How often can you get steroid injections for arthritis?

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Getting Cortisone Shots for Arthritis: What to Know Before Getting Your First Shot

Remember the Carly Simon song “I Haven’t Got Time for the Pain”? She may have been talking about heartbreak, but arthritis pain is something you don’t want to make time for either. When you have osteoarthritis or a type of inflammatory arthritis, such as rheumatoid arthritis or gout, you may get used to living with daily chronic pain, but when an acute arthritis flare occurs, it can really throw you off your daily routine and ability to work, be active, run errands, etc. That’s where corticosteroid injections (cortisone shots) come in — a treatment option for acute bouts of pain.

Before Cheryl Ackerman was diagnosed with rheumatoid arthritis, she was experiencing pain so excruciating that she could barely walk, sit, or stand for any length of time. Per a doctor’s recommendation, she received corticosteroid shots in both of her knees, neck, and back. “After about three weeks I finally felt the full effect by the inflammation going down and this gave me great relief,” says Ackerman, who is from Florida. Even with the maintenance and pain, Ackerman says getting the injections is worth it. “They have improved my quality of life living with rheumatoid arthritis immensely.”

Steroid injections can relieve pain and improve mobility for many people, but they don’t work equally well for all types of arthritis. There are also important precautions about how frequently you can safely receive them. Here’s what you need to know before you face the needle.

What Does Cortisone Do?

Cortisone, also known as a corticosteroid or a steroid, is a hormone your body naturally produces via the adrenal glands. When delivered as a medication, corticosteroids reduce the activity of your immune system, which relieves inflammation and pain for people with different kinds of arthritis (as well as a wide range of other inflammatory diseases).

Corticosteroids comes in many different forms, which vary by how long they stay in your body, how easily they dissolve, and how quickly they take effect. They can either be delivered “locally” (in a specific location, like the knee or shoulder), or “systemically” (which means throughout the whole body). Systemic corticosteroids are usually taken orally (pills) or as injections (shots) into a vein or muscle. Local corticosteroids for arthritis can be given as an injection into a joint; for other types of health issues, they can also be delivered as skin creams, eye drops, or ear drops.

Why Would I Get a Cortisone Shot vs. Take Corticosteroid Pills?

Oral versions of corticosteroids are preferred to help control inflammation that affects multiple parts of your body, such as inflammatory forms of arthritis like rheumatoid arthritis. Pills may also be recommended if an area is difficult to inject, such as the spine or hip, says rheumatologist Paul Sufka, MD, of Health Partners in St. Paul, Minnesota. However, oral forms of corticosteroids can come with significant side effects and risks, such as elevated blood sugar and blood pressure, eye problems such as glaucoma, and increased risk of osteoporosis and infection, among others.

Corticosteroid injections, or steroid shots, can provide higher doses of medication to treat a specific problem area. According to Michael Schaefer, MD, director of musculoskeletal physical medicine & rehabilitation at the Cleveland Clinic in an , steroid injections are used most commonly for knee and shoulder pain, but they can be used for any joint in the body.

There are many different kinds of injected corticosteroids. According to data from the American College of Rheumatology, the most commonly used ones include methylprednisolone acetate, triamcinolone acetate, and triamcinolone acetonide.

Which Conditions Are Steroid Shots Used to Treat?

Cortisone shots can treat both inflammatory arthritis and osteoarthritis, but they may be more effective at treating inflammatory arthritis than osteoarthritis, according to the Mayo Clinic. “For osteoarthritis, sometimes people don’t get relief, and it’s hard to predict why,” says Dr. Sufka. In osteoarthritis patients with advanced disease, in which the cartilage in a joint is mostly worn away, it may be that the disease has progressed far enough along that the steroid injection isn’t effective.

No matter what type of arthritis you have, steroid shots are just one part of an overall treatment plan. For osteoarthritis, this could include NSAID medication, exercise and physical therapy, weight loss, and heat and ice therapy. For inflammatory arthritis, treatment includes disease-modifying drugs (from methotrexate to biologics) as well as those options. Steroid injections can help relieve inflammatory arthritis pain in the short term while longer-acting treatments like DMARDs have time to take effect.

“Treating joint pain usually involves multiple approaches,” according to Dr. Schaefer on the Cleveland Clinic’s site. “Depending on what condition is causing the pain, we try to find other long-term pain relief solutions through physical therapy, bracing, other medications or, in some cases, joint replacement.”

Where Are Steroid Injections Given?

It’s not like getting a flu shot, where you roll up your sleeve and present your arm. The steroid injection is given in the place where the pain radiates from. Locations such as the CMC (carpometacarpal and metacarpal bones at the base of the thumb), wrist, elbow, shoulder, knee, ankle, and big toe are common locations. For the spine and hip, doctors often use imaging, such as ultrasound for precise placement of the injection. This can help improve the accuracy of where the injection is placed, which can improve the effectiveness.

