Even more warnings about the dangers of cortisone injections

Here is an example of the damage that can happen from a single cortisone
injection for "Tennis Elbow" several months later.  This woman
is left with very thin de-pigmented skin over a diffuse area
and loss of protective fat.

I have written more than a few articles about the dangers of injecting cortisone into body parts, like tendons, ligaments, joints and muscles.  Have a read here of one of my earlier warnings about these harmful injections.  The photos look very similar to the ones in this article don't they?

And here is the search string for a whole lot of articles I have written about cortisone injections.

These injections can leave their victims suffering from visible deformities and ongoing structural weakness, including catastrophic rupture of muscles and tendons.  These are not theoretical or rare - these are common side-effects of a surgical procedure that is enthusiastically promoted as the "quick-fix" panacea of all musculo-skeletal aches and pains.

Give me a shot doc

The protective fat of the elbow has been lost, exposing the
bone, tendons, nerves and ligaments to injury from
bumping.  It is visibly unsightly.  This skin damage and loss
of protective cover will become more and more of a
problems as she gets older.

 How come?  Here is my speculation as to why (excuse me if the following comes across as being a bit cynical):

• It is a surgical procedure that wannabe surgeons who never quite made the grade can employ.
• It is cheap, quick and easy to perform with a very good rate of financial return for the administering doctor.
• It fits with the criteria for most medical procedures of today - Fast Medicine!

The adverse reactions to these injections are grossly understated.  Why?

The site of the "tennis elbow" that was injected was the wrong spot!
So, several months later, she still had elbow pain which has now
resolved with some firm deep tissue massage.

• Because the adverse effects such as deformity and tendon rupture may not be obvious, or happen until several months later.  By which time the injury may not be linked with the cortisone injection.
• The doctor who caused the harm may be reluctant to acknowledge the link and even less reluctant to report it to officials (Less than 10% of all adverse medical reactions ever get reported: Some cynics believe the true figure to be less than 1%).
• The drugs company that supplied the cortisone may dispute any attempts to link the procedure with cases of harm.
• Accident Compensation is the master at wiggling out of injury claims.  It does this by hiring medical experts who are expert at turning real injuries into fictional degenerative processes.
• The patient usually does not have the nous, the time, nor the energy to take a case through to acceptance.

This woman needs a skin graft and fat injections.  She
is hoping for a successful ACC claim to cover
these procedures.  My advice to her is not to hold
her breath!  It will be interesting to see how she gets on.

My advice if offered a cortisone injection is this:

Say "No!"

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About this website

The advice in these articles is given freely without promise or obligation.  Its all about giving you and your family the tools and information to take control of your health and fitness.

Auckland University Study finds steroid treatment beneficial - Updated

Steroid treatment for osteoarthritis knee suffers was thought to progress the disease, but that belief has been overturned following a review of the literature by researchers at The University of Auckland.
Associate-Professor Bruce Arroll, from the School of Population Health at the University, says that osteoarthritic knee pain is one of the leading causes of disability amongst older people.

Photo: Example of the devastation that can be caused by cortisone injections

"Previously it was thought that you could give sufferers about 20 mgs of the steroid cortisone (prednisone) for a couple of weeks, but that it promotes disease progression if it is used any longer."

"From reviewing all the hospital-based research, we have found that there was no evidence that cortisone progresses the disease. In fact, it provides an effective pain relief for up to five months particularly if the dose is increased to between 40 and 120mgs," Dr Arroll says.

There is no cure, other than surgical joint replacement, for knee osteoarthritis, but Dr Arroll says the study gives hope of pain relief for sufferers.

"Our finding that giving steroids is effective for longer periods means that knee replacements won’t be needed so urgently. The injections will enable people to walk, be more comfortable and have less trouble from their knees," he says.

The study, commissioned by the Accident Rehabilitation and Compensation Insurance Corporation, was co-authored by Dr Arroll and Dr Felicity Goodyear-Smith from The University of Auckland and was published this month in the British Medical Journal.

Dr Arroll says surgeons and doctors are already showing an interest in the work.

"Another concern that was raised in the past by surgeons is that treatment could weaken the joints and therefore make joint replacement surgery less effective. But none of the research supports that, so it seems that cortisone will not have a negative effect on later surgery," he says.

Dr Arroll says it is the first time a review of research into cortisone treatment for osteoarthritis of the knee has been undertaken. He says future research into the area is needed, which would include longer studies that look at the impact of higher doses of cortisone.

Please read this article below from Complete Fitness
"How do cortisone injections work?
Cortisone is a powerful anti-inflammatory medication that occurs naturally in the body to controls and assists normal body functions. When therapists use cortisone to treat tendonitis, bursitis, and arthritis it acts as a potent local anti-inflammatory drug. Cortisone is useful in suppressing inflammation in the short term, and in the long term, dissolving scar tissue, stabilizing the body's defenses, speeding the healing process, and is very effective in causing certain cysts to disappear.Cortisone is not directly a pain relieving medication, as it only treats the cause or site of inflammation. Your pain is decreased by a cortisone treatment because the inflammation is diminished and this is turn reduces the pain. By injecting the cortisone into a particular area of inflammation, very high concentrations of the medication can be given while keeping potential side-effects to a minimum.
What is cortisone?Cortisone is a type of steroid that is produced naturally by a gland in your body called the adrenal gland. Cortisone is released from the adrenal gland when your body is under stress, and natural cortisone is released into the blood stream and is relatively short-acting. The absence of cortisone in the body is called Addison's Disease.Injectible cortisone is synthetically produced but is a close derivative of your body's natural product. The most significant differences are that synthetic cortisone is not injected into the blood stream, but into a particular area of inflammation. Also, the synthetic cortisone is designed to act more potently and for a longer period of time (days instead of minutes).
Are there side effects to a cortisone injection?Unfortunately yes. Probably the most common side-effect is a 'cortisone flare,' a condition where the injected cortisone crystalizes and can cause a brief period of pain worse than before the shot. This usually lasts a day or two and is best treated by icing the injected area. Another common side-effect is whitening of the skin where the injection is given. This is only a concern in people with darker skin, and is not harmful, but patients should be aware of this. Other side-effects of cortisone injections, although rare, can be quite serious. The most concerning is infection, especially if the injection is given into a joint. The best prevention is careful injection technique, with sterilization of the skin using iodine and/or alcohol. Also, patients with diabetes may have a transient increase in their blood sugar which they should watch for closely. Because cortisone is a naturally occurring substance, true allergic responses to the injected substance do not occur. However, it is possible to be allergic to other aspects of the injection, most commonly the betadine many physicians use to sterilize the skin."

