Adverse effects of extra-articular corticosteroid injections: a systematic review

Two researchers read a share of the abstracts for inclusion in this review. Only studies that reported original patient material (e.g. case reports, case studies, cohort studies, clinical trials and case control studies) that reported on the occurrence of adverse events after intervention with local non-intra-articular corticosteroid injections were included. Studies concerning epidural injection and intramusculair injections were excluded. Because the adverse events of therapy are not always mentioned in the article abstracts, the full article of all relevant clinical trials were carefully read to find any reported adverse events [15].

Only two articles mentioned an adverse event after a corticosteroid injection in the bursa round the hip. One of these studies reported a complication after a ten-fold higher dose was accidentally given [16], and the other reported a case of a necrotizing fasciitis after a corticosteroid injection in the trochanteric bursa - which proved to be a lethal complication [17]. Necrotizing fasciitis after corticosteroid injection for trigger finger was presented as another severe complication [18]. Six studies described hypopigmentation of the skin [19‐24], and two studies described atrophy of the skin [21, 23]. Atrophy of the plantar fat pad was reported after injecting an interdigital neuroma, and another group reported perilymphatic atrophy [25, 26]. Atrophy of the skin and subcutaneous fat with hyperpigmentation was described in one patient after intralesional injection of a neuroma at the feet [27]. A skin defect was observed after two injections of triamcinolone injected into a hypertrophic scar [28]. Osteomyelitis of the humerus was reported after three injections with hydrocortisone for a tennis elbow [29]. Osteomyelitis of the calcaneus was reported after an injection for plantar fasciitis [30]. Localized abscess containing Staphylococcus aureus was described after injection of corticosteroid for the treatment of chronic tendinitis of the Achilles tendon [31]. Another article mentioned a sterile abscess after injecting a patient with a plantar fasciitis [32]. Protothecosis (a rare infection caused by an achlorophyllic algae) was seen in two patients after intralesional injections with corticosteroids [33]. Atypical mycobacterium soft tissue infection was reported after corticosteroid injection for de Quervain's disease [34]. An allergic reaction was reported after giving an injection to a patient who had tendonitis [35]. A tendon rupture of the hand was described after an injection into the carpal tunnel, and a tendon rupture after an injection for tennis elbow [36, 37]. A delayed flexor superficiales and profundus rupture occurred after a steroid injection for trigger finger [38]. Seven weight lifters presented at the hospital with ruptured patellar tendon, they all had a history of multiple local steroid injections [39]. A rupture of the Achilles tendon associated with corticosteroid injections was reported in three studies [40‐42]. Another case report described an avulsion of the calcaneal tendon after steroid injections administered because of an acute flare-up of rheumatoid arthritis [43]. One study described thirteen patients who developed 15 ruptured tendons subsequent to injection of a depository steroid in or around the tendons injected [44]. One study reported ischemia of the hand after carpal tunnel injection and one study after a corticosteroid injection for de Quervain tenosynovitis [45, 46]. Nerve injury after steroid injection for carpal tunnel syndrome is described in 3 studies [47‐49]. Soft tissue calcifications were reported as a complication due to adjusted materials in the solvent or due to an accumulation of insoluble steroid [50‐52].

Of the 37 prospective studies, 11 reported no adverse effects. Hypopigmentation was reported in three studies [53‐55]. Atrophy was described in four studies [54, 56‐58]. Increased or persistent pain after injection or pain at the site of injection was described in 19 studies. Adverse events not mentioned in the case reports were flushes and disturbance in menstrual pattern [59]. Cellulitis, ecchymosis and subcutaneous nodule were three other symptoms not mentioned earlier in the case reports [55, 60]. Table 1 presents information on the minor and major adverse events in the prospective studies.

In one retrospective study septic bursitis was described after corticosteroid injection in traumatic olecranon bursitis [61]. Tachon's syndrome (subacute back pain and/or thoracic pain following local injections of corticosteroids) was reported in one study [62]. Table 2 presents information on the adverse events in the retrospective studies.

The following adverse events were registered by the 'Lareb' institute following extra-articular indications: after corticosteroid injection for bursitis trochanterica flushing was reported, after injection for tennis elbow, rash, menstrual disorder, and skin depigmentation and in one patient dyspnoea and eyelid ptosis were reported. In one patient hallucination, increased intracranial and intraocular pressure, and paresis occurred after corticosteroid injection for a calcaneal spur. In another patient, after corticosteroid injection for carpal tunnel syndrome hirsutism, nail changes and vaginal hemorrhage were reported. After injection for trigger finger an allergic skin reaction was observed. Reported adverse events after corticosteroid injections for tendonitis were: anaphylactic reaction in one patient, erythema and skin atrophy in another, and rash and tendon disorder in the third patient.