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Cortisone InfographicAlternative to cortisone shots

Ross Hauser, MD

In this article, we will discuss new cortisone research including troubling findings which say that:

  • Corticosteroid triamcinolone acetonide increases knee cartilage destruction.
  • 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.
  • Corticosteroids can alter the healing environment of the joint by effecting damage on the native stem cells in cartilage.
  • Do you have a question about finding an alternative to cortisone shots? Get help and information from our Caring Medical staff.

New research is providing more warnings that cortisone does not heal and, in fact, accelerates deterioration of already damaged joints.

It is my opinion that the increase in the number of hip and knee replacements is a direct result of the injection of corticosteroids into these joints

The fact that new research is pouring in on the detrimental effects of cortisone injections should not convince anyone that suddenly medicine is being alerted to the risk of corticosteroids. The dangers of cortisone injections have long been known. But in eagerness by health professionals and the patients themselves to get instant relief, the dangers were accepted as part of the treatment, the let’s manage the pain until the patient is ready for joint replacement treatment.

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 damaged knee cartilage and provided no significant pain relief after two years.

In 2017, doctors from Tufts Medical Center in Boston asked, “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?”

Writing in the Journal of the American Medical Association, (JAMA) they published their answer:

“Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”(2)

  • Corticosteroid damaged knee cartilage and provided no significant pain relief after two years.

Cortisone can work in the short-term and make the problem worse in the long run

The idea that cortisone can cause damage was not an easy sell for some researchers. Corticosteroid injections have been used for a very long time. Their anti-inflammatory and pain relief properties made its use a common practice within the medical community. Further, they are effective.

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 the 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, cortisone can either work or make the problem worse.

Cortisone disrupts and hurts stem cells

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 usage will make the patient’s condition worse.

Cortisone disrupts and hurts stem cellsCortisone vs. Prolotherapy

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.(3Please see our article on How stem cells heal degenerative joint disease after years of cortisone and painkillers.

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.”(4)

In the American Journal of Sports Medicine, university medical researchers in Japan demonstrated a case history in which a patient received high-dose cortisone treatments for a case of Bell’s Palsy, the same patient was also a volunteer subject in a study to test a stem cell based Tissue Engineered Construct for cartilage and bone defect. Stem cells were harvested from the patient to “build a scaffold patch.”

  • At three weeks after the cortisone treatment, the patient’s stem cells could not help generate the construct needed for the cartilage/bone patch.
  • At seven weeks after steroid therapy the stem cells could, the stem cells had successfully withstood a direct attack from the cortisone, but it did take 7 weeks to recover.(5)

Cartilage cell counts decline with cortisone and exerciseIt 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, side effects, and tissue toxicity

Despite the research, the first trip to the joint pain specialist is usually a recommendation to cortisone. 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.

This is what cortisone does:

  • Cortisone has a harmful effect on soft tissue healing by inhibiting blood flow to the injured area, suppressing new blood vessel formation, suppressing growth of immune cells like leukocytes and macrophages, preventing protein synthesis, fibroblast proliferation and ultimately collagen formation.
  • Cortisone inhibits the release of growth hormone, which further decreases soft tissue and bone repair.
  • Cortisone weakens collagen and therefore soft tissue such as ligaments and tendons.

This is what research says about it:

  • Research 2013: Cortisone works well for some but not for others and no one seems to be able to identify why:
    • From the journal Seminars in Arthritis & Rheumatism: “Previous research has not identified reliable predictors of response to intraarticular corticosteroid injections, a widely practiced intervention in knee and hip osteoarthritis. Further studies are required if this question is to be answered.”(6)
  • The Journal of the American Academy of Orthopaedic Surgeons (2009) 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.(7)
    • (My comment, good for one week, damages stem cells for three weeks, referring to above research).
  • From the International Journal of Clinical Rheumatology, a paper entitled: “Future directions for the management of pain in osteoarthritis”. (2014) 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.”(8)
    • (My comment: Cortisone is clearly not part of the Future directions for the management of pain in osteoarthritis).
  • In March 2017, Italian researchers publishing in the medical journal Expert Opinion in Drug Safety noted: local glucocorticoids injections have shown positive results in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures have been reported. (9). 
    • The was a confirmation of a study that appeared 40 years earlier in 1977. Here Stanford University Medical Center and Kaiser-Permanente Medical Center researchers suggested that 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.(10)
  • The evidence for the effectiveness of intraarticular epidural steroid injection for Sacroiliac joint dysfunction treatment is poor (11)

Cortisone injections can predispose a joint to infection. Patients have reported severe pain, including muscle pain, and burning after a cortisone injection.

In research from 2015, doctors at the University of Toronto wrote of the problem of injection infection.

