Cortisone injections have long been used to treat orthopedic conditions. Despite this, there is a scarcity of high quality data favoring the use of cortisone injections. What is clear - cortisone injections provide short term relief but cause long term harm. Read on to learn more.
History of Cortisone Injections
Physicians have used cortisone injections in orthopedics and sports medicine since the 1960s. Amateur and professional athletes requested cortisone injections because it allowed them to compete. Yet even in the 1970s, physicians counseled patients about the potential side effects of cortisone injections.
James Nicholas MD was a well known orthopedic surgeon who established the Nicholas Institute of Sports Medicine in New York. He said, “In 1963, cortisone was still the best treatment for tendonitis. Today, I won't even use it for tennis elbow.” That quote came from the 1970s.
Now here we are in 2020. 50 years later. And we are offering the same treatment option as the 1960s.
It turns out there is actually a scarcity of high quality data examining the use of cortisone injections. Most physicians don't know this. They think it is well validated. The use of cortisone injections is more grounded in culture rather than in science. So how can we expect patients to make an informed decision if their doctor doesn't know the data?
What are Cortisone and Steroid Injections?
Cortisone and steroids are anti-inflammatory medicines. They will relieve pain to the degree that your pain comes from inflammation. At least that’s what we theorize - the true mechanism of pain relief is not well understood. What is clear is that cortisone injections have significant long term negative effects.
Cortisone Injections and Cartilage Damage
Dragoo et al (Orthop J Sports Med, 4/2015) summarized that the steroids “methylprednisolone, dexamethasone, hydrocortisone, betamethasone, prednisolone, and triamcinolone were reported to display dose-dependent deleterious effects on cartilage morphology, histology, and viability in both in vitro and in vivo models.” They went on to say that “higher doses were associated with significant gross cartilage damage and chondrocyte toxicity.”
Researchers found that cortisone and steroid injections caused damage to cartilage. Cartilage is the protective lining of your bones. The higher the cortisone injection dose, the more damage to the cartilage.
Cortisone Injections and Increased Rates of Arthritis
McAlindon et al (JAMA, 5/2017) randomized patients with knee osteoarthritis into two groups. One group received cortisone injections and the other group received saline injections. They followed these two groups for two years and took MRIs of the patients’ knees.
They made two shocking conclusions.
There was no significant difference in pain between the cortisone group and placebo.
The cortisone group had significantly greater cartilage volume loss than placebo.
What does this mean?
The researchers concluded that cortisone injections did not provide any pain relief when compared to saline injections. They also concluded that cortisone injections potentially accelerated arthritis.
Cortisone Injections and Increased Rates of Knee Replacements
The problem with all this is that there is limited treatment available for end stage arthritis. Many patients end up with a knee replacement (total knee arthroplasty). So shouldn’t we do everything possible to prevent the progression of arthritis? That’s what one group of researchers looked at. They asked, is there an association between cortisone injections leading to more knee replacements?
Wijin et al (Bone Joint J, 5/2020) followed almost 4000 patients with knee osteoarthritis. They found that patients receiving cortisone injections had an increased risk of getting a knee replacement. Each additional cortisone injection increased the absolute risk of a knee replacement by 9.4%. The group concluded that “corticosteroid injections seem to be associated with an increased risk of knee arthroplasty.”
Cortisone Injections in Skin Conditions
We can also turn to our dermatology colleagues to look at the effects of cortisone injections on our body. Steroids treat keloids. Keloids are a benign skin condition resulting from the overgrowth of scar tissue.
Coppola et al (Clin Cosmet Investig Dermatol, 7/2018) found that steroids such as triamcinolone can “induce keloid regression through many different mechanisms. First, they suppress inflammation by inhibiting leukocyte and monocyte migration and phagocytosis. Second, they are powerful vasoconstrictors, thus reducing the delivery of oxygen and nutrients to the wound bed. Third, they have an anti-mitotic effect that inhibits keratinocytes and fibroblasts, slowing reepithelialization and new collagen formation. Furthermore, they may reduce plasma protease inhibitors, thus allowing collagenase to degrade collagen.”
Let’s break this down one point at a time.
Steroids suppress inflammation by inhibiting immune cell function. This is the anti-inflammatory effect of cortisone. This was the basis of using cortisone to treat "tendonitis." Now we have a better understanding of tendon problems.
Steroids reduce the delivery of oxygen and nutrients to the wound bed. If you have an injured tendon, the last thing you want to do is restrict the delivery of nutrients to that tendon.
Steroids slow new collagen formation. Ligaments and tendons consist of collagen. If you have an injured tendon, the goal is to form new healthy tissue. Steroids will slow this process down.
Steroids may reduce plasma protease inhibitors, thus allowing collagenase to degrade collagen. The effects of steroids will speed up the degradation of collagen. Collagen is what ligaments and tendons are made of. Degrading collagen would be the opposite of healing.
Let’s take a step back and actually think about this.
Dermatologists are using the properties of steroids to remove keloids. Steroids are so powerful that they BREAK DOWN the overgrowth of scar tissue. Yet here we are injecting steroids into areas of the body that cause pain. Won’t it break down the injured tissue even more?
Cortisone Injections and Tendon Rupture
In 1977, Dr. Alan Halpern published in Western Journal of Medicine a case series of five patients who had tendon ruptures after receiving corticosteroids. We can now explain this. Corticosteroids restrict delivery of nutrients. They slow formation of new tissue. They increase tissue degradation. The cumulative effect causes a well known side effect of steroid injections. Tendon rupture. Physicians knew about this in 1977.
Doctor Patient Expectations
So why do orthopedists and sports medicine physicians continue to use cortisone?
It could be there is an expectation on the physicians to do something. It could be there is an expectation from the patients to have something done. Cortisone injection costs are cheap. Insurances cover them. They will help reduce pain. But at what cost?
Cortisone Injections Cause Long Term Harm
Coombes et al (Lancet, 11/2010) reviewed many high quality randomized controlled trials, all of which consistently showed that corticosteroid injections reduced pain in the short term.
However, that’s where the good news stops.
Let’s take for example “lateral epicondylitis” or tennis elbow. This is a common condition involving the extensor tendons of the lateral elbow. Analysis of the studies showed that while cortisone “significantly improved tennis elbow in the short term, it worsened it in the intermediate term and long term.”
Patients who got cortisone injections ended up worse in the long term compared to those that didn’t get the injections. We are trading short term relief for long term harm.
Similar studies have made the same conclusions for many other musculoskeletal conditions.
Alternatives to Cortisone Injections
So what other options do patients have?
Physical therapy is a great option. It addresses the biomechanical issues that led to the injury in the first place. Read about how physical therapy can help treat degenerative meniscus tears.
But many patients have pain despite intensive physical therapy. Surgery is an option but it is usually seen as a last resort. Few people love the idea of rushing off to the operating room.
What about the middle ground? For the longest time, there wasn’t one. But now there are.
They fall under the world of orthobiologics.
Orthobiologics are in office injections that improve pain and disability. They focus on healing damaged tissues. Procedures such as platelet rich plasma injections are some of the most exciting therapies. Read here to learn more about platelet rich plasma injections.
Think long and hard whether you want a cortisone injection for your pain. They still serve a purpose in some clinical situations. But for most people, the toxicities and harm are real. Discuss with a doctor knowledgeable in orthobiologics to find out what the best treatment option is for you.