Does Getting a Cortisone Shot for Arthritis Hurt?

No doubt you’ve heard stories or have been warned that cortisone shots can be painful. Steroid shots are usually either mixed with a local anesthetic to help relieve pain or patients are given a local anesthetic first before the steroid shot is given. Some people feel minimal discomfort, while others feel intense pain; it’s hard to explain why injections hurt some and not others, says Dr. Sufka. One thing is certain: being anxious doesn’t help. “Many times pain comes from tensing up muscles around the needle,” he says. Dr. Sufka helps his patients his patients completely relax the area before the injection.

When Peggy Meyer, an osteoarthritis patient from North Carolina, was exploring her pain management options, she heard good and bad things about steroid shots but decided to go for it. “I recall how I dreaded those shots initially, but the few seconds of discomfort is worth the relief it brings,” Meyer says. “Now, when my knee tells me it’s time for another shot, and I actually look forward to it.”

Immediately icing the area after the injection can help relieve swelling and pain. You may feel fine right after the injection while the anesthetic is still effective, but as it wears off, you may actually feel pain that is worse than what you experienced before the procedure. This increased level of pain — remember, a needle was just injected into your body — should only last up to two days before things start to improve.

How Long Does the Pain Relief from a Cortisone Shot Last?

For some (lucky) patients, cortisone shots can bring immediate pain relief; for others, it can take a few days after the injection to start feeling improvements. According to Dr. Schaefer at the Cleveland Clinic, it can take up to a week for the cortisone to take effect. For others, the shots don’t seem to have a big impact on pain and other symptoms. The duration of time for which the shots can bring relief varies tremendously. For some patients, they only work for a few months; for others, a single injection can provide relief for a year or longer.

Any Precautions After Getting Steroid Shots for Arthritis?

Your doctor will likely recommend that you go easy on the affected joint for a few days after the steroid injection. If you got a shot in your knee, this means resting/elevating it when you can throughout the day. If you got a shot in your shoulder, you should avoid lifting heavy things. You should use ice on the area to help swelling go down, but not heat therapy. Here are more examples of how to use cold therapy for arthritis pain.

How Often Is It Safe to Get Steroid Shots?

There’s no universally approved number — and the frequency will depend to some extent on individual patient factors, such as extent of pain, other treatments received, overall health, comorbid conditions, etc. — but as a general rule, doctors limit the number of steroid injections you can get in a joint to no more than three to four a year. That’s because cortisone shots can cause side effects and, in some cases, even do more damage to the joint itself if given too frequently.

What Are the Main Side Effects of Steroid Injections?

Any medication has some tradeoffs with side effects, but overall, the risk of serious side effects with steroid shots for arthritis is low. Injected steroids for arthritis have a lower risk of side effects than oral corticosteroids.

Any time you get an injection, there’s a risk of infection, so it’s important to keep the area clean and avoid getting steroid injections if have an infection elsewhere in your body. Since an increase in pain is common after a steroid injection — sometimes called a postinjection flare — it’s important to be able to distinguish this from the signs of infection. The main things to look out for in the case of infection are: a pain flare lasts more than two days or begins more than two days after the injection; there’s redness or drainage around the injection site; and you also have fever or fatigue.

Other possible side effects of steroid shots include facial flushing, skin discoloration, local bleeding, or an allergic reaction. Cortisone shots can also raise your blood sugar in the short term, so they’re not recommended for people with diabetes whose blood sugar is poorly controlled.

Too-frequent injections in the same area can weaken the bones, ligaments, and tendons, which is why doctors limit how often you get steroid shots in a given joint.

“Some studies have shown that can cause damage in tendons and may predispose people to tendon rupture,” according to Dr. Schaefer from the Cleveland Clinic. “I often remind patients that inflammation is also damaging to their joints, and cortisone actually prevents this damage. However, if patients rely on multiple cortisone injections just to cover up their pain, they may eventually wear out their joints prematurely.”

This is why, he adds, it’s important not to rely only on steroid injections for short-term pain relief but to also treat underlying contributions to arthritis pain, including losing weight, improving posture and body alignment, and taking disease-modifying drugs for inflammatory/autoimmune arthritis.

Keep Reading

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  • Common Questions About Taking Methotrexate for Rheumatoid Arthritis

What to Know Before Getting a Cortisone Injection

Cortisone injections allow doctors to deliver potent medicine directly to sites of inflammation with minimal side effects. Depending on the patient and the condition being treated, a successful cortisone injection can suppress localized inflammation for anywhere from 6 weeks to 6 months.

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Cortisone is a synthetic version of cortisol, a steroid produced by the body’s adrenal glands.
Read: What Is Cortisone?

While cortisone injections can be an important tool in treating joint inflammation and pain, they do have limitations. Many of these limitations are described below.

