Intra-articular Steroid Therapy Research Articles

Ultrasonographic evaluation of changes in the joint before and after intra-articular injection in children with juvenile idiopathic arthritis.

The aim of this study is to ultrasonographically (US) evaluate the course of the knee joint in oligoarticular juvenile idiopathic arthritis (JIA) patients who received intra-articular steroid (IAS) application to the knee joint. 237 knee joints of 175 patients with oligoarticular JIA were evaluated retrospectively. The patients were divided into two groups: those who received only IAS therapy and those who were methotrexate to IAS therapy. Synovial fluid grade changes, synovial proliferation in B mode examination and power Doppler (PD) changes were evaluated with musculoskeletal ultrasonography (MSUS) separately for each joint before the treatment and at the 2nd, 6th and 12th weeks of the treatment. The percentages of regression in synovial fluid grade at the second, sixth, and 12th weeks were respectively 73.4%, 88.6%, and 89.0% (n=174, 210, 211, respectively). Meanwhile, the percentages of regression in PD grade were 69.2%, 82.7%, and 84.0% (n=164, 196, 199, respectively). At the second, sixth and 12th weeks, the percentage of those with synovial fluid grade 0 was 24.1%, 54.9%, 73.4%, respectively (n=57, 130, 174, respectively), while the percentage of those with PD grade 0 was 39.7%, 67.9%, 80.6%, respectively (n=94,161,191, respectively). The percentage of those without synovial proliferation in the second, sixth and 12th weeks was found to be 26.2%, 54.9%, 73.8% respectively (n=62, 130, 175, respectively). The mean time to regression of synovial fluid, synovial proliferation, and PD in the only IAS group was significantly short. The percentage of synovitis regression was higher in the only IAS group at all weeks. This difference was especially more pronounced in the early period. When the 12th-week results were evaluated, there was no difference between the two groups. This study highlights the utility of MSUS in evaluating the early results of IAS therapy applied to the knee joint in oligoarticular JIA patients.

Current Trends in Intra-articular Knee Injections Among Family Physicians.

Family physicians use a variety of medications and techniques to perform intra-articular knee injections in the treatment of knee osteoarthritis. Currently, there is no consensus in the literature among the various specialties that perform joint injections for osteoarthritis of the knee regarding frequency of injections and injectate. The purpose of this study is to examine (1) the types of intra-articular knee injections used by family physicians for arthritis, (2) the most commonly used injectate, (3) the procedural approach, and (4) the maximum number of times the majority of family physicians would inject a single knee. Our study provides a descriptive epidemiology of current knee injection practices in the United States among family physicians. Surveys were emailed to family physicians. We evaluated and analyzed responses. We received 360 responses, of which 317 family physicians indicated using intra-articular knee injections for pain. The majority (99%) used intra-articular injection steroid therapy in the treatment of knee osteoarthritis. About half (57.4%) of the family physicians would inject the same knee between one to five times. This study provides an overview of current practices in intra-articular injections among family physicians in the United States and provides important information regarding injection practices. Given the lack of consensus and that current practice contradicts evidence in the literature, consideration should be given among all specialties who perform joint injections to create evidence-based clinical practice guidelines to optimize patient care.

A Prospective Study Comparing Arthroscopic Release, Intra-articular Steroid and Physical Therapy for Frozen Shoulder

Introduction: Frozen shoulder or Adhesive Capsulitis (AC) is a painful condition with fibrotic and contracted shoulder joint capsule. There is a lack of development of an effective treatment protocol for idiopathic AC. Aim: To evaluate the relative efficacy of Arthroscopic Capsular Release (ACR) and intra-articular steroid injections compared to standard physical therapy in isolation for frozen shoulder. Materials and Methods: This prospective interventional study was conducted at Maulana Azad Medical College, New Delhi, India between October 2012 to October 2015. Patients older than 40 years of age, with symptoms of AC for at least six months, without any related trauma or surgery or uncontrolled diabetes mellitus, and who did not respond to the conservative treatment, were selected. Ten patients were recruited each in the ACR, intra-articular steroids injection, and physical therapy groups. Shoulder Range of Motions (ROM), and the pre and post-treatment Shoulder Rating Questionnaire (SRQ) scores were calculated. Data analysis was performed using a Statistical Package for the Social Sciences (SPSS version 17). Results: The sample consisted of 12 male (40%) and 18 female (60%) patients with an average age of 52.2 years. There was no difference between the groups as far as the demographic characteristics were concerned. The SRQ scores and ROM in all the groups registered significant improvement compared to their pretreatment levels with a p-value of less than 0.005 for all three groups. However, the relative efficacy of different modes of treatment i.e. ACR, intra-articular steroid injection, and physical therapy, were found to be similar (p-value 0.165). Conclusion: The ACR does not provide any significant advantage over less invasive treatment alternatives. Therefore the authors recommend ACR only as a last option where other less invasive treatment modalities have failed.

