Cortisone Injections and Musculoskeletal Conditions: What You Should Be Considering
- Aleksandra Nikolovski, PT, MScPT
- Sep 4, 2024
- 7 min read
What is Cortisone?
Cortisone was discovered in the 1920s through animal research at the Mayo Clinic. In 1934, compounds were separated and named. It is widely used for treating musculoskeletal conditions like spinal pathologies, tendinopathies, and arthritis. While commonly used for short-term pain relief, scientific evidence for long-term benefits is limited, with varying results across studies.
Where Does Cortisone Come From?
Cortisone is a powerful compound derived from cortisol, which is a hormone naturally produced by the adrenal glands, which are small organs that sit on top of our kidneys and help us regulate our blood pressure, immune system, and stress responses.
The discovery of cortisone revolutionized the field of medicine upon its discovery in the 1930s. The first use of cortisone was in German Pilots to enhance their muscle activity, stress resistance, and alertness. Early research was conducted by Merck & Co (the company that now produces Gardasil for HPV, Januvia for Diabetes, and Keytruda for cancer) and found that cortisone was found to have positive effects on muscle activity, carbohydrate metabolism, and resistance to cold and stress.
This research by Merck & Co led to the initial trials of cortisone on patients suffering from Rheumatoid Arthritis, which yielded astonishing results, showcasing its ability to swiftly alleviate symptoms and improve the quality of life for those afflicted with the condition. This study granted Dr. Edward C. Kendall the prestigious Nobel Prize in Physiology or Medicine in 1950. This recognition not only highlighted the significance of cortisone but also propelled extensive investigations into its diverse applications across different medical fields.
Subsequent studies delved deeper into the mechanisms of action of cortisone, shedding light on its anti-inflammatory properties and immunosuppressive effects. Researchers and clinicians alike began exploring the potential of cortisone in treating a myriad of conditions, ranging from autoimmune disorders to allergic reactions, paving the way for the development of cortisone-based therapies that have since transformed the landscape of modern medicine.
From Cortisone to Hydrocortisone and Beyond
After cortisone gained more acceptance in the field of medicine, researchers started exploring a different compound derived from the cortisol hormone due to early findings indicating superior anti-inflammatory properties when compared to cortisone alone. This compound, now recognized as hydrocortisone, has undergone extensive testing in numerous Rheumatoid Arthritis patients over time, with injections administered in various joints for comparative analysis.
A significant trial conducted by Hollander et al. in 1951 involved the administration of 700 injections to 39 patients suffering from arthritis. The study revealed that the relief provided by hydrocortisone injections lasted for up to 6 months without any reported adverse effects. However, it was noted that hydrocortisone should be viewed as a supplementary treatment to rehabilitation rather than a definitive solution. Long-term monitoring of patients over a decade indicated that disease progression could potentially continue even in the absence of noticeable symptoms.
Over time, cortisone and hydrocortisone have been used both independently and together for the management of arthritic pain and musculoskeletal conditions. A broad term used to describe these two compounds is "corticosteroids". Corticosteroids are now often used with other compounds such as lidocaine (an anesthetic or numbing agent) and methylprednisolone (a much more potent type of steroid than hydrocortisone and cortisone).
How do Corticosteroids Work?
Corticosteroids can be found circulating either freely or bound to receptors, which then work to block inflammatory cytokines. Additionally, corticosteroids decrease the response of white blood cells and reduce the dilation of blood vessels and swelling, although the precise mechanism of action remains incompletely understood at present.
The Good and the Bad
There are hundreds, if not thousands of trials involving corticosteroid injections for musculoskeletal conditions and comparing this treatment to other interventions such as physiotherapy. For the purpose of this blog, I couldn't possibly go through every article highlighting the pros and cons of this treatment. Rather, I opted to highlight some examples.
The Good
In 2021, a study was conducted by Hajivandi et al. involving 96 patients with full thickness rotator cuff tears (tears in shoulder muscles).
The goal was to see what was best: physiotherapy, steroid injections, or both?
None of the patients were allowed to take any other pain medications or use home remedies such as topical creams, oral tablets, herbal baths, etc., and their pain, range of motion, and function was measured at the start and end of the trial.
The 96 patients were split into 3 groups:
Group 1 had 12 physio sessions over 6 weeks
Group 2 had two steroid injections, 3 weeks apart
Group 3 had both a steroid injection and 3 weeks of physio
Which treatment won in the end? GROUP 3
What the researchers found was that the steroid injections helped reduce pain that allowed the patients to engage more fully in physiotherapy, which led to a better result than trying to push through physiotherapy with pain or simply getting the injection and doing no physio.
Another study conducted in 2018 by Kraal et al. assessed the difference between corticosteroid injections on their own and injections combined with physiotherapy for frozen shoulder. This study included 21 patients who were divided into two groups:
Group 1 received corticosteroid injections only
Group 2 received corticosteroid injections as well as physiotherapy 2x/week for 12 weeks
At the end of the trial, the group who received physiotherapy in addition to the corticosteroid injection showed greater improvements in pain, range of motion, and overall shoulder function compared to the group that only received the corticosteroid injection.