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Gary Moller comments:
These articles completely underplay the dangers of cortisone injections while overplaying their benefits.
While there may be some benefit for advanced cases of osteoarthritis, I do not think there is any place at all for mild cases and definitely not for young people.

I am always wary of research that comes out with results that confirm the status quo while going against what I see happening in the field. Please read my earlier articles on this subject.

Photo: another example of the permanent damage and disability that can be caused by cortisone injection (These injections were done by experienced sports medicine physicians)
The mechanism of cortisone is not adequately explained in most articles on the topic. Cortisone is a form of chemical excision and this can be more indiscriminate than a scapel. The side effect of skin blanching (whitening) that is described shows what is happening deep in the area that was injected: the blood flow to the area is shut off, causing tissue death. This is why there is the risk of tendon, ligament or muscle rupture following these injections. That these terrible side effects are not officially reported as often as they are known to happen is par for the course. Adverse medical reactions are seldom recorded with the reported rate being less than 10% by some estimates.
Why is there such a paranoia about inflammation? Have you ever wondered why the body in its wisdom invented inflammation? Inflammation is a natural healing process that one is advised not to interfere with, either by drugs or by excessive use of cold. Inflammation happens when the body pumps blood and nutrients to the damaged area and the cells that remove the damage and rebuild healthy tissue proliferate. If we interfere with this natural process, we do so at the cost of proper healing. We end up with weak tissue that will tear with the first application of strain. Such is the consequence of the ignorant application of drugs and other misguided therapies.

What these articles fail to tell you is that there are excellent alternatives. But these alternatives are unpopular. Is it because these are non-drugs therapies which take time and for which there is no profitability for the professionals being consulted?

The alternatives are remedial exercises, nutrition and deep tissue massage. Done correctly and given time, these encourage natural healing processes, including supporting the natural healing powers of inflammation, rather than suppressing it.

If you are considering cortisone injections for a chronic injury and want to better explore the possible alternatives, contact me.

Beware of quick-fix remedies, including cortisone injections - Updated

Hi Gary
As promised ages ago the following is a blurb about my ankle injury.

Photo One: Permanent damage from loss of tissue to the Tibilais Posterior tendon caused by cortisone injection. She is compensating for loss of muscle function with overuse of other muscles which shows as an unusually contoured foot.



I originally contacted you back in early September of 2006 to get a second opinion about an ankle injury that had been an ongoing issue for me for close on a year. I first became aware of a problem whilst training for the Kepler Challenge last year (2005), it started out as niggling pain on the inner side of the left calf and I initially assumed it was my Achilles reacting to a running load that was heavier and faster than usual. I had been training with guys and as a result was pushing myself harder and faster and training runs were tending to become all out races. When easing back, reducing the load and rest did not seem to help I went to a local physio for advice.




Photo Two: The loss of tiabialis posterior function is compensated for by excessive use of the tibialis anterior (That is the tense-looking tendon on top of her foot)

The physio initially treated me for a strained soleus but then arranged an ultrasound which showed tendinitis in the Tibialis Posterior tendon just above the left ankle. The doctor who reviewed the ultra sound offered to "whack in some cortisone" there and then as a cure. The physio also recommended cortisone and referred me to a sports specialist who arranged for a cortisone injection under ultra sound. The specialist said that usually he recommends a two week break to let the cortisone work but that as I was training for an impending race to take two days rest before getting back into training.
The cortisone gave a fairly instant result - within a couple of days there was no sign of the injury left. All pain and swelling had disappeared. I went on to train and run not only the Kepler Race but several others over the ensuing months with seemingly no injury issues - BUT.. about six weeks after the injection I was left with an obvious hollow at the injection site and what was clearly a more seriously damaged tendon than I'd started out with.
I went back to the sports specialist who advised to take 3 months absolute rest from weight bearing exercise - which I did. But by the end of that rest period there were still obvious lumps along the tendon line below the ankle and the ankle bone itself was still nearly hidden by swelling. On returning to the sports specialist I was sent for a second ultra sound which showed that the synovial sheath of the tendon showed degeneration with 'ganglionic lumps' along it in an area below the ankle bone and the tendon above the ankle bone showed fluid and swelling with secondary scar tissue.
The original injury had been exacerbated by the cortisone injection and the consequences of it enabling me to run through the injury for too long.

The specialist arranged a referral to an orthopaedic surgeon. When I got to see the surgeon around 8 weeks later the Surgeon stated that surgery was the best solution but that it had to be my decision and should be done once I was sure that I could not run without it as being able to run after surgery was not guaranteed. The surgeon said that the operation would involve scraping down the tendon and if necessary - using a neighbouring tendon to help bear the load.
He advised and arranged for for orthotics to be made up and for me to go from neutral running shoes to Nike Gel Kayanos with the goal of starting to run on a treadmill - 3 x a week - building up by no more than 10% each week and starting from around 5 minutes at a time.

Not happy with trying to build up running on a still injured ankle I went to a different (recommended) physio and a massage therapist to see if I could avoid surgery and get some improvement. Regular massage treatment & acupuncture helped to a point that the ankle was visibly much less swollen and much of the scar tissue had been broken down. But the tendon was no longer doing the job it should be able to do and walking bare foot was uncomfortable. The sports specialist then made a call that he didn't think that the injury was is realistically going to improve enough on its own to allow me to run comfortably again so sent me back to the surgeon as he thought that the surgery track was the likely solution.

