Etienne A. Mejia, M.D.
Cortisone injections are commonly used to treat many musculoskeletal conditions and can provide relief of pain and improvement in function. Most cortisone injections are performed in joints, but they also can be helpful in other inflamed areas, like tendons, bursas, muscles, etc. There are multiple cortisone preparations used in different concentrations and with different lasting effects. There are also other preparations that can be injected, such as lubricants and “biologics” which are beyond the scope of this discussion. Most patients are more familiar with cortisone and should be aware of the benefits but also some potentially harmful effects of the use of these injections.
Cortisone is a type of steroid called corticosteroid. Corticosteroids come in oral, topical, inhalational, and injectable forms and can be used to treat rashes, asthma, rheumatoid conditions, and others. Injectable steroids, like cortisone, break down tissue, which has positive and negative effects. When used in a controlled manner, cortisone injections can reduce swelling and inflammation, and are therefore helping to reduce pain. However, because corticosteroids break down tissues, they must be used with caution, since repeated cortisone injections can damage cartilage and tendons.
Caution with Cortisone Injections
We avoid injecting certain tendons, like the Achilles and patellar tendons due to a relatively high risk for these tendons to rupture sometime after an injection. However, other tendons with broader attachments are more resistant to rupture, for example, “tennis elbow” and the bursa around the shoulder’s rotator cuff. Yet, repeated injections of the rotator cuff and elbow tendons can predispose the tendon to rupture by turning the tissue into “mush.”
Injections around the rotator cuff are helpful in providing relief, restoring function, and facilitating rehabilitation. However, partial and complete rotator cuff tears will not heal with cortisone injections and can make them worse. In fact, injections may compromise healing after surgery. The relief from a steroid injection may be temporary, particularly in partial and complete tears. There has been interest in the negative effects of steroid injections of the shoulder in a number of recent studies. Although the risk of infection in shoulder arthroscopy and rotator cuff repairs is low, there is a slight increase in infection after cortisone injection, especially when administered within a month from surgery. There is also a higher incidence of repeat surgery (failures) when an injection is done within 6 months from a rotator cuff repair. The risk is higher if multiple injections have been administered within a year. Other conditions, like diabetes, immunosuppression, and smoking compound the risks even further.
Another common application for cortisone injections is for the treatment of painful joints. Ideally, injections are part of a broader treatment plan, including oral analgesics, rehabilitation, light exercise, etc. Swollen joints from arthritis, gout, or other inflammatory conditions like rheumatoid disease, can benefit greatly from cortisone injections. Repeated cortisone injections in a joint may be reasonable if the joint is arthritic and the cartilage is already compromised. However, repeated injections in healthy cartilage can create cartilage damage, and therefore, other root causes of pain must be explored before resorting to injections. A joint infection can be made worse after an injection, and must be identified by the treating provider before considering a cortisone injection. The arthroplasty literature, which deals with joint replacements, has established a high risk of infection if a joint replacement is performed within 3 months after an injection.
Although cortisone injections can provide significant benefits for many conditions, they must be used for the right indications and with a long-term treatment plan in mind, instead of the potential short benefit. Beware of the use of multiple injections! Rather than continuing to receive cortisone injections, let us find the root cause of the problem and treat it appropriately. Surgery may be a consideration instead of burning bridges by the use of injections. At Sports Medicine Center, we take steps to educate patients about their condition, the treatment options, and possible consequences in formulating a treatment plan. I feel that an informed patient is the best partner in developing the best treatment plan for each individual.