Intra-Articular Steroid Injection for Patients with Hip Osteoarthritis: A Systematic Review and Meta-Analysis.

Purpose The aim of this current review was to confirm the efficacy of intra-articular steroid therapy (IAST) for patients with hip osteoarthritis (OA) and discuss the duration and influential factors of IAST. Methods Online databases (Medline, EMBASE, and Web of Science) were searched from inception to May 2019. Both randomized controlled trials (RCTs) and noncontrolled trials assessing the efficacy of hip IAST on pain were included. Common demographics data were extracted using a standardized form. Quality was assessed on the basis of Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. Results 12 trials met the inclusion criteria. According to data from individual trials, IAST had significant efficacy on hip OA in both immediate and delay pain reduction, which persisted up to 12 weeks after IAST. The influences of the baseline severity of hip OA or synovitis and injection dose or volume on the clinical outcome of IAST were still controversial. The IAST appeared to be well tolerant by most of the participants. Conclusion IAST was proved to be an efficacious therapy in both immediate and delay pain reduction for hip OA patients within 12 weeks. The longer follow-up data of efficacy and safety and potentially influential factors are still unclear and needed further confirmation.

Interobserver and Intraobserver Reliability of Clinical Assessments in Knee Osteoarthritis.

Clinical examination of the knee is subject to measurement error. The aim of this analysis was to determine interobserver and intraobserver reliability of commonly used clinical tests in patients with knee osteoarthritis (OA). We studied subjects with symptomatic knee OA who were participants in an open-label clinical trial of intraarticular steroid therapy. Following standardization of the clinical test procedures, 2 clinicians assessed 25 subjects independently at the same visit, and the same clinician assessed 88 subjects over an interval period of 2-10 weeks; in both cases prior to the steroid intervention. Clinical examination included assessment of bony enlargement, crepitus, quadriceps wasting, knee effusion, joint-line and anserine tenderness, and knee range of movement (ROM). Intraclass correlation coefficients (ICC), estimated kappa (κ), weighted kappa (κω), and Bland-Altman plots were used to determine interobserver and intraobserver levels of agreement. Using Landis and Koch criteria, interobserver κ scores were moderate for patellofemoral joint (κ = 0.53) and anserine tenderness (κ = 0.48); good for bony enlargement (κ = 0.66), quadriceps wasting (κ = 0.78), crepitus (κ = 0.78), medial tibiofemoral joint tenderness (κ = 0.76), and effusion assessed by ballottement (κ = 0.73) and bulge sign (κω = 0.78); and excellent for lateral tibiofemoral joint tenderness (κ = 1.00), flexion (ICC = 0.97), and extension (ICC = 0.87) ROM. Intraobserver κ scores were moderate for lateral tibiofemoral joint tenderness (κ = 0.60); good for crepitus (κ = 0.78), effusion assessed by ballottement test (κ = 0.77), patellofemoral joint (κ = 0.66), medial tibiofemoral joint (κ = 0.64), and anserine tenderness (κ = 0.73); and excellent for effusion assessed by bulge sign (κω = 0.83), bony enlargement (κ = 0.98), quadriceps wasting (κ = 0.83), flexion (ICC = 0.99), and extension (ICC = 0.96) ROM. Among individuals with symptomatic knee OA, the reliability of clinical examination of the knee was at least good for the majority of clinical signs of knee OA.

