- Jeffrey Peng MD
- Mar 4
- 5 min read
By Dr. Jeffrey Peng, MD · Published March 4, 2026 · 8 min read
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Cortisone injections have been a staple of musculoskeletal medicine for decades. They are fast, relatively inexpensive, and can deliver meaningful short-term pain relief for conditions ranging from arthritis to tendinitis and bursitis. But what does the clinical evidence actually say about the long-term consequences of cortisone shots on your tendons and joints?
In my practice as a sports medicine physician, I regularly field questions from patients about whether cortisone is safe. The short answer: cortisone can have a role, but the growing body of evidence suggests that repeated use carries real risks to both tendon integrity and cartilage health. Here is what the research shows.
What Are Cortisone Shots and How Do They Work?
Corticosteroids are potent anti-inflammatory medications. When injected directly into an affected area, they reduce inflammation, swelling, and pain. This makes them a popular option for conditions such as osteoarthritis, tendinitis, and bursitis.
However, the same properties that make corticosteroids effective also create problems. Laboratory research has shown that corticosteroids restrict nutrient delivery to injured tissue, slow the formation of new tissue, damage existing collagen, and increase tissue degradation. These are the exact catabolic effects that dermatologists leverage when treating keloid scars — but in the musculoskeletal system, this mechanism can work against healing.
How Do Cortisone Shots Affect Tendons?
Our tendons are composed of collagen, so the collagen-degrading properties of corticosteroids pose a direct risk. A landmark systematic review published in The Lancet evaluated the efficacy and safety of corticosteroid injections for tendinopathies across 41 randomized controlled trials. The findings were striking: cortisone injections reduced pain in the short term, but this benefit reversed at intermediate and long-term follow-up (Coombes et al., 2010). For lateral epicondylalgia (tennis elbow), the data represented high-level evidence that cortisone injections were actually harmful in the long term.
This is also why corticosteroid injections into certain tendons — particularly the quadriceps tendon and the Achilles tendon — are associated with an increased risk of tendon tearing and even complete rupture.
Do Cortisone Shots Damage Cartilage?
Cartilage is the smooth tissue that cushions the ends of bones within a joint. In osteoarthritis, this cartilage progressively wears away, leading to pain, stiffness, and reduced mobility. For years, cortisone injections were recommended to manage these symptoms — but emerging evidence has raised serious concerns about their effect on cartilage health.
A systematic review examining multiple commonly used steroids — including methylprednisolone, dexamethasone, hydrocortisone, betamethasone, prednisolone, and triamcinolone — found dose-dependent harmful effects on cartilage morphology, histology, and cell viability. At higher doses, corticosteroids were associated with significant cartilage damage and chondrocyte toxicity (Wernecke et al., 2015).
A randomized controlled trial published in JAMA confirmed these concerns in a clinical setting. Among patients with symptomatic knee osteoarthritis, those who received triamcinolone injections every three months for two years experienced significantly greater cartilage volume loss compared to those who received saline injections — with no meaningful difference in pain relief (McAlindon et al., 2017). This trial was pivotal because it demonstrated that cortisone was accelerating cartilage loss without providing superior pain outcomes.
Can Cortisone Injections Lead to Rapidly Destructive Joint Disease?
Perhaps the most alarming finding in recent research involves rapidly destructive joint disease (RDHD), which is characterized by progressive joint space narrowing, bone loss (osteolysis), and collapse of the joint architecture. A study published in the Journal of Bone and Joint Surgery found that hip corticosteroid injections were associated with an adjusted odds ratio of 8.56 for developing RDHD. There was a clear dose-response relationship: higher doses and multiple injections significantly increased the risk. Post-injection RDHD was diagnosed at an average of just 5.1 months following injection (Okike et al., 2021).
Do Cortisone Shots Increase the Risk of Knee Replacement Surgery?
Given the evidence that cortisone can accelerate cartilage loss and potentially cause destructive joint changes, researchers investigated whether cortisone injections increase the likelihood of needing a knee replacement. Using data from the Osteoarthritis Initiative — a large, multicenter observational cohort study — investigators found that each cortisone injection increased the absolute risk of knee arthroplasty by 9.4% at nine-year follow-up compared with patients who did not receive injections (Wijn et al., 2020).
It is important to note that these associations do not establish direct causation. Some argue that patients with more severe arthritis are more likely to receive cortisone shots and were destined to progress regardless. This is a valid consideration. However, the fact that alternative treatments — such as platelet-rich plasma (PRP) and hyaluronic acid injections — have shown a potential to decrease the risk of knee replacement strongly supports the notion that cortisone injections may be contributing to joint damage rather than simply reflecting disease severity.
Are There Safer Alternatives to Cortisone Injections?
The field of orthobiologics and regenerative medicine is expanding rapidly, and several alternatives to cortisone offer both symptom relief and potential structural benefits. Platelet-rich plasma (PRP) injections concentrate your body's own growth factors and have shown promising results for both tendon and joint conditions. Hyaluronic acid injections restore the natural lubrication of the joint and have demonstrated potential to slow disease progression. These treatments are worth discussing with your physician, especially if you have been relying on repeated cortisone injections.
When Are Cortisone Shots Still Appropriate?
Despite these concerns, cortisone injections are not without value. In my opinion, one or possibly two cortisone injections in a specific body part is likely safe. The primary goal of a cortisone shot should be to manage an acute flare-up effectively — reducing pain and improving function so that you can participate in other treatments such as exercise and physical therapy. What the evidence cautions against is relying on a treatment plan that involves repeated cortisone injections every three to four months.
If you are still experiencing pain after a cortisone injection or are looking for alternatives, I encourage you to schedule a consultation to discuss evidence-based options tailored to your specific condition.
References
1. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751-1767. doi:10.1016/S0140-6736(10)61160-9
2. Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthop J Sports Med. 2015;3(5):2325967115581163. doi:10.1177/2325967115581163
3. McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967-1975. doi:10.1001/jama.2017.5283
4. Okike K, King RK, Merchant JC, et al. Rapidly destructive hip disease following intra-articular corticosteroid injection of the hip. J Bone Joint Surg Am. 2021;103(22):2070-2079. doi:10.2106/JBJS.20.02155
5. Wijn SRW, Rovers MM, van Tienen TG, Hannink G. Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty. Bone Joint J. 2020;102-B(5):586-592. doi:10.1302/0301-620X.102B5.BJJ-2019-1376.R1
Medical Disclaimer: This content is for educational purposes only and does not substitute for the medical advice of a physician. Always consult your healthcare provider before beginning any new treatment program. The information presented reflects the opinion of Dr. Jeffrey Peng and does not represent the views of his employers or affiliated hospital systems.