Alternative to cortisone shots
- cortisone injections increase the risk of joint surgery,
- cortisone injections increase the need for secondary surgery and possible higher risk for post-surgical infections in the joint.
- further that corticosteroids can alter the healing environment of the joint by effecting damage on the native stem cells in cartilage.
Over the years we have seen many patients who have received corticosteroid (cortisone) injections for joint pain. Unfortunately for many, excessive cortisone treatments lead to a worsening of chronic pain.
In 2009, I wrote in the Journal of Prolotherapy “It is my opinion that there is no doubt that the rise of osteoarthritis, as well as the number of hip and knee replacements, is a direct result of the injection of corticosteroids into these joints.”1 This was my evidence then was a summary of the effects of cortisone on articular cartilage which included:
- a decrease of protein and matrix synthesis (the nutrient and healing bed that cells grow in),
- mutation of (cartilage) cell shape
- growth of new cartilage inhibited,
- cartilage destruction risk and enhancement
- cartilage surface deterioration including edema, pitting, shredding, ulceration and erosions, etc, etc.
Corticosteroid injections have been used for a very long time. Their anti-inflammatory and pain relief properties have made its use a common practice within the medical community. Corticosteroid injections have been shown to be effective in decreasing the inflammation and pain of ligament injuries for up to 8 weeks; however, these same properties lead to destruction of cartilage as mentioned above. Simply, the body heals via inflammation, cortisone inhibits inflammation and healing by disrupting the 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 non-healing treatment options? Cortisone as well as other anti-inflammatories, and the RICE (rest, ice, compression and elevation) protocol– which has very recently been rescinded by its author due to its detrimental effect on healing all are considered “non-healing,” and whose long-term useage will make the patient’s condition worse.
Cortisone Prevents Healing at the Cellular Level
Cortisone disrupts and hurts stem cells
Recent research from the Mayo Clinic says cortisone may hinder the native stem cells in cartilage. (Mesenchymal stem cells (MSCs) are the building blocks of cartilage other musculoskeletal tissue.) Cortisone threatens their innate regenerative capacity in exchange for temporary analgesia.2 Please see our article on Stem Cells and Osteoarthritis
It becomes perplexing then, that these medications continue to be routinely injected into people’s joints “therapeutically” for pain. While corticosteroid and analgesic injections have the potential to temporarily relieve pain by shutting down the body’s inflammatory mechanisms, these medications are toxic to cartilage cells. Results of bovine cartilage studies from the University of Pittsburgh School of Medicine revealed the following:
“A direct correlation between increased steroid concentration and increased chondrocyte apoptosis (cartilage death) as well as increased chondrocyte toxicity (cartilage poisoning) with increasing time of exposure to methylprednisolone. The addition of lidocaine to methylprednisolone significantly increased the rate of chondrocyte cell death.”3
It is the message over and over – When injected into joints, corticosteroids not only trigger cartilage cell death, but also completely suppress healing by their innate mechanism of action, which is to suppress the immune system and block inflammation.
Cortisone Injection Risks
Shortly after doctors started injecting cortisone and other steroids into knee joints in the 1950s, researchers began noting severe problems of joint degeneration and so discouraged the use of cortisone injections. Today, despite the dangers, cortisone use remains widespread as a standard of care.
The research on cortisone
- Researchers concluded that corticosteroids reduce knee pain for at least 1 week and that intra-articular corticosteroid injection is a short-term treatment of a chronic problem.”4,5
- 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.”6
- Cortisone has a harmful 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.
- Cortisone causes bone death 7
- 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.8
- Cortisone shots cause degeneration which eventually leads to surgery.
- Cortisone injections can predispose a joint to infection.
- Patients have reported severe pain, including muscle pain, and burning after cortisone injection.
These last two points were the subject of new and independent research. Here is a summary of that research
Intraarticular hip injections of corticosteroids and hyaluronic acid may be used to treat hip osteoarthritis. Although sterile technique is recommended to avoid infiltration of the joint with microorganisms normally found on the surface of the skin there remains a risk of infection. (This is not much different to risks with Prolotherapy or any injection.) HERE IS THE DIFFERENCE -This may increase the risk of joint infection, particularly when coupled with corticosteroid-related immunosuppression .
Therefore, in the setting of total hip replacement, preoperative receipt of a hip injection may increase risk of infection, leading to early revision arthroplasty.
While the researchers were unable to determine what agent was injected into the joint prior to surgery, they concluded that the most likely therapies were corticosteroids and hyaluronic acid, with or without a local anesthetic.
As hyaluronic acid has no proven benefit for hip osteoarthritis, it is likely that most of the injections were of corticosteroids.
- Corticosteroid joint injection may have local immunomodulatory effects that may increase risk of infection following hip replacement.
If so, there may be a period of time required for these effects to be “cleared” before a hip replacement can be safely implanted into the joint. Regardless of the solution injected, intraarticular injections expose the joint to the external environment and may allow seeding by microbes, particularly when improper sterile technique is used. Further research is warranted to determine whether the documented increased risk of infection following hip injection differs according to the solution used (corticosteroids versus hyaluronic acid).9
More on hyaluronic acid and cortisone damage
In new research, doctors in China released their findings on animal studies on the damaging effects of cortisone on cartilage and the ability of Hyaluronic acid to repair this and other damage.
