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Research · Medication

Joint corticosteroid injections

Injected into an arthritic knee, corticosteroids eased pain more than saline for a few weeks, with no effect by 6 months. Repeated knee injections thinned cartilage in a 2-year trial. Epidural injections gave small, short-term sciatica relief and none for spinal stenosis. Tennis elbow did worse at 1 year. FDA warns of paralysis and stroke after epidural use.

Add to Bio HackChecked 2026-11-14
Status
Prescription drugs in the US. Triamcinolone acetonide (Kenalog) and methylprednisolone acetate (Depo-Medrol) suspensions are FDA-approved for short-term injection into a joint or soft tissue for osteoarthritis synovitis, rheumatoid arthritis, bursitis, tenosynovitis, epicondylitis and acute gout. Extended-release triamcinolone (Zilretta) is approved only for a single injection into the knee for osteoarthritis pain. Epidural injection of corticosteroids is not FDA-approved, and the labels carry an FDA warning of serious neurologic events after epidural use.
Also called
cortisone shot, steroid shot, steroid injection, joint injection, intra-articular corticosteroid, knee injection, shoulder injection, epidural steroid injection, ESI, triamcinolone acetonide, Kenalog, Kenalog-40, Zilretta, extended-release triamcinolone, methylprednisolone acetate, Depo-Medrol, betamethasone, Celestone Soluspan, dexamethasone injection
Taken for
knee arthritis pain, osteoarthritis, shoulder pain, frozen shoulder, rotator cuff pain, tennis elbow, tendinitis, bursitis, sciatica, back pain, spinal stenosis, hip pain, joint inflammation

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help5

Reported risks8

What people take it for, and what was found

Shown to help5

StrongVery common

Knee osteoarthritis pain, first weeks

Shown to ease knee osteoarthritis pain more than sham or saline injections for up to about 6 weeks, about 1 point on a 10-point scale.

Compared with sham or saline injections, or no treatment [1]; placebo injections [2]

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
Injected into the knee joint, corticosteroids lowered pain more than control (SMD -0.40, 95% CI -0.58 to -0.22), about 1.0 cm on a 10-cm scale and a number needed to treat of 8. The effect was moderate at 1 to 2 weeks (SMD -0.48) and small to moderate at 4 to 6 weeks (SMD -0.41). Function improved (SMD -0.33, number needed to treat 10) [1]. A second meta-analysis found pain 1.6 points lower and WOMAC 9.9 points lower than placebo at 6 weeks or less, both past the smallest clinically important difference [2].
Population
1,767 participants in 27 trials [1]; 842 patients in 11 placebo-controlled RCTs [2].
Sources
[1], [2]
Caveats
Evidence was low quality, with high heterogeneity and smaller effects in larger trials [1]. Both reviews found risk of bias [1][2].
Limited

Extended-release triamcinolone (Zilretta) in the knee

One trial found extended-release triamcinolone eased knee osteoarthritis pain more than saline at 12 weeks, but not more than standard triamcinolone on the main pain measures.

Compared with saline injection [4]; standard triamcinolone acetonide crystalline suspension 40 mg [4]

The numbers and sources
Effect
After a single 32 mg injection into the knee, average daily pain fell 3.12 points from baseline at week 12 against 2.14 on saline (P < 0.0001). Pain improvements were not significant against standard triamcinolone on the daily-pain secondary measures, while exploratory WOMAC and quality of life scores favored the extended-release form. Adverse events were similar across groups [4]. The label says the efficacy and safety of repeat injections have not been demonstrated, and it is not for small joints such as the hand [5].
Population
484 adults aged 40 and older with knee osteoarthritis, Kellgren-Lawrence grade 2 or 3, over 24 weeks [4].
Sources
[4], [5]
Caveats
One phase 3 trial, with comparisons against the standard form as secondary end points [4].
Moderate

Frozen shoulder

Shown to lower frozen shoulder pain by about 1.3 points on a 10-point scale at 4 to 6 weeks against no or sham injection, with smaller effects by 6 months.