The Bad
Over the years, researchers and clinicians began to evaluate the long-term effects of corticosteroid injections. What has been found is that higher frequencies of injections at higher doses have negative effects on joints and muscles.
Brinks et al., (2010) conducted a literature review of 87 studies and identified major and minor reactions in several of them, including:
Major Events | Minor Events |
Osteomyelitis (bone inflammation) | Skin rash |
Cellulitis (skin infection) | Flushing |
Protothecosis (blood infection) | Disturbed menstrual patterns |
Nectorizing fasciitis (flesh-eating disease) | |
Ecchymosis (large bruising) | |
Tendon ruptures |
Another systematic review published in 2021 [1] identified several adverse effects including:
Toxicity to articular cartilage
Increases in blood glucose levels
Reduction in immune function
Risk of infections because of immunosuppression
This systematic review recommends that clinicians should limit their use of this medication to conditions with a clear inflammatory component associated with acute pain that requires immediate reduction to minimize adverse risks to those who will not benefit from the treatment.
Furthermore, data taken from osteoarthritis initiative, which is a a multicentre observational study that followed nearly 5000 patients with or at risk for knee OA, did annual follow-ups for up to 108 months.
The goal of this study was to identify how many patients who received corticosteroid injections with knee osteoarthritis underwent knee replacement compared to those who did not have injections.
The result? 31% of patients who received corticosteroid injections had knee replacement surgery during the follow up period, while only 5% of the patients who did not receive injections had knee replacement surgery.
While we cannot infer causation, we can recognize a clear association between corticosteroid injections and joint degeneration [6].
Low Bone Density and Osteoporosis
Long-term use of corticosteroids have been shown to cause bone loss and subsequent fractures in up to 40% of individuals. There are many reasons for this, including the tendency for steroids to activate osteoclasts (bone degenerating cells), and to reduce the number of osteoblasts (bone building cells) [7].
While not everyone will experience bone loss or fractures, there are certain groups who are at higher risk, including post-menopausal women and those with frailty who take steroids longer than 6 months [8].
Let's look at one more study by Donovan et al., (2022). A systematic review of 10 knee arthritis trials was conducted. Across the 10 studies, patients received between 2 and 8 corticosteroid injections with follow-ups between 3 months and 2 years.
The result is that over a 2-year period, corticosteroid injections offered no difference in pain levels compared to doing absolutely nothing.
So, Should You Get A Cortisone Shot?
The answer to this question is "it depends". What does it depend on?
Severity of your pain
Impact of pain on your daily life and functioning
Nature, cause, and prognosis of your condition
is it inflammatory?
What caused it?
How quickly do people typically recover?
Which treatments are typically recommended?
Have you tried other treatments such as 4-6 weeks of physiotherapy?
Drug allergies you may have
Drug interactions (are you taking other medications that may make it unsafe?)
Other health conditions that may be aggravated by an injection
The only way to identify if a cortisone injection is right for you is to talk to your healthcare team. Get a full picture and don't be scared to get second (or third) opinions. Your physician can administer the injection but your physiotherapist can help you better understand your condition and help identify risks and benefits for your long-term recovery.
For an easy read, please check out my infographic that summarizes the content of this blog!
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Downloadable PDF
References
[1] Stone S, Malanga GA, Capella T. Corticosteroids: review of the history, the effectiveness, and adverse effects in the treatment of joint pain. Pain Physician. 2021;24(S1):S233.
[3] Hollander JL, Brown EM, Jessar RA, Brown CY. Hydrocortisone and cortisone injected into arthritic joints: comparative effects of and use of hydrocortisone as a local antiarthritic agent. Journal of the American Medical Association. 1951 Dec 22;147(17):1629-35.
[4] Hajivandi S, Dachek A, Salimi A, Mamaghani HJ, Mirghaderi SP, Dehghani J, Borazjani R, Babaniamansour A, Sarallah R, Javanshir S, Salimi M. Comparison of the separate and combined effects of physiotherapy treatment and corticosteroid injection on the range of motion and pain in nontraumatic rotator cuff tear: a randomized controlled trial. Advances in Orthopedics. 2021;2021(1):6789453.
[5] Brinks A, Koes BW, Volkers AC, Verhaar JA, Bierma-Zeinstra SM. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC musculoskeletal disorders. 2010 Dec;11:1-1.
[6] Wijn SR, Rovers MM, van Tienen TG, Hannink G. Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty: A multicentre longitudinal observational study using data from the Osteoarthritis Initiative. The bone & joint journal. 2020 May 1;102(5):586-92.
[7] Yasir M, Goyal A, Sonthalia S. Corticosteroid adverse effects.
[9] Donovan RL, Edwards TA, Judge A, Blom AW, Kunutsor SK, Whitehouse MR. Effects of recurrent intra-articular corticosteroid injections for osteoarthritis at 3 months and beyond: a systematic review and meta-analysis in comparison to other injectables. Osteoarthritis and Cartilage. 2022 Dec 1;30(12):1658-69.
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