A Cortisone Injection Is Part of a Larger Treatment Plan

Cortisone injections typically provide temporary relief. Most patients seeking better, long-term relief are advised to participate in physical therapy to stretch and strengthen their joints, muscles, and other soft tissues. Patients may also be advised to lose weight or make other lifestyle changes, such as changing footwear. These steps can improve a joint’s biomechanics and possibly decrease or eliminate the need for additional cortisone shots.

Patients who do have repeated cortisone shots may notice that the period of pain relief becomes shorter and shorter over time. This is not necessarily because the patient has built up a tolerance to the medication but because the joint is degrading. Again, physical therapy, weight loss, and changes in day-to-day lifestyle can help slow down or stop joint degradation.

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Activity Should Be Increased Gradually

It may take a few days for the benefits of the cortisone medication to take full effect. During this time, patients are usually told to rest and cut back on normal activities. Once the joint pain is relieved, a well-intentioned patient may be tempted to jump right into an exercise routine. However, in order to avoid injuries or possibly making the condition worse, a doctor typically advises a patient to resume normal activities gradually and add intensity over time.

In This Article:

  • Cortisone Injections (Steroid Injections)
  • What to Know Before Getting a Cortisone Injection
  • Cortisone Injection Procedure
  • Cortisone Injection Risks and Side Effects

Repeated Injections Can Affect Soft Tissue

Too many injections over a short period of time can cause damage to the tendons, ligaments, and articular cartilage at the injection site. For this reason:

  • Injections should be spaced at least 4 to 6 weeks apart, and patients are advised to have 4 or fewer injections in the same place per year.
  • A doctor will not inject cortisone medication directly into a tendon, even if a tendon is suspected to be the root of pain. Because cortisone works locally, an injection near a tendon can still reduce its inflammation.

In fact, the Achilles and patella tendons are particularly prone to injury post-injection, even if an injection is directed near, rather than in, the tendon. For this reason, doctors avoid cortisone injections for Achilles and patella tendinopathies.1

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The Initial Injection Usually Works

For most people, the initial corticosteroid injection will reduce inflammation and pain. If the patient’s pain is not adequately relieved, the doctor may recommend trying a second injection. To protect a joint’s soft tissue, injections should be at least 4 to 6 weeks apart.1 If the patient gets limited or no relief from the second injection, then a third injection is unlikely to provide relief and is not recommended.

  • 1.Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002 Jul 15;66(2):283-8. PubMed PMID: 12152964.

Regular cortisone injections are among the most effective methods your doctor can use to relieve joint pain from an injury or arthritis. These injections work by reducing the inflammation in and around your joint.

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We asked Michael Schaefer, MD, Director of Musculoskeletal Physical Medicine & Rehabilitation, to answer key questions about these treatments.

Q: What joints can receive injections for pain?

A: We use them most often for knee and shoulder pain, but cortisone injections can be used in any joint in the body.

RELATED: Shoulder Pain Treatment Guide

Q: How is pain in these joints treated overall?

A: It is possible to give the injections indefinitely, but treating joint pain usually involves multiple approaches. Depending on what condition is causing the pain, we try to find other long-term pain relief solutions through physical therapy, bracing, other medications or, in some cases, joint replacement.

We may also use injections of platelet-rich-plasma, prolotherapy or even cell-based “stem cells” to help repair the injured or arthritic area.

RELATED: Pain Management Treatment Guide

Q: How often do doctors give cortisone injections to a patient?

A: We try to limit the injection to one every three months for any single joint, but also we like to limit it to a total of six injections a year for the whole body.

We know that the cortisone can sometimes weaken or suppress the immune system and, in diabetics, it raises blood sugar. So we don’t use cortisone injections in people with diabetes if their blood sugar is unstable. It must be used with caution if the blood sugar is over 200.

Q: How long do the injections need to take effect?

A: There is a usually a delayed reaction. It may take up to seven days for the cortisone to take effect.

Q: Is it possible to inject more than one body part at a time?

A: I do two different body parts, sometimes on the same visit, and I can adjust the dose of cortisone accordingly to limit the risks. Often, I’ll do a lower dose if we’re treating multiple body parts. I’ll use a higher dose if we’re treating a condition that’s really inflammatory, like rheumatoid arthritis or an autoimmune disorder.

RELATED: Do You Know Your Options for Osteoarthritis?

Q: Do you ever use anything other than cortisone for these treatments?

A: I sometimes use artificial joint fluid injections, or what some people call “gel” injections. Those are a very good alternative treatment for knee arthritis if it is not severe enough for knee replacement.

They’re not approved for use in other joints in the United States, but they are commonly used in other countries. Occasionally, they are used in shoulders and hips — even in this country.

Q: How do you decide whether to use cortisone or artificial joint fluid?

