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Wednesday, May 02, 2007

Cortisone Injections - pain relief at what cost? (Updated)

Note: This is an update of an earlier article.

Let me present the case of a very fit woman who, by anybody's terms, completely overdid the exercise for a few months towards the end of last year. She developed left ankle pain that would not resolve. She was referred to a sports medicine physician who injected the spot with hydrocortisone. Being a sports physician, he would have been well aware of the risks associated with these injections and would have exercised due care with the procedure.

The relief was immediate and she was able to resume normal activities several days later.

About 6 months later, she developed diffuse ankle joint pain when running. It refused to respond to treatment, including rest. The ankle would throb while sitting. Running out of options, she came to see me.

Photo One shows the left ankle appearing to be less meaty in appearance as compared to the right. 
Photo Two shows a hollow towards the front margins of the ankle bone 

Photo Three shows a marked hollow where there should normally be fat and ligaments 
Her case is quite typical of what I see months after cortisone injections and long after the patient has been declared "cured" of their musculoskeletal pain.

So, what is going on here?

What hydrocortisone does
Hydrocortisone is a means of doing a "chemical exision". In other words, it is a way of removing tissue without the need to cut. The chemical literally dissolves tissue. This is very effective at removing spots of persistent pain - it makes the problem literally disappear!

The problem
While it removes the pain, it invariably leaves the structure weakened. Furthermore, wherever the fluid leaks, tissue is killed off. In this case, healthy tissue - including shock absorbing fat and gristle and protective ligaments were damaged and even disappeared altogether!

It would also appear that some cortisone leaked into the joint itself, causing arthritic changes that now show as diffuse pain throughout the ankle joint, including the other side and general throbbing.

These complications are common. The first instance I can recall was of a running mate who was just on the heels of elite milers like Dixon, Quax and Walker. He developed plantar fasciitis of the foot and had a cortisone injection that fixed the problem. A few months later, he was out for a training run when he felt something snap in his foot. The plantar fascia had completely detached from the heel bone. His foot catastrophically collapsed. When I examined his foot, the arch was absent, he had knee pain due to altered foot mechanics and there was no fatty pad under the skin of his heel - it had been completely dissolved! That was the end of his running career.

Once the tissue is gone, it aint ever coming back.

I have seen plenty of cases of delayed complications. Possibly the most common is cortisone injections to relieve tennis elbow types of pain. This can result in complete avulsion of the wrist extensor muscle where it attaches at the elbow.

In these kinds of cases where there is a delayed complication, the treating doctor may forever remain blissfully unaware and will have chalked the case up as a treatment success.

Sometimes, the cure can be much worse than the ailment itself.

34 comments:

wayne said...

do these problems come about through a single injection or from a course of injections, I think we've all come across someone who will swear by cortisone in helping them, so i wondered it if was more protracted use or a matter of luck if a single shot helped or hindered

Gary Moller said...

In the case presented here, it was a single shot done by a highly qualified and respected sports medicine physician.
Generally, the limit is no more than 2-3 to an area and spread over time.
Whyt take the risk of catastrophe when there are very safe and effective alternatives? I will cover some of these in a followup article.

Julie said...

Your article has completely freaked me out. I had a cortisone injection after extensive physio failed to relieve a very painful ankle which hurt any time I was walking or running over uneven surfaces. The cortisone injection was a "last resort" and I too was referred to a highly respected sports doctor and athlete for the treatment. More than 6 months has passed since I had that treatment and things seem to be fine. I've had lots of friends and colleagues though who've subsequently warned me about having this treatment ever again. Needless to say, after having read your article - won't.

Gary Moller said...

Julie,
Do not get too freaked out. These injections can and often do work; but they sure can go wrong now and then. That you have remained symptome free is encouraging and you will probably be fine as and never look back. I am going to do a followup that covers some of the alternatives, including what I have recommended for the case presented in this article.

wayne said...

makes me wonder about any injection, given the large hard sore lump on my shoulder (no not my head) from my tetanus shot a week ago

Debra said...

