Cortisone Injection: Will It Help or Hurt You?

That tendinitis in your shoulder is really bothering you, but you'll miss your weekend football games if you sit out. Will a cortisone injection make things all better and get you back out on the field?

Stopping the Pain...and the Healing?

Cortisone injections, also known as cortisol or corticosteroid injections, work well at reducing pain associated with inflammation. Robert Leach, MD, editor of the American Journal of Sports Medicine, explains that cortisone is an anti-inflammatory medication. It eases pain by reducing inflammation in an injured or arthritic joint, or other inflamed tissues. The pain may be the result of a swollen tissues in the joint such as a tendon, bursa, or the synovium.

To injured athletes this drug can be mistaken for a miracle cure for their pain. It is true that cortisone injections are effective at reducing pain. But cortisone does not assist in the healing process. In fact, it's actually been shown to slow it down.

According to Dr. Leach, if you put cortisone in a joint, it will reduce the inflammation in the synovium. However, he adds, if you immediately return to your normal activities, you can wear it down. Dr. Leach tells patients not to do any strenuous exercise for 10-12 days after a cortisone injection. He also cautions that the cortisone did not fix the problem, it merely eased the pain.

Using Cortisone Wisely "It is not a miracle," says Dr. Leach. "It can be effective." Cortisone should be used to reduce the pain and inflammation for a time. This allows the patient to begin exercises that will strengthen muscles in the area and reduce the stress that caused the tendinitis in the first place. "Most orthopedic surgeons, given a choice in tendinitis, would not use a cortisone shot as a first option," says Dr. Leach. He explains that cortisone injections are usually used when other treatments, such as nonsteroidal anti-inflammatory medications (ie, ibuprofen), rest, and strengthening exercises, have failed to stop the pain. For example, a patient with rotator cuff tendinitis, would have to stop the offending activity (throwing overhand, swimming freestyle, etc.) and then begin specific exercises to strengthen the muscles of the rotator cuff. So the strengthening exercises are what fixes the problem, not the cortisone. Complications From Cortisone Injections Cortisone's ability to reduce pain and inflammation is both a blessing and a potential curse. When we no longer have pain in an injured area, we assume we are healed and ready to get back into action. By aborting the body's inflammatory response, cortisone can lead us into a false sense of wellness.
If you don't feel pain, you don't know that it may be time to stop an activity that is putting too much stress on your joint. An extreme case would be the complete rupture of a tendon. Such as what happened to basketball great Wilt Chamberlain years ago after several cortisone injections. Tendon rupture related to cortisone injection is uncommon and not completely understood. Some studies have shown that the long-term use of cortisone (ie, repeated injections over a period of months or years) can cause degeneration of tendon tissue if injected into the tendon itself. Dr. Leach explains that if you inject cortisone directly into a tendon, and then the athlete immediately begins exercising at high intensity, the tendon is at risk and could rupture. This is why orthopedic surgeons inject cortisone into a joint or into the space between the tendon and its thin lining, but not directly into the tendon. In a commentary published in the British Journal of Sports Medicine (June 1999), Rod Jaques of the British Olympic Medical Centre, explains that the surgeon must be aware of the amount of resistance he feels against the injection fluid as it exits the syringe. He explains: "...a high resistance indicates a 'dangerous' injection into an anatomical structure rather than a low resistance indicating a 'safe' injection into tissue space or an anatomical plane"areas around the tendon.
A Viable Option to Aid Recovery In general, cortisone injections are safe and have a low rate of complications if performed with adequate precautions. In his commentary in the June 1999 issue of the British Journal of Sports Medicine, Karim Khan, MD, PhD, points out that the few studies of corticosteroid injections for tendon problems have yielded conflicting results regarding the long-term outcomes, though they have shown short-term benefits (ie, reduced inflammation and pain). Dr. Leach describes tendinitis as the body's "failure to repair an area [of a tendon] that has deteriorated." Cortisone is simply a drug that will reduce the inflammation in the area, so that the tendon can repair itself, with the help of some rest and the proper exercises. Exercising the muscles attached to the tendon puts stress on the tendon, which causes it to repair itself. Of course, too much stress would hurt rather than heal the tendon. An orthopedic doctor or physical therapist can teach you how much stress is appropriate. In deciding if a cortisone shot will help your recovery, your doctor will have some recommendations and you will need to decide if you feel comfortable with the risks associated with the procedure.
RESOURCES: American Academy of Orthopaedic Surgeons http://www.aaos.org American College of Sports Medicine http://www.acsm.org CANADIAN RESOURCES: Canadian Orthopaedic Associationhttp://www.coa-aco.org/ Health Canadahttp://www.hc-sc.gc.ca/index_e.html Refernces: Arroll B, Goodyear-Smith F. Corticosteroid injections for painful shoulder: a meta-analysis. Br J Gen Pract. 2005;55:224-8. Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005;15:E370. Richie CA 3rd, Briner WW Jr. Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. 2003;16:102-6. Smidt N, Assendelft WJ, van der Windt DA, et al. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain. 2002;96:23-40. Smith AG, et al. Common extensor tendon rupture following corticosteroid injection for lateral tendinosis of the elbow. British Journal of Sports Medicine. 1999;33:423-425.
Thornton J. Pain relief for acute soft-tissue injuries. The Physician and Sportsmedicine. 1997;25. Last reviewed March 2008 by Marcin Chwistek, MD Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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