A: Typically, I’ll use cortisone when the joint is inflamed, or if it’s the first presentation of a bad case of arthritis, I’ll use cortisone first. But then, for ongoing injections, I prefer to use the artificial joint fluid once the inflammation settles down.

It’s got a lot of different names. Hyaluronic acid (HA) is the other most common name. In general, I prefer to use HA unless the knee seems inflamed (red and swollen) or if the patient has severe knee arthritis (bone-on-bone). In those cases, cortisone seems better.

Q: Does cortisone cause any damage to the joint tissues?

A: Usually there isn’t any joint damage from the cortisone, but some studies have shown that it can cause damage in tendons and may predispose people to tendon rupture.

I often remind patients that inflammation is also damaging to their joints, and cortisone actually prevents this damage. However, if patients rely on multiple cortisone injections just to cover up their pain, they may eventually wear out their joints prematurely.

This is why it’s important to diagnose and treat the underlying conditions which predispose people to arthritis, such as obesity, malalignment, poor body mechanics, and inflammatory/autoimmune disorders.

Q: What do patients need to know about these injections?

A: Every injection has a small risk of infection, so patients need to keep the area where they receive the injection clean.

Also, patients shouldn’t get the injection if they have any infection, even if the infection is somewhere else in their body because of the immune system suppression. There is also a chance that there could be bacteria in the bloodstream that could get into the joints after the injection.

Remember, if you have any concerns or questions, it’s important to ask your doctor. He or she can help you by also considering your individual case and medical history.

Cortisone Use in Orthopedics

What is Cortisone and How Does it Work?

Cortisone is a strong anti-inflammatory medicine. Most types of muscle, bone and joint pain are associated with inflammation of the tissues. By controlling inflammation, cortisone helps reduce or eliminate the pain with this conditions.

How is Cortisone Given?

Cortisone can be taken by mouth or it can be injected. For many types of tendonitis and joint inflammation, an injection is much more effective and works more quickly. In addition, smaller doses are given with injection than are taken orally. This is because it puts the medicine directly where it is needed as opposed to diluting it in the bloodstream before it arrives at the source of the problem.

What Conditions are Treated with Cortisone?

Almost any painful muscle, tendon, bone or joint problem and many nerve conditions can be treated with cortisone.

Some common conditions include:

  • Tendonitis
  • Rotator cuff tendonitis of the shoulder
  • Tennis elbow
  • Trigger fingers
  • Plantar fascitis of the foot (heel spurs)
  • Joint inflammation
  • Pain
  • Swelling or arthritis of the shoulder, elbow, wrist, fingers, knee, ankle and foot
  • Nerve inflammation
  • Carpal tunnel syndrome
  • Morton neuromas in the foot
  • Muscle inflammation
  • Neck and back pain
  • Trigger points

Is Cortisone a Cure or a Temporary Fix?

It depends on the condition. Many times, with a simple inflammatory condition a single injection can cure the problem. On occasion, an additional follow-up injection may be necessary to “complete the job”.

Sometimes even temporary relief is helpful. Physical therapy is often facilitated by reducing or eliminating inflammation and pain with a cortisone injection. This allows the patient to work on the stretching, strengthening and conditioning necessary to rehabilitate an injury.

Obviously, an injection can not be expected to cure a chronic arthritic condition. An injection can, however, certainly give an extended period of symptom relief.

How Often Can Cortisone Be Given?

This depends upon the condition and structure in question. With an arthritic joint, there are no specific limitations on cortisone. For example, an arthritic knee can be re-injected as long as it gives reasonable relief. Generally we do not like to give it more often than every few months. Basically, it is either going to work or not work. If it becomes apparent it only gives a relatively short and temporary effect, we will usually recommend some other type of treatment after several injections.

Are There any Complications?

Yes, there are, but fortunately complications with cortisone are extremely rare. They include:

Oral Cortisone

Short term: when given by mouth, cortisone very rarely causes any problems. It does not cause drowsiness and a person rarely feels anything other than relief of their pain symptoms. Sometimes patients will complain of a “flushing” sensation. Cortisone can cause loss of sugar control in diabetics, and stomach or gastrointestinal upset can also occur. Remember that cortisone is often given to counteract reactions, so it is quite rare that it causes a reaction.

Injectable Cortisone

Long term: Too much cortisone over a long period of time can cause organ and tissue damage. That is why a standard course of oral cortisone only lasts a little over a week.

Too many cortisone injections can cause tissue damage or tendon rupture. Again it depends upon the location of the injection. Multiple tennis elbow injections are very safe, but only a limited number of trigger injections are advisable. Other areas such as Achilles tendons are rarely injected for fear of tendon rupture.

Isn’t Cortisone a Steroid?

It is true that cortisone is a type of steroid. However, like all drugs and medications, when taken appropriately, it is very safe. Steroids can be harmful if taken in high does over long periods of time. We do not generally use cortisone in this manner in Orthopedics.

