must be good ‘evidence’ that these injections work, right?
A study published in JAMA recently evaluated saline injections versus triamcinolone injections for knee Osteoarthritis. The patients either received kenalog (triamcinolone) 40mg or saline injections every 3 months. They discovered that there was no difference in knee pain and the joints of the steroid patients actually got worse.
“Among patients with symptomatic knee OA, two years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support [steroid shots] for patients with symptomatic knee OA.” 
WHY are we doing these shots?!?
Now the thing that irritates me is that many of the physicians doing steroid shots are the same ones that won’t do something like prolotherapy because “there is not evidence it works.” And this is why they are hypocrites.
Speaker 1: 00:00 Welcome to against the grain podcast with Dr Chad Edwards, where he challenges the status quo when it comes to medicine. We get into hot topics in the medical field with real stories from real patients to help you on your way to a healthy lifestyle. Get ready because we’re about to go. Go against the grain
Speaker 2: 00:23 Chad Edwards and you’re listening to podcast number 85 of against the grain.
Speaker 3: 00:27 Hey guys, this is Diana Edward. Thanks for coming back to against the grain podcast. Uh, we’ve taken a small break. We wrapped up summer, got the kids back off to school. And lately we’ve been trapping a lot of raccoons to keep our chicken safe. I think we’ve got that pretty much wrapped up so we can get back to making our podcasts. And actually this week one of the things that we’re going to be talking about, um, hits close to home. I was scrolling through my facebook feed and noticed one of my friends had actually posted. I’m soliciting help from anyone. She had been going and getting a cortico steroids, cortisone shots in her knee so that she could stay active. But she was not getting any better, it would last for a little bit and then of course you would have to make another appointment and go back in and get more injections. Of course she wanted a more long term solution. So I guess my question, um, fits right along with what we’re going to be talking about, Dr Edwards, why do the cortisone shots not fix it?
Speaker 2: 01:31 Well, that is a great question and I think it’s going to make a great topic for our podcast today. And the first thing I would like to say, I will tell you that, you know, this was, you know, obviously I’m board certified in family medicine. It’s that I had very traditional training and I’m, I’ve deviated from, from a, a lot of my initial training in my current practice. But what I have discovered over the years is that when it comes to stuff like this, these steroid injections, many of my traditional medicine colleagues are hypocrites when it comes to this particular topic. No Way. You got to be kidding me. How can I, how could I, how could I say something like that. But it is, it is a very, very true statement. I’m not saying they’re bad people, I’m not saying they’re, they’re dumb, but it’s very hypocritical. And I’ll, we’ll get into, we’ll get into that topic and why I would make something so, so boulder inflammatory, why I would make a statement
Speaker 3: 02:27 inflammatories or upon there this week.
Speaker 2: 02:30 Wow. That, that, that may work out well for us here. Um, so the, uh, steroid injections for the knee, they do help with some things. They reduce inflammation. They are shown to do that. So they reduce inflammation and they can reduce symptoms in the short term. And I will tell you, I’ve had a steroid injection. It was actually on my shoulder. I was in college and you know, we did a lot of overhead lifting and things like that. And I had shoulder pain, went to my traditional doctor, got an injection and my symptoms got better and ultimately went away and I didn’t do anything else. A lot of times what I see in, you know, in, in our clinic at revolution is the, uh, the people that go get steroid injections specifically in the knee. And then they come back to us saying, I had two rounds of this, I even had some synvisc injections, especially in older patients with osteoarthritis and so they’ve been doing several things and nothing’s, get getting better.
Speaker 2: 03:31 So I wanted to start off with how steroids work, what they do, and then talk about some risks that are posed with steroid injections. And then, uh, then we’ll get into why I think prolotherapy or PRP, which is platelet rich plasma therapy or even stem cell therapy are better. And we’ll talk a little bit about each one of those and why I would say skip and forego the steroids because I think that’s detrimental to you and go with something that’s more proactive. So that’s, that’s Kinda my, my little segway or intro part. So basically you’re going to teach us how to not mask the problem that actually fixed the problem. You got it. Absolutely. So steroids, they’re corticosteroids, steroids, they are a group of chemicals. Your body actually makes some of these, uh, cortisone is, is one of them, and will actually inject those into the knee with the intent being to reduce the inflammation, which we think is what’s causing a lot of pain.
