I’m going to discuss the single WORST side effect associated with cortisone injections. Recent clinical trial data looking at the effects of cortisone shots have revealed some astonishing data and they can have serious consequences to your joints and your tendons. So what exactly is this drawback and how is it going to affect your body? Keep reading as we are going to uncover the true risks behind cortisone injections.
Corticosteroid injections also known as cortisone injections are a type of medication commonly used to treat musculoskeletal conditions. When injected into the affected area, corticosteroids have anti-inflammatory properties. This means they can help reduce inflammation, swelling, and pain associated with various musculoskeletal conditions, such as arthritis, tendinitis, and bursitis.
Now, let's address the elephant in the room. What we know from laboratory research is that corticosteroids restrict the delivery of nutrients to a wounded area. They slow the formation of new tissue. They damage existing collagen. And they increase tissue degradation. These are the exact properties that dermatologists are looking for when treating scar tissue. They actually leverage the catabolic effects of cortisone to break down excessive collagen tissue in keloids.
However, this poses a significant problem in orthopedics because our tendons are also composed of collagen. Cortisone injections can provide temporary relief for tendonitis and tendinopathies but they also put the body at risk for further tendon damage. And this is exactly what we see in clinical trials.
This study is a systematic review looking at the efficacy and safety of corticosteroid injections for the treatment of tendinopathies. They write that there are “consistent findings between many high quality randomized controlled trials that corticosteroid injections reduce pain in the short term. But this effect was REVERSED at intermediate and long terms. This is a landmark meta-analysis in that it presents high level evidence that cortisone injections are HARMFUL in the long term for tennis elbow.”
This is also why corticosteroid injections into some tendons such as the quadriceps tendon and the achilles tendon are associated with tendon tearing and even tendon rupture.
Now, let's turn our attention to the impact of cortisone injections on joints. Recent data has raised concerns about the potential harm they can cause to cartilage. Let’s take osteoarthritis as an example. This is a common degenerative joint disease that primarily affects the articular cartilage. Cartilage is a smooth tissue that pads and cushions the ends of our long bones. Loss of cartilage results in an inflamed and painful joint, leading to stiffness, swelling, and reduced range of motion.
For years, doctors have recommended cortisone shots as a means to alleviate pain and symptoms associated with arthritis. However, this study found that common steroids such as 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 go on to write that “higher doses [of steroids] were associated with significant gross cartilage damage and chondrocyte toxicity.”
So while cortisone shots can provide temporary relief and alleviate pain and symptoms, it is important to be aware that they can potentially contribute to the deterioration of healthy cartilage, resulting in further cartilage loss. In fact, that’s exactly what this clinical trial showed. They found that among patients with symptomatic knee osteoarthritis, intra-articular cortisone shots, compared with placebo saline injections, resulted in significantly greater cartilage volume loss and no significant difference in knee pain.
To make matters worse, recent studies have unveiled a concerning association between cortisone injections and rapidly destructive joint disease. This is characterized by progressive joint space narrowing, osteolysis, and collapse of the joint architecture. This study found a dose response association between intra-articular hip cortisone injections and rapidly destructive hip disease. Higher dose injections as well as multiple injections significantly increased the risk.
All of this recent data suggests that corticosteroid injections can inflict substantial harm on the joints, potentially worsening arthritis and ultimately necessitating joint replacement surgery. That’s why this study wanted to see if there was an association between cortisone injections and the risk of requiring a knee replacement surgery.
They found that each cortisone shot increased the absolute risk of knee replacement by 9.4% compared with those who did not receive injections. They conclude that “corticosteroid injections seem to be associated with an increased risk of knee arthroplasty in patients with, or at risk of developing, symptomatic osteoarthritis of the knee.”
Of course, it is important to note that the associations mentioned do not establish causation. Some argue that individuals with more severe knee arthritis are more likely to receive additional cortisone shots, and were destined to get worse arthritis to begin with. This is a valid perspective.
However, what sets cortisone shots apart is the lack of similar effects observed with other common treatments for knee arthritis. In fact, quite the opposite has been found. Several studies indicate that both platelet-rich plasma injections as well as hyaluronic acid injections have shown a potential to DECREASE the risk of requiring knee replacement surgery. The contrasting outcomes between cortisone shots and alternative treatments strongly support the notion that cortisone injections may indeed be causing more damage.
So I think it’s evidence that corticosteroid injections carry significant and real side effects and all of this highlights the need for doctors to exercise greater caution when administering them. But I also want to be very clear. I’m not saying there still isn’t a use for cortisone injections. In my opinion, one or possibly two cortisone injections in a specific body part is likely safe.
The primary objective of these shots should be to effectively manage symptoms, reduce pain, and improve function. This enables patients to continue other treatments such as exercise and physical therapy. What we don’t want to do is to rely on a treatment plan that involves frequent cortisone shots every 3 to 4 months.