When I read your article it could have been about me. I had a cortisone injection into the posterior tibialis tendon in November of last year. It did the trick initially - allowing me to compete in several more races before starting to play up again. I am now left with a hollow above the left ankle and am on a waiting list to see an orthopaedic surgeon to see what he can do. Needless to say I'm not running an am missing it sorely.

Gary Moller said...

Debra,
I am sorry to hear of your ongoing foot problems, I guess it is of little comfort that you are not alone.
If you are able, you might like to have me take a look at your injury. Surgical solutions (of which cortisone is one) should be last resort options only to be exercised after other less radical and risky options have been thoroughly tried and exhausted.

Paul Leslie said...

Hi Gary,

Back on New Years Day I came of my bike and landed on my shoulder. This seemed to flair up an ongoing problem with my Rotator Cuff so I went back to my Physio for some treatment (yes, covered by ACC). After extended treatment I had achieved some relief but it had plateaued so my Physio sent me for an Ultrasound, the result - "a large full thickness tear which involves all but the anterior border of the supraspinatus tendon".

My Physio suggested surgery to be the likely treatment but referred me to my doctor. My doctor has suggested that the appropriate treatment is most likely Cortizone and has provided me with a choice of referral to one of two specialists. The first a Sports Medicine Specialist who is more than competent to carry out the surgery (also my Physio's preference) and the other a general Orthopaedic Specialist competent to give a Cortizone injection but "not someone he would recommend me to if he thought surgery was required".

I have been trying to set up an appointment with the first surgeon and, having waited a month already, have finally received an appointment for mid-July. I don't think I can wait another 6 weeks but am loathe to go down the Cortizone track if it is not going to give me complete mobility back in my shoulder and arm.

Your advice or comments appreciated.

Regards
Paul Leslie

Gary Moller said...

Paul, without seeing you in the flesh and properly evaluating the shoulder, it is hard to be specific with advice. Are you in Wellington?

While I am very cautious about cortisone, it does have its uses. However, in most cases where it may used there are often good alternatives. In the case of a shoulder, this may be a mix of massage, exercises and manipulation.

I recommend that you consult a specialist in shoulders. If you are in NZ I may be able to make a recommendation for you.

Anonymous said...

My daughter runs track in college and has developed pain in her foot. The location of the pain is on the top inside part of her foot. She had rested it for about 5 weeks and the pain came back upon running for about 20 minutes. Xrays and an MRI show no sign of any kind of fracture and her coaches want her to get a cortisone injection but I am hesitant to do so. She is going to see what her chiropractor can do...any suggestions or recomendations regarding cortisone shots to the area?

Anonymous said...
This comment has been removed by a blog administrator.
Gary Moller said...

First of all, the coaches should not be making these kinds of decisions. Assuming your daughter is a legal minor, then you must be her guardian angel in such circumstances.

Such injuries are not medical but coaching and nutrition ones. Give her time to grow and go easy on the high intensity running.

Find a good massage therapist to massage her feet and calf muscles.

There is no need for cortisone in young people (or oldies for that matter!). There are usually plenty of safer and more effective ways to deal with these problems.

susannejulia said...

Hi,
I just read through your acticle and you'd mentioned you'd write a follow up-couldn't find anything though :O(
I have been dealing with bursitis over the trochanter for 8 weeks now and the Dr wants to give me a cortisone injection which I do not feel good about.
What are other treatment options?
The Dr. said the inflammation could become chronic after such a long time and the cortisone would take care of it.
I want to believe him but I don't feel good about it.
Any advice would be appreciated!
Thank you so much!
-Susa

Gary Moller said...

Susa,
I have never encountered a condition for which there is not an alternative to a cortisone.

Generally speaking, in your case, the best action is to massage the affected areas. These will be thickened and very tender and the skin will go red when the area is massaged. While it is most unpleasant to have done the results after 2-3 sessions can be dramatic relief. This needs to be combined with massage of the entire muscle of the limb - the whole forearm for example because muscle tension can be at the root of the problem.