Compared with no injection or sham injection [7]

The numbers and sources
Effect
Injected into the shoulder joint, steroid lowered pain against controls at 4 to 6 weeks (MD 1.28 cm, 95% CI 0.75 to 1.82), 12 to 16 weeks (MD 1.00 cm) and 24 to 26 weeks (MD 0.65 cm, 95% CI 0.19 to 1.10), and improved external rotation, abduction, flexion and disability scores. Trial sequential analysis confirmed the effect at 4 to 16 weeks but not at 24 to 26 weeks [7].
Population
416 patients with frozen shoulder in 8 RCTs [7].
Sources
[7]
Caveats
One meta-analysis of small trials. Both groups improved over time [7].
Moderate

Rotator cuff tendon pain

Shown to give small, short-lived pain relief at 4 to 8 weeks against placebo injection under the shoulder bone, with no difference by 3 months.

Compared with placebo injection [8]; other treatments [9]

The numbers and sources
Effect
Corticosteroid injected under the acromion did not lower pain more than placebo at 3 months. Pain relief at 4 to 8 weeks was small (SMD 0.52, range 0.27 to 0.78), and at least 5 people had to be treated for 1 to have pain reduced to mild or less. Repeat injections were no better than one [8]. A review of tendon injections found the short-term effect for rotator cuff tendinopathy unclear [9].
Population
726 patients in 11 placebo-controlled studies [8]; 41 RCTs of tendon injections [9].
Sources
[8], [9]
Caveats
Heterogeneity was substantial [8].
Strong

Sciatica, epidural injection

Shown to reduce sciatica leg pain and disability slightly against placebo injections in the short term, about 5 to 6 points on a 100-point scale, with no lasting effect.

Compared with placebo injections of saline, local anesthetic or sham, into the epidural space or nearby tissue [11][12]

The numbers and sources
Effect
Pooling 23 trials, epidural corticosteroids lowered leg pain in the short term (MD -6.2 on a 0 to 100 scale, 95% CI -9.4 to -3.0) and disability (MD -3.1), with smaller, nonsignificant effects at 12 months or more [11]. The Cochrane update of 25 trials found leg pain 4.93 points lower (95% CI -8.77 to -1.09, 8 trials, moderate quality) and disability 4.18 points lower at short-term follow-up, below what patients may find clinically important [12].
Population
23 trials [11]; 2,470 participants in 25 trials, mean age 37 to 53 [12].
Sources
[11], [12]
Caveats
The Cochrane review is an update of [11] by the same group [12]. Thresholds of 10 to 30 points have been proposed for a clinically important change [11]. Epidural injection of corticosteroids is not FDA-approved [13].

Mixed results1

Moderate

Tennis elbow

Mixed results: injections eased tennis elbow pain strongly at about 4 weeks, but people did worse at 6 and 12 months than with no injection or a placebo injection.

Compared with no intervention and other treatments [9]; placebo injection, with or without physiotherapy [10]

The numbers and sources
Effect
Against no intervention, corticosteroid injection had a large short-term effect on pain (SMD 1.44, 95% CI 1.17 to 1.71), but no intervention was favored at intermediate (SMD -0.40) and long term (SMD -0.31) [9]. In a placebo-controlled trial, complete recovery or much improvement at 1 year was 83% after corticosteroid and 96% after placebo injection, and recurrence was 54% against 12% (RR 0.23, 99% CI 0.10 to 0.51). At 26 weeks, 55% against 85% had recovered or much improved [10].
Population
2,672 participants in 41 RCTs of tendon injections [9]; 165 adults with tennis elbow over 6 weeks, followed 1 year [10].
Sources
[9], [10]
Caveats
Effects differed between tendon sites [9]. Physiotherapy did not change 1-year outcomes [10].

Not shown to help3

Strong

Knee osteoarthritis pain after 3 months

Not shown to ease knee osteoarthritis pain more than placebo by 6 months, and injections every 3 months for 2 years did not lower pain against saline.

Compared with sham or saline injections, or no treatment [1]; placebo injections [2]; saline injections every 12 weeks [3]

The numbers and sources
Effect
The pain effect was small at 13 weeks (SMD -0.22, 95% CI -0.44 to 0.00) and absent at 26 weeks (SMD -0.07, 95% CI -0.25 to 0.11), and function did not differ at 13 or 26 weeks [1]. At 6 weeks to 3 months, differences no longer reached clinical importance, and none was found at 6 months or later [2]. In a 2-year trial of triamcinolone 40 mg into the knee every 12 weeks, pain did not differ from saline (difference -0.6 on a 0 to 20 scale, 95% CI -1.6 to 0.3) [3].
Population
27 trials [1]; 11 RCTs [2]; 140 adults with symptomatic knee osteoarthritis and synovitis on ultrasound [3].
Sources
[1], [2], [3]
Caveats
Few trials followed people beyond 3 months [2].
Limited

Knee osteoarthritis, compared with physical therapy

One trial found less pain and disability at 1 year after physical therapy than after knee corticosteroid injections, a WOMAC difference of 18.8 points.