Speaker 2: 04:32 And we know I was sports medicine at Oklahoma Baptist University and was a, an athletic trainer there. And we had, um, we had tee shirts that said just ice it. And the whole concept was reduced inflammation, reduce inflammation, reduce inflammation. And what we find is that a lot of times the inflammation isn’t really the real problem, although sometimes, you know, there’s definitely a role with it. So steroids, uh, they have several actions and some of them we don’t completely understand, but the first one is that they will suppress or completely prevent a full inflammatory reaction. And it doesn’t matter if it’s due to infections or an infectious process, if it’s due to a physical kind of mechanical stress problem, or if it’s an immunologic reaction, it will reduce the inflammation across the board. It also reduces early inflammatory events like Edema, cellular exudation. So we’ve got fluids being secreted out, a fibrin deposition, a capillary dilatation, leukocyte migration, and phagocytic activity.
Speaker 2: 05:34 So we’re talking about components of the immune system that result in inflammation, which ultimately is part of the healing mechanism. At least it should be. Steroids also inhibit later events like a capillary and fiberblast proliferation and Pirlo therapy stands for proliferative therapy. And one of the things that, uh, that’s talking about is the Collagen within ligaments and tendons and, uh, some of the other tissues. And when you proliferate fibroblasts, fibroblasts are the cells that produce Collagen. It’s actually part of that healing mechanism. It also suppresses the deposition of Collagen and scarring. So that to me is a key point right there. It suppresses the deposition of Collagen.
Speaker 3: 06:19 We want the college and at the point if we’ve got an injury, we’re going to want the college in there to come and repair.
Speaker 2: 06:25 Absolutely. That’s absolutely. And inhibiting that is preventing your body from healing period. So, and then the last component that, that stereotype, we don’t understand some of the mechanisms by which steroids work. So there are some potential benefits. Uh, you know, I, I said my story where I had an injection in my shoulder and, but I will tell you that I do not recommend them and I won’t do steroid injections for musculoskeletal applications because of what I learned on active duty, what I’ve learned over the last eight, nine years doing prolotherapy steroids are necrotic to the tissues they destroy the tissues. And I have an example, uh, that was a, yeah, a study that proves what I’m talking about and we’ll talk about that in just a minute, but you got to understand that these injections have risks, steroid injections have risks. And the first piece of this is that tissues don’t heal.
Speaker 2: 07:25 Just like what I was saying, in fact, one lady medical paper stating all Glucocorticoids, Gluco corticosteroids, uh, normally I say glucocorticoids inhibit growth, regeneration and repair of cellular and interest. Other components of dermal connective tissues when pr when penetrated through the skin barrier. So in other words, you do an injection, it suppresses the regeneration and repair ability. The resulting atrophy is a logical manifestation of the actions of the compounds. So what does that mean? It means that these medications, the steroids, they destroy tissues, period, the end, the study will be referenced in the show notes, so you can go back and in the show notes, look at, uh, our references and you can go straight to the source. It’s not just me saying this. So would you say
Speaker 3: 08:09 someone went in on a regular basis to get these Gluco corticosteroid injections that they are actually doing definitely more damage, but over the long term, um, they’re going to have some serious consequences in the joint. There are not only just masking the pain and the issues, but they are destroying the tissue that has been left behind from the injury, making it much worse.
Speaker 2: 08:33 Absolutely. And we’re going to get into that with a study that I’ll reference a in a, in a few minutes. Uh, so, and that’s. So, that’s a great question. Great Point. Uh, so at the bottom line is 10 tissue simply can’t heal completely when steroids are present or that they can’t heal. So what are some of the other risks? Uh, well before we started recording, you brought up a great point about one of the risks of steroids and what, what is that?
