Hip, Knees & Bones

For many patients navigating chronic illness — particularly those treated with long-term corticosteroids — joint and bone health becomes an unexpected but significant part of the journey. Understanding what is happening in your body, what options are available, and how to protect your joints before and after intervention can make a profound difference in mobility, independence, and quality of life.

Steroid-Induced Joint & Bone Problems

Corticosteroids — medications like prednisone, methylprednisolone, and dexamethasone — are powerful anti-inflammatory drugs widely used to treat conditions ranging from autoimmune diseases and asthma to neurological disorders and organ transplant rejection. While they can be life-saving, long-term or high-dose use carries serious consequences for the musculoskeletal system. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), steroid-induced bone and joint damage is one of the most common and underrecognized complications of corticosteroid therapy.

Osteoporosis and Bone Loss

Corticosteroids interfere with the body's ability to absorb calcium and suppress the activity of osteoblasts — the cells responsible for building new bone. The result is glucocorticoid-induced osteoporosis (GIOP), the most common form of secondary osteoporosis. Bone density can decline significantly within the first few months of steroid treatment. Fractures — particularly of the spine, hip, and wrist — can occur even from minor falls or, in severe cases, with everyday activities. The Mayo Clinic recommends that anyone on long-term steroids be monitored with bone density scans (DEXA) and supplemented with calcium and vitamin D as a standard preventive measure.

Avascular Necrosis (Osteonecrosis)

One of the most serious steroid-related complications is avascular necrosis (AVN), also called osteonecrosis — the death of bone tissue caused by a loss of blood supply. Corticosteroids are the leading non-traumatic cause of AVN. The femoral head (the ball of the hip joint) is the most commonly affected site, followed by the knee, shoulder, and ankle. Steroid use causes fat deposits to accumulate in the small blood vessels supplying the bone, cutting off circulation and causing the bone to collapse from within. Symptoms include deep, aching joint pain that worsens with weight-bearing — and frequently progresses to joint destruction requiring surgical intervention. The NIH/NIAMS estimates that 10–40% of patients on long-term high-dose steroids will develop AVN.

Steroid-Induced Myopathy

Beyond the bones and joints, prolonged corticosteroid use causes steroid-induced myopathy — progressive weakness and wasting of the large muscle groups around the hips, thighs, and shoulders. This muscle loss (proximal myopathy) further destabilizes joints, increases fall risk, and compounds the functional limitations caused by bone and cartilage damage. Physical therapy and gradual steroid tapering — when medically appropriate — are the primary approaches to recovery, as outlined by the Johns Hopkins Medicine musculoskeletal team.

Therapies Before Joint Replacement

Surgery is rarely the first step. For most patients, a range of conservative and interventional therapies can significantly reduce pain, improve function, and delay — or in some cases avoid — the need for joint replacement. The goal is always to preserve the natural joint as long as safely possible while maintaining quality of life.

Physical Therapy and Exercise

A structured physical therapy program is typically the first line of treatment for hip and knee joint pain. Strengthening the muscles surrounding the joint — particularly the quadriceps for the knee and the hip abductors for the hip — reduces the load placed on damaged cartilage and improves joint stability. The American Physical Therapy Association emphasizes that consistent, targeted exercise is one of the most evidence-supported interventions for osteoarthritis and steroid-related joint disease. Low-impact activities such as swimming, cycling, and water aerobics are particularly beneficial for protecting joints while building strength.

Medications

Pain management before surgery typically involves a step-wise approach. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can reduce inflammation and pain, though they require caution in patients with kidney, heart, or gastrointestinal issues. Topical NSAIDs (diclofenac gel) offer a safer alternative for localized knee pain. Acetaminophen remains useful for baseline pain control. For patients with steroid-induced osteoporosis, bisphosphonates (such as alendronate or zoledronic acid) are commonly prescribed to slow bone loss and reduce fracture risk.

Injections

Several injection-based therapies can provide meaningful relief when oral medications are insufficient:

• Corticosteroid injections: Direct injection of anti-inflammatory medication into the joint can provide weeks to months of pain relief. However, repeated injections may accelerate cartilage breakdown over time, and they carry particular risk in patients already dealing with steroid-related bone damage.
• Hyaluronic acid (viscosupplementation): Hyaluronic acid injections lubricate the knee joint and can improve cushioning in mild to moderate osteoarthritis. They are more commonly used in the knee than the hip.
• Platelet-rich plasma (PRP): PRP therapy uses concentrated growth factors from the patient's own blood to promote healing and reduce inflammation. Evidence is growing, particularly for knee osteoarthritis, though it is not yet universally covered by insurance.