Taking cortisone is like breathing oxygen when you are out of breath. We have a normal level of cortisone in our bloodstream. When we give cortisone, we are temporarily boosting these levels for the anti- inflammatory effect, but the medicine is only given for a short period of time, and the blood levels then quickly return to normal.

What Can I Expect After the Injection?

This can be explained with three phrases:

Immediate: Naturally, all injections cause pain to some extent. The amount of pain depends both on the patient’s pain tolerance and the location of the injection. This is short term and resolves within a few minutes.

Intermediate: Next, you will usually experience a period of numbness lasting up to several hours. This is because the cortisone is mixed with a numbing agent similar to that used in a Dentist’s office. We usually use either Lidocaine or Marcaine. Sometimes, you might experience a rather severe burning pain the night of or the day following the injection. This is a fairly common experience and you should not be alarmed. It will help to apply ice to the area. This invariably passes in 24 to 36 hours.

Long Term: You may experience immediate relief of your problem, or it may take anywhere from a few days to a few weeks to know the final result of your injection. In general we recommend you give at least three weeks, and if needed, reschedule and appointment for follow-up.

Summary

Cortisone, given both by mouth and by injection, when used appropriately is very safe and effective. It remains a common and standard treatment for many types of Orthopedic problems, including arthritis, tendonitis, muscle and joint inflammation, and other common conditions such as trigger fingers and carpal tunnel syndrome.

To consult with one of our doctors at Orthopedic Associates of Port Huron, please call (810) 985-4900 or click on the Appointment Request button.

Why would I need a cortisone shot?

In many instances of shoulder bursitis, arthritis, tennis elbow, or carpal tunnel syndrome, cortisone shots are often a prescribed medication. But what is cortisone and how does it work?

Cortisone is a powerful anti-inflammatory medication, not a pain reliever. When pain is decreased from cortisone, it’s due to the inflammation being diminished. By injecting the cortisone into a particular area of inflammation, very high concentrations of the medication can be given while keeping potential side effects to a minimum. Cortisone injections usually work within a few days, and the effects can last up to several weeks.

Inflammation is an underlying problem of bursitis, arthritis, trigger finger, tennis elbow, and carpal tunnel syndrome, making them all amenable to cortisone shots. The shot can be slightly painful, especially when given into a joint, but in skilled hands, it usually is well tolerated.

Often the injection can be made with a very small needle causing little discomfort. Sometimes, a slightly larger needle must be used, especially if your doctor is attempting to remove fluid through the needle prior to injecting the cortisone. Numbing medication, such as Lidocaine or Marcaine, is often injected with the cortisone to provide temporary relief; topical anesthetics can help numb the skin in the injected area, too.

There can be side effects, the most common being “cortisone flare,” a condition where the injected cortisone crystallizes and causes a brief period of pain worse than before the shot. This usually lasts a day or two and is best treated by icing the injected area. Another common side effect is whitening of the skin at the point of injection. This is only a concern in people with darker skin and is not harmful, but patients should be aware of this so as not to be alarmed if it happens.

Other side effects of cortisone injections, although rare, can be quite serious. The most worrisome is infection, especially if the injection is given into a joint. The best prevention is careful injection technique, with sterilization of the skin using iodine and/or alcohol. Also, diabetic patients may have an increase in their blood sugar, which they should monitor.

For more information about cortisone injections, contact the doctors at Southern California Orthopedic Institute by calling (888) 791-7766.

How Long Does a Cortisone Shot Last & What are its Side Effects?

Are you suffering from joint pain? Has your doctor asked you to take cortisone shots to relieve the pain? Wondering how long does a cortisone shot last & what are its side effects? Read on to get the answers.

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What is a Cortisone Shot?

Cortisone shot is an injection containing steroids, which is administered into specific areas of the body like hip, elbow, knee, ankle, wrist, shoulder or spine. Small joints in the feet and hands may benefit from cortisone shots.The medication injected (cortisone shot) is generally meant to relieve the inflammation and swelling of tissue in the joint space. Cortisone shots are also helpful in relieving pain and other symptoms triggered by irritation in the joint.

Cortisone shot given in the joint basically contains a steroidal medicine coupled with a local anaesthesia and requires only a few minutes to be administered. The procedure of giving a cortisone shot comprises of a needle being inserted through the skin and deeper tissues which may cause some amount of pain to the patient during the process. However, the skin and deeper tissues are sometimes numbed with a local anaesthesia prior to inserting the needle of the cortisone shot into the joint.

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Often, one receives a cortisone shot at a doctor’s clinic. Just after the cortisone shot is administered, one may feel that their pain has more or less relieved. This is because of the local anaesthesia that is injected along with the steroid. This relief will, however, last only for a few hours. The pain will return and one may have a sore joint for a day or two. This happens because of the mechanical process of needle insertion and the initial irritation from the steroid itself. One should start noticing relief in the pain starting from the 3rd of the cortisone shot onwards. Because of its potential side effects, the number of cortisone shot that one can receive in a year is generally limited.