Speaker 3: 08:59 Uh, immune suppression. Um, I witnessed this. My son growing up had to be on regular steroids inhaling, so to help with the control of some early asthma issues and one of the things that we were warned about was his immune system is going to be compromised. So of course, you know, going to daycares and stuff like that, um, was something that we had to be aware of that he was going to be a more susceptible to getting sick. So I’m assuming that all steroids are that way, whether they are injected into a joint or breathed into the, to the lungs.
Speaker 2: 09:31 That’s exactly right. If you go back to how steroids work, I remember they suppress or completely prevent the full inflammatory reaction even if it’s because of an inflammation or a get an infection or an immunologic reason. So when you’re exposed to something, you’re doing these inhaled steroids, it does suppress your immune system, which, you know, with, in the case of asthma, that’s a good thing because asthma is a, it’s a, it’s another mechanism which will be the topic of another podcast. But um, so your, your immune system’s kind of overreactive and so you’re using steroids to prevent that. The problem is, is that the consequences that you’re a slightly more prone to other infections. Uh, and so, you know, immune suppression is one, and if you certainly, as you alluded to, if you inject steroids, it does suppress your immune system. In fact, you can’t get certain immunizations a, you there.
Speaker 2: 10:25 There’s certain things that you cannot do if you’ve had a steroid injection recently, uh, because your immune system will not mount a response against it. Oh Wow. So a risk of infection goes up, you know, the immune suppression, a tissue damage. One of the things that you mentioned earlier, when you get those steroid injections over time, it destroys tissue. In fact, I remember when I was in college, there was one of our cheerleaders got a steroid injection and she got it in her hip, you know, like for seasonal allergies, and she had a crater, we called her craiger, but my goodness, she had a crater. And so there’s beautiful attractive girl, got an injection in her in her hip and her bottom and got a big crater because the tissue. Exactly. Yep, exactly. So, uh, steroids, you know, as systemically, any way you can get an increased appetite weight gain, you get somebody that’s on chronic steroids and, or at least had to start them because of any number of conditions.
Speaker 2: 11:21 And there is frequent weight gain. It’s a common issue. You can get sudden mood swings, muscle weakness, blurred vision, increased growth of body hair. Uh, I don’t know of anybody that likes that easy bruising. You get a swollen, puffy face, swollen, puffy face. Yep, exactly. A acne osteoporosis. So if you have patients that are like, I’m a rheumatoid arthritis, any chronic conditions, and they are on steroids, it’s one of the things that we do is follow, uh, their bone health because it, it destroys your bone over time. And so you have to be very, very careful in longterm steroid use. Steroids also inhibit your body’s ability to regulate your blood sugar a. So you have some insulin resistance problem. So diabetes is worse. A blood sugars go up, that’s very common. You can have high blood pressure associated with them. Certainly they can irritate your stomach and I don’t remember if we’ve done a podcast on antiinflammatory medications, but we probably need to put that on the list because that’s a, that’s one that it just screws up your stomach and they can be beneficial.
Speaker 2: 12:33 But again, I don’t use anti inflammatory medication like insead’s or nonsteroidals, like Motrin, Ibuprofen, things like that, unless it’s for like headaches, tooth pain, I do not use them for musculoskeletal problems, uh, because of these issues and it’s been shown in the data over and over and over again. Um, so, but they can, they can tear up your stomach and it’s one of the things that we see with longterm, both with corticosteroids and with a antiinflammatory medications like Motrin, the, you get stomach ulcers and things like that. And we’ll go over that in the antiinflammatory podcast so you can get some nervousness, restlessness, a difficulty sleeping, very common steroids are activating and you know, if you go, go back and listen to our adrenal dysfunction or adrenal fatigue podcasts, and I talk a lot about the court, the I’m a circadian rhythm associated with steroids, uh, that your body produces and the effect on sleep.
