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[Physio Explained] Corticosteroid Injections: when, why, and how with Dr. Sharon Chan-Braddock

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In this episode with Dr Sharon Chan-Braddock, we dive deep into corticosteroid injections. We discuss: 

  • How corticosteroid injections work
  • How long corticosteroid injections last
  • How has has the use of corticosteroid injections changed over time
  • Use of local anesthetics with corticosteriod use
  • When we should be using corticosteroid injections
  • Repeated corticosteroid injections

Dr Sharon Chan-Braddock is a highly experienced Musculoskeletal Medicine clinical academic and Advanced Practice physiotherapist, with many years of diverse experience of MSK across clinical, academic, education and quality agenda areas regionally and nationally. In 2024, Sharon became the first physiotherapist in the UK, and internationally, to gain dual SOMM Fellowship and MACP Membership, which is a recognition of meeting consultant level of practice and International MSK standards of practice set by IFOMPT.

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Our host is @James_Armstrong_Physio

SPEAKER_02:

Stirring injections definitely have a place in our MSK2 box. It's not the one and only treatment and it's definitely not the first line of treatments. I think that's something we bear in mind. But if we can use in the right patient at the right timing and right diagnosis, that is brilliant because we give our patient a window opportunity to rehab.

UNKNOWN:

Music

SPEAKER_00:

Welcome to Physio Explained. In today's episode, we're joined by Dr. Sharon Chan-Braddock. Sharon completed her professional doctorate in physiotherapy in 2016 and brings over 14 years of experience in postgraduate musculoskeletal education. She is the MSC module lead for injection therapy and developing professional practice with the Society of Musculoskeletal Medicine, the SOM, and holds a distinction of being the first physiotherapist in the UK and internationally to achieve both SOM fellowship and MACP membership. in this episode we cover everything from what corticosteroid injections aim to achieve how effective they really are in clinical practice And we look at the evolution and changes in practice over the last 15 years. And then finally, we look at patient selection and timing, when we should consider utilising corticosteroid injections. This is a fascinating discussion packed with insights for any clinician considering or using corticosteroid injections in their practice. I'm James Armstrong, and this is Physio Explained. sharon it's great to have you on the podcast today thank you so much for joining us

SPEAKER_02:

Thank you for having me today. So

SPEAKER_00:

we're going to be talking about a really interesting topic, particularly interesting for me as well. It's about corticosteroid injections and we're going to get dive straight into the up-to-date sort of clinical reasoning, the evidence and how we should be using them at the moment. I thought what better way to kick this off with what are corticosteroid injections aiming to do and how are they aiming to work in the body, Sharon?

SPEAKER_02:

So steroid injections have been used in musculoskeletal medicine for a long time, since 1960. So the main properties of steroid injections is anti-inflammatory medications, but also has its immunosuppressive effects. And the main indication to use an MSK practice is to reduce pain and inflammation, and therefore it facilitates that patient's rehab and loading program. Majority of the steroid injections will be used in conjunction with other managements. So it's fairly, it's used as a standalone treatment. And therefore we always have to think about that wrap around care, personalized care. So ingestions are often best used as a total management of the plan. So for example, if someone's pain is the main barrier to prevent them from rehab or pain really disturbed their sleep or affect their function, like their work and their hobbies, then that could be the indications of using pain. steroid injections to give them a window of opportunity to be able to engage with rehab and physiotherapy. So in terms of how steroids work, your buddy is very clever. So steroids is a liposoluble hormone and it interacts with one of the biological targets, which is the receptors. So basically the receptors bind with the glucocorticoid receptors and it's diffused into the cyprism and this will trigger a number of events in the nucleus And that's how they create the anti-inflammatory effects of your body. So that's

SPEAKER_00:

basically how it works. Wonderful. In terms of steroid injections, obviously, we use them around the body in different areas. Do we know sort of how long they tend to work for?

SPEAKER_02:

Yeah, that's a really good question because our evidence is so important to inform our practice. And part of the important part to give our patient informed choice or consent is we are able to give our patients treatment options. And that's when we have to have the understanding about the risks versus benefits for our patients, understanding about the possible risks and complications. There is so much research out there in corticosteroid injections, but the general themes in terms of joint, for example, arthritis, the general themes is short to moderate benefit. So it could be between a few weeks to a few months effectiveness, and there is no evidence to suggest any long-term benefits. In terms of tendinopathy, it's short-term benefit only. We know steroids is not the best for tendinopathy, but that That could give some patients a window of opportunity for them to rehab or for that loading program. So those are the general themes of evidence. Obviously, we have evidence on individual lesions that you can look into that. I

SPEAKER_00:

suppose with the evidence, it brings us probably really nicely on to a topic that we were talking about just before we started recording, and that's how things have changed. We talked about this. Corticosteroid injections have been used for a long time. How have things changed over the years, Sharon?