At that stage I felt as though I was just being passed from one specialist to the next. The physio who I had been making slow progress with suggested getting a second opinion before going to the drastic measure of surgery, and your name came up as a possible person to contact.
After an appointment with you and dutifully following your exercise instructions I feel that I've gained some strength and am feeling a lot more positive about running again than I was before talking to you.

Though the injury is by no means better, It has improved significantly since I was first sent to the surgeon and that improvement has come form strengthening exercised that you prescribed and from shear damn determination to do everything possible to strengthen and get back to at least being able to run with enjoyment again. In the process I have learnt that there is rarely a single solution to an injury and that you really need to educate yourself and question advice given even if it is from professionals who know more than you.

I am now at a point where I can run fairly comfortably for about 30 minutes (abet at a slower pace than I'd like) and where I can still see improvement week to week in strength and the visible look of the ankle. I've taken up mountain biking and spin classes to help get a good level of fitness back and have even partaken in a couple of bike races. Hard task is going to be holding of from getting out on the road running again to soon.
Debra

Feedback from the runner with the ankle pain

Here is some feedback from a runner with the ankle pain.

“I'm great... I've been back runnning for about 7 weeks...

“When you told me to start back , you will probably remember I still had the throbbing scenario - after that the ankle was giving me pain in the first few weeks of running. I've crept up slowly in kms and have had to go at a slower pace than I want ... but it's now not throbbing at all and only the very rare day do I feel familiar scary pains here and there.in the ankle... if that happens I get as much rest before the next session or swap sessions around.

So to answer your question yes your intervention did work for me, I was going backwards for many months (9 in total ) with the rehab exercises which I reckon were aggravating it more.

Before I ate healthily but now am using protein (just after a session which I never did before), calcium, minerals and flax will keep going and will keep the joint powder going for a good while yet.

Yes looked at the blog, and that is a great article, I hope it helps others make the right decision, all you need is a perceptive experienced advisor.You are the only person that I saw that wanted the entire background to my running habits and history.... and thank you ! “
___________________________

Gary Moller comments:
This very fit woman has made a remarkable return to running training. What she shows is the value of looking at the total person, including her health and exercise history, training programme, diet, physique and biomechanics - and let's not underplay the role of her determination to get back into running!

When attempting to understand how such injuries develop in the first place, it is essential to understand the constant balancing act that is going on inside the body between anabolism and catabolism. If an athlete is in a state of chronic catabolism, there is no way that any kind of medical treatment is going to "cure" her.

Although this dedicated runner has made a quick and remarkable recovery, healing and repair should be regarded as a slow and gradual process, taking several months, if not years to fully run their course. Too much therapy is on the basis of a 1/2 dozen visits and, if there is no cure, then more drastic action is recommended like surgery, or cortisone. Of course, these don't work and can leave the athlete with much worse problems over the longterm.

Central to modifying her training and diet and her doing some special exercises, is the moto "Body, heal thyself". This is a phrase all health professionals should constantly mutter away to themselves as a constant reminder that they never heal or cure - it is the patient's body that does that!
______________________________________

If you have a chronic injury or illness that you are getting nowhere with fast, and if you are in Wellington, I run a private clinic in the central city. Get hold of me to arrange a consultation - I really do enjoy the challenge of working with people like you!

A fresh warning about the dangers of cortisone injections

I continue to receive inquiries from people who have had cortisone injections to treat injuries to joints, tendons and ligaments, or have recommended that they undergo such treatment. This type of treatment remains disturbingly common and the consequences can be catastrophic.

Photo: Example of chemical excision by cortisone injection causing permanent damage to the ankle joint (note the large indentation where the lateral ligaments of the ankle once were). Only one injection is required to cripple the recipient.

Cortisone is a form of chemical excision. It kills living cells, dissolving living tissue, killing off everything it has contact with. While the relief from pain may be immediate and lasting, the adverse consequences may not appear for weeks or months or even years later. The consequences may be the catastrophic snapping of a tendon or muscle, loss of protective ligaments or the loss of protective cushioning tissue, such as that found in the heel pad. While many people get away without apparent long term consequences, I can tell you that many people definitely are not so fortunate.

Why is it that cortisone continues to be used to widely and for so many different musculoskeletal problems?

• It is cheap, quick and easy and can be done in any medical consulting room
• Relief from pain is instant and it tends to lastJust 1-4 injections seem to do the job which is usually much better and quicker than one would get than other therapies like physio
• If there are any catastrophic consequences, the association with the cortisone injections may never be known and the injecting Dr will never be any the wiser

When a Dr tells you the "risk is 1/1000" bear in mind that this estimation may be based on worthless stats that do not take account the dozens and dozens of unreported adverse side effects that run parallel to each reported case!

If you have an injury that fails to respond to rest and/or medical treatment, or are bothered by chronic pain and treatment with cortisone has been recommended, you are welcome to write to me and I will do my best to assist with helping you with deciding on what is the best course of action to take.

A Football Player with Posterior Tibial Tendonitis - Cortisone Injections

Hello Gary,

I watched your video on youtube and it seems that nutrition is very important. I have been suffering for PT for the past 7 months. It started as a minor discomfort which I ignored and continued playing football. and running. It eventually got worse and I haven't been playing any football for the past 6 months. My foot was almost cured 2
weeks ago but still felt very weak.  Unfortunately, It went downwards again when I walked a lot last week using my normal shoes. I had to see some clients and could not afford walking in my running shoes.

I went to see my doctor again on friday and he injected some cortisones and said to come back in 5 weeks. I read loads of negative things about it but kinda got fed up having my ankle always inflamed. It has been 3 days now and I do feel better but my ankle seems to have lost muscle and my calf has a pulling sensation. Is that normal ?