Clostridium Sacroiliitis (Gas Gangrene) Following Sacroiliac Joint Injection – Case Report and Review of the Literature

An 80-year-old woman presented with chronic lumbosacral pain since her laminectomy and instrumentation 10 years ago. Examination was consistent with left sacroiliitis, and the patient underwent an elective left sacroiliac joint injection. Two days following her procedure she fell and landed on her left hip and on the next day, she presented to the emergency room with acutely worsening left gluteal pain. On evaluation in the emergency department, she was found to be suffering from a fever, headache, nausea, vomiting, and dysuria. A computed tomography (CT) scan was performed and this showed extensive foci of gas throughout the posterior aspect of the left iliopsoas muscle, sacrum, and ileum surrounding the left sacroiliac joint. The patient underwent emergent surgical debridement. The microbiology report of blood culture revealed clostridium perfringens, while her pathology showed necrosis and acute inflammation of fibroadipose tissue, skeletal muscle, and fat. The patient’s hospital course resulted in multi-organ failure and the family elected for comfort care measures only. Unfortunately, she passed away 36 hours later. Septic arthritis is a potential catastrophic complication following intra-articular steroid therapy. The cause of the septic joint can be multifactorial but is likely caused by one of the following processes: direct inoculation of bacteria by the injection, hematogenous seeding of the percutaneous injection tract, or due to activation of a quiescent infection by the injected steroid. Clostridial spores are very resistant to standard aseptic skin preparations, including chlorhexidine and betadine solutions. The only effective methods to eliminate the spores is to heat them at a temperature greater than 100 degrees Celsius for 10 minutes or with use of a 10% potassium hydroxide (KOH) solution. We hypothesize that clostridium spores were present on the patient’s skin from previous stool soiling, and that these were introduced directly into the soft tissue by needle trauma. Rare complications such as this one are scarcely reported in the literature and thus it becomes difficult to adequately identify risk factors or to formulate strategies to improve practice management. Key words: Lower back pain, sacroiliitis, sacroiliac joint injection, clostridium perfringens, gas gangrene

Synovial tissue volume: a treatment target in knee osteoarthritis (OA)

BackgroundSynovitis occurring frequently in osteoarthritis (OA) may be a targeted outcome. There are no data examining whether synovitis changes following intra-articular intervention.MethodsPersons aged 40 years and older with painful knee...

Determinants of long term treatment response following intra-articular steroid therapy in knee OA

Determinants of long term treatment response following intra-articular steroid therapy in knee OA

Bone marrow lesions may not respond to anti-inflammatory treatments in knee osteoarthritis(OA)

Bone marrow lesions may not respond to anti-inflammatory treatments in knee osteoarthritis(OA)

Do psychological factors predict response to intra-articular steroid therapy in knee osteoarthritis?

s / Osteoarthritis and Cartilage 22 (2014) S57–S489 S381 the Nuffield Orthopaedic Centre (Oxford) between 2010–2012. LoS data was highly skewed and underwent natural log transformation. Linear regression methods were used to assess the association between TUG and LoS after adjustment for age, gender and BMI. To assess whether the association between preoperative TUG and postoperative LoS was consistent across operation type an interaction between these two variables was also included. Table 1 Mean values of baseline characteristics in sample population (n 1⁄4 534).

Mechanical pain threshold predicts response to intra-articular steroid therapy in symptomatic knee osteoarthritis

Mechanical pain threshold predicts response to intra-articular steroid therapy in symptomatic knee osteoarthritis

A35: Differential Benefit of Temporomandibular Joint Steroid Injections by Juvenile Idiopathic Arthritis Subtype