What Should One Do After Taking A Cortisone Shot?

If taking the cortisone shot in the doctor’s clinic, the patient should head straight back home after the procedure. They may apply ice to the affected area if they feel the need and they should perform activities as per their tolerance. Unless any complications arise, one can resume their regular course of activities from the following day. The most commonly experienced complication one may feel is a sore joint.

How Long Does the Effect of a Cortisone Shot Last?

The immediate effect of the local anaesthesia that is injected usually wears off in a few hours. The cortisone shot begins to work in about 3 to 5 days and its effect can last for a duration of several days to a few months. In case the first cortisone shot does not relieve the symptoms in 2 to 3 weeks, one may be advised to take another cortisone shot. If the individual responds to this cortisone shot, but continues to have residual pain, they may be recommended to take further cortisone shots as and when needed. These cortisone shot should, however, be taken depending on the underlying state of the joint.

What are the Side Effects & Risks Associated with Cortisone Shots?

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Generally cortisone shot is considered a safe procedure and serious side effects rarely occur. However, like any other procedure, even cortisone shots are accompanied with some risks, side effects and potential complications. The most commonly experienced side effect of cortisone shot is temporary pain. Risks like bleeding, infections and worsening of symptoms, etc. are also involved. The other risks linked to the side effects of steroids include increase in blood sugar, water retention, weight gain and suppression of body’s own natural production of cortisone.

Who Should Not Take A Cortisone Shot?

People should let their doctor know if they are allergic to any of the medications, which are can potentially be injected in a cortisone shot. If they are already taking a blood thinning medication or are suffering from an active infection, uncontrolled diabetes or cardiac disease, they should avoid taking cortisone shots. They should consider postponing these injections until their overall medical condition improves.

One should remember that it is difficult to predict whether a cortisone shot will help them or not. However, patients who have had a recent onset of pain or milder pain may respond much better than the individuals with severe or longstanding pain.

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In the late 1940s, the steroid cortisone, an anti-inflammatory drug, was first synthesized and hailed as a landmark. It soon became a safe, reliable means to treat the pain and inflammation associated with sports injuries (as well as other conditions). Cortisone shots became one of the preferred treatments for overuse injuries of tendons, like tennis elbow or an aching Achilles, which had been notoriously resistant to treatment. The shots were quite effective, providing rapid relief of pain.

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Then came the earliest clinical trials, including one, published in 1954, that raised incipient doubts about cortisone’s powers. In that early experiment, more than half the patients who received a cortisone shot for tennis elbow or other tendon pain suffered a relapse of the injury within six months.

But that cautionary experiment and others didn’t slow the ascent of cortisone (also known as corticosteroids). It had such a magical, immediate effect against pain. Today cortisone shots remain a standard, much-requested treatment for tennis elbow and other tendon problems.

But a major new review article, published last Friday in The Lancet, should revive and intensify the doubts about cortisone’s efficacy. The review examined the results of nearly four dozen randomized trials, which enrolled thousands of people with tendon injuries, particularly tennis elbow, but also shoulder and Achilles-tendon pain. The reviewers determined that, for most of those who suffered from tennis elbow, cortisone injections did, as promised, bring fast and significant pain relief, compared with doing nothing or following a regimen of physical therapy. The pain relief could last for 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 much lower rate of full recovery than those who did nothing or who underwent physical therapy. They also had a 63 percent higher risk of relapse than people who adopted the time-honored wait-and-see approach. The evidence for cortisone as a treatment for other aching tendons, like sore shoulders and Achilles-tendon pain, was slight and conflicting, the review found. But in terms of tennis elbow, the shots seemed to actually be counterproductive. As Bill Vicenzino, the chairman of sports physiotherapy at the University of Queensland in Australia and senior author of the review, said in an e-mail response to questions, “There is a tendency” among tennis-elbow sufferers “for the majority (70-90 percent) of those following a wait-and-see policy to get better” after six months to a year. But this is not the case for those getting cortisone shots, he wrote; they “tend to lag behind significantly at those time frames.” In other words, in some way, the cortisone shots impede full recovery, and compared with those adopting a wait-and-see policy, those getting the shots “are worse off.” Those people receiving multiple injections may be at particularly high risk for continuing damage. In one study that the researchers reviewed, “an average of four injections resulted in a 57 percent worse outcome when compared to one injection,” Dr. Vicenzino said.

