A common question I receive from patients is whether they should consider cortisone injections. While these injections fall outside my scope of practice, my stance on their use depends on the individual case and the available research. I encourage patients to review the peer-reviewed research and discuss the Pros and Cons with their physician to make an informed decision.
In this article, I will present some of the key findings from research to help you draw your own conclusions or at least spark some interest in learning more about the benefits and risks of cortisone injections that you can discuss with your physician.
Article Index:
Pros of Cortisone
Cortisone injections, or corticosteroid injections, are a mainstay in the management of musculoskeletal (MSK) conditions due to their potent anti-inflammatory and immunosuppressive properties. These injections are particularly effective in treating conditions such as osteoarthritis, rheumatoid arthritis, tendinitis, and bursitis, where inflammation plays a pivotal role in the pathophysiology. The primary mechanism of action involves the suppression of inflammatory cytokines and inhibition of the phospholipase A2 enzyme, leading to a reduction in the production of pro-inflammatory mediators like prostaglandins and leukotrienes.
This biochemical process can rapidly alleviate pain and swelling, significantly enhancing joint function and patient mobility. The decrease in pain not only improves daily activities but also leads to better sleep quality, as discomfort often disrupts rest. Furthermore, with reduced inflammation and pain, patients can more comfortably engage in physical exercise and tolerate manual therapy, critical components of a comprehensive rehabilitation program.
Enhanced mobility and reduced pain also allow patients to participate more effectively in physical therapy, which is essential for long-term recovery and maintenance of joint health. This holistic improvement in function and comfort underscores the value of cortisone injections in the therapeutic arsenal for MSK conditions.
Cons of Cortisone
Now that we have covered the benefits of cortisone injections, it’s essential to consider some of the potential negative factors. Despite their anti-inflammatory advantages, cortisone injections carry significant risks, especially with repeated use. Peer-reviewed studies highlight that frequent corticosteroid injections can lead to the thinning and weakening of ligaments, tendons, and cartilage. This is primarily due to the catabolic effects of corticosteroids on collagen, a crucial structural protein in connective tissues, which inhibit collagen synthesis and promote its degradation, thereby undermining tissue integrity and tensile strength.
Cortisone-induced tendinopathy is a notable adverse effect, resulting from corticosteroids directly impairing tendon fibroblast function. This leads to weakened tendons and an increased risk of tendon rupture, particularly in high-stress, weight-bearing joints like the Achilles tendon and the rotator cuff. Additionally, corticosteroids disrupt the balance between matrix metalloproteinases (MMPs) and their inhibitors, further compromising tendon structure.
Furthermore, corticosteroids adversely affect cartilage by inhibiting chondrocyte proliferation and reducing proteoglycan synthesis, compromising cartilage integrity and function as a shock absorber in joints. This accelerates degenerative changes seen in osteoarthritis. Long-term use of corticosteroids is also associated with osteonecrosis. Osteonecrosis is the death of bone tissue due to a lack of blood supply. Particularly at the femoral head, caused by disrupted blood supply due to fat embolism, intravascular coagulation, and increased intraosseous pressure. Subchondral bone atrophy can also occur, leading to structural failure and joint surface collapse.
Systemic side effects include elevated blood glucose levels, posing risks for diabetic patients, alterations in adrenal function leading to adrenal suppression, hypertension, increased susceptibility to infections due to immunosuppression, and potential exacerbation of peptic ulcer disease. Cortisone injections can interact with medications like anticoagulants, increasing bleeding risks, and with certain vaccines, reducing efficacy.
Too Much of a Good Thing
Cortisone injections can effectively manage inflammation and pain in musculoskeletal conditions, but their frequency should be carefully considered. General guidelines suggest limiting injections to three or four times a year in a single joint to minimize tissue damage and systemic side effects. For some patients without pre-existing conditions such as diabetes, osteoporosis, or a history of tendon injuries, this frequency may effectively manage symptoms without significant adverse effects. These individuals benefit from reduced inflammation, pain relief, and improved joint function.