I also ice it every couple of hours and make sure I eat well.

Should I start some basic exercises in the coming weeks? I have been resting my ankle for the past 3 days and trying not to walk too much.

Do you think this will ever cure? i am going to be 30 in 5 days and used to very active but I am getting very depressed now ....

Any ideas?
____________________________________
Gary:
The best exercise to do, in addition to walking and gradually resuming running and activities like football is the exercise in the above video.  Do about 30 repetitions every 2nd day and gradually build up to about 60-100 continuous reps over a few weeks.  Keep doing them as a habit even if your ankle is 100%.  You can also take up walking on sand barefoot.  Walking and running across a grassy slope, either barefoot, or in a pair of snug running shoes will help strengthen the lateral and medial structures of the ankle.  Start very conservatively and never repeat the same exercise/activity on consecutive days - mix things up so that there is a variety of stresses on the legs and never the same the following day.

Nutrition is important.  In the case of tendons and ligaments, magnesium, copper, zinc, iodine and pyridoxine are most important.  Stress can be from multiple sources, including exercise, work, toxins (eg: smoking), relationships, financial, to name some.  Depletion of these nutrients hardens collagen which is the main constituent of tendons and other connective tissue structures.  This may be seen as conditions such as "Trigger Finger" or "Dupuytren's contracture".  While trigger finger is the most obvious manifestation, I see it often in more subtle forms, such as hard and inflexible leg tendons that are prone to chronic injury.  A lengthy period of stress is often the precursor of these injuries.

The best source of these nutrients, in as near to perfect combination is Dr Wilson's Adrenal Fatigue Formulations.  These are "Practitioner Only" products that are dispensed by prescription only.  Please complete the initial Adrenal Fatigue Assessment here and send me the results and we will go from there.

With regards to the cortisone injections you have had, it is interesting to note that the cortisone injected into the ankle by your doctor is a synthetic version of cortisol which is produced by the adrenal cortex of the adrenal glands.  It is fascinating to see how seemingly unrelated health issues (stress - tendons) may, in fact, be related!  There is a small but significant risk of future complications such as tendon rupture as long as several months from now.  Please read the articles in this search list.   Reduce the chances of suffering complications by a gradual buildup in physical capacities over the next three or so months and definitely get onto the adrenal supplements for at least three months.

There is no need to ice the ankle and do not take anti-inflammatory medication.  Read the articles in this search.

_______________________________________

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The advice in these articles is given freely without promise or obligation.  Its all about giving you and your family the tools and information to take control of your health and fitness.  Please give me your support by subscribing to my free email updates. Please shop at my Online Store. Please encourage your family and friends to do the same. While we may not always be able to compete with the big operators on price, we aim to more than compensate through personal service!

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Heel spurs - Is there any danger in one cortisone shot to each heel?

Gary
I am 53 and suffering from heel spurs. I tried off the shelf orthotics and am going to a custom in a few days. Trying to prevent surgery. My podiatrist says I should try one shot of cortisone only before going to surgery-do you agree? Is there any danger in one shot to each heel?
Thanks

Mike
______________________________
Gary replies:

Mike, let me answer your question by telling you about the very first time I witnessed the harm that these injections are doing to fit and healthy people.

He was a talented middle distance track athlete during the 1970's and early 80's, biting at the heels of athletes like John Walker, Dick Quax and Rod Dixon.

He developed a painful heel spur in one foot. Several courses of physiotherapy gave no relief. The sports physician he consulted gave him a single cortisone shot into the base of his heel. The pain relief was almost instantaneous. He was advised to rest up for a few weeks and then to very gradually resume running under the supervision of a physiotherapist. He carefully followed this advice.

He was out on an easy training run several months later when he felt and heard something snap in his foot. He was unable to run. To his horror, the arch of his foot had collapsed! His running career was over.

When I examined his foot a few years after this incident, I was shocked with what I found: The arch of the affected foot was non-existent. The plantar fascia had completely detached from the heel bone. In addition, the fatty heel pad under the thick skin of the heel had completely disappeared, leaving a hollow about the size of a 50 cent coin through which the heel bone was easily palpated.

That foot had lost its spring. The heel bone was now without its protective fat pad, causing jarring pain even when walking. The collapsed foot was making the foot rotate inwards, causing stress on the knee joint which was showing signs of painful arthritis. Running from now on was completely out of the question.

All of this career-ending damage was due to just a single quick-fix injection. I have since seen numerous cases of permanent damage and disability caused by cortisone injections.

Cortisone is a quick and convenient form of chemical excision. It is a surgical procedure. The trouble with this surgical procedure is the chemical is indiscriminate about which structures it kills off. It can leak into other tissues other than the piece of gristle being injected and it only takes an errant drop or two to do irreparable damage. It does not deal with the underlying causes.

Doctors are well aware of the hazards of injecting cortisone and, like the doctor in the example above, most responsibly follow the strict guidelines for their administration. But these guidelines make the flawed assumption that cortisone can be safely injected into structures like tendon sheaths and tendon attachments. The problem with this handy surgical procedure is that there can be months or even years of lag between its administration and the expression of harm, like the development of an arthritic ankle or a ruptured muscles or tendon. In most cases, the connection may never be made and certainly could not be proven.

In some cases, however, the connection is very obvious because the point of injection can be seen years later in addition to the consequent disability. The photo that accompanies this article shows the injection point into the sore ankle of a female athlete. You can see how the cortisone dissolved the ankle's structural tissue leaving a distinct hollow in the ankle which is now permanently and painfully weakened.

My advice is to go back to your podiatrist and patiently explore all of the possible underlying causes of the heel pain. What is really causing the heel spur? The answer will be multifactoral with issues like poor nutrition, weight gain, weak leg muscles, unsuitable footwear and doing too much exercise all at once, rather than less exercise more often. Medication such as statins and bisphosphonates are known contributors to muscle, tendon, bone and joint harm and far too many 50 year olds are being needlessly placed on these drugs.