Compared with physical therapy [6]

The numbers and sources
Effect
From similar baselines (108.8 and 107.1 on a 0 to 240 scale), WOMAC scores at 1 year were 55.8 after glucocorticoid injections and 37.0 after physical therapy (difference 18.8, 95% CI 5.0 to 32.6). Secondary outcomes went the same way. One patient fainted during an injection [6].
Population
156 adults with knee osteoarthritis, mean age 56, in the US Military Health System [6].
Sources
[6]
Caveats
One trial, not blinded to treatment type [6].
Limited

Spinal stenosis, epidural injection

One trial found epidural glucocorticoids plus lidocaine did not improve disability or leg pain at 6 weeks more than lidocaine alone in lumbar spinal stenosis.

Compared with epidural lidocaine alone [14]

The numbers and sources
Effect
At 6 weeks, disability scores (adjusted difference -1.0 on a 0 to 24 scale, 95% CI -2.1 to 0.1) and leg pain (-0.2 on a 0 to 10 scale, 95% CI -0.8 to 0.4) did not differ, with no difference by injection route [14].
Population
400 adults with lumbar central spinal stenosis and moderate to severe leg pain [14].
Sources
[14]
Caveats
The comparison was lidocaine, not inert placebo. Funded by the US Agency for Healthcare Research and Quality [14].

Doses studied

Injections into the knee in the trials used triamcinolone acetonide 40 mg every 12 weeks for 2 years [3] and a single extended-release dose of 32 mg or standard triamcinolone 40 mg [4]. The Kenalog label gives 2.5 to 5 mg for smaller joints and 5 to 15 mg for larger joints as a starting dose, says up to 10 mg for smaller areas and 40 mg for larger areas have usually been enough, and says single injections into several joints have totaled up to 80 mg [13]. The Zilretta label gives one 32 mg injection into the knee and says the efficacy and safety of repeat doses have not been demonstrated [5]. Doses in the shoulder, elbow and epidural trials varied by trial and drug [7][9][11].

Risks

Reported risks8

ModerateCommon

Facial flushing and fainting

Shown in frozen shoulder trials to cause facial flushing in 1.78% and fainting-type dizziness in 0.71% around shoulder injections.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
Complication rates after steroid injection into the shoulder joint were 1.78% for facial flushing, 0.71% for dizziness from vasovagal reactions during injection, 1.07% for chest or shoulder pain and 0.36% for nausea [7]. In the knee trial against physical therapy, one patient fainted during an injection [6].
Population
416 patients in 8 frozen shoulder RCTs [7]; 156 adults with knee osteoarthritis [6].
Sources
[7], [6]
Caveats
The review gives these as complication rates without a control rate [7].
ModerateUncommon

Tendon rupture, joint infection and skin changes

Shown to be rare in tendon injection trials, with 1 tendon rupture in 991 people. The labels list joint infection, skin thinning, lighter skin and post-injection flare.

The numbers and sources
How common
Uncommon: between 1 in 1,000 and 1 in 100 people.
Effect
Of 991 people given corticosteroid injections in tendon trials that reported adverse events, 1 (0.1%) had a serious adverse event, a tendon rupture [9]. The Kenalog label lists septic arthritis, cutaneous and subcutaneous atrophy, hypopigmentation and hyperpigmentation, post-injection flare, tendon rupture and Charcot-like arthropathy [13]. Septic arthritis is listed among Zilretta postmarketing reports [5].
Population
991 people in RCTs of tendon injections [9]; label reports [13][5].
Sources
[9], [13], [5]
Caveats
Trials were short and not powered for rare harms [9].
LimitedHow often is not known