Background/Purpose:20–70% of juvenile idiopathic arthritis (JIA) patients have radiographic involvement of temporomandibular joints (TMJs), often reflective of cartilage loss and erosive bony changes. Intra‐articular steroid (IAS) injections have been shown by magnetic resonance (MR) imaging to reduce TMJ inflammation; however, it is less clear that this therapy provides longer term benefit in terms of preventing or retarding structural changes. Herein, we review the outcomes of our JIA patients treated with IAS for TMJ synovitis.Methods:Records of JIA patients treated with IAS for TMJ synovitis between January of 2003 and March of 2013 were reviewed. Determinations of symptomatic relief and duration of relief were made from both subjective and objective portions of notes generated at clinic visits subsequent to an initial IAS procedure. Determinations of radiographic progression were based on structural changes occurring between 1st and 2nd IAS procedures. The IAS used was triamcinolone hexacetonide in doses of 5–20 mg per joint.Results:63 patients received IAS at least once for TMJ synovitis, almost all for bilateral disease activity by MRI. Within this cohort, 55% of patients had received g1 injection per TMJ (mean of 2.75 for enthesitis‐related arthritis (ERA) patients vs. 1.95 for other combined JIA subtypes, p = 0.03). For 25% of patients, the TMJ was their first synovitic joint (58 % of ERA vs. 7.5% of other JIA subtypes, p < 0.001). ERA patients were older at at the time of TMJ diagnosis than the other JIA subtypes (mean age 14.0 vs. 11.5 years respectively, p = 0.003) and more likely to be symptomatic at the TMJ(s) than the other JIA subtypes (79% vs. 48% respectively, p = 0.018). Symptomatic ERA patients had a shorter mean duration of pain relief than the other symptomatic JIA subtypes (107 vs. 363 days respectively, p = 0.001). Second MR studies indicated progressive structural damage in all (32/32) patients re‐imaged at intervals of 6N36 months following their initial study. More acute TMJ symptoms and heightened concern for progression in the ERA patients resulted in a shorter mean inter‐injection interval of 10.9 vs. 19.9 months in the other JIA subtypes (p = 0.004).Conclusion:Of the JIA patients in clinic who have received IAS for TMJ synovitis, those with ERA benefitted the least in terms of pain relief duration and slowing of structural damage. In light of the higher frequency of IAS and the shorter duration of symptomatic relief in ERA patients, it is possible that TMJ synovitis is more aggressive in this subtype, or that a symptom‐driven increase in the frequency of IAS therapy has contributed to the rate and extent of structural damage. IAS therapy, in our experience, has not prevented the progression of TMJ damage in any JIA variant.

Change in MRI synovitis correlates with change in pain following intra-articular steroid injection

Purpose: Synovitis is a well recognised finding in knee osteoarthritis. It can be identified on Magnetic Resonance Imaging (MRI) as synovial thickening, although injection of contrast material is required to distinguish synovial tissue from synovial fluid. The aim of this analysis was to determinewhether change in synovial tissue volume as assessed using gadolinium (Gd) enhancedMRI imaging correlates with change in knee pain following intra-articular steroid therapy. Methods: Men and women aged 40 years and older who met ACR criteria for the disease, were recruited for participation in an ongoing open label clinical trial of intra-articular steroid therapy. Subjects who took part in the study had significant knee pain and grade 2 or higher knee OA. At baseline visit they completed a questionnaire about their symptoms including KOOS pain scale (100 1⁄4 no pain to 0 1⁄4 extreme pain) and also a VAS score (0 1⁄4 no pain] to 10 1⁄4 extreme pain) for pain on a nominated activity (VASnA). They subsequently had a Gd enhanced MRI immediately prior to having an intra-articular steroid injection with repeat questionnaire and Gd-enhanced MRI scan at follow up visit to assess synovial response usually within 2 weeks after the injection. To assess synovial tissue volume, sagittal (post CE T1W Fat Suppressed images: TR 500ms, TE 17ms; FoV 15.9 x 15.9cm; slice thickness 3mm) scans were obtained. Manual segmentation of the synovial tissue layer was performed on the post contrast knee image by a single observer. Using computer image analysis we excluded cartilage within the segmented space, by thresholding in the associated sagittal (3DWATSc: TR 20ms, TE 7.7ms, FoV 15cm, 288x288) scan. The rest of the segmented space was assumed to be a mixture of fluid and synovial tissue. We calculated the proportion of synovial tissue in every voxel using P 1⁄4 (I mf) / (ms mf) truncated to [0,1], where I is the voxel intensity and mf, ms are the means of the intensity distributions of fluid and synovial tissue volume respectively. We looked at mean synovial volume before and after the steroid injection and looked at the Spearman Rank correlation coefficient between change in synovial volume and change in the level of KOOS-pain and also VASnA. Results: We analysed data from 41 patients. Their mean age was 62.4 years (SD 10.5 years), and 21 were female (51.2%). The median time between baseline and follow up scan was 9 days (IQR 7 to 14 days). The median synovial tissue volume at baseline was 7,556mm (IQR 4,670mm to 11,269 mm), and at follow up was 7,078mm (IQR 3,642mm to 8,541mm); median difference -1,007mm (95% CI -1,909mm to -320mm). Both KOOS pain (24.7pts; 95% CI 18.4 pts to 31.0 pts) and VASnA (-3.2cm; 95% CI -4.1cm to -2.2cm) improved significantly between baseline and follow up. The change in synovial tissue volume correlated with change in VASnA (rs 1⁄4 0.39; p 1⁄4 0.01) though not with KOOS-pain (rs 1⁄4 -0.11 ; p 1⁄4 0.50). Change in VASnA did not appear to correlate with synovial tissue volume at baseline (rs 1⁄4 -0.03; p1⁄40.85); nor did change in KOOS pain (rs 1⁄4 0.17; p1⁄40.30). Conclusions: Synovial tissue volume in knee osteoarthritis, assessed with Gd-enhanced MRI correlates with change in pain assessed as pain on a nominated activity, though not KOOS, in response to intra-articular steroid injection.

