THE BENEFITS, RISKS, AND LIMITATIONS OF CORTISONE SHOTS

Cortisone shots are strong doses of steroids that are injected by needle into a joint or tissue. This type of injection puts a powerful anti-inflammatory medication directly into the irritated tissues, as compared to other types of anti-inflammatories that are taken by mouth and must travel through your digestive and circulatory system to reach their target.

It is still a hit-or-miss treatment, however. While some patients experience positive results, many others get little or no relief. In fact, it’s basically a coin toss, as patients generally have about 50% chance of feeling better after a steroid injection.

With those kinds of odds and the potential for quick and/or significant relief, patients may be inclined to say “well, it can’t hurt to give it a try”, but in fact:

  • There are significant risks that must be considered and weighed
  • Doctors usually prefer skilled physical therapy as a first course of treatment rather than injections, and for good reasons
  •  If you desire long-term relief, skilled physical therapy is crucial even after “successful” cortisone shots

Pain, irritation, and limited movement are signals that something about your body’s biomechanics or movement patterns are “off” and are stressing certain joints or tissues, and simply taking some painkillers – no matter how strong – will not treat the underlying, long-term issues. With that in mind, let’s examine the positive benefits, the inherent risks, and the overall limitations of cortisone shots, as well as why skilled physical therapy should be part of your treatment whether you choose to get cortisone shots or not.

What are some of the benefits of cortisone shots?

The key benefit of a steroid injection is the delivery of anti-inflammatories directly to the joint, which as noted above allows the full dose of the drug to reach the irritated tissues without being dispersed by traveling through the digestive system and being distributed throughout the body. It also avoids irritating the lining of the stomach for those who have difficulty taking common over-the-counter or prescription-strength NSAIDS – Aleve, Motrin, Advil, etc. – especially the large doses that may be called for in some cases.

If you are one of the 50% of patients who indeed respond positively to a cortisone injection, the resulting relief can be short or long-lasting, and in the best-case scenario can provide dramatic enough relief to allow you to quickly return to daily activity with decreased pain.

The risks should not be overlooked, however, both of receiving a single injection as well as undergoing repeated injections.

What are some of the risks of cortisone shots?

There are a variety of potential problems to consider.

Even one shot carries some risk.

The primary risks of a single injection come mainly from the needle itself. First of all, it is not uncommon to experience significant irritation or pain in the joint or tissue due to the needle being driven in so deep, which could make your symptoms worse in the short term. This may be seen as painful but acceptable to those who experience significant relief of their overall symptoms, but will be especially miserable and frustrating for the 50% of patients who ultimately receive little or no overall relief.

In addition, the risk of infection can never be fully eliminated when inserting a needle deep into the body. There is always a small percentage of patients who get infections from injections, no matter how carefully the skin is treated beforehand.

You may also experience nerve irritation, and there is even a small risk of nerve damage if the needle contacts a nerve. This is particularly true in the spine, but can occur in any region of the body.

Finally, if you have diabetes or have elevated blood sugar the steroids may cause your blood sugar to spike, so you will need to carefully monitor glucose levels.

Repeated injections are even more worrisome.

In addition to the risks of a single injection, repeated injections in the same joint have further and more worrisome risks. Steroids are a powerful drug, and their anti-inflammatory benefits do not come without a price. If you receive more than one injection in a particular joint, you may be at risk for, among other things

  • higher likelihood of infection
  • tissue death
  • bone thinning or even bone death in the surrounding area
  • tendon weakening or even tendon rupture.

For repeated cortisone shots in the same joint, the standard recommendations are for a minimum of six weeks between injections, and a maximum of three shots per year. And these recommendations are only intended to minimize the risk of bone thinning or tendon rupture – they cannot eliminate it.

Why is physical therapy often preferred over injections as a first course of treatment?

The most obvious answer to this question is that it is preferable to avoid risks like infection, tendon weakening, or bone thinning, but the fact is that skilled physical therapy can often be just as successful in providing pain relief in the short term, and almost always is more effective in the long term.

So in addition to providing quality pain relief without the inherent risks of invasive cortisone shots, you also don’t want to mask the pain that allows skilled diagnosis of whatever biomechanical issues are causing your pain long term, and you don’t want to mask the pain just so that you can continue beating up your joints with improper movement patterns.

Consider this analogy: if your car has a flat tire on a bumpy road, you’re in for an very uncomfortable ride. You could install a super duper shock absorber that would make the ride smoother, but eventually you are going to ruin your car’s wheel, your axle, and probably a lot of other things too.

It may seem obvious that “it’s a flat tire problem, fix the flat tire”, but it’s the same with your body: you may be able to mask the effects of a flawed movement pattern with a powerful steroid injection, but you will be ignoring the real problem, and potentially causing even further damage that you will pay for later.

Why is physical therapy important even if cortisone shots have been “successful”?

Sometimes pain is so bad, or the need for an immediate solution so important that a cortisone injection can be an acceptable risk. But as described above, even if the best-case scenario plays out and it provides significant and long-term pain relief, skilled physical therapy will still be necessary to insure that more damage is not occurring “under” the pain-masking steroid, and to determine what needs to be done to instill healthy movement patterns.

Pain, irritation, and functional limitations are signals that something about your body’s mechanics or movement patterns is overburdening certain joints, tendons or muscles. If you hope to achieve your best possible recovery you must reduce or eliminate these burdens. Simply applying “pain relief” in the form of a cortisone shot may make the irritated tissue “happy” for a while, but it will not reduce the burdens on the tissues.

It’s critically important to know which positions and activities may create irritation, and this absolutely should not be overlooked even if you feel dramatic improvement after an injection.

Conclusion

While cortisone shots have their place in some treatment programs, there are very good reasons that doctors usually prescribe skilled physical therapy as a first course of treatment. If you have been offered cortisone shots, you should carefully consider the benefits they offer versus the risks they entail, the fact that they only work for about half of the people who receive them, and the fact that skilled physical therapy can often provide equal or better short- and long-term outcomes without the risks. And if you do choose to get a cortisone shot (or shots!), you must keep in mind that they almost never solve the problem, and that good physical therapy is required to identify the underlying issues and help you become pain free for a lifetime.

Further Reading:

Adverse effects of extra-articular corticosteroid injections: a systematic review

Septic and Aseptic Complications of Corticosteroid Injections: An Assessment of 278 Cases Reviewed by Expert Commissions and Mediation Boards From 2005 to 2009

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