Cortisone Steroid Injections: Can They Actually Make Things Worse?!
Cortisone Shots: The good, the bad and the ugly.
Cortisone has been one of the most commonly-prescribed treatments for joint and tendon injuries, as well as for the pain caused by osteoarthritis, since it was developed in the 1940’s. It’s no surprise why: corticosteroid injections are often more effective than any pill, and can provide rapid relief of pain.
But even the earliest clinical trials raised doubts about cortisone’s long-term side effects. In fact, a 1954 study showed that more than half of patients who received a cortisone shot for tendonitis suffered a relapse within six months. But that didn’t stop cortisone injections from becoming a standard, much-requested treatment for joint and tendon problems, with over 9 million cortisone injections given every year.
What is cortisone, anyway?
Cortisone is a steroid that acts as an anti-inflammatory. In the case of tendonitis, bursitis or discitis, it’s prescribed to reduce the ‘itis’ – ‘itis’ refers to inflammation and/or swelling in soft tissue.
So if you’ve had someone recommend a cortisone injection, you might be thinking “Ok, perfect! I’ve got swelling and inflammation, this stuff will be great – where do I sign up?”
Unfortunately, new research might make you think twice.
In reality, the inflammation phase of the injury healing process is a very small window of a week or two. Most of the injuries corticosteroids are prescribed for occur over an extended period of time due to excessive loading and stress placed on soft tissues (“micro-tear formation”). As this happens, tendon and ligament fibers “fray” and are gradually replaced with scar tissue. Ultimately, it’s the built-up scar tissue that causes the intense long-term pain, not the short-term inflammation phase.
Why corticosteroids can make things worse
Why cortisone shots should slow the healing of tendonitis, bursitis, discitis and arthritis is a good question. It comes down to this: because cortisone eliminates the inflammation phase of the healing process without correcting the root of the problem, it actually accelerates tendon and ligament degeneration.
Sure, inflammation sucks, but it’s a necessary evil – inflammation and swelling brings in large quantities of oxygen and nutrients necessary for the repair process. The clotting proteins that enter soft tissue during the inflammation process form a gel-like mesh that functions as a kind of scaffolding for repair.
In fact, in recent years the greater medical community has moved from calling tendon injuries tendonitis (the “itis” ending referring to inflammation) to tendinopathy – emphasizing that degeneration is the problem, not inflammation.
What the evidence says
A new review study, published in The Lancet, examined the results of nearly four dozen randomized trials on the effectiveness of corticosteroid injections. The studies encompassed thousands of patients suffering from elbow, shoulder and hip pain. The researchers found that for most of the patients cortisone injections did, as promised, bring fast and significant pain relief that could last for several weeks.
But when the patients were re-examined at 6 and 12 months, the results were substantially different. Over all, people who received cortisone shots had a significantly lower rate of full recovery than those who simply rested or underwent physical therapy and/or chiropractic care.
They also had a 63% higher risk of relapse than those who took a wait-and-see approach – the cortisone shots seemed to actually be counterproductive. Those who get multiple injections are at particularly high risk for continuing damage. In one study that the researchers reviewed, “an average of four injections resulted in a 57% worse outcome when compared to one injection.”
Even worse, research has shown that for every cortisone injection your risk of bone fracture due to demineralization is increased by 21%!
Are cortisone injections worth it?
The study authors also determined that the NNT for cortisone injections – or Numbers Needed to Treat to get a clinically significant benefit – was 1 in 5. In other words, you only get a 20% likelihood of any significant short-term pain relief in exchange for long-term damage and the return of pain after 8 weeks.
So the question of whether cortisone shots still make sense as a treatment depends on how you choose to balance short-term pain relief versus the likelihood of longer-term negative outcomes. Is reducing soreness now worth an increased risk of delayed healing and possible relapse a few months down the road?
If the pain is severe enough, some people, including physicians, may decide that the answer remains yes. But based on the research, it’s worth thinking twice about the wisdom of cortisone shots.
A better approach to pain
Today we’re seeing a quantum shift in how healthcare providers are approaching soft tissue injuries. That shift lines up exactly with what we do at Ascent Chiropractic: Correct movement, strengthen the supporting structures, and decrease inflammation naturally.
- Correcting Movement: Improving joint movement and allowing musculoskeletal system to work more efficiently is at the heart of treating injuries at Ascent Chiropractic.
- Strengthen Supporting Structures: We understand that the joint is only one component and that the muscles surrounding a joint provide a very important role. They support the joint and help to control its movement. Rehab exercises are vital to keeping the low back moving properly and staying healthy.
- Decrease Inflammation Naturally: Avoiding inflammatory foods like sugar, processed foods and alcohol can help to reduce inflammation during pain episodes. Pain intensity is often increased in those who have a high level of systemic inflammation. By eating a clean anti-inflammatory diet filled with Omega-3 fats, antioxidant-rich fruits and vegetables, and foods that stabilize your blood sugar, you can reduce pain sensitivity.
Share the science. Being well informed comes with the responsibility of sharing what you know with others who don’t. We encourage you to share what you know with others who are curious and can benefit from knowing the research. Have friends or family who could benefit from what we do at Ascent Chiropractic? We’d love to help. Call us at 262-345-4166 to set up an appointment, or use our online scheduling app.
Image Source: Medical photo created by welcomia – www.freepik.com