Cortisone Injections: Helpful or Harmful?

October 30, 2009

General Information, Orthopaedic


Tis the season!  Happy Halloween! Photo credit: OakleyOriginals on FlickrShould I get a cortisone injection? Are they safe?  Do they help?  Is it a steroid?  Is it just going to mask the real problem?  Will it do more harm than good to the body in the end? These are just a few of the questions that I am frequently asked regarding cortisone injections.  Physicians perform the injections and physical therapists can help patients capitalize on its effects.

Let’s begin by understanding why cortisone injections can be a useful adjunct to your physical therapy.  First, it can be helpful in making a diagnosis.  Many different musculoskeletal and neuromuscular disorders can have similar symptoms.  When it’s not clear which one is the culprit, making a physical therapy treatment plan can be difficult.  Is that shoulder pain you’re experiencing caused by a shoulder disorder or from a pinched nerve in the neck?  If the physician injects the shoulder and you still have pain then it is more likely the nerve in the neck that is the culprit.  Second, a cortisone injection decreases inflammation and the associated pain.  When a patient can get adequate pain relief they are able to move easier, exercises are less painful to perform, and from a physical therapist’s perspective, we can better address the root causes of the problem (poor posture, limited joint mobility, weakness, etc…) rather than trying to just alleviate pain.  For some patients, a cortisone injection can be effective for weeks, months, or even years (though this is rare in my practice).

What exactly is cortisone? Ok, I’m going to get slightly technical, but bear with me as I try and break it down for you.  Cortisone is categorized as a glucocorticoid or corticosteroid.  So yes, this drug is a steroid, but it’s not exactly the kind that has been circulating in baseball.  Glucocorticoids, including cortisol, are produced naturally in our bodies to manage glucose metabolism, growth, and stress by breaking down muscle into glucose.  Glucose = sugar = energy source.  These natural steroids also help to limit inflammation.  Under stressful situations, our bodies release more cortisol, which increases circulating glucose and limits the ability for muscle and fat cells to take glucose in, thus blood sugars rise.  Glucose is a ready energy source and prepares us for increased activity to handle stress.   Glucocorticoids are also immunosuppressive, which also helps to explain why it is anti-inflammatory, because inflammation is an immune response.  The man-made variety of glucocorticoids, which includes cortisone, are powerful anti-inflammatory drugs that are delivered in a larger quantity than the body produces normally in order to provide therapeutic benefits for certain diseases.  My patients usually ask me about using cortisone for the management of different types of arthritis or inflamed soft tissues, such as bursitis.

So, how does it relieve pain? Inflammation causes pain.  Cortisone works by altering the genetic material in certain cells which causes them to stop releasing the chemicals that cause inflammation and limit damage to the surrounding structures.  It also decreases swelling by constricting the surrounding blood vessels thus limiting their ability to take on more fluid.  No more inflammation = no more cranky, swollen joints.

There are many side effects to taking glucocorticoids.  Here are the biggies:

  1. It breaks down things in our body that contain collagen, which include: muscles, bones, ligaments, and the skin.  This can lead to myopathies, which cause muscle wasting and weakness. Also, increased risk of osteoporosis
  2. Increased risk of developing infection because it suppresses the immune system. Increased risk of developing peptic ulcer
  3. Increased risk of developing glaucoma
  4. Diabetics take note of this side effect: Hyperglycemia, insulin resistance, decreased control of blood glucose
  5. Mood changes
  6. Hypertension or High blood pressure
  7. Your body’s natural processes for making glucocorticoids may be suppressed

So, how do I feel about cortisone injections? Since the medication is administered locally at the joint where you want to limit inflammation, it will be less likely to affect other areas of the body, unlike an oral medication.  It is highly effective at decreasing pain in most people in the short term.  If pain is controlled, your therapist can start to work on areas of the body that can help to reduce joint stress and limit the progression of your disease.  Also, because cortisone breaks down muscle and bone, it is even more important to come to therapy and work on your strength.

Cortisone Injections and Expectations

  1. The injection itself may hurt.  They are sticking a needle into your cranky joint.
  2. The injection often has numbing medication in it too, so it may feel numb.
  3. The doctor may want you to rest the area for a few days.
  4. Sometimes the pain after the injection can last a few days. You should ice it to limit this pain or call your doctor if you are really concerned.
  5. Sometimes the face can become flushed.
  6. Increased blood glucose.  If you are diabetic, make sure your doctor is aware.
  7. Significantly decreased pain after a few days, maybe even immediately.  Different people have different reactions.  As I mentioned before some people have longer term relief with this treatment.

So, yes I do think cortisone injections are helpful and highly effective tools when used judiciously.  Because of the long list of side effects, these drugs shouldn’t be taken lightly, and many doctors limit the number of injections per year to 3 or 4 max.  You may feel like you have a new lease on life after your cortisone injection, but remember that the effects are usually temporary.  By working with your physical therapist, you can really capitalize on cortisone’s effects and address the contributing factors to your condition!