Reduction in synovial tissue volume following intra-articular steroid injection in knee osteoarthritis

Reduction in synovial tissue volume following intra-articular steroid injection in knee osteoarthritis

The intraarticular and local application of glycocorticosteroid preparations

The author reports the use of short-acting and combined short + long-acting betamethasone injections for intraarticular and local treatments. In this paper the author describes his experiences with intraarticular and local treatments of 214 patients with 965 short-acting, and 416 patients with 2932 combined short + long-acting betamethasone preparations from 1978 to 2003. To describe the optimal application of intraarticular and local steroid therapy based on the author's experience and according to the literature data. Patients were selected on the bases of rheumatological, laboratory and imaging investigations. The preparations were administered according to ARA guidelines. The results were evaluated based on patients' health status and symptoms, in addition to patients' and doctors' opinion. A combination of intraarticular short-acting + long-acting betamethasone injections resulted in patients being symptom-free (48.8%) or with significant improvement (37.5%), while local application led to a significant improvement (50%) or improvement (29%). Locally applied short-acting betamethasone resulted in symptom-free or significantly improved cases (40.6%), or ordinary improvement (40.3%). The short-acting + long-acting preparation was associated with mild side effects (62 cases), while the short-acting one had fewer mild side effects (10). The results are in agreement with the literature data, though in present author's case with a much fewer number of side effects. Intraarticular application of a combined short-acting + long acting agent is suggested exclusively in cases of visible and laboratory signs of inflammation that are limited to a few joints. In a treatment episode, not more than 3 injections may be permitted except in special cases. Initially, extraarticular management of cases is recommended using mainly short-acting preparations, except in protracted cases or when the application of short-acting steroids prove ineffective. Short-acting agents have little or short-term manifestations of corticosteroid toxicity. Taking such factors into consideration, treatment may be regarded as beneficial and safe. The aim of this publication is partly to influence practices in Hungarian surgeries.

The historical development of thermal imaging in medicine

The association between disease and human body temperature is as old as medicine itself. Hippocrates defined fever in different forms, such as malignant, benign and acute. It was claimed that if wet mud was applied to the skin, and one area dried rapidly while the remainder was still moist, that an underlying tumour may be suspected. It was not until Gallileo Gallilei developed his simple thermoscope in 1595 that attempts to measure temperature really began, and some hundred years later before closed thermometers and calibrated scales were used. Carl Wunderlich made the greatest progress in medicine by his development of the clinical thermometer and systematically recorded the progression of temperature in a large number of sick patients in 1871 [1]. His treatise On the Temperature in Disease carries a substantial section on temperature graphs from diseased patients, some with ‘rheumatic fever’. He argued for the routine measurement of temperature and that a graphic record be established for every patient. Following the work of Horvath and Hollander in the late 1940s [2], temperature measurements were used as a means of monitoring intra-articular steroid therapy by a number of authors. However, intra-articular temperature and isotope clearance techniques were invasive, unlike the infrared remote sensing techniques, which were available from the late 1950s. The story of infrared radiation began in 1800, when Sir William Herschel, the astronomer, detected heating rays beyond the visible red of the spectrum. After his death in 1840, his son John Herschel made the first thermal image from sunlight using the evaporograph technique. He used the term thermogram to describe the image, which is still in common use today [3]. Early infrared imaging systems were developed during the 1940s and became available to industry and medicine first in 1959. The Pyroscan (a 1942 instrument) was first used in Bath in 1959 (Fig. 1) and was used to image the increased heat over arthritic joints. Picture quality improved with the Mark 2 instrument (Fig. 2), although each image took 3–4 minutes to acquire and was almost impossible to quantify. Later, with improved equipment, better dynamic (and objective images) were obtained that could usefully supplement radiological investigation [4].

Contrast-enhanced power Doppler sonography of knee synovitis in rheumatoid arthritis: assessment of therapeutic response.

