Skip to main navigation
Skip notifications
Access to POEMs and Essential Evidence Plus will no longer be included in CMA membership as of Dec. 1, 2023.
Search
Minimal difference, if any, in the efficacy of intramuscular vs intra-articular steroid injection for knee osteoarthritis
Clinical Question
Is an intramuscular glucocorticoid injection noninferior to an intra-articular glucocorticoid injection in reducing knee pain in adults with knee osteoarthritis?
Bottom line
This study found that IA glucocorticoid injection may work better for reducing pain from knee OA at 1 month, but there was no significant difference in pain resolution between IA injection and IM injection at 2 months or 6 months. 1b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Foundation
Setting: Outpatient (primary care)
Synopsis
Intra-articular (IA) glucocorticoid injections are associated with greater cartilage loss and a rare but increased risk of joint infections and septic arthritis. These investigators identified adults (N = 145), 45 years and older, with knee osteoarthritis (OA) diagnosed by their primary care provider, presence of symptomatic knee OA for at least 3 months, and moderate to severe knee pain over the past week (at least 3 on a scale of 0 to 10; 0 indicates no pain). Eligible participants randomly received (concealed allocation assignment) either an intramuscular (IM) injection (40 mg triamcinolone acetonide) in the gluteal region or the same drug and dose given as an IA injection in the index knee. Patients self-reported severity of knee pain at 2, 4, 8, 12, and 24 weeks after treatment using a previously validated knee pain scoring tool (0 to 100; 0 indicates extreme pain). Although the minimal clinically important difference for this tool is 9, the investigators chose to prespecify the noninferiority margin at 7. Per-protocol data were available for 138 (95%) of participants at 24 weeks. Using both per-protocol and intention-to-treat analyses, noninferiority could not be declared at 4 weeks because the lower limit of the 95% confidence interval exceeded the noninferiority margin for IM versus IA injections (-3.4; 95% CI -10.1 to 3.3). However, IM injection was declared noninferior to the IA injection at 8 weeks and 24 weeks. The investigators reported multiple secondary outcomes, all of which showed that the IM injection was most effective at 8 weeks after injection, the IA injection was most effective at 4 weeks, and there were no significant group differences at any time points.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Intra articular steroids in OA patient did not score over in
Steroids are likely to be absorbed again by the vascular parts of the joint cavity and act similar to intramuscular route. The possibility of introduction of joint sepsis may be avoided by deferring intra articular route
Systemic risks from IM steroid
IM and IA may be similar in effectiveness, but is the risk of systemic toxicity higher when the drug is given IM?
IM vs IA injections
This surprises me greatly but now I understand how some patients do relatively well on chronic low dose prednisone for OA. That however is a practice that must be discouraged
Which steroid what doses
A/a
IA vs IM steroids for knee OA
Too bad there was not a placebo arm since there is good evidence that IA steroids are not effective in the medium to long term compared to placebo. The results of this study are limited in applying them clinically due to the lack of a placebo arm.
Limited usefulness
No placebo arm and therefore limited usefulness in this case
IA steroids vs IM injection
I think IA is better and safter then IM injection