High Risk of Adrenal Insufficiency After a Single Articular Steroid Injection in Athletes

Purpose: To determine whether a single intra- or periarticular injection of corticosteroid for posttraumatic or microtraumatic articular injuries in young healthy subjects can induce a biological suppression of hypothalamo-pituitary-adrenal axis activity and reactivity.

Methods: Ten healthy young male athletes (aged 28.8 +/- 2.5 yr) received a single intra- or periarticular injection of either cortivazol (available in Europe but not in the United States) or betamethasone. Morning cortisol levels were measured on four occasions: the day of steroid injection (D0) and 2 d (D2), 7 d (D7), and 14 d (D14) later. During the second visit (D2), a short ACTH test (1 microg) was performed.

Results: Two days after corticosteroid administration, adrenal insufficiency (cortisol levels below 100 nM and/or blunted peak cortisol after stimulation with 1 microg of ACTH) occurred in 9 of the 10 subjects. Seven days after steroid injection, cortisol levels were still lower than basal values in all subjects (48.2 +/- 7.3% of D0 levels), and five subjects had abnormal cortisol levels (< 260 nM). Fourteen days after steroid injection, cortisol levels remained significantly lower than preinjection levels (P = 0.02), averaging only 77.3 +/- 8.3% of D0 levels, and three participants remained with abnormal cortisol levels. The extent of biological adrenal suppression was directly related to the steroid dose injected.

Conclusion: As some athletes are exposed to a high risk of trauma, which can lead to an acute adrenal crisis, they should be informed about the risk of adrenal insufficiency after an intra- or periarticular corticosteroid injection, and they should report any symptoms to their physician.