SPEAKER_02:

So I've been doing injections for 15 years. So when I trained doing steroid injections, using local anesthetic was a default. So we know some risks associated with local anesthetic. in our central nervous system, cardiovascular system, and allergic reactions such as anaphylactic reactions. So we very much focus on those. And we don't really question why you use local anesthetic in every single injection in those days. But in the last 10 years, practice has been changed because there are increasing amount of evidence to suggest steroids is not great for our articular cartilage and tendons. So we understand, we know the systemic effects. But in terms of locally, evidence suggests steroids can cause chondrotoxicity. So basically, it's toxicity to our chondrocytes, which is cells in articular cartilage, but also tenotoxicity, which is toxicity to tendon cells. And you can see these deleterious changes very, very similar to the natural process of arthritis and tendinopathy. So the question is, Do we need to use local anesthetic if there's not good clinical reasoning? So the use of local anesthetic should be used when there is, for example, a diagnostic purpose. So you can use local anesthetic when you want to aid that differential diagnosis. So for example, between cervical reflopping and the subchromic impingement, you want to help that differential diagnosis. or you want to give your patients some relief, like a pain relief, a short-term pain relief, usually local anesthetic like the common one like Lidocaine lasts for 90 to 120 minutes. So it's not a short-term benefit, a long-term benefit that you can cover that post-injection flare, which can last for a few days, or it doesn't bridge that gap until the steroids work after 24, 36 hours. So if you are confident with your diagnosis, and you don't need a diagnostic purpose, then the question is, are you adding more benefits to give your patient local anesthetic? So the change of practices, we become much more careful in terms of the selection of our use of local anesthetic. So I think that is down to clinical reasoning, case-by-case basis, always thinks about that risk versus benefits of our patients and informed choice to our patients first. when you're utilizing steroid injections.

SPEAKER_01:

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SPEAKER_00:

quite important, isn't it? Because I think some individuals may be working under a patient group directive or things like that, but whereby the local anaesthetic is already mixed and that's not necessarily giving clinical reasoning as to whether you're using it or not then, is it? You're taking that clinical reasoning away from the clinician?

SPEAKER_02:

Yeah, and I think that is a very, very common question people are being asked when we're teaching. And sometimes I think we just need to go back to our services and ask about, can we have other options? Because it really depends on the patients and the lesions. I'm not saying steroid, local anesthetic definitely have a place. And in some cases, we may use pre-mix. In some places, we may use a steroids plus local anesthetic. In some cases, we may use steroids alone. So it really depends on the lesions we're dealing with, but also patient's factors as well.

SPEAKER_00:

Definitely. And that leads us really nicely onto sort of when we should be using these. We've talked already, haven't we, really about patient selection. And I think we could probably dive into that a little bit more now in terms of some of the conditions and types of patients that we know the steroid injections are good for. And we also potentially with the evidence emerging now on where we, when they might now not be so much used. Can you talk to us a bit more about that, Sharon?

SPEAKER_02:

Yeah. So usually steroid injections used in joint, so such as arthritis. So it could be degenerated, traumatic or inflammatory arthritis. It could be used in tendinopathy, bursitis and some nerve entrapments such as carpal tunnel injections. In terms of when we're going to use it, as everything else in MSK management, we often adopt that step approach. So we want to be the least invasive to start with and self-management, physiotherapy, exercise, medications. If people fail to respond to dose and pain still are barriers for them to engage with rehab and physiotherapy and affecting their function, then you may consider steroid injections can be an option. So often it's really important for patients to understand about what are they having. So it's your job to discuss the intended benefit and risk. But also it's really important for people to understand this is just part of their rehab. It's not a one-off. It's not the end of it. It's the start of their rehab. So the aftercare is really important. So you give them appropriate aftercare advice. At the moment, we're drafting a guidance document in terms of aftercare in injection therapy. And also think about the rehab pen hose injections as well. I would probably say the one-off that you may never see a patient again, it could be trigger finger or trigger thumb, but the rest of everything, you often have to thing about rehab and patients need to engage in terms of relatively rest for two weeks after injections and then go back to engage with the physiotherapy and rehab afterwards so it's kind of agreement and a contract with your patients that they have to understand those to get the maximum benefits of it.