Each must be thoroughly investigated and each put soundly to rest before resorting to surgical procedures, including cortisone injections. Such procedures will ultimately be doomed to failure if the underlying causations of your pain are not dealt with. This takes time and discipline.

With surgery there is no going back if it goes horribly wrong, so please give the conservative measures a good and proper go first.

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Is building the core muscles the best option for sacroiliac pain relief?

"I have been suffering from sacroiliac joint pain for over a year. Some times the pain is worse than others.

Most recently I went to a Spine Therapy Center and received considerable relief from a few chiropractic maneuvers two doctors performed. A follow-up physical therapy consultation earlier this week included several core muscle-focused exercises, which I am doing twice a day and just about anytime I think about it (sitting at my office desk, etc.).

The Physical Therapist said the adjustments the doctors and he made also would realign my spine and pelvis, but the core muscles must be built up again, particularly on my left side, where the joint pain persists. My muscles on that side are “inhibited” according to the therapist. My next PT visit is Monday morning.

As a backup if the pain persists I am scheduled for an injection on Wednesday. I am naturally concerned about the injection (which prompted me to visit your site) and will probably cancel that appointment if the longer term risks appear to outweigh the benefits.

My lifestyle -- I am a runner and continue to run four days a week (soft surface, 3-mile jogs – nothing too strenuous). Regime includes going to the gym two days a week for light weight resistance work.

I want the pain to go away, but I don’t want the problems that could surface later, nor do I want the risk of diabetes, which is something I have heard is possible with such injections. Does the approach on building the core muscles seem the best option for relief?"

Donna
________________________________
Gary Moller comments:
Donna, while core conditioning is definitely the flavour of the month right now, I do not think it will do much at all for you. Neither will an injection. If it is a cortisone-based one, it may give temporary relief at the cost of lasting relief.

That you are a runner (even "non-strenuous") says it all: The most likely cause of your ongoing pain is that various muscles, including your low back, gluteals, iliotibial band and more are probably in spasm. Traditional forms of PT, including manipulation may give temporary relief, as might medications and stretching. (I am making assumptions based on many years of working with runners and other athletes who run their bodies ragged). But you need to go much further than is offered by these treatments: You need to discover the underlying metabolic causes which may be due to a mineral imbalance, a depletion of a few key amino acids, fatty acids or a set of vitamins. Any of these will cause muscles and joints to lock up.

Good nutrition begins with ensuring that your body tissue salts (minerals) is just right - not too much and not too little of each - and then ensuring that your body has adequate supplies of vitamins, fatty acids and amino acids in more or less that order.

I suggest you begin your quest for pain-free health and vitality by completing the Active Elements Assessment. Take care when answering each question and make liberal use of the "Comments" section to give me plenty of background information.

You will also benefit from seeing an experienced massage therapist who should spend the best part of an hour massaging each group of muscles that are found to be knotted and inflamed. This should commence about a week or so after you begin any nutritional interventions because, if you are nutritionally deficient in any way, the benefits of the massage will be compromised. One massage every 4-6 days for several sessions should see huge improvements if you get the nutrition side sorted.

Severe ankle sprain, chronic ankle pain and cortisone injections

Dear Gary,
You have a great website. You must feel proud and blessed to have helped so many injured people. May God bless you.

Long story short, severe right ankle sprain in July 2007, 4wks. later MRI shows 2 torn ligaments and sinus tarsi syndrome, sl. marrow edema, alot of pain w/ weight bearing and less at sleep, Oct. 2007 MRI shows slight diastasis of tibia, and one remaining torn ligament, worsening of sinus tarsi syndrome, have had pain everyday, worse w/ increase in weight bearing, can be pain free while sitting, pain at night varies, off and on. Saw the lead instructor at the XXXX school of podiatry, he was doing very conservative treatment, but my workman's comp. agent and family was annoyed at my slow progress and inability to walk much (due to increased pain w/ ambulation). So I saw another doc , ankle/foot surgeon from XXXX University Hosp. He focused on the 4mm? diastasis occurring by my fibula, pulling away from my tibia, and wanted to do surgery and insert a syndesmotic device which is a screw in the tibia, then a screw in the fibula, then a wire that pulls and keeps the bones together, which will "fix my ankle". I read up on this device, and being overweight, I am not a "good candidate". In Nov.15th, 2007, I saw another ortho. ankle doc at XXXX Hospital. He did stress fracture xrays and then injected my ankle w/ 4cc =1cc of cortisone agent and 3cc of lidocaine=4cc injection. My gut told me that's alot of fluid, and where will it all go in the ankle area? Well it went in OK, he injected under guidance of an xray, (not ultrasound). I was in pain that day and severe pain that night. Called the next day, his nurse told me I was having an injection flare, very common. Keep taking motrin and ice it. I did so all weekend. The next week the pain continued, I called and called, saw him the next Monday11 days after the injection, I also was running a low grade temperature everyday 99.3-99.8, even with motrin everyday. He said I did not have an infection. The site looked sl. swollen, like the fluid was under the skin, but it 'Burned" so bad, off and on, the pain was worse than before I saw him. He told me he was baffled and I should see his partner. He took more xrays, which showed nothing new. He did not address the fever, as they did not have a thermometer to check my temp. He gave me a note to be off work for 1 week, as I was now back in a walking cast and on crutches. It hurt too much to walk. The next week, Dec. 3rd I returned to work, non weight bearing, desk duty, 4 hours a day only. He wants me to begin physical therapy now. I did nothing this week but work.

I am scared. I still have a really intense deep burning that occurs usually after I have been on the foot abit, in the area he injected. It's a very intense burn, that stops me in my tracks, and I have to shake the foot as it feels like it's on fire. Then it passes, and I can breathe. What do I do now?

How can I flush or minimize the cortisone/lidocaine from eating up my nerves or ligaments? Have increased my fluids.

