Cortisone injections, or corticosteroid injections, are often used in medical practice to treat a variety of pains including bursitis, tendinopathy (tendinitis), carpal tunnel syndrome, tennis elbow, plantar fasciopathy (fasciitis), arthritis and back pain (sciatica). The pain relief is often immediate and hailed as a miracle cure… so why are physios against cortisone injections… or are they?
What is in a Cortisone Injection?
Cortisone injections commonly are a combination of a steroid (Celstone or Kenacort) and a local anaesthetic (Bupivacaine or Marcaine). The injection should be guided by imaging, usually ultrasound, so that the site is specifically targeted and the depth of the injection is measured. The injection places a concentrated dose of local anaesthetic that offers immediate pain relief and steroid which provides strong anti-inflammatory effects.
This dose directly at the site of injury makes it a very potent treatment often with immediate pain relieving effects……a miracle cure.
Corticosteroid injections are quite safe with minimal side effects:
- Facial flushing
- Increased blood pressure
- Elevation of blood sugar levels which affect diabetic patients
- More seriously, bone infection or muscle inflammation can occur but this can be avoided with careful monitoring by a doctor.
Corticosteroid injections will ease the pain and there is usually a remarkable improvement in 4-8 weeks. However, the problem is it does not treat the reason for the pain and therefore there is a high recurrence rate of injury.
Studies have demonstrated that:
With a corticosteroid injection:
- At 1 month; 70-75% of patients have significant improvement
- 3-4 months; 41-55% of patients still have improvements
- 12 months; No difference between cortisone and wait and see
With exercise targeted at treating the actual problem:
- At 1 month; 7% of patients have significant improvements
- 15 months; 80% of patients have significant improvements
So that begs the question, if immediately after an injection, pain is significantly improved then why don’t people have the injection and do the exercises???
This is because a corticosteroid injection weakens tissues, delays healing and > 3 injections into the same structure make it vulnerable to rupture. So, if you are trying to strengthen a tissue by exercise it clearly is not helpful to weaken it first.
WHY HIT A NAIL WITH A SLEDGEHAMMER?
The best place to start is with Physiotherapy to progress through
- specific exercises to target muscle weakness
- education about load modification & rest days
- management strategies to make practical changes in day to day life
Physiotherapy should effectively reduce pain and then address the cause of the problem and help patients to understand their own capabilities.
In Summary
However, sometimes the pain is not reduced with conservative measures.
When there is pain a patient cannot progress through rehabilitation.
This is when a Corticosteroid injection is extremely helpful TO BREAK THE PAIN CYCLE.
The pain relief from the injection works in conjunction with Physiotherapy because the patient knows the pain relief is temporary and what exercises to do to solve the problem. They use the injection to progress through rehabilitation, not to presume the problem is fixed.
So next time you are offered a cortisone injection from your Doctor, it may give some pain relief at first, but then the pain will most likely return and you have probably weakened your tissues in the meantime………Why not try Physiotherapy first?