Why cortisone shots should slow the healing of tennis elbow is a good question. An even better one, though, is why they help in the first place. For many years it was widely believed that tendon-overuse injuries were caused by inflammation, said Dr. Karim Khan, a professor at the School of Human Kinetics at the University of British Columbia and the co-author of a commentary in The Lancet accompanying the new review article. The injuries were, as a group, given the name tendinitis, since the suffix “-itis” means inflammation. Cortisone is an anti-inflammatory medication. Using it against an inflammation injury was logical.

But in the decades since, numerous studies have shown, persuasively, that these overuse injuries do not involve inflammation. When animal or human tissues from these types of injuries are examined, they do not contain the usual biochemical markers of inflammation. Instead, the injury seems to be degenerative. The fibers within the tendons fray. Today the injuries usually are referred to as tendinopathies, or diseased tendons.

Why then does a cortisone shot, an anti-inflammatory, work in the short term in noninflammatory injuries, providing undeniable if ephemeral pain relief? The injections seem to have “an effect on the neural receptors” involved in creating the pain in the sore tendon, Dr. Khan said. “They change the pain biology in the short term.” But, he said, cortisone shots do “not heal the structural damage” underlying the pain. Instead, they actually “impede the structural healing.”

Still, relief of pain might be a sufficient reason to champion the injections, if the pain “were severe,” Dr. Khan said. “But it’s not.” The pain associated with tendinopathies tends to fall somewhere around a 7 or so on a 10-point scale of pain. “It’s not insignificant, but it’s not kidney stones.”

So the question of whether cortisone shots still make sense as a treatment for tendinopathies, especially tennis elbow, depends, Dr. Khan said, on how you choose “to balance short-term pain relief versus the likelihood” of longer-term negative outcomes. In other words, is reducing soreness now worth an increased risk of delayed healing and possible relapse within the year?

Some people, including physicians, may decide that the answer remains yes. There will always be a longing for a magical pill, the quick fix, especially when the other widely accepted and studied alternatives for treating sore tendons are to do nothing or, more onerous to some people, to rigorously exercise the sore joint during physical therapy. But if he were to dispense advice based on his findings and that of his colleagues’ systematic review, Dr. Vicenzino said, he would suggest that athletes with tennis elbow (and possibly other tendinopathies) think not just once or twice about the wisdom of cortisone shots but “three or four times.”

Pros and Cons of Cortisone for Osteoarthritis

Osteoarthritis Pain Relief: Side Effects of Cortisone Injections

While cortisone injections can provide you with significant osteoarthritis pain relief, they are not without risk. More serious potential side effects of cortisone injections include:

  • Cortisone “flare” reaction. This occurs in about 2 percent of people who receive cortisone injections. This reaction happens when the injected corticosteroids crystallize in your joint, resulting in severe pain. Flares usually resolve after 12 to 48 hours with icing.
  • Damage to soft tissues. In some people who receive cortisone injections, the cartilage softens and the tendons weaken in the joint that is being treated, which can be permanent. This side effect tends to occur when people are receiving frequent — weekly or monthly — cortisone shots.
  • High blood sugar. If you have diabetes, your blood sugar level could significantly increase after you receive a cortisone shot. People who have diabetes should be carefully monitored for 24 to 48 hours after receiving a cortisone shot.
  • Infection. Infection at the site of your injection is a rare, but still serious potential side effect of cortisone shots. Your chances of infection can be minimized if your skin is properly sterilized before you receive the injection.
  • Hypercortisolism. People who are exposed to high levels of cortisol over a prolonged period of time are at increased risk of developing a condition called hypercortisolism, or Cushing’s syndrome. This can result in upper body obesity, a round-shaped face, increased bruising, trouble healing, weak bones, excessive hair growth, irregular menstrual periods in women, and fertility problems in men. To treat hypercortisolism, you will have to gradually reduce your use of cortisone, and adjust your dosage to reduce side effects.

Osteoarthritis Pain Relief: Recommended Injection Schedule

Because of these risks, it is recommended that people not receive cortisone shots more than two to four times per year. And it is best that you schedule your injections at least three months apart.

In addition, talk with your doctor about the risks of getting cortisone shots if you:

  • Have septic arthritis (an infection in a joint)
  • Have a skin infection where you received a previous injection
  • Have had an allergic reaction to a previous cortisone shot
  • Use blood thinners
  • Are injured — a recent head trauma or broken bone, for instance
  • Are a competitive athlete

Obviously, cortisone injections can do a lot of good, but, if overdone, can create some serious problems. It’s wise to understand the pros and cons of these shots before receiving your first one.

Corticosteroid injections

Corticosteroids (also known as steroids) are medicines that can be used to treat inflammation. When corticosteroids are injected into or around a painful area (such as a joint or muscle) they can reduce the inflammation in that area, relieving pain, reducing tissue swelling, and improving function and mobility.

Depending on the condition that is being treated, steroid injections can provide pain relief for several weeks to many months.

