Alternative to cortisone shots
Ross Hauser, MD.
Over the years we have seen many patients who have received corticosteroid (more commonly referred to as cortisone) injections for joint pain. This sounds like a good solution to relieve pain but can leaves patient with a worse chronic pain after the injected cortisone runs its course.
Corticosteroid injections have been used for a very long time. Their anti-inflammatory and pain relief properties have made its use become very common practice within the medical community and society as a whole. They have been shown to be effective in decreasing the inflammation and pain of ligament injuries for up to 8 weeks; however, these same properties inhibit the opposite ones of ligament tissues that would bring about the proper healing of muscles. Since the body heals via inflammation, cortisone inhibits healing simply by its mere nature. Instead of regenerating ligamentous tissue, cortisone injections cause further degeneration of the weakened structure and longer and more painful healing periods and symptoms.
What did Cortisone do to this patient’s knee?
This is the first MRI of a patient with significant knee pain
The patient had:
- Intact menisci
- Mild chondromalacia is noted along the weight-bearing medial femoral condyle, and to a lesser extent within the posterior lateral tibia
- Mild chondromalacia is noted within the patellar apex, with minimal subchondral reactive edema
- Mild strain of the medial gastrocnemius tendon origin
Chondromalacia means softening, or wear and tear, of the cartilage under the kneecap. It is easily treated with a few Prolotherapy treatments, as Prolotherapy stimulates new cartilage growth and repair, (cartilage repair) as well as strengthens the surrounding ligaments and tendons. By making the ligaments stronger and the knee more stable, the kneecap can track better in the joint and decrease Knee Pain. (Please see our article Chondromalacia patella and Prolotherapy).
Over the next six months the patient continued her normal exercise routine with aerobics, weight training, cycling, and using the stair-stepper and elliptical at the gym. In order to keep up with this exercise regimen, the patient got two cortisone injections into her right knee. These anti-inflammatory shots helped to decrease her knee pain and allow her to exercise pain-free, but did not do anything to heal her condition. Six months later, she got another MRI because her knee pain kept returning. This time, the results were much worse. She still had the chondromalacia, but now also had developed a partial thickness chondral defect and a partial thickness fissure of her patellar cartilage:
MRI findings 6 months later:
- 6 mm x 4 mm partial thickness chondral defect of the lateral aspect of the central weight-bearing surface of the medial femoral condyle
- Minimal chondromalacia of the posterior aspect of the lateral tibial plateau
- Linear, oblique, partial-thickness fissure of the lateral patellar cartilage and minimal fraying of the median ridge cartilage at the level of the mid-patella
- No meniscus or ligament tear
- No bursitis or abnormality of the iliotibial band
- Small to moderate knee joint effusion
What do MRI changes mean? Instability causes the joint to swell.
These results mean that during those six months after her original MRI, not only did the patient fail to heal, but her knee had gotten significantly worse despite no new injuries!
She had developed a hole in the cartilage covering her femur (the chondral defect) and a fissure (or as call it in the office, gigantic crack) in the cartilage under her kneecap. The rest of the cartilage under her kneecap had also begun to fray and she developed a joint effusion (swelling inside the knee joint). Knee effusions can develop from instability in the knee joint – as she continued to exercise on an unstable knee joint, her body tried to stabilize the knee itself by swelling the area and making it less mobile.
Injuries and chronic pain are a common occurrence in our increasingly active lives, whether as a result of playing sports, a repetitive task at work or slipping and falling on a patch of ice. The healing process that follows has three characteristic phases: inflammatory, proliferative and remodeling. The first phase, the inflammatory-reparative phase, sets the stage for the others, and is critically affected by the treatment options chosen. These options can either block or stimulate the healing process. In other words, it can either heal the affected area or make it worse.
So what are the treatment options? Traditional modern medicine uses cortisone as well as other anti-inflammatories, in addition to the RICE (rest, ice, compression and elevation) protocol- which has very recently been rescinded by its author due to its detrimental effect on healing. All of these modalities provide temporary pain relief, but hinder healing.
An alternative to cortisone injections as well as these other options is Prolotherapy, because it promotes healing. The difference between these options can determine one’s ultimate path to
1) chronic pain, tissue degeneration and possibly eventual surgery, or
2) pain relief, healing and often a strengthening of the areas involved. A seemingly easy choice: pain relief and healing versus chronic pain management.
