Injection therapy for musculoskeletal pain and injury is an option frequently prescribed from general practitioners, especially cortisone. However, is it effective for managing your particular injury? How long does the effects of the injection last for? Is it safe? Does it carry risks, especially in the future? What actually is in a cortisone shot? Are there better first line treatments for your musculoskeletal pain/injury?

These are the questions you are not likely asking your doctor, however are the questions you should be asking. Spoiler alert, the evidence does not stack up well for supporting injection therapy for treating musculoskeletal conditions. Now this is not to say that I am against them altogether, there is a time and place they may be suitable. Conditions like early-stage frozen shoulder and sciatica/ other radicular pains, I will often encourage them in assisting the management plan. The reason being is that frozen shoulder for anyone unfortunate enough to have suffered it, is a significantly painful/debilitating condition. It reduces sleep and quality of life. To make things worse, frozen shoulder is a pathology that can take 1-2 years to fully resolve. The evidence supports the use of cortisone injections in the early painful stage of frozen shoulder, as it can really improve patient reported pain levels and quality of life. It does not fix the condition, it just aids the individual to better manage it in those painful early months. Sciatica and other radicular pains need no explanation for how painful they can be. Once again, to potentially aid an individual in keeping active whilst their pathology resolves, the use of injection therapy can help.

 

The typical story I always hear from my patients is that they had shoulder pain, so they went to the doctor. Firstly, do not go to your GP about musculoskeletal pain as your initial step. Book in with a qualified allied health professional, experienced in managing your condition and is evidence based. I cannot stress how important it is to see someone who is evidence based! Most general practitioners are not informed about musculoskeletal health, it is not their focus. They follow up by saying that their GP ordered a scan, which came back showing bursitis. The GP then orders a cortisone shot explaining that will stop your pain, as “the pain is because of bursitis”. The patient looking for answers and a quick fix (quick fixes do not exist, I promise you will not find it), gets the shot, and in a number of weeks either feels worse or their pain has returned.

This is a great example of a GP not being evidence based/informed. Scans should only be used when a practitioner is concerned about signs or symptoms that are red flags. Or, if after a period of 10-12 weeks of evidence-based management the pain is still at the same intensity/level. The reason being is that your scan does not show you why you are in pain. Many studies have proven this in the lower back, knee and shoulder, where they imaged asymptomatic people (they had no pain at all), to find they had imaging findings of injury/pathology. But they had no pain! So, the bursitis was likely not the reason for their shoulder pain. To fully understand better why you have shoulder pain, speak to a qualified evidenced based practitioner, like a sports based osteopath. There is a reason I have a passion in managing shoulder pain, I get results many others have not for my patients. Now, let me put it simply to drive the message home. Your shoulder pain is likely not from bursitis, and why did the pain come back after the cortisone injection? The simple answer is that like manual therapy, injections are a band-aid solution at best. You are not doing anything to treat the pathology for your pain/injury.

 

What is a corticosteroid injection?

A corticosteroid is a strong anti-inflammatory, with a similar chemical make up to the stress hormone cortisol. Corticosteroids are immunosuppressive, and therefore lower the immune system response. This shocking effect can be as long as 4 weeks! A compromised suppressed immune system for 4 weeks, I bet your doctor never told you that. A large reason why many get a potential acute benefit from the cortisone shot, is that it is often injected alongside a local anaesthetic.

The cortisone injection was first pioneered in 1951 for rheumatoid arthritis by Dr James Hollander. Shortly after it was trialled in the treatment of osteoarthritis, as osteoarthritis was incorrectly believed to be an inflammatory disease. The early results of these trails showed there was a short-term benefit.

 

What do the national guidelines recommend?

• Australian National Guidelines 2024 - Approved as an adjunctive short-term treatment for pain relief - More related to knee osteoarthritis specifically.

• Long term use is not supported – Repeat injection may cause cartilage damage, further joint deterioration and reduced beneficial effects!

• English National Guidelines 2022 – Consider intra-articular injections when other pharmacological treatments are ineffective, or to support exercise rehab – They only provide short term relief for about 2-10 weeks.

• Corticosteroid injections should not be used in the treatment of Tennis Elbow. There is strong evidence against the use of corticosteroids for tennis elbow - British National Guidance 2023

 

What are the risks vs benefits of cortisone injections?

I am sorry in advance if this next section makes you angry at your doctor/health professional for not informing you about the risks and long-term effects of cortisone injections. Remember, the benefits are it may provide short-term pain relief. The key word there is “may”, as there is no certainty that the injection will help at all. These potential short-term effects only last about 2-10 weeks. That is the whole list of benefits, if we want to call them benefits.

The list of risks is extensive, strap yourself in.

Local effects of corticosteroid injections

• Joint arthropathy – Harmful to joint cartilage health.

• Weakens tendons

• Bleeding/Bruising

• Post injection flare up – 1 in 5 individuals will have a post injection flare up of their pain/injury. These post injection flare ups’ usually take a few days to settle down (Cushman et al., 2023).