Corticosteroids mimic natural hormones produced by the body — specifically by the adrenal glands, which sit atop the kidneys. Corticosteroids should not be confused with anabolic steroids which are sometimes misused by athletes and body-builders to increase muscle mass and strength. Anabolic steroids may refer to the male steroid hormone testosterone or a synthetic version of testosterone.

Which conditions can corticosteroid injections treat?

Corticosteroid injections can be used to treat a variety of conditions, including the following.

Arthritis

Steroid injections can effectively treat the joint inflammation that is seen in people with rheumatoid arthritis. They can also be used to relieve the pain of osteoarthritis (the most common form of arthritis) and gout.

Bursitis

Bursas are small, fluid-filled pads that allow tendons and muscles to slide easily over bones. The pain associated with inflammation of a bursa (bursitis) — a condition which usually affects the shoulders, elbows, hips and knees — can be treated with steroid injections.

Tendinitis

Tendons are the thick bands of tissue that connect muscles to bones. Repeated motion and stress to a tendon can cause it to become inflamed — this is known as tendinitis. Rotator cuff injury of the shoulder is a common example of tendinitis that can be treated with corticosteroid injections.

Carpal tunnel syndrome

Carpal tunnel syndrome is when the median nerve (which supplies sensation to your thumb and most of the first 3 fingers) is compressed within the narrow passageway in your wrist known as the carpal tunnel. This causes pain, numbness and tingling in the wrist and hand. By reducing inflammation in the carpal tunnel and relieving pressure on the median nerve, corticosteroid injections can ease the pain of carpal tunnel syndrome.

When are corticosteroid injections used?

Although steroid injections can often effectively relieve the pain associated with musculoskeletal conditions, they are usually not used as the initial treatment option. Less invasive treatments, such as rest, oral pain reliever medicines, hot and cold compresses and physiotherapy, are usually tried first.

Make sure you tell your doctor about any other conditions you have and any medicines (including complementary medicines and dietary supplements) you are taking before having a steroid injection.

Is the injection painful?

Cortisone injections can sometimes be performed in your doctor’s office. Often, they are done under ultrasound or X-ray guidance, to make sure that the injection goes into the right spot. The injection itself can be uncomfortable, so your doctor may give you a local anaesthetic to numb the skin before the injection.

A local anaesthetic medicine such as lignocaine is also usually added to the corticosteroid injection. This anaesthetic can relieve your pain immediately, confirming the injection has hit the right spot. After a few hours, the anaesthetic will wear off, and you may feel some pain or discomfort until the anti-inflammatory effect of the steroid kicks in, which is usually after a couple of days.

Putting ice on the area and taking a pain medicine (such as paracetamol) may help relieve any discomfort in the meantime.

Do I need to restrict my activities after the injection?

After you have had a corticosteroid injection, you need to rest the affected area for 24 hours and avoid strenuous activity for several days.

Advantages of steroid injections

The main advantages of corticosteroid injections is that they relieve pain and inflammation. This can in turn can reduce swelling and improve mobility. The beneficial effects can last for several months.

In some cases, getting a steroid injection allows you to take part in physiotherapy or rehabilitation exercises to help longer-term improvement or recovery.

Risks and side effects

The most common side effects are pain and inflammation of the tissues surrounding the injection site. This temporary worsening of symptoms is known as post-injection flare, or steroid flare, and may last for a couple of days.

People occasionally report skin discolouration around the injection site. The skin may become lighter around where the injection was given. There is also a risk of nerve damage associated with steroid injections.

There is a small risk of infection associated with the injections. Joint infections (septic arthritis) are especially serious, and can result in permanent damage to the joint. See your doctor as soon as possible if:

  • you experience pain for more than 48 hours after the injection;
  • pain develops more than 2 days after the injection;
  • the area becomes red, hot or swollen; or
  • you develop a fever following the injection.

Corticosteroid injections should never be given if you have an infection, including an infection of the skin at the injection site.

Corticosteroid injections may weaken tendons, sometimes possibly causing tendons to rupture. Repeated injections of steroids may also damage joint cartilage and contribute to thinning of nearby bone (local osteoporosis). For these reasons, as well as the risk of general side effects, there are limits to how many times and how frequently corticosteroid injections can be used in the same area.

General side effects may include:

  • a rise in blood sugar levels that lasts for up to 48 hours after the injection (usually only noticed if you have diabetes);
  • a temporary rise in blood pressure lasting a few days;
  • sleep problems; and
  • flushing of the skin on the face and chest – this usually lasts no more than a few hours.

Long-term problems associated with corticosteroid medicines

People who take steroid medicines orally (by mouth) for prolonged periods are at risk of several side effects, including weight gain, high blood pressure and osteoporosis. There is only a very small risk of these problems developing following injections of corticosteroid, because, unlike when a person takes corticosteroid tablets, only very small amounts of the medicine enter the bloodstream.

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Last Reviewed: 16/07/2019

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