FDA warning: serious neurologic events after epidural injection

The labels warn that serious neurologic events, some fatal, including spinal cord infarction, paralysis, cortical blindness and stroke, have followed epidural corticosteroid injections.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
The Kenalog and Depo-Medrol labels state that serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids, including spinal cord infarction, paraplegia, quadriplegia, cortical blindness and stroke, with and without fluoroscopy, and that safety and effectiveness of epidural use have not been established [13][15]. The Zilretta label says corticosteroids are not approved for epidural or intrathecal use and that Zilretta is for injection into a joint only [5].
Population
Postmarketing reports summarized on the labels [13][15][5].
Sources
[13], [15], [5]
Caveats
Reports give no rate. FDA's 2014 Drug Safety Communication on this warning could not be retrieved at the address tried, so the label text is cited instead.
LimitedHow often is not known

Cartilage loss and faster arthritis with repeated knee injections

One 2-year trial found more cartilage thinning with knee injections every 3 months than saline, and a cohort linked injections to about 3 times the x-ray progression.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Triamcinolone 40 mg into the knee every 12 weeks thinned cartilage by 0.21 mm against 0.10 mm on saline over 2 years (difference -0.11 mm, 95% CI -0.20 to -0.03), with no pain benefit [3]. In a propensity-matched cohort, x-ray worsening occurred at 21.7 per 100 person-years in people starting injections and 7.1 in comparators (HR 3.02, 95% CI 2.19 to 4.16), and 4.67 with continued injections [16].
Population
140 adults with knee osteoarthritis [3]; 684 matched adults with mild to moderate knee osteoarthritis, 148 starting injections [16].
Sources
[3], [16]
Caveats
The cohort is observational, and people who get injections may have worse disease to begin with [16]. The clinical meaning of the cartilage change was not defined [3].
LimitedHow often is not known

Rapid joint destruction and bone collapse

Case reports: a review describes faster arthritis, small bone fractures under the cartilage, bone death and rapid joint destruction seen after hip and knee steroid injections.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
The review describes four adverse joint findings seen after intra-articular corticosteroid injection: accelerated osteoarthritis progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction including bone loss [17]. The Kenalog label lists Charcot-like joint damage and post-injection flare [13].
Population
Published case reports and series reviewed in [17]; label [13].
Sources
[17], [13]
Caveats
A narrative review without rates. The authors note a lack of prospective and large studies [17].
LimitedHow often is not known

Raised blood sugar in people with diabetes

Small studies found blood sugar rose after joint injections in every study of people with diabetes, peaking up to 500 mg/dL, often 24 to 72 hours later.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
All 7 studies found a rise in blood glucose after intra-articular steroid injection in people with diabetes, substantial in 4, with peaks up to 500 mg/dL and a rise often within 24 to 72 hours [18]. In people with type 2 diabetes, average glucose rose 14.7 mg/dL over days 1 to 3 after extended-release triamcinolone and 33.9 mg/dL after standard triamcinolone (difference -19.2, 95% CI -38.0 to -0.4) [19].
Population
72 patients with diabetes in 7 studies [18]; 33 patients with knee osteoarthritis and type 2 diabetes [19].
Sources
[18], [19]
Caveats
Very small studies [18][19].
ModerateHow often is not known

Infection after a later joint replacement

Linked to about 39% higher odds of joint replacement infection when the injection was given within 3 months before surgery, with no rise for earlier injections.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Overall, odds of periprosthetic infection did not differ between people who had an injection before hip or knee replacement and those who had not (OR 1.22, 95% CI 0.95 to 1.58). Injection within 3 months before surgery raised the odds (OR 1.39, 95% CI 1.04 to 1.87), while injections 3 to 6 months before did not (OR 1.19, 95% CI 0.95 to 1.48) [20].
Population
173,465 hip or knee replacements in 11 retrospective studies, 73,049 with prior injections [20].
Sources
[20]
Caveats
All studies were retrospective [20].
LimitedHow often is not known

Adrenal suppression and use in pregnancy

The labels warn corticosteroid injections can cause reversible adrenal suppression lasting months, and that no adequate studies in pregnant women exist.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
The Zilretta label warns of reversible hypothalamic-pituitary-adrenal axis suppression with possible adrenal insufficiency after withdrawal that may persist for months, and says there are no data in pregnant women, with animal studies showing fetal harm at exposures below the human dose [5]. The Kenalog label says corticosteroids were teratogenic in several animal species and advises watching infants born to mothers given corticosteroids for low adrenal function [13].
Population
Label statements and animal studies [5][13].
Sources
[5], [13]
Caveats
Most published pregnancy data are for oral, topical and inhaled corticosteroids, so the label says they apply poorly to a single joint injection [5].