Speaker 2: 13:29 If your cortisol levels are high at night, can’t sleep or have difficulty sleeping. A cataract and Glaucoma, we see a lot, especially with topical steroids, but you can get them with system systemic steroids as well. A water retention swelling, you know, you’ve got the person that that’s on steroids and they, they’re like, I’ve gained 20 pounds and some of that fluid, a tendon rupture. So that’s a really interesting one. If you get a steroid injection in your Achilles tendon, a then your risk of having a tendon Achilles tendon rupture goes up dramatically. In fact, most people will not do a steroid injection in the Achilles or in the patellar tendon. But of course with prolotherapy PRP and stem cell, we can direct, we can inject them directly into the tendon because it doesn’t work that way. And then you can have the subcutaneous atrophy, which also goes along with what we talked about with that, that girl that got an injection.
Speaker 2: 14:18 Yeah. Um, so, um, these, uh, this, these are the, the issues that you can have with steroids and the, that’s the basis, you know, that whole kind of discussion up to this point. It’s the whole basis or foundation for using steroid injections for knee pain. And the idea is to reduce that swelling and improve their pain. Uh, so there’s got to be good evidence for these injections. Right. What do you think? Absolutely not. No. Yep, exactly. So there was a study that came out a, again in the show reference in the show notes. Uh, I believe it was. Um, let me see if I can find it here. Um, uh, well it was a journal of Ortho or I’m sorry. Um, Journal, the American Medical Association, Jama. This is major peer reviewed data and it was called the effect of Inter articular triamcinolone, which is a corticosteroid versus saline injection on knee cartilage volume and pain and patients with knee osteoarthritis.
Speaker 2: 15:14 So again, reference in the show notes and you can go straight to a straight to the, uh, the study and see, again, I’m not making this stuff up. This is um, this is out there. So the, uh, this study was, was really interesting. Um, the basically they had two groups and one group was the, was the placebo group that got saline injections and the other group was the one that received the Kenalog or try him send alone injections. Uh, those guys got 40 milligram injections, which is fairly standard a every three months. And over the course of the study they discovered that they, there were, it was actually very, very interesting. Um, so what do you think they, what do you think they found
Speaker 3: 16:03 the ceiling group? I’m going to say either got better or at least stayed the same, didn’t get worse. I don’t want to say the steroid got worse.
Speaker 2: 16:12 Yep, that’s exactly right. So this is a quote directly from the authors in this study. Uh, so it said among patients with symptomatic knee osteoarthritis, so we’re talking about a very specific group of patients, uh, two years of Intra articular triamcinolone compared with intraarticular Salian resulted in significantly greater cartilage volume loss and no significant difference in knee pain. So the pain didn’t really improve with steroid injections versus with saline injections or they lost cartilage and they lost cartilage. The cartilage is the cushiony stuff. And again, straight from, you know, this isn’t like Weirdo Medical Journal, you know, 2017. This is Journal of American Medical Association, Major Peer Reviewed Journal. And this, um, this study to me is just fascinating. And so they, they went on to say that these findings do not support steroid shots for patients with symptomatic knee osteoarthritis. And again, when you, when you look at the foundation of how these things work there, anti-inflammatory, they reduced or they destroy tissues there necrotic to the tissues and we go to our doctor and our doctor says, oh, well let’s do a steroid injection in that. If they say that don’t walk, run, run away, don’t ever do that. It’s not shown to be beneficial. And I would argue that there is tremendous harm associated with those injections. So absolutely. So why, why are we still doing the shots?