Photo: An example of a cortisone injection gone wrong

I never had this burn, until after the injection. My low grade fever broke on Thursday Dec.6th...98.8 and 98.3. I had no other illnesses, no UTI, not a sniffle. I am healthy except for this ankle.

Also, I have sprained this ankle before, in 2002, and again in 2005. I was off work 1 week in 2005, then returned to weight bearing duty quickly, and did PT....found PT little to no help. During my last session, the P.T. had electrodes that burned my skin, so I skipped any future sessions and seemed to heal OK. My ankle would hurt if I was on my feet all day, hiking, or really walking non-stop for 8hours. Then I would take motrin and it was better.

_____________________________________

Gary Moller replies:

Charlotte,

I appreciate your deep concerns about what is happening and the pain you are suffering right now (I fractured my own ankle a few months ago and have suffered several bad sprains over the years).
Ankle sprains, even severe ones tend to resolve of their own accord if given the time. An ankle sprain can remain painful for a year or longer. I am very much in favour of conservative treatment and giving the body time to do its healing work. To administer cortisone injections into the painful site just months after the injury is not conservative. Even if there are signs of slight instability between the tibia and fibula, I would still play a waiting game rather than operate. It just makes no sense to chemically excise structural tissue that is already weakened through injury. Having said this, please discuss your needs with your doctor, including what is advised in this article, thank you.

The body has a remarkable capacity to heal of its own accord. All you have to do is help it by providing the right conditions such as:

• Going on a weight loss programme if overweight - not by starvation but by a natural wholefoods diet plus exercise
• Exercise in the form of aquajogging and aquaerobics - the partial weightbearing and hydraulic pressure burns calories, stimulates the citrculation, reduces swelling and strengthens the muscles
• Glucosamine and chondroitin 3 times daily to assist joint healing
• 2,000 mg vitamin C daily to assist healing and to reduce inflammation
• 2,000 mg daily of fish oil with vitamin E to assist healing and as a natural anti-inflammatory
• MSM (Methysulfonylmethane) daily. MSM is a natural anti-inflammatory and aids healing.
• Massage the area using effleurage and depp tissue massage techniques. The effleurage can begin immediately following a sprain and the deep tissue massage which can be painful can commence gently within 3-4 days of the injury and become more "forceful" as the weeks turn into months.
• Soak daily for up to an hour in a very warm Epsom Salt bath. The Magnesium and Sulphur aids healing and relaxes and the heat improves circulation.

All of these products are available from my website store

These measures may assist with giving you some relief from the pain associated with the cortisone that was injected. You might like to add a quality natural vitamin B complex to the supplements, since any deficiency in these will add to muscle and nerve pain and you don't want that.

Please go easy on the Motrim which has a raft of nasty side effects if taken over a prolonged time, including liver and kidney damage. Try as much as possible to put up with the pain and to use natural remedies like those listed above that improve health, rather than risk compromising it.

Your history of repeated sprains indicates that you have disrupted the nerve proprioceptors in your ankle. A weak ankle is more to do with the way your reflexes respond, rather than to do with weak muscles. As you ankle pain subsides, you need to commence doing balance exercises. You need nothing other than to be bare foot and practice balancing on one foot and then the other. Once you are proficient, progress to balancing on the ball of each foot. Once you master this, practice these with your eyes closed. Do these daily and you will develop strong and stable ankles.Charlotte, I hope that this advice helps somewhat for what is a painful injury that is very slow to recover from at the best of times. Whatever has been done from the cortisone is done and dusted and the focus must now be on recovery. Having said this, I would still be going back to the Dr that injected you and ask what he/she is going to do for you (So long as it does not involve more drugs or invasive treatment), since the cortisone appears to have made you worse, rather than better.

Take your time, give healing time and do not panic. Time heals eventually.

A weight lifter with seriously injured shoulders

Hi Garry
I saw Walking NZ magazine while waiting in physio waiting room and read your Cortisone injection article with a rapidly sinking feeling in the pit of my stomach!

I'm a 42 yr old female weightlifting athlete and have competed 6 times in 2007. I took up this sport after powerlifting for 4 years. I developed left shoulder pain and then right. Continued to weightlift and compete throughout. Things started to get really bad and I was diagnosed with supraspinatus impingement. I was injected with cortisone and carried on. The right shoulder started to play up and Xrays/arthrogram and MRI showed a 'Large full thickness tear through the superior half of subscapularis associated with up to 20mm of retraction. The tear has further intrasubstance extension into the musculotendinous junction over 3cm'. I had 2 cortisone injections within weeks of eachother as I had 2 major competitions to get through. No mention of the possibility of surgery to repair such a large tear.

Since my last contest in August, myshoulders have deteriorated to the point where I can no longer do ANY upper body lifting. I have been given exercises and stretches by the physio and just left to my own devices! I am in constant pain, ranging from a dull ache, throbbing, and stabbing type pains. I have now decided to see an orthopedic surgeon as I'm not responding to any treatments or rest and am unable to train!

Although I accept my weightlifting is over, I certainly wish to carry on weight training. This whole thing has been going on for over 12 months.

Your advice please. "S"

_______________________________

Gary Moller responds:

Dear S,
I am sorry to hear about your injuries. While they appear to be serious, take heart. The human body has a remarkable capacity to repair and to compensate for losses. While it is a shame that you have had these cortisone injections we can not turn the clock back, so let's look forward.

As a devoted disciple of Kung-Fu's Master Po, I do not believe in an after-life but I do believe in reincarnation. I am talking about reincarnation within one's lifetime. We live only once; we all are endowed multiple talents and it is our obligation to Life to express them as best we can. So, S, I think your body is telling you that you have lived your life as a weight-lifter. You did well. It is now time to reincarnate as another being. Take my sister Lorraine as an example: Once an Olympian - now a writer and, by all accounts, a very good one.