Here is what they said:
Intra-articular injection of corticosteroids is used to treat the inflammatory pain of arthritis and osteoarthritis, but (in their previous study) found a deleterious effect of these steroids on chondrocyte cells. Hyaluronic acid (HA) injection has been suggested as a means to counteract negative side effects through replenishment of synovial fluid that can decrease pain in affected joints.. . .
Combinations of steroid and Hyaluronic acid treatments have not been completely understood or standardized and are still a matter of concern. We suggest that if this combined treatment cannot be avoided, then an appropriate treatment duration should be provided.10
Alternative to cortisone
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 Platelet Rich Plasma Therapy, 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.
Comprehensive 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.
In addition, the collagen that forms in ligaments and tendons treated with cortisone is disrupted and weaker, while that treated with Prolotherapy is 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.
Comprehensive Prolotherapy includes the use of Blood Plasma or Platelet rich Plasma Injections. Recently in the research below – medical investigators looked at PRP and “blood injection” as options to cortisone.
Autologous blood injection, a derivative of Platelet Rich Plasma where the blood is reintroduced without the platelet concentration improved pain and function patients with chronic lateral epicondylitis (Tennis elbow), who had not had relief with cortisone injection.11 In later studies patients responded much more favorably to the “stronger” PRP injection. Showing increases in function and strength as well as pain decreases.12-14
Rotator Cuff Tears
Compared with cortisone injections, Autologous blood injection injections show earlier benefit in rotator cuff tendinopathy as compared to cortisone injections although a statistically significant difference after 6 months could not be found. (This is why we use the stronger Platelet Rich Plasma) Therefore, subacromial Autologous blood injection injections a good alternative to subacromial cortisone injections, especially in patients with contraindication to cortisone.15
Compared with cortisone injections, PRP showed significant clinical benefit. Additionally the PRP benefit worked best when the patient did not have a PREVIOUS CORTISONE INJECTION.16
References to this article
1 Hauser RA The Deterioration of Articular Cartilage in Osteoarthritis by Corticosteroid Injections Journal of Prolotherapy. 2009;1(2):107-123.
2. Wyles CC, Houdek MT, Wyles SP, et al. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res. 2015 Mar;473(3):1155-64. doi: 10.1007/s11999-014-3925-y. Epub 2014 Sep 4.
3. Seshadri V, Coyle CH, Chu CR. Lidocaine potentiates the chondrotoxicity of methylprednisolone. J Arthr and Related Surg. 2009 Apr; 25(4): 337-347.
4. 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.
5. Hepper CT, Halvorson JJ, Duncan ST, Gregory AJ, Dunn WR, Spindler KP. The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: a systematic review of level I studies. J Am Acad Orthop Surg. 2009 Oct;17(10):638-46.
6. Sofat N. Kuttapitiya A. Future directions for the management of pain in osteoarthritis. Int J Rheumatol. Apr 2014; 9(2): 197–276.
7. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ 2004; 328:869.
8. Sweetnam R. Corticosteroid arthropathy and tendon rupture. Journal of Bone and Joint Surgery. 1969: 397-398.
9. Ravi B, Escott BG, Wasserstein D, Croxford R, Hollands S, Paterson JM, Kreder HJ, Hawker GA. Intraarticular hip injection and early revision surgery following total hip arthroplasty: a retrospective cohort study. Arthritis Rheumatol. 2015 Jan;67(1):162-8. doi: 10.1002/art.38886.
10. Siengdee P, Radeerom T, Kuanoon S, Euppayo T, Pradit W, Chomdej S, Ongchai S, Nganvongpanit K. Effects of corticosteroids and their combinations with hyaluronanon on the biochemical properties of porcine cartilage explants. BMC Vet Res. 2015 Dec 4;11(1):298. doi: 10.1186/s12917-015-0611-6.
11. Massy-Westropp N, Simmonds S, Caragianis S, Potter A. Autologous blood injection and wrist immobilisation for chronic lateral epicondylitis. Adv Orthop. 2012;2012:387829. doi: 10.1155/2012/387829. Epub 2012 Dec 4.
12 Khaliq A, Khan I, Inam M, Saeed M, Khan H, Iqbal MJ. Effectiveness of platelets rich plasma versus corticosteroids in lateral epicondylitis. J Pak Med Assoc. 2015 Nov;65(11 Suppl 3):S100-4.
13 Yadav R, Kothari SY, Borah D. Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus. J Clin Diagn Res. 2015 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213. Epub 2015 Jul 1.
14 Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J.Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2015 Sep 11. [Epub ahead of print]
15. von Wehren L, Blanke F, Todorov A, Heisterbach P, Sailer J, Majewski M. The effect of subacromial injections of autologous conditioned plasma versus cortisone for the treatment of symptomatic partial rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2015 May 28. [Epub ahead of print]
16. Gosens T, Den Oudsten BL, Fievez E, van ‘t Spijker P, Fievez A. Pain and activity levels before and after platelet-rich plasma injection treatment of patellar tendinopathy: a prospective cohort study and the influence of previous treatments. Int Orthop. 2012 Sep;36(9):1941-6. doi: 10.1007/s00264-012-1540-7. Epub 2012 Apr 27