A Cortisone injection has been commonly used to treat persistent/chronic pain – in particular with tendons in the shoulder, elbow, wrist, knee & ankle. I also got offered one for my spine when suffering with a severe disc injury.
In my experience patients often get offered this through their GP once other inventions like rest or anti-inflammatories haven’t worked. But should you get that cortisone injection if you’re offered one? What are the chances of success? ‘And’ what are the side effects?!
In my opinion cortisone injections should only be used as a last resort in certain situations only…and I’ll explain why!
What is cortisone?
Cortisone is a corticosteriod that works as an anti-inflammatory. It’s prescribed to treat inflammatory based problems like tendinitis, bursitis etc and is injected directly into the affected tissue, literally dumping a huge amount of anti-inflammatory medication exactly where you want it.
Sounds amazing right?!
The actual procedure itself can vary from uncomfortable to bloody f***ing painful! I’ve not seen any correlation with body part and suspect this is much more to do with the practitioners experience of delivering injections. But after the initial injection, what is meant to happen?
After you get a cortisone injection there are 3 possibilities:
- Things get better
- Things get worse
- Things stay the same
Things get better
For about 1 in 5 people things will get better after a cortisone injection. One patient in particular I can think of having a cortisone injection was definitely advised AND they had a great outcome with no pain or reoccurrence. 70yr old male had left wrist pain (intersection syndrome for the geeks out there!) which after an initial trauma steadily increased in pain over the following 6 weeks. The patient is left handed, on a variety of blood pressure and stroke prevention medication (all of which will affect healing) and had a stroke 18mths previously with no effect on movement but did leave the patient with cognitive damage causing confusion and memory loss. All of these factors meant they were unlikely to follow an exercise protocol, there was fear/apprehension about the pain and recovery time was slow.
They had a cortisone injection, I saw them 5 days later and they had zero pain. And this has continued to this day.
So for 1 in 5 people they get pain relief like this but….
Even for those people who DO get pain relief most will have a return of pain within 8 weeks 🙁 and check out the next 2 sections to understand why
Things get worse
So in this case we have had patients who get worse after receiving a cortisone injection. I suspect this is for a few reasons none of which is directly related to the cortisone itself – but are side effects you should be aware of:
- Trauma – There actually is increasing evidence that this is a positive effect for most patients, but in reality having an injection into a tendon or joint is a traumatic process. After any trauma this triggers a healing crisis, or an increase in inflammation, which causes pain, reduced mobility and increased stress. The cortisone, and any local aesthetic, is designed to counteract this – but fundamentally putting a needle into stressed tissue, the injecting fluid – that is going to cause trauma. However personally I don’t this is the main mechanism for causing pain after the injection
- Reduced movement/changed behaviour – After any intervention, manual therapy, sports massage or a cortisone injection the soft tissues are going to be affected. Because of the temporary increase in swelling, locally there will be a reduction in movement – and on a global scale you’ll often see patients ‘protecting’ or favouring that body part, reducing or changing the movement in that area. This may be as a direct result of percieved increase in pain OR through an increase in fear, but either way NOT moving joints is a bad idea and limits recovery. Most structures in the body, if not all actually, are designed to heal through movement. Any time there is a reduction in movement through an area this reduce health and, in this instance, increase pain.
- increased vigilence/stress – The biggest reason that I see explaining an increase in pain immediately after a cortisone injection is increased vigilience and increased stress. Firstly pain works like a ticking clock, once you hear it you can’t unhear it! And if you start to get frsutrated and annoyed about it, the sound seems to get louder and louder – even though in reality it was the same volume the entire time. After any type of treatment patients often suffer increased vigilience – can you still feel the pain? Is it better? Is it worse? What’s that new grinding sensation mean? All of these questions increase your vigilience, which directly increases the volume of your pain. The best advice post treatment is ALWAYS just to try and ignore the affected body when the pain is below 4/10 and to carry on life as if you are pain free. Increased stress is the second reason pain can increase. Pain is an alarm system, you’re much more freaked out by noises in the house if you’re alone, been watching a horror film and a power cut has just happened – but during the day with people around it doesn’t bother you AT ALL! Context is everything. And when you’re going for a painful treatment like a cortisone injection there is a lot at stake. The GP will probably already have told you things might not work, you’ll definitely have been told it will be painful, and you’ll be worrying about how this is going to affect you, whether you have take time off work, if you’re going to be able to keep training. All of these things increase the ‘risk’ of the situation taking completely begnin creaks and aches in your body and turning them to sinister noises that could indicate more damage and more injury. And a lot of people get depressed when they ‘think’ a treatment hasn’t worked – regardless of whether they are right or not this thought leads to increased stress, increased risk because they feel like it’s going to be like this forever. If you’re interested in this side of pain then check out resources
- Tendon degeneration….see the next section!
Things stay the same
Now in reality, although you may feel nothing has changed either way, it turns out the evidence is showing us that in the background things are likely to have gotten worse.
We’re now getting increasing evidence that by having a cortisone injection, halting the inflammatory process, actually INCREASES the rate of degeneration in the tendon.
We also know that having multiple injections makes this worse AND that more injections doesn’t increase your chances of getting pain free.
A number of studies are showing that either these cases are self-limiting (just get better on their own with time) OR that with sports massage, rehab and manual treatment that you are MUCH more likely to get improvement and stay that way.
Are you considering getting a cortisone injection?
Get in touch with us first – if you are not local to Cambridge then drop us an email at [email protected] or if you are Cambridge based then book a Sports Massage appt with one of the team and let us assess you first. Sports Massage, in our Cambridge clinic, can be very effective at both managing and reducing tendon-related pain. You can book online here to work with one of our expert Sports Massage Therapists. Get a second opinion before you go under the needle!! The evidence is growing it is NOT the best idea if you haven’t explored every other option first!