What are your talents that are lingering below the surface waiting to burst forth with fervent expression? What can you do with all of that physical and emotional energy that was previously directed into heaving the heaviest weights above your head? Are you a latent artist? A healer? A triathlete, or even a writer of great fiction or poetry? Who knows! You do.

I have competed in several different sports. I find I tend to go hard at one for about 4-6 years, do my best and then say; "That's enough of that!" Give up and switch to something else. That might have been running and the switch is to canoeing. Right now, it is mountain bike riding.

Reincarnation is healthy for mind and body. It breaks the rutted mindset many of us fall into. Think about it S. Your body is telling you it needs a change. Try an activity that does not hurt your shoulders anymore. Get out of the gym - you need a change of environment. It is a bit like an alcoholic getting away from the pub to put distance between themselves and temptation. It is that reincarnation idea at work. Got the idea S? Move on and live life over and over.

With regards to the shoulder pain, there are some things you might try to relieve the pain and dysfunction because chronic pain and dysfunction are not healthy:

• Find an experienced sports massage therapist and get several massages on the neck, back and shoulders spread about every 4 days apart. If you are in Wellington, I can do this for you.
  
• Take a mix of the following with food spread over the day for about three months to assist the body with making as full a recovery as possible (These are also natural anti-inflammatories that do no harm).
  
• MSM (methylsulfonylmethane) - take 2-6,000mg per day
  
• Vitamin C (natural) - take 2,000 mg per day
  
• You could add 1-3,000mg of natural vitamin E (These items are all available from my website store www.garymoller.com)
  
• Do weights for the arms and shoulders using only light weights and concentrating on re-establishing as near to full painless range of motion and good muscle tone (Take care not to add to the damage already done).
  

If you get back into heavy duty lifting, which I do not recommend, then find yourself a highly competent lifting coach. There are far too many injuries to lifters who take up competitive lifting as adults. Correct lifting is a highly skilled task that takes many years to master and best learned as a child. As an adult one's enthusiasm and strength can vastly exceed skill and there are few highly competent lighting coaches in NZ. The consequent combination is serious injuries to shoulders, backs and knees. If you are really serious about getting back into lifting, then start with a broomstick for 12 months and only begin loading up once your technique is biomechanically faultless.

Better still, pack your bags and go to Bulgaria for several years. They have the best lifting coaches on the planet!

Please keep us informed as to your progress. Wishing you good health S.

I have a large "spur" under the sole of my foot

Hi -

I have a large "spur" under the sole of my foot, as well as several smaller ones. My GP has put me on anti inflammatories and also referred me to a sports medicine doctor who injected quortizon (don't know correct spelling) directly into the sole. My question is, how do I deal with this very painful condition without resorting to surgery?

Dear Sue,

You have asked a very interesting question that will be of interest to many readers.

Before I can answer your question in detail I need more information:

How old are you?
Please describe your physique – are you over or underweight? Strongly built? Sedentary or athletic?
What do you do to keep fit?
What do you think/know has caused the development of the heel spurs and what aggravates them?
Is it one foot that is affected or both?
Have you ever been told that you have weak or pronating feet?
Has the cortisone treatment given relief? And how long ago was this administered and how many times?
What other treatment have you had, or currently receiving, including any medications – Are you still on the anti-inflammatories?

In the meantime, try to avoid activities that cause foot pain and choose ones that take the load off your feet – activities like aqua-jogging (Refer to these guidelines), indoor rowing or riding a bike.

Sue's response
I'm 60, not very athletic at all, slightly over weight.

Up until this time, have enjoyed walking quite long distances. The injection was given about 2 weeks ago now, and the relief was almost instantaneous. Both feet are sore, but only one was x-rayed and treated, only just started on the anti-inflammatories.

Unfortunately, I'm about to do a lot of walking. Never been told that I have weak or pronated feet.

Until this point in time, I have been very lucky with my health and have been on no medications at all, but my marriage has just finished after 41 years and since that time, things seem to be going hay wire with my health.

I haven't a clue what started the spurs hurting, feels like walking on broken glass, and until my marriage split, I had no symptoms whatsoever. Because I have been walking so badly, I have now got a sore Achilles tendon which the GP advised I get physiotherapy on.

Gary's response
Thanks for the additional information. The information about your marriage breakup after so many years is most relevant, as are the other details, including age.

Sustained stress of any sort drains the body in many ways, including depleting the body’s reserves of minerals like magnesium and of vitamins, principally the B group. The end result is what I refer to as “Wobbly Wheels Syndrome” (WWS). Sufferers just feel like their wheels are close to falling off and no amount of rest therapy or medication seems to produce anything more than passing relief.

The feet are windows on the body and it is the feet that I first examine if a person is complaining of chronic health or injury problems. This is because the feet are furthest from the heart and other organs and they are very hard working. If there is anything amiss with the body that affects the health and vitality of one’s cells, it is often first to show in the feet by way of complexion, fluid retention, skin tone, the health of the nails or injury such as what you describe. If wear exceeds repair, due to poor cell health, then injury will be the result, as will failure to heal 100% even with long periods of rest. The injury comes back, or pops up in the other leg much to the frustration and dismay of the sufferer.

Other factors may come into play. Of greatest interest is vitamin D deficiency. To date, I have not encountered a single person in New Zealand older than 50 years who has optimum vitamin D levels. In its active form vitamin D is not a vitamin, but a master hormone that is crucial for bodily health, including the uptake and use of vitamins and minerals. This is why vitamin D deficiency results in osteoporosis. It is also the reason why a person with low vitamin D is prone to connective tissue weakness and pain and joint and muscle pain.

You need to determine what your current vitamin D levels are. You can arrange for a blood test via your doctor. Once you have the results, you will need to write to me with them and I can assist further. Right now will be your seasonal peak and levels will decline until next summer. For details about what are optimum levels and how to interpret results go here.