Speaker 3: 17:42 Well, first of all, we all feel like if something’s not at 100 percent function that we’ve got to intervene. There has to be kind of intervention. Um, and a lot of the time I feel like our medical community feel like they need to intervene on behalf of the patient so that they feel like they’re doing something for them and the patient’s going to be satisfied that the doctor is doing something for them. Um, one of the other major factors of course for that patient is that insurance is going to pay for this, right? So there are definitely going to go that route instead of picking up the tab themselves,
Speaker 2: 18:16 right? Or at least at least common frequent. And most people don’t know any better, which is why we’re doing this podcast. Exactly. Tell your friends, let them know, make them stop. And, you know, I wouldn’t say that, you know, so we got to do something. Insurance pays for it. And finally, because we think it works. The reality is it doesn’t work and it’s been shown in studies. And when you look at the biochemistry of how steroids work, when you look at the biochemistry of a, you know, knees, when you look at the physiology of wear and tear and things like that, I would never, ever, ever, ever, ever get a steroid shot in my knee. That’s, it doesn’t make any sense to me. Uh, I think it’s ridiculous. And so this, you know, now at the end of all of this, I can say, this is why I think it’s very hypocritical because when I started doing prolotherapy on my office manager when I was at a large clinic in Tulsa, more in clinic actually, um, and we were doing prolotherapy on her and one of my colleagues said, well, what’s the evidence that it works? And I heard that time and not, not just from from this other physician, but I’ve heard it time and again from so many people, what’s, well, what’s the evidence for it? You know, if you look at the Cochrane Review, the Cochrane Review shows that, uh, it’s, it’s marginally better than placebo and it just, there’s just not good evidence for it.
Speaker 3: 19:37 But there’s a ton of evidence against steroids shots. That’s exactly right.
Speaker 2: 19:42 And that is why I would say this is ridiculous. It’s a moot point. It’s a. and I’m happy to have the conversation because we know that that prolotherapy works. We know, in fact, there’s a lot of evidence coming out about PRP or platelet platelet rich plasma therapy. There’s good evidence coming out for and stem cell injections, uh, specifically for the knee, hip, shoulder, those kinds of things. There is a lot of good data on these things and yet so many people will shy away from them. Um, and I mean prolotherapy has been around for 100 years. It’s very safe. I’m not aware of a single infection. There may be one somewhere, but I have never heard of it. Uh, I’m affiliated with the hack at him while foundation and they track all of the data worldwide on prolotherapy and we just don’t see risks and complications like this yet when we do steroid injections, when I was taught to do steroid injections, that was a sterile procedure.
Speaker 2: 20:36 You’re talking sterile gloves, what? You’ve got to be very careful about how you wash this kind of stuff and why it’s because those medications are immune suppressive you, you’re into that area. You’re suppressing the immune system. And so you can’t fight an infection if there’s to be one there. So, I mean, you’re, you’re putting your body in a position where it’s going into a battle with one arm tied behind his back. And it’s, to me, it’s, it’s absolutely ridiculous. I was trained to do these in the steroid injections, uh, and we do see people that feel better, but the studies show that they don’t work and they destroy the cartilage in your knee. I would never, never, never get another steroid injection for musculoskeletal stuff.
Speaker 3: 21:22 Can you guys can’t see me right now? I am just shaking my head. I am just baffled that so many people go in on a regular basis to get steroids shots. Right now we’re talking about the knee, but this is any joint. They’ll go in and get these steroid shots and then in the long run they’re doing way more damage to the tissue then the initial injury. Absolutely.
Speaker 2: 21:45 And one of the common things that we’ll hear about not doing something like prolotherapy or prp or stem cell is, well, insurance doesn’t cover it. Okay, well insurance doesn’t cover my food. Insurance doesn’t cover my going for a run. It doesn’t cover my gym fees. It doesn’t cover any of those things that we need to be doing to keep ourselves healthy. I had a patient that came into my clinic that had an above the knee amputation because she had a total knee replacement. They got infected. Now we’re not talking about knee replacements here, but this, these are things that we think, oh, this is just routine. You know, we do these all the time, but the reality is bad stuff does happen. And I argue and you know, absolutely knee replacement has its place, but if that’s the first thing that you’re doing that that’s wrong, it’s, you should never go to your doctor.