Prolotherapy stimulates the normal inflammatory-reparative mechanisms of the body, encouraging normal collagen and extracellular matrix growth, which causes the connective tissues, ligaments and tendons to become thicker and stronger.
- Shortly after doctors started injecting cortisone and other steroids into knee joints in the 1950s, researchers began noting severe arthropathies, and so discouraged the use of cortisone injections. Today, despite the dangers, cortisone use is widespread and has become the standard of care.
- Benefits of cortisone injections are short-lived. Researchers “concluded that intra-articular corticosteroids reduce knee pain for at least 1 week and that intra-articular corticosteroid injection is a short-term treatment of a chronic problem.”1,2
- Dangers of cortisone injection include cartilage and joint destruction, especially in those with osteoarthritis of the joint. “Corticosteroid therapy as well as NSAIDS can lead to destruction of cartilage, suggesting that a positive effect on joint pain may also be associated with accelerated joint destruction, which is an extremely important factor in a chronic, long-term condition such as osteoarthritis.”3
- Cortisone has a deleterious effect on soft tissue healing by inhibiting blood flow to the injured area, new blood vessel formation, immune cells like leukocytes and macrophages, protein synthesis, fibroblast proliferation and ultimately collagen formation. Cortisone weakens collagen and therefore soft tissue such as ligaments and tendons.
Corticosteroids are the main hormone secreted by the adrenal gland, the small gland located on top of the kidneys. The typical corticosteroid is cortisol, also called hydrocortisone. Its many effects allow us to live in an ever-changing environment. For example, our body normally produces cortisol in response to an allergic reaction, or to keep our blood sugar high when we haven’t eaten for quite a long time. They are especially necessary for normal bodily functions during times of stress.
Corticosteroids are used to provide anti-inflammatory relief in affected areas of the body. However, the synthetic analogues used are many times stronger than our naturally occurring forms. They lessen swelling, redness, itching and allergic reactions, and, in addition to their use for acute and chronic pain, are often used as part of the treatment for a number of different diseases, such as severe allergies or skin problems, asthma, or arthritis. The discovery that they could be injected was received with enthusiasm, and led to widespread use. However, shortly after doctors started injecting cortisone and other steroids into knee joints in the 1950s, reports of terrible arthropathies, or joint diseases, began to surface, an indication that all was not well with this treatment choice. “Steroid arthropathy appears to be of two types after intra-articular injection of corticosteroids; the first causing the development in otherwise normal joints-specifically the shoulder, hip and knee- of a large area of avascular necrosis; the second a rapid disorganization of the joint.”3 Way back then, the researchers discouraged their intra-articular use, because of the cortisone side effects of arthropathy and cell death in the bone.4
Nevertheless, cortisone shots are still considered the standard of care for the injured athlete and other painful or inflammatory conditions. Corticosteroid injections have been used for a very long time. Their anti-inflammatory and pain relief properties have made its use become very common practice within the medical community and society as a whole. They have been shown to be effective in decreasing the inflammation and pain of ligament injuries for up to several weeks2; however, these same properties inhibit the healing properties that would bring about the proper healing of the injured area. As noted earlier, both corticosteroid treatments and NSAID usage cause destruction of cartilage, and are contributing factors in the development of conditions such as osteoarthritis.3
Long term effects of cortisone treatments
Let’s say you like to play tennis—a lot. Over time you notice a painful elbow, which your doctor diagnoses as golfer’s elbow. Maybe you’ve taken anti-inflammatories, such as aspirin, or non-steroidal anti-inflammatories, such as ibuprofen, Motrin or Naproxen for a while, but with only temporary relief. Your doctor may recommend a cortisone shot in the elbow next. You get temporary relief, but the pain doesn’t go away—it may even be getting worse. In the case of an acute athletic injury, such as a knee sprain, a cortisone shot is sometimes given on the spot in order to check the edema, relieve the pain and allow the athlete to return to the sport either immediately or in a very short period of time. So while the goal of the cortisone shot is to decrease the painful inflammation of the injury, the goal of the normal inflammatory-reparative healing cascade is to do its work regenerating the collagen and extracellular matrix (called proteoglycans) that give the connective tissues their strength and characteristic ability to handle great strain forces. Unfortunately for many individuals, corticosteroids block this normal healing process. “It is likely that an infiltration of corticosteroid around painful tendons in athletes, who are thereby enabled to continue their strenuous pursuits, may lead to tendon rupture.”5
The dangers of corticosteroid injections in suppressing inflammation and healing
- Corticosteroids decrease collagenase and prostaglandin formation. “Secretion of collagenase, elastase, and proteinase are inhibited by corticosteroids.”5 Prostaglandins help recruit immune cells to the injured area to clean up the damaged tissue and start the repair process. Prostaglandins also help increase circulation to the injured area. This migration and repair process is what causes the pain. Cortisone inhibits this repair, so the person feels better, but healing is being sacrificed for pain control. The person now has a weakened structure that they think is fine – so they continue to do sports and activities, not realizing that they are accelerating the degenerative process.
