Benefits and Drawbacks of Cortisone Injections

It is easy to take for granted the ability to move and function without pain. When we experience pain, our first thoughts are, “How can I make this go away and FAST?” This is what leads many of my patient’s to the question, “Well, can’t I just get an injection and get the pain to go away?” We are all looking for that quick fix. Unfortunately, the answer is usually not that simple. Cortisone injections are a commonly used medicine in orthopedics to help reduce pain and inflammation. While a quick shot may sound appealing, let’s dive a little deeper into the effectiveness, benefits, and drawbacks for receiving a corticosteroid injection.

What is Cortisone?

Cortisone is a steroidal anti-inflammatory medication. It’s injected into or around a tissue that’s irritated in order to reduce swelling and pain. It’s often thought that cortisone is simply a pain reliever, however it does have effects beyond pain relief that can help an individual recover faster.

Healing is a process marked by three stages: inflammation, tissue regrowth, and tissue remodeling. Inflammation is necessary to alert the immune system of damage and mark an area for the cascade of events that begins the healing process. As the inflammatory response tapers, the tissue can begin to regrow and the bulk of “healing” takes place. Finally, the injured area remodels as scar tissue is replaced by healthy tissue and important blood vessels reach their targets.

If an individual is stuck between the first two stages of the healing process, the tissue never has the chance to fully heal. Tumbling between the stages of inflammation and tissue regrowth can cause chronic pain and increase the chance of re-injury. A cortisone injection can quell inflammation enough to push a tissue into the second stage of healing and promote better growth of new cells.

Benefits Of Cortisone

When used appropriately, cortisone can boost tissues out of an inflammatory phase into a growth phase. This is particularly useful when all movement causes pain. Movement is crucial in returning a tissue to its previous elasticity. As a physical therapist, prescribing the appropriate exercises to promote tissue healing, increase tissue strength, and increase movement tolerance is the key to returning to pain free function. Some (not all) patients will present to therapy with too much inflammation and pain to tolerate any exercises. In those rare causes, an injection may allow patients to tolerate more movement and exercise; thus beginning the rebuilding phase and a better response to physical therapy. Exercise encourages good development of blood vessels that supply essential nutrients and oxygen for tissue healing.

Potential Drawbacks of Cortisone

When used in the correct dosage and frequency, cortisone can accelerate healing. If used too frequently, cortisone may actually have the opposite effect. Cortisone is a hormone that, in excess, signals for cell destruction. Chronic use of injections to manage pain can result in weakening of the very tissue in need of growth. This is why doctors recommend injections no more than once every three months.

While cortisone injections are commonly used in treatment for chronic tendon injuries (examples include Achilles tendonitis, tennis elbow, rotator cuff injuries) there is minimal evidence supporting the long term effectiveness (1). A meta-analysis on the effectiveness of cortisone injections of tendon lesions indicate that overall short and long term outcome of injection alone does not have statistically significant outcomes versus placebo (2). On a positive note, this study concluded that using an injection to improve ones tolerance to rehabilitative exercise is indicated.

Should I have a Cortisone Injection?

Cortisone is a medication, and if it’s not needed, it shouldn’t be used. An injection should be thought of as a last ditch measure to break a cycle of inflammation. It should follow a thorough orthopedic exam to determine why inflammation persists. An injectable steroid, like cortisone, enables an individual to participate in more exercises that increase blood flow, strengthen, and/or mobilize tight tissues, thus addressing the reason BEHIND the chronic inflammation. It is recommended that cortisone injections should be coupled with physical therapy or a professionally prescribed exercise program to ensure the best treatment outcomes.

References
1. C A Speed “Corticosteroid injections in tendon lesions.”
BMJ. 2001 Aug 18; 323(7309): 382–386.

2. Coombes, Brooke K, et al. “Efficacy and Safety of Corticosteroid Injections and Other Injections for Management of Tendinopathy: a Systematic Review of Randomised Controlled Trials.” The Lancet, vol. 376, no. 9754, Nov. 2010, pp. 1751–1767.

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