Have a look at the Active Elements mineral therapy programme as well. An underlying deficiency may be a factor in your weak and inflammed tissue and the inability to heal as should be the case in a healthy person. The link is in the right hand column of this web page.

Please let me know how you get on.

rossi said...

Hi-i had a cortisol injection after seeing a Shoulder specialist who after an MRI to see the problem, said my tendon was fine, but some imflamation due to some current impegment problem, so to try Cortisol and see if it feels an easier. The Consultant made it sound all very simple and would feel tendor for 3-4 days, but i'm currently worried as i never had day to day pain, only problems after i did amounts of swimmming, but since injection i now have very tendor shoulder and arm and have been told since that in 40% of people the injection takes time to settle down and can make area worse instead. it is now affecting my work and can't type very well or use arm properly and sometimes get sharp pains in part of the arm. is this side effects normal or should i be concerned? I'm currently upset that the consultant didn't tell me what may happen and give me proper choice, he just made it sound simple and good way to go. i have seen anothe consultant since who has tried to assure me all will be okay, but it is hard to feel that as i have to try to work and am taking stronger pain killers.

Gary Moller said...

Rossi
Please can you write me an email:
gary at (@) myotec.co.nz

Thanks

Anonymous said...

I had a corisone injection for tennis elbow in February of 08. It seemed to work well for about 4 months until I noticed a 4.5cm x 2.5cm hole around my elbow. After being told that it sometimes happens by the nurse and it should be ok I let it go. But, by Nov. I was in a lot of pain and called again, and started physical therapy for the 2nd time. There was no relief. I just went back, and my doctor said he was so sorry he injected me with cortisone. I have no protection around my elbow if I'm bumped, and have just found out that I have a 50% tear in my tendon. Surgery is what is lurking. But, I am concerned that the injection has somehow made the whole situation worse. My skin on my forearm is very sensitive and he is concerned that something else is going on also. I am going to get a 2nd opinion before doing anything else. Any advice for me?

Gary Moller said...

I am sorry to hear of your situation.

I feel sometimes I am a lone and exasperated voice when expressing concern about the safety of cortisone injections.

It is possible that the tendon tear is due to the cortisone. If I was in your situation, I would ask for all future costs to be covered by the Dr who did the cortisone. I would certainly expect a refund of costs to date.

Avoid surgery if possible. I find cases of tennis elbow easily treated in about 3-4 sessions with deep tissue massage of the entire forearm, upper arm and hand combined with appropriate nutrition. Tissue salts, including Calcium Fluoride and Silicaea help keep tendons and ligaments strong and supple as does methylsulfonylmethane (Do the Active Elements Assessment on this site). You could also add several tsp of flax oil per day to the diet. This should commence a few weeks before the massage and the massage only once a week and then no more between sessions, although continue moderate ROM exercise.

Give recovery plenty of time - like 1-2 years. Get the massage ongoing as required and keep the diet thing going. If you are in Wellington, I can assist you.

Be patient.

Anonymous said...

Hi my name is Veta, I have been suffering with bursitis, tendonitis and arthritis for about nine months now. within tat time I have had three cortisone injections, two of them in the last two months. After reading your article I am very worried.

Gary Moller said...

Veta,
Do not worry: The best course of action is to read the many articles on this site about joint pain, arthritis and muscle pain and get into a course of supplementation that addresses the underlying causes of your pain and not the symptoms.

Take your time in healing. Do not go for the sexy quick fixes such as cortisones.

If you are on medications such as for cholesterol then you might want to consider their possible role in causing your pain.

I am here to help if you have any specific questions that are not answered in previous articles.

Muzza said...

Hi,just have been reading,and now im not too sure what to do.
Im a heavy truck driver, in Auckland, and a month ago created a split/tear on the cartlige bone that works next to the ulna in my wrist.
nothing showed under xray, and for two weeks with no cast on was in pain, the hand specalist has told me,when he put a cast on(2weeks ago)that i had 3 options,1-cast with inflamatories(voltaren),2 cortisone injection if no1 doesnt fix it, or 3 a 4mm shortning of the ulna.
with all this, still might be off work up to 6 mths, or have to retrain to something else as every thing we do is heavy.
the problem is, the pain isnt going away, and ive heard tooo many people telling me not to have a cortisone injection as the initial pain is imence and the long term aspects dont work.
Any idea's would be gratefully recieved

Gary Moller said...