The aim of this study was to evaluate the ability of power Doppler sonography (PDS) with ultrasound contrast agent to assess the synovial perfusion changes induced by intra-articular steroid injection therapy in the knee joints of patients with rheumatoid arthritis (RA). Eighteen RA patients (16 women, 2 men) with a history and signs of active knee synovitis were studied. Tenderness was evaluated using Thompson's modified index of synovitis activity. All patients underwent joint aspiration followed by intra-articular injection of 40 mg of triamcinolone hexacetonide. Gray-scale ultrasonography and PDS with an intravenous ultrasound contrast agent (Levovist) examinations were carried out before and 3 weeks after the intra-articular steroid injection. The calculation of the time--intensity curves provided a quantitative estimation of the synovial perfusion. The median values of the index of synovitis activity decreased significantly from 7.0 (95% confidence interval (CI) 6.0-8.0) to 3.0 (95% CI 2.0-4.0) ( p<0.01) 3 weeks after the intra-articular steroid injection. All patients showed a reduction of PDS signal after intra-articular steroid therapy and the baseline and follow up median values of the area underlying time-intensity curves were 7.48 (95% CI 5.79-8.73) and 2.45 (95% CI 1.92-3.61), respectively. The comparison between baseline and follow-up median values of the area under the curves showed a statistically significant reduction of PDS findings ( p<0.01). At follow-up examinations the changes in the index score of the synovitis activity were significantly correlated to the changes in the values of the area underlying time-intensity curves ( r=0.785; p<0.01). A significant correlation was also observed between baseline values of the area underlying time-intensity curves and C-reactive protein (CRP) ( r=0.548; p=0.023). In conclusion, PDS with an intravenous ultrasound contrast agent has been shown to be able to detect changes in synovial perfusion after intra-articular steroid injection and may be an additional useful method in the evaluation of synovial inflammation and in the assessment of the therapeutic response.

Weight bearing following intra-articular steroid injection of the knee: survey of current practice and review of the available evidence

Intra-articular steroid therapy is one of the most common clinical procedures performed by rheumatologists. There is wide variation in the postoperative instructions given to patients following such injections. The aim of this study was to determine what advice is given with regards to non-weight-bearing following steroid injections of the knee by rheumatologists, orthopaedic surgeons, and general practitioners (GPs). A questionnaire examining advice on non-weight-bearing following knee steroid injections was posted to 100 rheumatologists, 100 orthopaedic surgeons, and 50 GPs. A significant proportion of respondents advised patients to avoid weight bearing after injection (42.4%). Most of these advised patients to do so for one (16.3%) or two (25.1%) days. As compared to 57.1% of general practitioners and 2.8% of orthopaedic surgeons, 70.7% of rheumatologists advised patients to avoid weight bearing (P < 0.05). A significant proportion of rheumatologists and general practitioners performing steroid injections of the knee advise patients not to weight-bear postinjection. Examination of the available literature fails to reveal strong evidence to support such a practice, which has potentially significant implications with regards to loss of working days, costs of mobility aids, and patient inconvenience.

Intra-articular corticosteroids in the treatment of juvenile rheumatoid arthritis.

Intra-articular injection of long-acting insoluble corticosteroids produces rapid resolution of active arthritis in nearly all injected joints. Almost all of our information on the use of intra-articular corticosteroids in children comes from observational or retrospective analyses or, by inference, from studies in adult patients with arthritis. The duration of response has been found to vary according to the subtype of arthritis, the dose of injected steroids, the accuracy of injection, the duration of disease prior to injection, and possibly the age of the patient. Although the duration of follow-up in most studies has been short, intra-articular steroid therapy seems to be remarkably free of clinically important detrimental effects. Side effects are relatively uncommon and include subcutaneous atrophy and radiologically detectable structural changes or calcification. There is transient suppression of endogenous cortisol production, which may not be clinically important. Although intra-articular steroid therapy is most effective in pauciarticular juvenile rheumatoid arthritis, there are still no solid data to indicate whether it should be used earlier in the course of the disease instead of or along with systemic anti-inflammatory therapy. It has been suggested that repeated injection of the same joint decreases the likelihood of a favorable response. There are still many unanswered questions about how steroids exert their beneficial effects. Newer imaging techniques promise to provide insight into the mechanism of action and possibly to a more informed basis for the use of intra-articular steroids.

Post-injection Rest Following Intra-articular Steroid Therapy for Knee Synovitis

Post-injection Rest Following Intra-articular Steroid Therapy for Knee Synovitis