Cortisone Injection Risks: Why Repeated Steroid Shots Can Backfire

Key Research Findings

Recent studies reveal significant risks from repeated cortisone injections for knee osteoarthritis:

57% increased risk of needing total knee replacement (JAMA 2019)
Accelerated cartilage loss compared to placebo injections
Higher radiographic progression with continuous injections (4.67x odds)
Short-term relief but long-term joint damage
Diabetics face additional risks from blood sugar spikes

The Cortisone Paradox

Cortisone injections are the most commonly prescribed treatment for knee osteoarthritis pain. They work quickly—often providing relief within days. But emerging research reveals a troubling pattern: the more cortisone you get, the worse your joint may become over time.

This creates a paradox: a treatment designed to help your knee may actually accelerate its deterioration.

What the Research Shows

JAMA Study: 57% Higher Surgery Risk

A landmark 2019 study published in JAMA analyzed data from thousands of knee OA patients and found that repeated corticosteroid injections were associated with a 57% increased risk of needing total knee replacement compared to hyaluronic acid injections.^[1]

Study Findings:

Group	Hazard Ratio for TKR
Corticosteroid injections	1.57 (57% increased risk)
Hyaluronic acid injections	1.00 (reference)

Each additional corticosteroid injection increased absolute TKR risk by 9.4% at nine years.

McAlindon Study: Accelerated Cartilage Loss

A randomized controlled trial by McAlindon et al. found that patients receiving cortisone injections every three months showed significantly greater cartilage volume loss on MRI compared to those receiving saline placebo injections.^[2]

After two years:

Cortisone group: Greater cartilage loss
Placebo group: Slower cartilage decline
No difference in pain outcomes

Translation: Cortisone didn’t help more than placebo for pain but caused more cartilage damage.

Radiographic Progression

A 2023 study in the American Journal of Roentgenology found that patients receiving continuous corticosteroid injections had 4.67 times higher odds of radiographic OA progression compared to those who didn’t receive injections.^[3]

Why Does Cortisone Damage Cartilage?

The Biological Mechanism

Corticosteroids are powerful anti-inflammatory agents, but they have multiple effects on joint tissues:

Chondrocyte toxicity - Cortisone can damage or kill cartilage cells

Collagen degradation - Weakens the cartilage matrix

Inhibited repair - Suppresses natural healing processes

Bone effects - May contribute to subchondral bone changes

The Short-Term vs. Long-Term Trade-off

Timeframe	Effect
Days 1-7	Rapid pain relief, reduced inflammation
Weeks 2-8	Benefit gradually wears off
Months 3-6	Pain returns; temptation to re-inject
Years 1-2+	Cumulative cartilage damage, faster OA progression

How Many Injections Are Too Many?

Current Guidelines

Most medical guidelines recommend limiting corticosteroid injections to 3-4 per year per joint, with a minimum of 3 months between injections.^[4]

Injection Frequency Guidelines:

Guideline	Recommendation
ACR/Arthritis Foundation	No more than 3-4 per year
AAOS	Limit frequency; patient-specific
Primary Care Best Practice	Minimum 3 months between injections
Cleveland Clinic	No more than 3-4 per year per joint

Red Flags: When Your Provider May Be Overusing Cortisone

Offers cortisone every 4-6 weeks

Doesn’t discuss long-term cartilage effects

Doesn’t mention alternatives like hyaluronic acid

Uses cortisone as the only non-surgical option

Doesn’t track how many injections you’ve received

Special Risks for Specific Populations

Diabetics

Cortisone injections can cause significant blood sugar elevation that lasts several days to weeks. For diabetics:

Blood glucose may spike 50-200 mg/dL or more
Effect can last 3-5 days (sometimes longer)
May require insulin adjustment
Repeated injections compound metabolic effects

Patients on Blood Thinners

Increased bleeding risk at injection site
May need to hold anticoagulation (discuss with physician)

Those with Osteoporosis

Systemic cortisone effects can affect bone density
Joint-adjacent bone may be vulnerable

Better Alternatives to Repeated Cortisone

Hyaluronic Acid Injections

Unlike cortisone, hyaluronic acid (HA) injections address joint mechanics without damaging cartilage:^[5]

HA Advantages Over Cortisone:

Factor	Cortisone	Hyaluronic Acid
Duration of relief	4-8 weeks	6-12 months
Cartilage effect	Potentially harmful	Neutral to protective
Frequency allowed	3-4 per year max	Every 6 months
TKR risk	Increased (57%)	Decreased
Diabetes impact	Spikes blood sugar	No blood sugar effect

Physical Therapy

Strengthening the muscles around your knee can:

Reduce joint stress
Improve stability
Decrease pain without medication
Provide lasting benefit with continued exercise

Weight Management

Every pound of body weight translates to 3-4 pounds of pressure on your knees. Weight loss can significantly reduce OA pain and progression.

Combination Approach

The most effective treatment often combines:

HA injections for lubrication and pain relief
Physical therapy for strength and stability
Weight management to reduce joint stress
Activity modification to protect the joint

When Is Cortisone Still Appropriate?

Cortisone isn’t inherently bad—it has legitimate uses:

Acute inflammatory flares - Sudden, severe inflammation

Occasional use - 1-2 times per year maximum

Pre-surgical planning - Brief relief while awaiting surgery

Diagnostic purposes - Confirm that joint is pain source

The Bottom Line on Cortisone

Cortisone can be a useful tool for occasional, short-term relief. The problem arises when it becomes the default—or only—treatment offered, leading to:

Repeated injections beyond safe limits
Missed opportunities for disease-modifying treatment
Accelerated joint deterioration
Earlier need for joint replacement

Questions to Ask Your Provider

Before accepting cortisone injections, ask:

How many cortisone injections have I had in this joint?
What are the long-term effects of repeated injections?
Are there alternatives like hyaluronic acid that might be better for my situation?
Am I at risk for accelerated cartilage damage?
What’s your plan beyond cortisone if this stops working?

The Bigger Picture

Rethinking the Default

Cortisone has been the go-to injection for decades—but the evidence now suggests we need to be more judicious:

Short-term relief comes at the cost of long-term joint health
Alternatives exist that don’t carry the same cartilage risks
Frequency matters - occasional use is safer than repeated injections
Patient education is essential so you can make informed choices

If you’ve been getting cortisone injections every few months and your knee keeps getting worse, it may be time to have a conversation with your provider about a different approach.

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References

Zeng C, et al. Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative. JAMA, 2019. PubMed
McAlindon TE, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis. JAMA, 2017;317(19):1967-1975.
Radiographic OA progression with corticosteroid injections. American Journal of Roentgenology, 2023. AJR Online
Cleveland Clinic. Cortisone Shots: Steroid Injections. Cleveland Clinic
Comprehensive review of viscosupplementation. Orthopedic Reviews. Full Text

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