SPEAKER_00:

I suppose that's where our patient education comes in we need the patient to understand the process and quite a lot really about what's happening and why we're doing it to then engage with that process don't we really?

SPEAKER_02:

Yeah because like I said that is when your evidence come along like it lasts for a few weeks to a few months but it doesn't mean after a few months you have your pain coming back again because if you can give your patients some short-term relief they will be able to go back to their normal function they will have better sleep they will feel happier and they can engage with their rehab better and all this just break that visual circle and on the top of other management and self-management, then that gives them a more sustainable effect.

SPEAKER_00:

Definitely. What are your thoughts around repeat injections? Because we might see a patient who we think, right, okay, they're not sleeping. They're struggling to engage with rehabilitation and actually an injection here. They've tried our over-the-counter medications. They've got that stepwise approach. We're thinking, right, give them the injection. And they get some relief. They undertake the rehab alongside it. They do everything we're asking. But that relief is quite short term. We know that sometimes it can be. What are your thoughts around repeating that injection?

SPEAKER_02:

That's a good question too. It could be case by case basis. So repeated injections is normally not recommended. If your first injection, it doesn't work because the first thing you think about is, is this the right diagnosis? So you need to think about differentiated diagnosis. There are also many factors. It's not necessarily your ingestion techniques or your diagnosis, but a lot of other factors, patient factors. For example, someone have a background of chronic pain, sensitizations, referral pain. So again, it's go back to that diagnosis and consider any, like, is there any other pathologies causing it? It could be, is that they're engaging their rehab? So again, In terms of guidelines, for example, NICE guidelines suggest a weight-bearing joint should not be injected more than four to six months. So you really should not have more than two or three times a year for knee injections. So if someone comes to me, for example, the third time of the year wanting a steroid injection of the knee, then I would consider whether it's too severe that they may need to consider surgery. Are we having a great diagnosis here? Or is there any other factors may causing this ongoing pain? And sometimes it's not just MSK issues. It's maybe you need to think about outside the box. People may have diabetes. Would that be like diabetic neuropathy? Would that be some kind of vitamin deficiency? It's got to be outside the box as well. Particularly many of us now were as First contact practitioner, which you may see those much more in primary care. So repeated injections need to, again, apply that clinical reasoning, case-by-case basis, but also study that patient individually.

SPEAKER_00:

So it's that reassess, think again process. Is your diagnosis correct? Lots of that clinical thinking.

SPEAKER_02:

Yeah. But also I need to think about a lot like past medical history, the drug history, the social history, consider all of this. And also it's got to be like a personalized care approach as well. So sometimes when you prefer someone for rehab or physio, but the reality is they are not very good at doing their exercise or following self-management advice. So those may be the reason for failure. It's got to be looking at various aspects. You are almost like a detective when someone fails injections or fails any treatments because there are so many variables. But I think one key thing is we want to be safe. So safety in terms of injections. So think about are we doing more harm to the patients if we give them more injections? So always going back to that risk versus benefit. And even I've been doing this for such a long time now, I often still discuss cases with my colleagues. We always like learning and every patient is very different. So this is how we carry on learning and make sure we ensure that ongoing capability for our practice.

SPEAKER_00:

Absolutely. What would you say some of the takeaways, if I was to kind of pin you down and say, what are some of the takeaways that you'd really want the clinicians listening to this now to take from today's episode?

SPEAKER_02:

Stero injections definitely have a place in our MSK2 box. It's not the one and only treatment and it's definitely not the first line of treatments. I think that's something we bear in mind. But if we can use in the right patient at the right timing and right diagnosis, that is brilliant because we give our patient a window opportunity to rehab. So always think about clinical reasoning, it's risk versus benefit assessments, familiar yourself with your local protocols and policies, safety, and also aftercare as well. Because again, injections should be used in conjunction with other management as a total management approach. So that would be my... Take home message for everybody.

SPEAKER_00:

Brilliant. Well, that's certainly what I think I've got from this. And it's been really, really useful, Sharon. It's been great. I really appreciate your time today on the episode. We've covered loads in a short space of time. It's gone really, really quickly. And I'm sure it'd be really great to have you on again to talk about maybe this in more detail and some of the lots of other things that you do, if that's okay with you.

SPEAKER_02:

Yeah, of course. No problem.

SPEAKER_00:

Thank you very much, Sharon. We'll see you again soon.

UNKNOWN:

Bye. Thank you.