Update 02/05/2013 – I’ve published a follow-up article with additional information and research on cortisone injections.  Click Here to Read More.

References

Ciccone C. (2002). Pharmacology in Rehabilitation (3rd ed.). Philadelphia, PA: F.A. Davis Company.

McCance K. & Huether S. (2002). Pathophysiology: The Biologic Basis for Disease in Adults and Children (4th ed.). St. Louis, MO: Mosby.

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  • C, PT

    Great article! I'm a PT and often get the same questions. Would it be OK if I printed this (with credit, of course!) for waiting room literature?

  • http://www.geaux2pt.com MoniquePT

    I'm really glad you liked the article and found it helpful! I recently saw a patient get a carpal tunnel injection, which prompted me to do this post. Absolutely feel free to reprint the article at your clinic to share with your clients. As part of the copyright license, all you have to do is add “© 2009 Monique Serpas PT, DPT” somewhere on the page as well as the http://www.geaux2pt.com URL. You also can't modify the content or use it commercially.

  • serpymom

    As someone who suffered with terrible pain in my elbow area for months because I did not want to get a cortisone shot, I can relate to your article. I finally gave in because nothing else seemed to work. Within days of receiving the injection, I was completely pain free. It has now been about 4 months and I am still doing great. Thanks for the info. Maybe if I had understood cortisone before, I wouldn't have waited so long to get the injection.

  • serpymom

    As someone who suffered with terrible pain in my elbow area for months because I did not want to get a cortisone shot, I can relate to your article. I finally gave in because nothing else seemed to work. Within days of receiving the injection, I was completely pain free. It has now been about 4 months and I am still doing great. Thanks for the info. Maybe if I had understood cortisone before, I wouldn't have waited so long to get the injection.

  • Pingback: Tennis elbow… or is it? « Geaux to Physical Therapy

  • Barb Daily

    I have been trying to find the physiology on cortisone injections and increased blood sugar. After days of searching, I finally found you. Thank you!!

  • http://profile.yahoo.com/ZEWZCZT2EMVYISTRTQIHFE5VHY B. J.

    when I take any medications that has steroids in it, I have chest pains.  I have had several cortisone shots and done have seemed to help me.  I got two shots today in each knee and you say you should have them no more than 6 months, so why did the doctor give me two shots?  Now I have been having chest pains and here it its 1:09 AM and I am taking anit acid pills to releive the chest pains.  I can not take Naprosyn, Advill, Celebrex or anything that has steroids in it.  Your paper was very enlightening, but I am so concerned that this wil lead to heart problems.  If so what should I do? 

  • http://www.geaux2pt.com MoniquePT

    Hi B.J.  You should seek medical attention right away for your chest pains.  Chest pains could be a symptom of something serious.  There is no hard and fast rule about how many cortisone injections someone can have in a year.  But as I mentioned, many doctors limit the number of injections someone has per year.  

  • Joshua Cohen PT, MS

    You might want to consider revising this post.
    http://well.blogs.nytimes.com/2010/10/27/do-cortisone-shots-actually-make-things-worse/
    This article is very high in the search ranking and doesn’t truly reflect the outcomes and risks associated with injections. Most times, physical therapy should be considered prior to the injection to properly assess and determine if injections are needed.

  • http://www.geaux2pt.com MoniquePT

    Joshua,
    Thanks for pointing me to that NYT blog. In all of my posts I advocate physical therapy first. The topic of cortisone injections is always a popular one. As Gretchen Reynolds mentions in her blog, it’s probably because the injections provide “a magical, immediate effect against pain.” The research and my experience tell me it does in fact provide quick pain relief. But members of the healthcare community, including physical therapists, have to provide the best information to patients about how that quick, magical injection can ultimately affect overall recovery and their condition in the future. On the order of tendinopathies, I wouldn’t recommend it, based on research and science related to how it affects collagen, as I mention in this post. The NYT post mentions tennis elbow and I have written about this topic previously, where I also mention evidence that shows poorer long term outcomes for those who have been injected. http://www.geaux2pt.com/tennis-elbow-or-is-it/1075/
    This post does need an update and I’ll be writing one so there isn’t any confusion.

    Thanks for the comment.

  • Pingback: Cortisone Injection or Physical Therapy? | Geaux to Physical TherapyGeaux to Physical Therapy

  • 1libra

    Had a cortisone injection on yesterday and I’m having unbearable chest pains is this normal. I already have mitral valve prolapse which causes me to have heart palpitations already. I not able to function at all.

    • http://www.geaux2pt.com MoniquePT

      Anyone having unbearable chest pains should call 911 and go to the emergency room.

  • UtahRed

    I have a chronic muscle spasm/nerve condition. I have used cortisone injections 3 times a year for a few years. And yes, repeated cortisone injections do cause atrophy as i am proof. Only use them sparingly. But they helped me a lot which is why i kept using them…unfortunately my doctors didn’t tell me to stop and that muscle atrophy could result. Live and learn.

    • http://www.geaux2pt.com MoniquePT

      Thank you for sharing your experience here.