Ross Hauser, MD, Danielle Matias, PA-C, Demi Foster, APRN

What are we seeing in this image? We see the comparison of a normal hip versus a steroid-injected degenerative hip. The right side hip generation was accelerated by multiple cortisone injections.

Concerns about cortisone are not new. Research is always developing an updated opinion on the impact of cortisone side effects.

A December 2020 study in the medical journal Radiology (1) offered “Considerations and Controversies” in the offering of cortisone injections for patients with knee and/or hip osteoarthritis. The considerations and controversies in part surrounded the known side effects of cortisone injections. Here is what the researchers wrote:

“Current management of osteoarthritis is primarily focused on symptom control. Intra-articular corticosteroid injections are often used for pain management of hip and knee osteoarthritis in patients who have not responded to oral or topical analgesics.

Recent case series suggested that negative structural outcomes, including accelerated osteoarthritis progression, subchondral insufficiency fracture (stress fractures in the bone below the cartilage in the weight-bearing bones), complications of pre-existing osteonecrosis (in the hip avascular necrosis), and rapid joint destruction (including bone loss) may be observed in patients who received intra-articular corticosteroid injections.”

What these researchers were looking for was whether there was a way that MRI or other imaging could predict which patients would be more prone to these side effects, so they could avoid getting the cortisone injection. What they found was:

“As of today, there is no established recommendation or consensus regarding imaging, clinical, or laboratory markers before an intra-articular corticosteroid injection to screen for osteoarthritis-related imaging abnormalities.

Repeating radiographs before each subsequent intra-articular corticosteroid injection remains controversial. The true cause and natural history of these complications are unclear and require further study.“

In other words, it is currently too difficult to determine with imaging who would be more prone to these side effects.

An April 2021 study from doctors at the University of Nottingham published in the journal Rheumatology (2) retrospectively analyzed previously published research articles on the effectiveness and safety of multiple intra-articular corticosteroid injections for the treatment of osteoarthritis. The researchers compared the cortisone with a placebo.

A December 2022 paper in the journal Skeletal Radiology (3) led by authors at Massachusetts General Hospital, Harvard Medical School, reviewed previously published studies on the use of image-guided corticosteroid injections in the treatment of patients with knee and hip osteoarthritis. Among this paper’s reviews were those of 10 knee osteoarthritis outcome studies. The researchers observed that cortisone “hip injections were found to be effective in treating short- and long-term pain and more effective than hyaluronic acid, Mepivacaine, NSAIDs, and normal saline in terms of improvement in pain and/or function. There was less impact on quality of life . . . (further) “hip injections may carry a risk of serious adverse outcomes.”

Efficacy and safety of multiple corticosteroid injections, reflecting the recommended best practice, have yet to be assessed

Here is what they found:

• “Multiple (steroid) injections are no better than a placebo for osteoarthritis pain according to current evidence. The preliminary finding of a detrimental effect on structural osteoarthritis progression warrants further investigation. Efficacy and safety of multiple (corticosteroid injections) reflecting recommended best practice has yet to be assessed.”

A paper published in September 2023 (5) in the journal Hip International looked into the risks associated with intra-articular corticosteroid injections for pain relief, weighing it against the chance that these injections may themselves speed up the need for hip replacement. In this research, patients diagnosed with hip pain but without femoroacetabular osteoarthritis received an intra-articular corticosteroid injection in the hip. The study analyzed a database of 25,073 patients who had received a corticosteroid injection. At the 5-year follow-up, the rate of total hip replacement was notably higher in the corticosteroid group compared to the control group. The likelihood and risk of undergoing total hip replacement increased with the number of injections, with the greatest risk observed in patients who had three or more cortisone injections.

A May 2025 study in the journal Arthroscopy, Sports Medicine, and Rehabilitation (6) reviewed data from studies that reported complications related to hip cartilage as a result of a history of hip intra-articular corticosteroid injections. A total of 34,367 hips that had hip intra-articular corticosteroid injections revealed the incidence of rapidly progressive osteoarthritis ranged from 0.2% to 21.1%; osteonecrosis ranged from 0.6% to 27.1%; femoral head collapse ranged from 3.2% to 20.4%; insufficiency fractures ranged from 0.4% to 1.3%; and worsening osteoarthritis ranged from 1.1% to 44.3%.

A December 2025 study in the Journal of Bone and Joint Surgery Open Access (x) notes the controversy surrounding the occurrence of rapidly progressive idiopathic arthritis after corticosteroid injections in the hip. The authors cite research showing a wide range of incidence rates for rapidly progressive idiopathic arthritis, with figures reported at 5.4%, 7.2%, 13.7%, and even as high as 21%.