Injured Tuck Driver:
First of all, it is early days and there is a lot more healing to happen, so do not panic as this stage.

Exhaust all the non surgical options, including cortisone, first.

First of all, how can you be sure that it is a split cartilage? Is there clear evidence or is it an educated guess? Please describe exactly how you hurt the wrist and I may be able to say more than general advice.

You could try a course of Balance Joint and Cartilage Repair formula for athletes. Take 3 scoops spread over the day and do so for three months. Start right away. You can get this off my webstore.

Please describe the therapy you are currently receiving as well as all medications across the board and then I will comment further.

Anonymous said...

I recently was referred to an orthopedist, whom I saw last Tuesday (3/9/10) for an elbow and hip problem. The Dr. seemed to blow off the hip problem and focus on my elbow ( of course this was after he was 1.5 hours late for the appointment and said insurance wouldn't let him look at two things at one appointment.I know I should have left the office right then - but I'd spent all that time waiting . . . )

I've had a sore spot on the inside of my elbow which, after carrying heavy items, seemed to get worse (with rest - better). I had taken my x-ray with me, but what would I know about reading it. He determined "tennis elbow" after yanking me around a bit - decided on a cordisone shot with almost no explanation (I KNOW, I SHOULD HAVE LEFT RIGHT THEN)which I suffered through that day and now feel much worse 1 week later.

After reading all your comments, I'm not really sure what to do. Any suggestions? How long does a cordisone shot take to "do the job" - am I already past that point? I just don't know how to handle this. Should I go back to my Primary Care doc who didn't seem to know how to diagnose this problem in the first place.

HELP.
Jane(the 70-year old who everyone thinks is only 50 - but I'm not)

Gary Moller said...

Jane
The injection is done and dusted and there is nothing you can do other than to look forward.

Start by reading the article here and follow the leads from the keywords at the bottom of the article.
http://blog.garymoller.com/2010/03/relationship-between-low-back-pain-and.html

Have a close look at the hair tissue analysis articles and the articles about hip pain and iliotibial band syndrome. Also read up the articles about knee pain.

These are all relevant to you. Massage and nutrition are the way to go.

Cortisones are a waste of time and may do more harm than good over the long term.

Laurie said...

I had been experiencing elbow pain for several months last spring before seeing my family physician in July about it. He recommended cortisone injections for elbow pain. I received one in mid-July and was pain-free until the beginning of October. My doctor originally advised that it may take 3 injections to solve the problem. I returned for a second injection in mid-October. Now, in mid-January, I am experiencing the same elbow pain again, radiating at the elbow bone and down my arm. Physical activity aggravates the pain. I am concerned about the long-term health of the tissue. Would you advise seeing a specialist at this point?

Gary Moller said...

Laurie
Yes I recommend that you see a specialist - A specialist massage therapist. You will benefit from a series of deep tissue massages of the fore and upper arms . Do both arms, concentrating on the sore regions. As the massage session progresses the excruciating pain should abate. You will feel a bit bruised for about 3-6 days.

Have the procedure repeated every week until there is no discomfort from the massage.

This procedure works brilliantly but you may have trouble finding a suitable therapist. If you are in Wellington, arrange to come see me.

Do not have any more cortisones!

Anonymous said...

I am a runner who has been suffering from IT band syndrome for about a year now. My wife wants me to get cortisone shots but I am skeptical. What are the other alternatives to help heal this injury?

Gary Moller said...

Injuries affecting the ITB usually involve a combination of muscle spasm affecting the muscles deep within the buttocks, spasm of muscles deep in the hamstring and outer thigh regions and painful adhesions binding the long muscles and tendons down the thigh including the ITB.

Cortisone may dull the pain for a while but will not cure.