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. (All injections can carry the risk of infection, this includes our injection techniques of Prolotherapy PRP Prolotherapy and stem cell Prolotherapy)

HERE IS THE DIFFERENCE -Patients prior to hip replacement surgery may typically receive hip injections of corticosteroids and hyaluronic acid to manage their pain until surgery day.

Intraarticular hip injections of corticosteroids and hyaluronic acid may increase the risk of infection because of the immune system suppression characteristic of cortisone.

Therefore, in the setting of total hip replacement, preoperative receipt of a hip injection may increase the 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 the 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 an 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).(12)

Hyaluronic acid cannot repair cortisone induced cartilage 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.(13)

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 during 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 and Platelet Rich Plasma. Comparisons to Cortisone

  • Patients with chronic gluteal tendinopathy for more than 4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection.(14)
  • 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.(15)
  • Journal of clinical and diagnostic research, a 2015 study reveals PRP as a superior treatment option to cortisone in cases of tennis elbow.(16)
  • Doctors in Pakistan have shown the effectiveness of platelets rich plasma versus corticosteroids or the “tennis elbow steroid injection.” The doctors looked at 102 patients in the study and divided them into two groups of 51(50%) each.
    • In the patients in the cortisone group 53% improvement
    • In the patients in the PRP group 82%
    • Their conclusion: PRP is an effective alternative to corticosteroid in the treatment of lateral epicondylitis (tennis elbow).(17)
  • International orthopaedics (2012) Compared with cortisone injections, PRP showed significant clinical benefit for patellar tendinopathy. Additionally, the PRP benefit worked best when the patient did not have a PREVIOUS CORTISONE INJECTION.(18)
  • Doctors in the United Kingdom found that PRP is as effective as Steroid injection at achieving symptom relief at 3 and 6 months after injection, for the treatment of plantar fasciitis, but unlike Steroid, its effect does not wear off with time. At 12 months, PRP is significantly more effective than Steroid, making it better and more durable than cortisone injection.(19)

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.

Do you have a question about finding an alternative to cortisone shots? Get help and information from our Caring Medical staff.

 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. [Journal of Prolotherapy]
2 McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee OsteoarthritisA Randomized Clinical Trial. JAMA. 2017;317(19):1967-1975. [Google Scholar]
3 Wyles CC, Houdek MT, Wyles SP, Wagner ER, Behfar A, Sierra RJ. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clinical Orthopaedics and Related Research®. 2015 Mar 1;473(3):1155-64.  [Google Scholar]
4 Seshadri V, Coyle CH, Chu CR. Lidocaine potentiates the chondrotoxicity of methylprednisolone. J Arthr and Related Surg. 2009 Apr; 25(4): 337-347.  [Google Scholar]
5 Yasui Y, Hart DA, Sugita N, Chijimatsu R, Koizumi K, Ando W, Moriguchi Y, Shimomura K, Myoui A, Yoshikawa H, Nakamura N. Time-Dependent Recovery of Human Synovial Membrane Mesenchymal Stem Cell Function After High-Dose Steroid Therapy: Case Report and Laboratory Study. The American journal of sports medicine. 2017 Dec 1:0363546517741307.  [Google Scholar]
6 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.  [Google Scholar]
7 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.  [Google Scholar]
8. Sofat N. Kuttapitiya A. Future directions for the management of pain in osteoarthritis. Int J Rheumatol. Apr 2014; 9(2): 197–276.  [Google Scholar]
9. Abate M, Salini V, Schiavone C, Andia I. Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies. Expert Opin Drug Saf. 2017 Mar;16(3):341-349. doi: 10.1080/14740338.2017.1276561. Epub 2016 Dec 28.  [Google Scholar]
10. Halpern AA, Horowitz BG, Nagel DA. Tendon ruptures associated with corticosteroid therapy. Western Journal of Medicine. 1977 Nov;127(5):378.  [Google Scholar]
11. Hansen H, Manchikanti L, Simopoulos TT, Christo PJ, Gupta S, Smith HS, Hameed H, Cohen SP. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May-Jun;15(3):E247-78.  [Google Scholar]
12. 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.  [Google Scholar]
13 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.  [Google Scholar]
14 Fitzpatrick J, Bulsara MK, O’Donnell J, McCrory PR, Zheng MH. The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: A Randomized, Double-Blind Controlled Trial Comparing a Single Platelet-Rich Plasma Injection With a Single Corticosteroid Injection. The American Journal of Sports Medicine. 2017:0363546517745525.  [Google Scholar]
15. 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.  [Google Scholar]
16 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.  [Google Scholar]
17 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. [Google Scholar]
18. 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 [Google Scholar]
19. Jain K, Murphy PN, Clough TM. Platelet rich plasma versus corticosteroid injection for plantar fasciitis: A comparative study. Foot (Edinb). 2015 Dec;25(4):235-7. [Google Scholar]

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