- Modern medicine has forgotten the first rule of healing: The body heals by inflammation. The whole inflammatory cascade, including phagocytosis (immune cells cleaning up the area), angiogenesis (new blood vessel formation), and fibroblast formation (new collagen formation) is inhibited by cortisone.
- Corticosteroids decrease the formation of granulation tissue, which is needed to heal the area.
- Corticosteroids block glucose uptake in the tissues, enhance protein breakdown and decrease new protein synthesis in muscle, skin, bone, connective tissue and lymphoid tissue. Muscle, ligament and tendon tissue is 70 to 90 percent collagen, which is a protein. “One of the earliest and most striking effects of corticosteroids is a change in cellular metabolism; such as the depression of glucose uptake.”5
- Corticosteroids are catabolic promoters, meaning they are involved in processes that break down tissue. “Corticosteroids given in the knee reduce the matrix of articular cartilage, an effect perhaps hardly surprising in view of the known catabolic action on protein in virtually all tissues of the body.”4
- Corticosteroids prevent lysosomal enzymes from releasing and inhibit the accumulation and synthesis of inflammatory cells and mediators at the injury site, and thus inhibit the ability of the tissues to heal. No inflammation, no healing. It is that simple.
- Cortisone injections degenerate the joint. Nothing can degenerate a joint quicker than cortisone shots (except, perhaps, arthroscopy with cartilage and meniscus shaving). Your risk of needing a joint replacement is about one in ten. Ten percent of people in the US will get a joint replacement. If someone has had cortisone injected, the percentage of needing joint replacement rises substantially Just keep having cortisone or its cousins injected into your joints, ligaments, and tendons. Cortisone is a poison to the connective tissues of the body, including cartilage, muscles, ligaments, menisci, and tendons. Thus, when cortisone is injected into these structures the death of cells is seen.
- Corticosteroids inactivate vitamin D, limiting calcium absorption by the gastrointestinal tract, and increasing the urinary secretion of calcium. Bone also shows a decrease in calcium uptake with cortisone use, ultimately leading to weakness at the fibro-osseous junction.
- Cortisone inhibits the release of growth hormone, which further decreases soft tissue and bone repair.
- Cortisone injections can lead to painful tendon and ligament ruptures. They compromise tendon and ligament strength, a scary finding considering that many athletes return to the game or the sport shortly after an injection.
- Cortisone injections can predispose a joint to infection.
- Cortisone shots cause degeneration which eventually leads to surgery.
The effect of cortisone on sports injuries
In the case of our knee sprain example, the result of a cortisone shot is weakened synovial joints, supporting structures, articular cartilage, ligaments and tendons. In fact, one study showed that even 16 weeks after a single joint injection, the cartilage remained biochemically and metabolically impaired or weakened. This weakness ultimately increases the pain. Guess what happens next? The increased pain leads to more steroid injections. Cortisone fools many athletes by providing pain relief instead of tissue repair and healing. Studies on animals have shown that even one cortisone shot into an area has been shown to cause irreversible biochemical damage to joints and cartilage. One of the quickest ways to cartilage deterioration and/or a hip or knee replacement is cortisone injected into these areas.
The following are examples of conditions and the reason why cortisone is contraindicated:
- Plantar “fasciitis”: cortisone shots further degenerate the already degenerating tissue; this condition should really be called plantar “fasciosis” because the fascia is degenerated (-iosis), rather than inflamed (-itis)
- Achilles “tendonitis”: cortisone shots enhance the degeneration of the tendons, which are usually degenerated as the result of an injury, and not inflamed
- Stress fractures and shin splints: cortisone shots further degenerate the tissue, which is actually suffering from localized connective tissue deficiency.
