The right way to use cortisone injections

On a daily basis, I am asked what the downsides of cortisone injections are.  The answer depends on location of the injection, medical history, type of steroid used, and technique.   Steroid injections have received mixed reviews in the media lately, but when used judiciously, they can cure joint swelling, restore motion, and significantly reduce pain.

The term “steroid” represents a broad class of medications that can be taken by mouth or injected.  With regards to steroid injections they take one of two forms: corticosteroids or anabolic steroids.  Corticosteroids (also known as glucocorticoids) defines the chemical class of steroids used to reduce inflammation and pain.  Corticosteroid medications mimic naturally produced cortisol, produced by the adrenal glands, which have immune system effects.  These are prescribed and injected into joints, tendons, and muscle tissue to reduce inflammation, swelling, and pain.   Corticosteroids are also prescribed by mouth to help with autoimmune and arthritic conditions, skin conditions, nerve disorders and some cancers.  They are used in inhaled form for asthma and airway diseases. Anabolic steroids (also known as androgens or male sex hormones) act as hormones in the body and are known for being abused by bodybuilders and illegally by high performance athletes.  Anabolic steroids when used appropriately have a therapeutic role in medicine to treat growth disturbances, certain tumors, muscle wasting diseases, and low testosterone.  When abused, anabolic steroids can cause cancer, stroke and heart disease along with serious mood disturbances.

Corticosteroid injections usually contain 1 of the 3 most commonly used types of steroid (methylprednisolone (depo-medrol), triamcinolone (kenalog), or betamethasone (celestone) mixed with one or both numbing medications  Lidocaine and Marcaine.  The numbing medications offer instant pain relief;  the steroids provide relief over a few days to weeks.   They can be injected into joints, the area around joints such as bursas or capsules, or muscle tissue.  Corticosteroids are rarely used into ligaments or tendons as they can cause weakening which may then lead to tears.

Cortisone injections function as the most powerful anti-inflammatory available to patients, as such, they break the cycle of swelling, pain and inflammation.  Once this cycle is broken, normal motion and muscle firing patterns return, taking the strain off surrounding joints and muscles and allowing full function and return to activities.

Side effects of corticosteroid injections vary by patient.  In diabetic patients, 1 injection can significantly raise blood sugar.  Technique is important as injection should not occur into blood vessels and therefore not be intended for the localized area.  Bleeding and infection may occur as with injection of any substance.  The standard guideline is to not inject a joint more than 3 times a year;  this is to avoid potential damage to the soft tissue structures surrounding the joint and the bone itself.  Corticosteroid’s worse side effects are causing a decrease in blood flow to bone tissue, which can lead to bone damage and severe pain.
With regards to recent media on corticosteroid injections, A New England Journal article revealed a study suggesting little to no improvement in pain 6 weeks after epidural. This article suggested that epidural injections are not indicated for back and leg pain from the spinal stenosis, however the study was limited in the amount of injections used.  My experience is injections for stenosis can be very effective but often repeated and multilevel injections.  Many patients avoid surgery by getting yearly series of epidural injections.

In 2012, serious and fatal infections were caused by epidural injections done using cortisone made in non-FDA approved facilities.  This was a tragic complication of illegal drug production by a facility that has now been shut down.

Last week a study was published in the Annals of Internal Medicine.  Comparing three months of physical therapy to cortisone injections of the shoulders and showing physical therapy to use less medical resources than injections.  After a year, both physical therapy and injection groups fared the same.
As a non-surgical sports and pain medicine physician, I use cortisone injections into the muscle as trigger point injections for immediate pain and inflammation relief in cases of extreme pain.  With regard to joint injections, I wait until a patient has undergone a trial of physical therapy or home exercise along with ice and anti-inflammatory medication, such as ibuprofen and naproxen.  These are types of non-steroidal anti-inflammatories (NSAIDS).  These drugs are used as first line treatment for inflammation instead of steroidal anti-inflammatories (cortisone), which can affect blood sugar and immunity.  While all drugs have side effects, corticosteroids, because of their effect on the immune system, should always be used judiciously.  I only use cortisone first line if there is severe pain limiting sleep and activity.  Sometimes the injection will be repeated after a few weeks; rarely do I find a patient needing more than 2 over the course of a month.

Known possible risks of cortisone injections include raising blood sugar, causing lack of blood supply to bone, infections, tendon or ligament weakening or rupture, bleeding and bruising, and reversible whitening of the skin.    Sometimes an injection site will flair in the first 24 hours after injections. This is a common side effect that is unpredictable.

If your doctor recommends a cortisone injection here are some guidelines to ensure safety and efficacy:

-Make sure it is not into an area that is hot or red or (suggesting signs of infection).

-Ask if the medication is from an FDA approved facility rather than a compounding pharmacy.

-Some doctors use ultrasound guidance to inject joints.  This can lead to a more precise injection location but is often not necessary; Use of ultrasound also adds to the dollar amount for procedures doctors can bill for to increase their insurance reimbursement.

-Make sure your doctor has experience with the type of injection you are getting, and the type of cortisone being used.

-Be aware of a possible “cortisone flare” in which pain actually increases for 24-48 hours after injection before improving.

-If you are sore after injection, apply ice for 10 minutes in 4-6 hour intervals.

-Don’t be discouraged if you do not have immediate pain relief;  sometimes this takes up to a week or two for the cortisone to have its full effect

Cortisone injections play an essential role in pain and musculoskeletal medicine.  When used appropriately, there are no complications and they can lead to complete resolution of symptoms.