Cortisone is one of the more familiar medicines that many people have either personally experienced, or heard of someone “having a jab”, particularlyin a sporting environment.
In fact, in the “olden days ”whenI was at school (as my kids would say), cortisone seemed like some wonder drug that was used for many different musculo-skeletal aches and pains. Almost everyone with a chronic shoulder problem ended up with a cortisone injection at some stage!
It is probably from this overuse of cortisone that many of the misunderstandings and controversies have arisen. Now (which is not necessarily a bad thing) we tend to find that many patients recoil in horror if we mention the possibility of a cortisone injection being required, and commonly get statements such as “There’s no way I’m having a cortisone, I’ve heard some really bad stories”.
Hopefully in this article, we’ll dispel some of the myths, and give a clearer understanding of what cortisone does, and why it can be an extremely useful drug when administered for the right problem, and at the right time.
What Is Cortisone?
Cortisone is a hormone that humans naturally produce in the adrenal gland. It is released in response to stress, and functions to suppress the immune system and reduce inflammation, pain and swelling at the site of an injury. Naturally produced, the cortisol released from the adrenal gland goes directly into the blood stream and is short acting.
Steroids work to imitate the properties of naturally of naturally occurring hormones – that is, they are manufactured to do what our own hormones should do. That is why, in medicine, we often hear the term “corticosteroid”, which relates to a synthetically manufactured product that is designed to imitate the effects of cortisone. In this case, the cortisone is not injected into the blood stream, but into the tissue or damaged joint, and is designed to be more potent and act for days rather than minutes!
Throughout the article we will be actually discussing the role and effects of “corticosteroids” but for simplicity “cortisone” will be used interchangeably with “corticosteroid”, as that is what people are familiar with.
In a nutshell, corticosteroids are a class of medications, related to cortisone, that powerfully reduce inflammation, by mimicking the action of our naturally produced cortisol.
What Does Cortisone Do?
Despite popular belief, cortisone has no direct effect on pain! It is not an analgesic (pain relieving) medication, it is a strong anti-inflammatory. When corticosteroids relieve pain, it is because they have reduced inflammation that would be causing pain. This point is very important because anti-inflammatory medications (particularly the lower dose ones like Mobic and Voltaren) are often used by people in the same way that you would use a pain killer – only at the time of pain, and often for just a single dose or single day dosage.
If your specialist or G.P has prescribed an anti-inflammatory medication, they have prescribed it to overcome what is probably either a very acute, or chronic and longstanding, inflammatory condition. One dose of the anti-inflammatory may possibly reduce some pain by reducing some inflammation, but it most certainly won’t have the fully desired effect on the overall persistence of the inflammatory response. Think of it like this – if you require a course of anti-biotics for a significant illness or infection, you never stop taking the tablets as soon as you feel a little better. The doctors are always very specific with their instructions to finish the course of medication in order to fully overcome the infection. Anti-inflammatory use follows a similar purpose: to overcome a process of inflammation, and this is highly unlikely to be achieved with a single dose use.
Extensive research over recent years has also changed our philosophy on the use of cortisone, particularly for tendon injuries! It used to be quite common to have areas such as the achilles and patella tendon injected with cortisone to settle the inflammation. However studies have shown little to no inflammatory changes occur in damaged tendons, hence the old term “tendonitis” (“itis” means inflammation) has now been superseded with the term “tendinopathy” (meaning pathology – not inflammation – of the tendon). It has also been shown that cortisone can cause a short term weakening of tendon tissue, actually leaving the tendon vulnerable to greater injury post injection for two reasons: firstly due to the weakening effect on the tendon, and secondly because the patient often feels a lot better post injection and participates in activity levels that are too strenuous for the state of the tendon to cope with. It is very rare these days, and not highly recommended, to hear of people having cortisone directly into tendons.
What Form of Cortisone Will Be Used and Which Delivery Method?
Well, this is where your specialist or G.P come in! As physio’s, we are unable to prescribe or advise on usage of prescription medication (but this may change soon!). Corticosteroids are administered by various means including orally (Prednisolone being one of the most commonly encountered), inhaled (common for asthmatics), applied to the skin, injected into a vein, or injected directly into the tissues or joints of the body.
The medical practitioner that advises the use of cortisone will decide the best form of delivery, however here is a breakdown of the main methods:
Oral: the most common form of cortisone treatment, and usually in the form of Prednisolone. Oral corticosteroids function to reduce your immune response by interfering with the chemicals in your body that normally cause inflammation, however this can obviously leave you prone to infections whilst your immune system is lowered.
Very importantly, using synthetic cortisone causes the adrenal glands to reduce the natural production of cortisol. It is therefore essential in many cases to wean off the oral dose of cortisone, to allow the adrenal glands to slowly take over again and produce the necessary amounts of natural cortisol!
Topical: comes in cream form and is used for skin rashes and infections. Probably the safest form of taking cortisone.
Injection: Cortisone injections can be used to treat local areas of inflammation. The significant benefit of injections over oral cortisone is the more rapid and powerful action, along with avoiding certain side effects that can accompany many oral anti-inflammatory medications, notably irritation of the stomach.
