Cortisone Injections: Helpful or Harmful?

Should 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!

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.