Assistive Devices and Lifestyle Modifications

Canes, crutches, and walkers can significantly off-load a damaged joint and reduce pain during daily activity. Bracing — particularly unloader knee braces for medial compartment osteoarthritis — redistributes weight away from the damaged area. Weight management is also critically important: according to the Arthritis Foundation, each pound of body weight lost reduces the force on the knee joint by four pounds — making even modest weight loss a meaningful intervention in joint preservation.

Core Decompression (for AVN)

For patients with early-stage avascular necrosis before the bone has collapsed, core decompression is a surgical procedure in which small holes are drilled into the affected bone to relieve pressure and stimulate blood vessel growth. When performed early enough, it can slow or halt the progression of AVN and delay or prevent the need for joint replacement. It is most effective in the hip and is often combined with bone grafting or biologic therapies.

Hip Replacement

Total hip replacement (total hip arthroplasty) is one of the most successful operations in modern medicine. The damaged ball-and-socket joint is replaced with prosthetic components — typically a metal or ceramic ball on the femoral stem, and a smooth cup implanted into the pelvis. More than 450,000 hip replacements are performed in the United States each year, according to the American Academy of Orthopaedic Surgeons (AAOS).

When Is Hip Replacement Recommended?

Hip replacement is typically recommended when pain significantly limits daily activities — walking, climbing stairs, rising from a chair — and conservative treatments have failed to provide adequate relief. For patients with steroid-induced AVN, the decision to operate often comes earlier, as the femoral head may collapse rapidly once bone death progresses beyond a critical threshold. The AAOS orthopaedic information resource provides detailed guidance on candidate criteria and timing considerations.

The Procedure and Recovery

Modern hip replacement is often performed using minimally invasive or anterior approaches, which cause less muscle disruption and allow for faster recovery. Most patients are walking with assistance on the day of surgery and are discharged within one to three days. Full recovery — including return to most physical activities — typically takes three to six months. The Johns Hopkins Medicine Hip Replacement Program notes that 95% of patients experience significant pain reduction, and implants commonly last 20 years or more with proper care. For patients who have had steroid-induced bone loss, pre-surgical optimization of bone density is often required before implantation.

Rehabilitation After Hip Replacement

Post-operative rehabilitation begins immediately and is central to a successful outcome. Physical therapy focuses initially on safe mobility, hip precautions (avoiding positions that risk dislocation), and regaining range of motion, before progressing to strengthening and functional activities. Aquatic therapy is particularly valuable early in recovery for patients with compromised bone health. The Arthritis Foundation's recovery guide outlines what to expect week by week after surgery.

Knee Replacement

Total knee replacement (total knee arthroplasty) involves resurfacing the damaged ends of the femur (thigh bone), tibia (shin bone), and often the underside of the patella (kneecap) with metal and plastic implant components. It is the most commonly performed joint replacement surgery in the United States, with over 700,000 procedures performed annually, per the AAOS.

Partial vs. Total Knee Replacement

For patients whose arthritis is confined to one compartment of the knee — most often the inner (medial) side — a partial (unicompartmental) knee replacement may be an option. This less invasive procedure preserves more of the natural knee structure, offers faster recovery, and carries a lower complication rate — though it is suitable only for carefully selected patients. Total knee replacement addresses all three compartments and is necessary when arthritis is widespread or when the knee is significantly deformed.

The Procedure and What to Expect

Knee replacement surgery typically takes one to two hours under general or spinal anesthesia. Most patients begin walking with a physical therapist on the same day. Hospitalization usually lasts one to three days, with home physical therapy or outpatient rehabilitation beginning shortly after discharge. Pain and swelling are normal for several weeks; full recovery and return to low-impact activities generally takes three to six months. According to Cleveland Clinic, more than 90% of patients report significantly less pain and improved function after total knee replacement.

Rehabilitation After Knee Replacement

Rehabilitation is the cornerstone of a successful knee replacement outcome. The early focus is on controlling swelling (using ice, elevation, and compression), restoring range of motion, and building quadriceps strength. Consistent participation in physical therapy — both supervised and home exercise — is the single most important factor in achieving a good long-term result. The Arthritis Foundation and the AAOS exercise guide for knee recovery both offer structured programs for the weeks following surgery.

Sources & Further Reading