Claims tested and not found

  1. That steroid injections slow knee arthritis. In a 2-year trial, injections every 3 months caused more cartilage loss than saline and no less pain [3].
  2. That epidural steroids help spinal stenosis. Disability and leg pain at 6 weeks did not differ from lidocaine alone [14].
  3. That a cortisone shot gives tennis elbow a better long-term outcome. At 1 year, fewer people had recovered after corticosteroid (83%) than after placebo injection (96%), and recurrence was higher [10].
  4. That repeat shoulder injections work better than one. Multiple injections were no better than a single injection at any time point in rotator cuff tendinosis [8].

Sources

  1. Jüni P, Hari R, Rutjes AW, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database of Systematic Reviews. 2015. https://doi.org/10.1002/14651858.cd005328.pub3
  2. Bensa A, Albanese J, Boffa A, et al. Intra-articular corticosteroid injections provide a clinically relevant benefit compared to placebo only at short-term follow-up in patients with knee osteoarthritis: A systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. https://doi.org/10.1002/ksa.12057
  3. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017. https://doi.org/10.1001/jama.2017.5283
  4. Conaghan PG, Hunter DJ, Cohen SB, et al. Effects of a Single Intra-Articular Injection of a Microsphere Formulation of Triamcinolone Acetonide on Knee Osteoarthritis Pain: A Double-Blinded, Randomized, Placebo-Controlled, Multinational Study. Journal of Bone and Joint Surgery. 2018. https://doi.org/10.2106/jbjs.17.00154
  5. Zilretta (triamcinolone acetonide extended-release injectable suspension), for intra-articular use, prescribing information (Pacira Pharmaceuticals). 2026. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cd5c4673-21f2-4126-9556-da847b3a228b
  6. Deyle GD, Allen CS, Allison SC, et al. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. New England Journal of Medicine. 2020. https://doi.org/10.1056/nejmoa1905877
  7. Sun Y, Zhang P, Liu S, et al. Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis. The American Journal of Sports Medicine. 2017. https://doi.org/10.1177/0363546516669944
  8. Mohamadi A, Chan JJ, Claessen FM, et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clinical Orthopaedics and Related Research. 2017. https://doi.org/10.1007/s11999-016-5002-1
  9. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet. 2010. https://doi.org/10.1016/s0140-6736(10)61160-9
  10. Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013. https://doi.org/10.1001/jama.2013.129
  11. Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Annals of Internal Medicine. 2012. https://doi.org/10.7326/0003-4819-157-12-201212180-00564
  12. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database of Systematic Reviews. 2020. https://doi.org/10.1002/14651858.cd013577
  13. Kenalog-40 and Kenalog-80 (triamcinolone acetonide injectable suspension), prescribing information (E.R. Squibb & Sons). 2024. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cf970688-cd77-b95c-4bd9-c541590e9722
  14. Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. New England Journal of Medicine. 2014. https://doi.org/10.1056/nejmoa1313265
  15. Depo-Medrol (methylprednisolone acetate injectable suspension), prescribing information (Pharmacia & Upjohn). 2026. DailyMed, US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=823b0010-2b57-4e76-b5ac-4a8c2963438f
  16. Zeng C, Lane NE, Hunter DJ, et al. Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative. Osteoarthritis and Cartilage. 2019. https://doi.org/10.1016/j.joca.2019.01.007
  17. Kompel AJ, Roemer FW, Murakami AM, et al. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought? Radiology. 2019. https://doi.org/10.1148/radiol.2019190341
  18. Choudhry MN, Malik RA, Charalambous CP. Blood Glucose Levels Following Intra-Articular Steroid Injections in Patients with Diabetes: A Systematic Review. JBJS Reviews. 2016. https://doi.org/10.2106/jbjs.rvw.o.00029
  19. Russell SJ, Sala R, Conaghan PG, et al. Triamcinolone acetonide extended-release in patients with osteoarthritis and type 2 diabetes: a randomized, phase 2 study. Rheumatology. 2018. https://doi.org/10.1093/rheumatology/key265
  20. Lai Q, Cai K, Lin T, et al. Prior Intra-articular Corticosteroid Injection Within 3 Months May Increase the Risk of Deep Infection in Subsequent Joint Arthroplasty: A Meta-analysis. Clinical Orthopaedics and Related Research. 2022. https://doi.org/10.1097/corr.0000000000002055

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