The solutions lie in getting regular deep tissue massage of the affected muscles and getting the underlying physiology of the muscles in healthy balance. This is best done with accurate testing with a Hair Tissue Mineral Analysis. Go here for more: http://www.myotec.co.nz/product.pasp?categoryid=53&productid=180

And you will find many articles on my blog about muscle pain, tendon injuries and so on, they are all relevant to you.

Anonymous said...

I injured my lower back during a day of vigorous gardening 10 months ago, I then had Physio which was supposed to treat "bulging disk" syndrome, not much changed, then I had an Xray, then an MRI, still without conclusive results, the pain persisted and I was referred to a muskulo-skeletal specialist, who, after letting me do some exercises for several weeks, without positive outcome, has now suggested cortisone injection(s) into the facet joints, lumbar 4 and 5, even though he is not sure, what causes my pain. He said cortisone injections would help in diagnosing the source of pain, but has warned me of the risks of infection, nerve injury and bleeding. What are my alternatives? Please advise me, I am desperate to get this resolved as it is debilitating.
Zita 48

Gary Moller said...

90% of the back pain I deal with has a significant biochemical and muscular component. While there may be a disc involvement, dealing with this alone is mostly fruitless.

Get this test done: http://www.garymoller.com/product.pasp?categoryid=53&productid=180

Purchase my book on back pain and do the exercises whcih focus mostly on the hips:
http://www.garymoller.com/category.pasp?categoryid=2

Google "Gary Moller adrenal fatigue" and read and follow the labels and links. Do the same for "Gary Moller back pain" and "Gary Moller fibromyalgia" Other key words to use along with my name are "low salt diets" and "thyroid" and enjoy the read.

Read this as well:
http://blog.garymoller.com/2011/06/cardiovascular-disease-arteriosclerosis.html

carron said...

I have had cortisone in my shoulder for a thickened burser, which caused me immense pain. 6 weeks later I'm in pain again. I saw a very highly respected sport doctor, but now I'm looking for an alternative, any suggestions please??

Gary Moller said...

Hi Carron, Please send me an email via my website with as much detail about your general health, how and when the injury first arose, treatments, all medications being taken and, if possible, a photo with the painful area highlighted with a felt pen.

I'll do my best to help.

No charge for my time if it a quick and simple exercise. I'll advise if it is not going to be the case.

I look forward to hearing from you.

Anonymous said...

hi u recieved an injury after running a half marathon last may. was undiagnosed for around 7 months and my mri came back normal, the ortho surgeon gave me a shot of kenalog cortisone in to my knee, didnt tell me of any side effects etc just said to rest for a couple of days. i then got server pain so bad i could walk get in and out of bed or anything, i kept ringing surgon and went in a few times. after a couple of weeks pain still really bad and then i noticed that fat has gone from the lateral part of my knee (there hardly any fat there to start) and this skin has discoulured (not right in the injection site but down a little further on my upper leg) since then i havent been able to walk or do daily actitvies let alone run, tramp and all the things i used to do. i got a second mri and a bone scan which finally diganosed me with a tibial plateau stress fracture but i dont think this is even the orignial injury anymore, i really feel the cortione has ruined my life. does the necrosis get better? what are the chances of bone necrosis? or that the ligments and tendons have been effected also, as there is not much tissue on the lateral side. wich i had never got the cortisone if i new the risks i would have walked out i really do believe my old injury would have been well and truely gone by now, will be a year next month.

Gary Moller said...

Dear Anonymous,
I can appreciate your distress. Sadly cortisone is used as a quick-fix all too often and with little regard for the possible long term consequences.

With regards to your knee injury I am limited in what advice I can give without seeing the leg. It might help if you can email me some photos taken like we have done for the ones in this article.

What treatment has your Dr recommended? And what treatment are you receiving?

One thing you can do is take Reparen. Google "gary moller reparen". Take this daily for as long as there is any pain. It will help with rebuilding damaged bone, ligaments etc.

I hope that I can be of further assistance once I have more information.

The best healer in such instances is usually time, by the way. Have heart it will get better!