• Local infection after the injection

• Skin depigmentation

• Fat Atrophy – This is not a good thing!

• A high-quality research review in 2015, found that 13% of corticosteroid intra-articular injections had a side effect.

Tendon effects from corticosteroid injections

• Loss of collagen organisation, increase collagen necrosis (death)

• Collagen synthesis was decreased

• Increased inflammatory cell infiltrate

• Increased cellular toxicity

• Tendon rupture!

As you can see here, corticosteroid injections are not good for your tendons. It makes you question why so many GP’s recommend them for tendinopathy and tendon related injuries. A study (admittingly was on rats) showed that a single dose of corticosteroid injection, significantly weakened the rotator cuff tendons at one week. This can last up to 3 weeks before the normal baseline levels of strength are returned. Therefore, the tendon related injury and overall body will de-condition even further, leading to worse tendon outcomes.

 

 Cartilage and Joint effects from corticosteroid injections

• Higher doses lead to chondrocyte apoptosis (cartilage cell death) & reduced collagen synthesis

A study by McAlindon et al., 2017 compared patients with symptomatic knee osteoarthritis over a 2-year period. One group of patients received steroid injections, whilst another group of patients received saline injections (placebo) every 3 months for 2 years. They found that the patients who received steroid injections had greater cartilage volume loss and damage. They also found there to be no significant difference in knee pain!

Further research investigated intraarticular injections of the hip and knee. They found that injections accelerated osteoarthritis progression, resulted in subchondral insufficiency fracture, rapid joint destruction/bone loss and osteonecrosis (bone death).

 

Systemic effects of corticosteroid injections

• Facial flushing

• Raised systolic blood pressure

• Menstrual irregularity

• Central serous chorioretinopathy (fluid build-up behind the retina)

• Psychosis

• Immunosuppression

• Anaphylaxis

Corticosteroids effects on diabetes

Corticosteroids alter diabetic control by increasing blood glucose levels. The effects of hyperglycaemia are maximal between 24-72 hours, and take up to 7 days to return to normal levels! All patients with diabetes must be educated this before considering a corticosteroid injection.

 

Summary

As you can see corticosteroids (cortisone) is an option that may provide very short-term relief for a few musculoskeletal conditions. Guidelines still recommend them despite the overwhelming evidence against them. Thankfully, the guidelines only recommend them after comprehensive exercise rehabilitation has been completed. As a patient, it is your health care practitioner’s responsibility to inform you on all the risks a corticosteroid has. The benefits do not outweigh the risks, it is as simple as that. Many of the risks are long-term, permanent and destructive. They do not treat the pain/injury, all they do is put a band-aid on it. If your doctor or another healthcare provider recommends a cortisone shot, educate them!

 

References

Conley, B., Bunzli, S., Bullen, J., O'Brien, P., Persaud, J., Gunatillake, T., Dowsey, M. M., Choong, P. F. M., & Lin, I. (2023). Core Recommendations for Osteoarthritis Care: A Systematic Review of Clinical Practice Guidelines. Arthritis care & research, 75(9), 1897–1907. https://doi.org/10.1002/acr.25101

Choudhry, M. N., Malik, R. A., & Charalambous, C. P. (2016). Blood Glucose Levels Following Intra-Articular Steroid Injections in Patients with Diabetes: A Systematic Review. JBJS reviews, 4(3), e5. https://doi.org/10.2106/JBJS.RVW.O.00029

 

Cushman, D. M., Kobayashi, J. K., Wheelwright, J. C., English, J., Monson, N., Teramoto, M., Dunn, R., Lash, M., & Zarate, M. (2023). Prospective Evaluation of Pain Flares and Time Until Pain Relief Following Musculoskeletal Corticosteroid Injections. Sports health, 15(2), 227–233. https://doi.org/10.1177/19417381221076470

Dean, B. J., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E., & Carr, A. J. (2014). The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Seminars in arthritis and rheumatism, 43(4), 570–576. https://doi.org/10.1016/j.semarthrit.2013.08.006

 

Jüni, P., Hari, R., Rutjes, A. W., Fischer, R., Silletta, M. G., Reichenbach, S., & da Costa, B. R. (2015). Intra-articular corticosteroid for knee osteoarthritis. The Cochrane database of systematic reviews, 2015(10), CD005328. https://doi.org/10.1002/14651858.CD005328.pub3

Kompel, A. J., Roemer, F. W., Murakami, A. M., Diaz, L. E., Crema, M. D., & Guermazi, A. (2019). Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?. Radiology, 293(3), 656–663. https://doi.org/10.1148/radiol.2019190341

 

McAlindon, T. E., LaValley, M. P., Harvey, W. F., Price, L. L., Driban, J. B., Zhang, M., & Ward, R. J. (2017). Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA, 317(19), 1967–1975. https://doi.org/10.1001/jama.2017.5283

 

Wernecke, C., Braun, H. J., & Dragoo, J. L. (2015). The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthopaedic journal of sports medicine, 3(5), 2325967115581163. https://doi.org/10.1177/2325967115581163