Speaker 2: 22:41 And the first thing they say is, oh, well, let’s do a knee replacement. Let’s try everything we can to avoid a knee replacement because you can’t undo it. And the risk of infection is much higher. And, or I’d say if you get an infection, maybe this is a better way of saying it. If you get an infection, then it can be catastrophic. In fact, the Dr Venuto is the guy that I trained with a stem cell, uh, he’s out of Orange County, California orthopedic surgeon, Super Guy. And he said the difference between stem cell and surgery is that if stem cell doesn’t work, there’s your, it just didn’t work. There’s no real risk. But if surgery doesn’t work, it’s catastrophic. And I think that’s a great way to say that. And to look at that, maximize your low risk procedures. Uh, you know, the prolotherapy very simple.
Speaker 2: 23:33 We do it in the clinic, very cost effective depending on the amount of damage inside the knee joint, how many steroid injections you’ve had up until that point, that destroyed the cartilage. Uh, you know, it, it, uh, we may need to go up in intensity and prolotherapy platelet rich plasma therapy is definitely more potent than prolotherapy. There’s an added cost associated with it because the kits that we use and the time that it takes to process the platelet rich plasma. And, uh, for the record, we draw your blood. We spin it down in this little contraption that the, uh, the harvesting kits provide us. And then we separated everything out and in and inject that platelet rich plasma and there’s good evidence for it. Um, and we inject that into the knee in an attempt to stimulate the healing mechanisms, but the coup de Gras, the ultimate for inside the knee, and you know, the more I get into stem cell injections for musculoskeletal issues, specifically knee, I am just absolutely blown away at the benefit that some of our patients are getting with stem cell procedures.
Speaker 2: 24:42 Um, you know, we, we, uh, and we are using autologous stem cells, meaning that we get the stem cells from the patient. We use platelet rich plasma therapy. So we draw your blood, we do adipose harvesting of stem cell and there’s a reason for that. We’ll have another podcast where we talk specifically about stem cell and why, you know, one part versus another versus another. But in the knee you definitely need adipose for multiple reasons. And we use bone marrow as well as a bone marrow aspirate most, most of the time. In fact, I thought when I first started doing stem cell, oh, we’re doing a stem cell, are we doing a bone marrow aspiration? That’s gonna like hurt really bad. And I’ll tell you, I, I have had zero complaints about the, um, uh, the bone marrow and it being uncomfortable. They said the, most of the time, the, uh, the needle from a, uh, from the blood draw hurts worse than the stem cell.
Speaker 2: 25:43 Uh, when you get the right anesthesia in there, when you treat the patient right and just go nice and easy. It goes very smooth, very easy. Patients tolerated incredibly well. Uh, one of the last ones that I did, the patient said he came back for a six week follow up and we had done other injections before and he just wasn’t getting the benefit that we like to see. So there clearly was some damage in there. And when he came back for a six week follow up, I mean, he, he was just, you know, doing backflips and he was like, I can’t believe how much better I’m doing. This is phenomenal. And he was ecstatic. And he said I was a little nervous about the, uh, the bone marrow part, but he said, if you wanted to do it, uh, again, I’m, I’m ready right now.
Speaker 2: 26:22 We could do it right now. It was nothing, it was easy. So I guess the take home first, don’t get steroids shots. Absolutely. And then secondly, maximize your other injectable techniques like prolotherapy, prp, stem cell, uh, those kinds of things. And we do all three of those in the clinic where you’re the only clinic in Tulsa in Oklahoma, uh, that’s affiliated or recommended by the Hackett, Him Wall Foundation, and we’re the only ones doing prolotherapy prp and stem cell. So got a great approach to muscular skeletal medicine. Don’t get steroid shots unless you absolutely have to have them and have no other options. And then come see us for your other musculoskeletal injections. We can get you fixed up. Absolutely. Thanks so much for listening. Stay tuned. We’ll have some other podcasts rolling out a real soon. Got Lots of good stuff coming at you and I’m excited to get it all out there.
Speaker 1: 27:25 Thanks for listening to this week’s podcast with Dr Chad Edwards. Tune in next week where we’ll be going against the grain.