Alternative to cortisone shots
Ross Hauser, MD.
In this article, Dr. Hauser discusses cortisone research including troubling findings which say that not only do cortisone injections increase the risk of joint surgery, but the need for secondary surgery and possible higher risk for post-surgical infections in the joint.
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.
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in addition to the RICE (rest, ice, compression and elevation) protocol– which has very recently been rescinded by its author due to its detrimental effect on healing.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.
Cortisone Injection Risks
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.
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 is widespread and has become the standard of care.
The research on cortisone
- 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.
- Cortisone causes bone death 3
- 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.4
- 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.
- Cortisone injections can predispose a joint to infection.
- Cortisone shots cause degeneration which eventually leads to surgery.
These last two points were the subject of new and independant 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 dissimiliar 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 replaceement.
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).5
Nevertheless, cortisone shots are still considered the standard of care for the injured athlete and other painful or inflammatory conditions.
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. 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.