Rapidly progressive hip osteoarthritis following intra-articular corticosteroid injections

A May 2024 study (7) in the Journal of Orthopaedic Case Reports explored eight cases of chronic hip pain treated with intra-articular corticosteroid injections. Subsequently, they experienced a swift deterioration of the femoral head integrity within as little as 10 weeks. The patients exhibited various health factors, including obesity, smoking history, cancer treatment, and deficiencies in Vitamin D levels, which have been found to increase the risk of femoral head collapse.

Cortisone and post-hip replacement infection: Surgeons are told to wait four months between cortisone injection and hip replacement

Doctors at the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, published a June 2021 study in The Journal of Arthroplasty. (4) Here are their concerns:

• Corticosteroid injections are commonly used for the treatment of osteoarthritis of the hip.
• There is a concern, however, that these injections may increase the risk of postoperative infection if a subsequent total hip arthroplasty is performed.

Therefore, their study surrounded the investigation to determine the relationship between Corticosteroid injections and the risk of periprosthetic joint infection and surgical site infections following total hip arthroplasty (total hip replacement).

In their investigation, the researchers examined 29,058 patients who had a corticosteroid injection in their hip within 6 months prior to total hip replacement. What were their findings?

• Corticosteroid injections within four months of surgery were associated with a higher incidence of periprosthetic joint infection at six-month follow-up
• An injection within one month of surgery corresponded to higher odds of periprosthetic joint infection than an injection four months before surgery.
• Furthermore, the number of Corticosteroid injections administered within the three months before total hip replacement demonstrated a dose-dependent relationship, with each subsequent injection increasing the odds of periprosthetic joint infection. A similar relationship was observed for surgical site infections.

Conclusion: Surgeons should consider delaying elective total hip arthroplasty if a corticosteroid injection has been administered within the 4 months before the planned procedure.

References

1 Guermazi A, Neogi T, Katz JN, Kwoh CK, Conaghan PG, Felson DT, Roemer FW. Intra-articular Corticosteroid Injections for the Treatment of Hip and Knee Osteoarthritis-related Pain: Considerations and Controversies with a Focus on Imaging—Radiology Scientific Expert Panel. Radiology. 2020 Dec;297(3):503-12. [Google Scholar]
2 Ayub S, Kaur J, Hui M, Espahbodi S, Hall M, Doherty M, Zhang W. Efficacy and safety of multiple intra-articular corticosteroid injections for osteoarthritis—a systematic review and meta-analysis of randomized controlled trials and observational studies. Rheumatology. 2021 Apr;60(4):1629-39. [Google Scholar]
3 Chang CY, Mittu S, Da Silva Cardoso M, Rodrigues TC, Palmer WE, Gyftopoulos S. Outcomes of imaging-guided corticosteroid injections in hip and knee osteoarthritis patients: a systematic review. Skeletal Radiology. 2022 Dec 15:1-2. [Google Scholar]
4 Forlenza EM, Burnett RA, Korrapati A, Yang J, Forsythe B, Della Valle CJ. Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty. The Journal of Arthroplasty. 2021 Jun 1;36(6):2033-7. [Google Scholar]
5 Angotti ML, Burnett RA, Khalid S, Terhune EB, Della Valle CJ. Intra-articular corticosteroids associated with increased risk of total hip arthroplasty at 5 years. HIP International. 2022 Jun 19:11207000221107225. [Google Scholar]
6 Parry D, Dhillon J, Kraeutler MJ. Risks of Intra-Articular Hip Corticosteroid Injections Include Rapidly Progressive Osteoarthritis and Femoral Head Collapse in Patients With and Without Osteoarthritis: A Systematic Review. Arthroscopy, Sports Medicine, and Rehabilitation. 2025 May 21:101169. [Google Scholar]
7 Rana P, Johnson A, Turcotte J, King P. Rapid Osteoarthritis and Femoral Head Collapse: A Case Series. Journal of Orthopaedic Case Reports. 2024 May;14(5):141. [Google Scholar]
8 McKay N, Hopkins E, Moulton L, Gao Z, Kirk L, Hopkins J, Smith N. A Retrospective Review of Intra-articular Methylprednisolone Hip Injection and Development of Rapidly Progressive Idiopathic Arthritis in Adults. JBJS Open Access. 2025 Oct 1;10(4):e25. [Google Scholar]