You also would benefit by knowing your cellular mineral makeup. This is so that most of the guess-work is taken out when determining your nutritional needs to achieve optimum balance. This is best determined by a hair tissue mineral analysis (HTMA). For more information about this and how to order a HTMA, email me and I will send you a collection kit. The HTMA is more useful to me than a blood test because it tells us about what is inside the body’s cells, instead of what is just in the blood.

I am not at all in favour of cortisone injections for the problems you describe. These injections are known to have catastrophic consequences. Please read my article here and the ones that link to it . It is important that you understand how cortisone injections work and what the potential consequences are. A mechano-chemical approach to your injuries is unlikely to give lasting relief.

Your mind and body, like a quality car that has been kept in the family, require ongoing tender loving care. It would appear the personal TLC is well overdue, so let’s change that from today.

Even without currently knowing your vitamin D and cellular mineral status, you can safely take some practical measures right now that will not compromise any future interventions. Here are my initial recommendations (All products mentioned below are available from www.myotec.co.nz ):

• Give your feet some relief. Purchase a pair of either Formthotics work inner soles or Formthotics Comfort inner soles from Myotec.
• Strengthen the muscles in the big calf muscles that reduce the load on the smaller foot muscles the attachments of which are developing bone spurs. Please read and follow the exercise guidelines in this free E-Publication .
• Build your body’s mineral reserves by taking two Nutra-Life Calcium Complete tablets spaced over each day with food
• Take a quality natural B-Complex multivitamin such as Kordel’s Executive B. Take 2 tablets spread over the day with food
• Minimise depletion of vitamin D levels over winter months by taking daily Red Seal cod liver oil. Take 2 capsules per day with food
• Get a proper foot and calf muscle massage 2-3 times weekly (If you live in Wellington, I can do this). You will need to find a good massage therapist locally and then coach a loving person how to take over for the long term once you know what is needed for ongoing foot TLC.
• Take up aqua-jogging 2-4 times a week to maintain fitness while relieving hard-working feet. Read this free E-Publication about how to aqua-jog properly .

There is more that you can do, but get started with these and see how you get on and please give us feedback and let us know those test results when they are in.

Finally, if you are currently receiving treatment for your foot pain, you should discuss these recommendations with your therapist before proceeding.

Will cortisone injections fix my shin splints?

Jennifer from the USA wrote asking about cortisone injections for treating shin splints. In reply to my questions she wrote:

"I am 24, 5'10", 180. I have played sports all of my life; softball and basketball.

About three years ago, I walked this really rocky trail (3.5 miles) and I developed shin splints. Well, like an idiot I didn't immediately stop exercising, and stress fractures developed. I took about a year off from all exercising, and then I got back into the gym. This one day I got on an elliptical for 30 minutes and then a bike for 30 minutes, and that familiar pain came back. I kept riding a bike, and my shin splints were not getting any better so I took about another year off. I got back into the gym last week and rode a bike for 20 minutes, and I could feel that dull ache.

I have read hundreds of Internet articles about shin splints. I have tried treating them with ice, heat, massages, stretches, ibuprofen, Aleve, tape, and nothing has worked. I went to a family doctor and he told me to take ibuprofen which I had been doing all along.

I have been calling sport medicine doctor offices, and none of them will treat them. They are all into knee injuries. I live in Indiana, if you know someone please recommend him or her to me.

No one has actually recommended the cortisone. I just figured that it was my last option (besides surgery).

Please help. I love sports and I love working out. I don't want to be benched any longer."

_______________________________________
Gary Moller responds:
Jennifer, I can understand your frustration. There are several things that you could try. Bear in mind that I am reading between the lines and making some assumptions. In doing so, the following advice is healthy, even where it might be off the mark! The advice centres about:

• ensuring that the underlying physiology of your body is such that you are able to heal properly and grow stronger because something is amiss in this regard
• Removing any muscle spasm, improving circulation and softening any scar
• Strengthening the affected areas and improving mechanics

Is it in the water?
Jennifer, you say that you drink a lot of water. While water is essential for life, you can still have too much of a good thing. I do not advocate drinking any more water than one needs because there is a risk that you end up flushing your body of minerals which are certain to already be in short supply in your body. If your minerals are depleted, you will suffer fragile tissue, weak muscles, cramps and spasms and poor healing. Much of this will be sub-clinical and never diagnosed. I would strongly recommend an assessment of your mineral levels by way of a hair tissue mineral analysis (HTMA). I can send you the kit for taking and sending off samples. This takes out the guessing.

In the meantime, drink only enough to ward off thirst - your body will tell you how much. Ensure it is mineral water and not distilled.

Multivitamins
Taking a multi is fine but just the recommended daily allowance probably has no significant effect on your status if you are already low. Furthermore, most multis contain synthetics that are of questionable health benefits. You are better seeking out quality natural supplements and you may have to take more than one or two different concoctions. These usually look like horse tablets! I would place priority on the fat soluble vitamins - A, D, E and K which you are probably low in.

Low iron
With young women, one can assume that their iron levels are low unless confirmed otherwise by a recent test (The HTMA will provide this information). Low iron is indicative of overall mineral status and will be a factor in poor healing etc as earlier described. Drinking lots of water will flush the body of this and other minerals - and the water soluble vitamins, of course!

Is it in the sunlight?
Low levels of vitamin D are associated with joint and muscle pain, including tendonitis and slow healing - and stress fractures, of course! Your run of injuries may have a common factor - low vitamin D and depleted minerals. It does no harm and potentially an enormous amount of good to do everything you can to boost your levels of vitamin D.

This website (http://www.garymoller.blogspot.com/) has a wealth of information about this topic.

Exercises for pronating feet

The exercises are your first exercises for preventing further episodes of shin splints and even stress fractures of the lower legs and feet. In conjunction with the exercise I recommend that you replace your shoe inner oles with Formthotics Acitve which mould to the shape of your feet and give the foot just that little bit of support it needs when working hard out. I have them in all of my shoes, including work shoes. I wear Formthotics Low profile in my cycling shoes and find that numb, cold feet while cycling has been all but eliminated.

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.