However, for others, even three or four injections a year may be excessive. Patients with diabetes risk elevated blood glucose levels, while those with osteoporosis may experience accelerated bone density loss. Individuals with prior tendon or ligament injuries are more susceptible to cortisone-induced tendinopathy or tendon rupture. The impact of repeated injections also varies based on the joint treated, with weight-bearing joints like knees and hips potentially being more vulnerable. Healthcare providers must tailor the treatment plan to each patient's health status and response, considering alternative therapies to reduce corticosteroid dependence.
Conclusion
In conclusion, cortisone injections play a role in managing musculoskeletal conditions by providing rapid relief from pain and inflammation, enhancing joint function, and improving patient mobility. These benefits can lead to better sleep quality and enable patients to participate more actively in physical therapy and rehabilitation programs, which are crucial for long-term recovery. However, it is essential to weigh these benefits against the potential risks, especially with repeated use. The adverse effects, including the thinning and weakening of ligaments, tendons, and cartilage, highlight the need for careful consideration of the frequency and necessity of cortisone injections.
For some patients, receiving cortisone injections three or four times a year may effectively manage symptoms without significant adverse effects. However, others, particularly those with conditions like diabetes or osteoporosis, or a history of tendon injuries, may face increased risks even at this frequency. The decision to use cortisone injections should be made on a case-by-case basis, with healthcare providers tailoring treatment plans to each patient's specific health status and monitoring their response closely. By thoroughly reviewing the peer-reviewed research and discussing with their physicians, patients can make informed decisions about the use of cortisone injections in their treatment plans.
Don't Forget the Rehab & Exercise
A key point is that these injections do not replace manual rehabilitation or a functional exercise program. Still, they may allow a patient to receive treatment or do their exercises with painful conditions they would not be able to otherwise. Cortisone injections should be considered part of a comprehensive treatment plan that includes manual rehabilitation and functional exercises, as these elements are vital for achieving long-term health and preventing future injuries.
I come from a multidisciplinary collaborative perspective where we all work as a team to achieve the best results for our patients. This team approach ensures that every aspect of a patient's condition is addressed, promoting optimal recovery and long-term well-being.
References
Assouline-Dayan, Y., Chang, C., Greenspan, A., Shoenfeld, Y., & Gershwin, M. E. (2002). Pathogenesis and natural history of osteonecrosis. Seminars in Arthritis and Rheumatism, 32(2), 94-124. https://doi.org/10.1053/sarh.2002.37235
Bhattacharjee, A., Bhattacharya, R., & Mallick, P. (2016). Intra-articular corticosteroids: Effects on articular and extra-articular pathology. Journal of Orthopaedic Surgery and Research, 11, 39. https://doi.org/10.1186/s13018-016-0383-9
Coombes, B. K., Bisset, L., & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. Lancet, 376(9754), 1751-1767. https://doi.org/10.1016/S0140-6736(10)61160-9
Dean, B. J., Getgood, A., Al-Mansoori, A., & Carr, A. J. (2003). The risks and benefits of corticosteroid injection for rotator cuff tendinopathy: A critical review. Clinical Journal of Sport Medicine, 13(1), 18-23. https://doi.org/10.1097/00042752-200301000-00005
James, R., Kesturu, G., Balian, G., & Chhabra, A. B. (2008). Tendon: Biology, biomechanics, repair, growth factors, and evolving treatment options. Journal of Hand Surgery, 33(1), 102-112. https://doi.org/10.1016/j.jhsa.2007.09.007
Nishii, T., Sugano, N., Miki, H., Takao, M., Yoshikawa, H., & Ochi, T. (2001). Does the extent of osteonecrosis affect the outcome of conservative treatment? Clinical Orthopaedics and Related Research, 386, 176-185. https://doi.org/10.1097/00003086-200105000-00023
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DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical practice and experience in treating over 25,000 patients with a success rate of over 90%, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.
As an internationally best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.
A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.
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