Examples of conditions for which local cortisone injections are used include:
· Inflammation of a bursa (which is a small fluid filled sac, situated throughout the body to reduce friction). The most common bursae injected are the subacromial (shoulder), trochanteric & gluteal (hip/buttock), ischial (buttock/top of hamstring), and retroachilles (between the Achilles and heel bone).
· Joints – cortisone can be successfully injected into painful, swollen, or arthritic joints. Most common joints injected are the knee and ankle, but it is not uncommon for people to also have their hip or upper limb joints injected as well. Cortisone also forms a component of the fluid injected during a hydrodilatation, which is an effective means of treating a frozen shoulder.
· Ligament/fascia problems – probably the most commonly known condition around the foot is plantar fasciitis, where the dense ligament type tissue of the heel bone becomes inflamed. The jury is out on whether cortisone or PRP (blood injections) are more effective, but anecdotally we have seen many people have great results with cortisone for chronic plantar fasciitis.
· The spine – cortisone is used in an “epidural” technique around the spinal nerves to help relieve acute spinal pain, particularly when it refers down an arm or leg. Cortisone can also be injected directly into the facet joints of the spine to relieve pain as well. These injections should always be performed under XRay or ultrasound guidance.
Sometimes corticosteroid injections are used for more widespread (or systemic) where many joints or large areas are affected. Rheumatoid arthritis is a classic example, where the inflammatory factors are in the blood stream and effect multiple joints at the same time. These injections are usually given intramuscularly, into a large muscle group such as the gluteus muscles in the buttocks, or into the deltoid muscle in the shoulder. The corticosteroid is then absorbed into the blood and travels through the bloodstream to treat the inflammation.
Short-term cortisone injections complications are uncommon but include
* lightening of the color (depigmentation) of the skin at the injection site,
* introduction of bacterial infection into the body (such as a joint infection),
* local bleeding from broken blood vessels in the skin or muscles
* soreness at the injection site,
* aggravation of inflammation in the area injected because of reactions to the corticosteroid medication (post-injection flare).
* Tendon weakening and potential risk of rupture (if injected directly into tendons)
* Facial flushing (usually only brief) in approximately 40% of cases.
In people who have diabetes, cortisone injections can elevate the blood sugar level so they should be used with care in diabetics.
Long-term complications of corticosteroid injections depend on the dose and frequency of the injections. With higher doses and frequent administration, which increases total systemic exposure to the corticosteroid, potential side effects include:
* thinning of the skin,
* easy bruising, weight gain,
* puffiness of the face,
* acne (steroid acne ),
* elevation of blood pressure,
* cataract formation,
* thinning of the bones (osteoporosis),
* a rare but serious type of damage to the bones of the large joints (avascular necrosis or osteonecrosis).
Despite potential and infrequently reported adverse reactions as described above, it is generally felt that low, intermittent doses of corticosteroids pose little risk of significant side effects.
Is Cortisone All I Need?
Unfortunately no! Whilst cortisone can be extremely helpful in settling an inflammatory response, what needs to be carefully managed is the cause of the inflammation! This is probably where some of the “bad news” following cortisone comes from – patients have a cortisone treatment (which settles the symptom, not the cause), feel great after the treatment, and go back harder than ever to their sporting/recreational activity, and then wonder why their pain has returned worse than ever.
Both before and after a cortisone regime is implemented, an effective rehabilitation program should be discussed with your physiotherapist. Cortisone treatment provides a means by which you can begin or continue a successful rehabilitation program – it’s the rehab that’s the key!
What Can I Do After A Cortisone Injection?
Recovery after a cortisone injection does not take long, and really only involves a few days of rest until you can return to some form of modified physical activity. Many people will feel an instant relief following the injection, but keep in mind that this will be due to the local anaesthetic that is injected at the same time as the cortisone, giving you a “false sense of security”! Resting the joint for a few days allows the inflammation to decrease, and the local anaesthetic to wear off so you have an accurate sense of your pain levels. Cortisone can often take 2-3 weeks to really take hold and overcome inflammatory conditions, so don’t stress if you don’t feel much improvement until a few weeks later.
How Many Cortisone’s Can I Have?
There are no hard and fast guidelines regarding the amount of cortisone injections you can have – typically, it is recommended you do not receive a second injection within six weeks of the first, and usually not more than three or four times a year. Your own unique circumstances will dictate the timing and frequency of treatment.
Whilst small amounts of cortisone in the body are probably reasonable, repeated injections can cause damage to tissues over time. Sometimes this is of little concern. For example, if a patient has severe knee arthritis, and a cortisone injection every 6 months helps significantly, then the number of injections probably does not matter too much because there may not be a lot of healthy tissue left in the joint that can be damaged by the cortisone. On the other hand, if a patient has shoulder rotator cuff tendon pathology, but an otherwise healthy shoulder, the number of injections should probably be limited to prevent further damage to the undamaged tendons.
In summary, cortisone is a synthetic product used to mimic the effects of cortisol, which is naturally produced by the adrenal glands in humans. Cortisone is a powerful anti-inflammatory medication that comes in many forms and is administered in various ways. Used for the right condition, in the correct dose, via the optimal mode, and for the recommended length of time, cortisone can be a very useful medication for pain and inflammation. But remember, the success of the cortisone is often dependent on the rehabilitation program that runs with it!
For further information, contact any one of our SSPC Physiotherapists.
