Human Data
Temporary and permanent damaging changes in soft tissue, bone, and cartilaginous structures, have long been reported to occur when corticosteroids are administered for human disease.58-62 In my pain practice, it is relatively common for a person to come in with X-rays or MRIs which demonstrate a rapid deterioration of the articular cartilage after being on a strong anti-inflammatory medication or receiving a corticosteroid shot. (See Figure 8.) 
One of the first reports of corticosteroid-induced cartilage damage was in 1960, where the authors reported on four cases of steroid arthropathy after patients were given corticosteroids.63 The authors noted, “Rapid destruction of the femoral head with subsequent disorganization of the hip joint rarely, if ever, occurs in uncomplicated rheumatoid arthritis or osteoarthritis. Recently we have seen four patients, all treated with corticosteroids, in which such destruction developed. The striking feature in each case was the relative freedom from pain in the presence of severe joint disorganization. Before advising treatment with either oral or intraarticular administration of corticosteroid, this possible complication should be borne in mind, and the likelihood of accelerated joint destruction weighed against the benefit which the patient is likely to derive.” There are many other reports of corticosteroids dramatically accelerating the arthritic process.63-67 The current literature continues to report on papers whereby intraarticular corticosteroid injections cause this rapid destruction of articular cartilage in various joints including the hips and shoulders.68-71
 Corticosteroids are injected into joints because they often provide some pain relief. Perhaps it is just this effect, however, that is one of the main reasons corticosteroids deteriorate cartilage. The thought process is simple. A person receives an intraarticular corticosteroid injection because of an injury within and/or around, the involved joint. The corticosteroid provides pain relief, generally lasting for a few weeks. So, some of the articular cartilage damage from steroids can be attributed to analgesia, resulting in microtrauma due to painless overuse. During the period of pain relief offered by the steroid shot, the person resumes normal activities, including athletics. Without the steroid, the person is unable to perform these activities or they are modified because of pain. Now, because the patient does not sense the pain, activities are resumed. This situation is much like the professional football players who receive steroid injections before or during an NFL game. A recent Caring Medical patient told me that during a typical NFL game, five players are receiving injections before or during a game. He said that he has even received two shots in one game. (See Figure 9.) Without a pain signal, the patient has no idea if the activities he is doing, such as running and jumping, are contributing to the deterioration of his cartilage.
 Another good example of painless cartilage deterioration is rheumatoid arthritis. Three papers clearly demonstrate the principle that cartilage could be deteriorating even though, clinically, a patient feels better. In the first study involving forty rheumatoid arthritis patients, patients reported feeling better due to medications including steroids, with resultant improvement in their blood tests as well. However, X-rays of their hands and feet over the years revealed worsening of the cartilage.72 In cases where the patients’ rheumatoid arthritis was in complete remission, researchers found that even though the rheumatoid arthritis was in clinical remission, articular cartilage deterioration was still reported.73,74 Simply put, pain is our protective mechanism to know something is wrong. Blocking the pain response with anti-inflammatories or corticosteroids overrides this mechanism. Cortisone shots and exercise can be a deadly combination for articular cartilage cells. A good example of this was an animal study where the researchers looked at cartilage cell counts in hydrocortisone injected knees without exercise and those in hydrocortisone injected knees with exercise. This would be akin to patients receiving cortisone shots so they could resume their tennis playing. In this study, all knees injected with cortisone showed cartilage deterioration, but severe cartilage damage was seen in 67% of animals that exercised and also received cortisone. The cortisone and exercise group also showed a significant decline in glycosaminoglycan synthesis and cartilage cell counts compared to the other group. The animals that received a cortisone shot and then ran showed areas of cartilage cell death, which weren’t seen in those animals that only exercised or only received a cortisone shot.75 (See Figure 10.)
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