- Chronic shoulder pain or elbow pain: cortisone further degenerates the already degenerating ligament or tendon
- Chondromalacia patella, also referred to as patellofemoral pain syndrome (PFPS): cortisone shots exacerbate the deterioration of the articular cartilage beneath the patella, or the kneecap
- Acromioclavicular joint pain due to sprain: cortisone shots cause a marked increase in the amount of long-term degeneration of first-degree sprains
- Jumper’s knee: cortisone leads to progressive tendon degeneration
- Disc degeneration and disc herniation: cortisone, as well as surgery and NSAIDs, speed up the process of tissue degeneration
Local inflammation of injured ligaments or tendons is necessary to heal injuries, whether acute or chronic. When a person sprains an ankle, the persistent swelling for one to three days is the body’s attempt to heal the area. If you want to stop healing, just stop inflammation. This is exactly what cortisone does. If you want healing, cortisone is contraindicated, because it interferes with this process.
The Prolotherapy alternative to cortisone
Prolotherapy stimulates, rather than interferes with, the normal healing process of inflammation. While corticosteroids inhibit the enzymes that block the production of prostaglandins and leukotrienes, which mediate the inflammatory process, Prolotherapy stimulates them. By blocking the production of these enzymes, cortisone has a deleterious effect on soft tissue healing by inhibiting blood flow to the injured area, new blood vessel formation, immune cells like leukocytes and macrophages, protein synthesis, fibroblast proliferation and ultimately collagen formation. Prolotherapy doesn’t.
In addition, the collagen that forms in ligaments and tendons treated with cortisone is disrupted and weaker, while that treated with Prolotherapy is—you guessed it—stronger. Prolotherapy provides the stimulus that is needed to bring in healing fibroblasts and allow them to proliferate and lay down new collagen fibers. This causes the connective tissues, ligaments and tendons to become thicker and stronger. Prolotherapy stimulates the normal inflammatory-reparative mechanisms of the body, encouraging normal collagen and extracellular matrix growth.
Prolotherapy strengthens and repairs the weakened and degenerated structures. In the case of athletic injuries, it will enhance athletic performance as the injured structures become stronger instead of weaker. The end result is a stronger joint and athletes who are back playing their sport instead of on the operating table getting their arthritis scraped or, even worse, getting a joint replacement.
Prolotherapy works by stimulating inflammation and since the body heals by inflammation, Prolotherapy concurrently stimulates healing. Comprehensive Prolotherapy includes injections into a joint and all ligament and tendon attachments that surround that joint. As these structures heal from treatments, the joint becomes more stable and causes less pain.
Prolotherapy is an alternative and effective treatment to heal chronic musculoskeletal injuries. Comprehensive Prolotherapy involves the injection of natural substances (named orthobiologics) used to induce healing within the body. There are two types of orthobiologics: those that come from the body (i.e. cellular Prolotherapy such as PRP, bone marrow, and adipose tissue) and those that naturally induce healing, such as dextrose (a chemical equivalent to normal d-glucose that is found in the body). Dextrose is a heavily studied proliferant and is extremely safe and effective. It can be used in high concentrations without threatening side effects. This allows us to treat multiple body parts on the same person in the same visit.
In summary, while cortisone shots weaken an injured area even further, Prolotherapy stimulates the body to repair it. Prolotherapy stimulates blood flow to the area, protein synthesis, fibroblast proliferation and ultimately collagen formation. The choice is simple: cortisone shots that lead to proliferative arthritis of joints or proliferative injections (Prolotherapy) that stimulate the repair of the injured tissue. One of the greatest benefits of Prolotherapy is that almost everyone, even extreme athletes, can still continue to train while receiving treatments as well.
References to this article
1. Hirsch G, Kitas G, Klocke R. Intra-articular corticosteroid injection in osteoarthritis of the knee and hip: factors predicting pain relief–a systematic review. Semin Arthritis Rheum. 2013 Apr;42(5):451-73. doi: 10.1016/j.semarthrit.2012.08.005. Epub 2013 Jan 29.
2. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ 2004; 328:869.
3.Sofat N. Kuttapitiya A. Future directions for the management of pain in osteoarthritis. Int J Rheumatol. Apr 2014; 9(2): 197–276.
4. Sweetnam R. Corticosteroid arthropathy and tendon rupture. Journal of Bone and Joint Surgery. 1969: 397-398.
5. Werb Z. Biochemical action of glucocorticoids on macrophages in culture. The Rockerfeller University Press. June 1978:1695-1712. Downloaded from jem.rupress.org on August 13, 2014.