Pain is a difficult experience to bear, and it’s normal for every human being to want it to go away as quickly as possible. When it becomes disabling and/or persistent, many people turn to more “invasive” solutions such as cortisone injections, hoping for sufficient relief to resume their activities. Despite their widespread use in the world of orthopedic medicine, cortisone injections carry significant risks that may outweigh the often temporary relief they can bring. This article will help you decide whether or not cortisone injections are a suitable option for the relief of persistent musculoskeletal pain.
Are cortisone injections really effective?
Corticosteroid injections, better known to you as “cortisone”, may provide short-term relief for some patients, but they do not cure the source of the pain. While they may have their place and represent an appropriate solution for some patients who don’t respond to a more conservative rehabilitation plan, cortisone injections should not be considered a “magic” solution for treating common musculoskeletal pains such as osteoarthritis and tendinopathies and/or bursopathies (formerly tendonitis and bursitis), even though they can indeed provide considerable temporary relief much appreciated by some patients who are fed up with being in pain. Indeed, guidelines from the National Institute for Health and Care Excellence (NICE) recommend that corticosteroid injections should be considered as a complement to therapeutic exercises (if ineffective on their own), or only when other pharmacological treatments are ineffective or unsuitable. The same guide also points out that the effect of these injections is short-lived, lasting from 2 to 10 weeks.
In fact, a recent meta-analysis (a review of rigorous scientific literature) showed that for people suffering from pain associated with rotator cuff tendinopathy (shoulder tendonitis), there was no significant difference in pain levels between patients who received an injection and those who received a placebo, three months after the injection. The same study points out that only one in five patients with shoulder “tendonitis” experienced mild transient pain relief. In other words, you’d have to treat five patients for just one to experience temporary relief.
Keep in mind, therefore, that a conservative approach to rehabilitation of at least 6-12 weeks remains the preferred approach before considering cortisone injection. What’s more, if cortisone injection is part of your treatment plan, it’s strongly recommended that you continue your rehabilitation with your chiropractor or physiotherapist, to prevent long-term loss of function.
Is it risky to receive a cortisone injection?
Risks are an important consideration if you’re thinking of opting for a corticosteroid injection treatment. Indeed, a recent study showed that repeated corticosteroid injections have the potential to accelerate the progression of osteoarthritis, causing rapid joint “destruction”, bone loss and weakening of the bone beneath the cartilage. Another study published in 2017 showed that corticosteroid injections administered every three months for two years resulted in a significant loss of cartilage volume (the surface at the end of the bone that keeps the joint functioning properly) without reducing knee pain in people with knee osteoarthritis.
So, when you choose a cortisone injection treatment, there’s a risk of creating a vicious circle that could accelerate the “degeneration” process of your joints and surrounding tissues (ligaments, tendons) and therefore, potentially accelerate their loss of function. The temporary relief provided could therefore increase your risk of experiencing more pain once the anti-inflammatory effect of a few weeks/months has worn off. It is this phenomenon (a vicious circle) that often leads patients to receive injections several times a year to manage the pain that eventually returns.
An exception: adhesive capsulitis of the shoulder (a.k.a frozen shoulder)
Adhesive capsulitis of the shoulder is one of the few musculoskeletal conditions for which cortisone injection is a recommended treatment approach. Indeed, the current scientific consensus is that the benefits of corticosteroid injection in the initial “chemical” phase (very painful phase) of shoulder capsulitis outweigh the risks associated with injection. However, accurate diagnosis is necessary to avoid confusing this condition with others, such as shoulder tendinopathy or an osteoarthritis attack, for which injections are not recommended as a first-line treatment. In patients suffering from shoulder capsulitis, the injection is generally more effective if delivered within the first few weeks following the onset of painful capsulitis symptoms. If you’re between the ages of 40 and 60, with severe shoulder pain that interferes with sleep, it’s strongly recommended that you consult a professional such as a chiropractor or physiotherapist as soon as possible, to clarify the diagnosis and determine whether an injection would be beneficial for you.
In a nutshell
The purpose of this text is in no way to frighten you or to suggest that cortisone injections should never be used. Rather, the aim is to help you better understand the benefits and limitations of this treatment, so that you can make more informed decisions that will help you achieve more lasting health results. Cortisone injections may be appropriate for some people, but represent only a short-term relief solution that involves risks to the health of your joints and soft tissues over the longer term for the majority of painful musculoskeletal conditions. These injections should therefore not be used as a first treatment option, with the exception of adhesive capsulitis of the shoulder in the painful chemical phase. They should be used in conjunction with long-term management strategies, such as strengthening exercises and lifestyle modification (e.g. physical activity, anti-inflammatory diet, stress management, sleep, smoking cessation, etc.).
If you are experiencing musculoskeletal pain that has recently appeared or seems to be persisting, my best advice would be to consult a professional in musculoskeletal diagnosis, treatment and rehabilitation, such as one of our chiropractors or physiotherapists, so that they can advise you properly and establish a game plan that is in line with YOUR health goals.
Important note (disclaimer): This blog is for educational purposes only, and is in no way intended to replace the personalized advice of your physician or other qualified health professional who has reviewed and assessed your situation.
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Références
Osteoarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2022 Oct 19. (NICE Guideline, No. 226.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK588843/
McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017 May 16;317(19):1967-1975.
Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought? Radiology. 2019 Dec;293(3):656-663.
Mohamadi A, Chan JJ, Claessen FM, Ring D, Chen NC. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017 Jan;475(1):232-243.
Dean BJ, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum. 2014 Feb;43(4):570-6.
Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015 Apr 27;3(5):2325967115581163.
Millar, N.L., Meakins, A., Struyf, F. et al. Frozen shoulder. Nat Rev Dis Primers 8, 59 (2022). https://doi.org/10.1038/s41572-022-00386-
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Dr Charles Bélanger
Chiropractor and owner
