Michael Huang, MD
Okay, after reading blog post #1, you know everything there is to know about cortisone (corticosteroid) injections. So, you might be asking, what’s with all the controversy? Well, there really isn’t all that much controversy, but there are a lot of myths and misconceptions out there that I hear all the time.
Before we tackle the myths and facts, let’s spend a bit of time learning a little more about cortisone. First thing is to clarify that we are talking about injections and not oral steroids. If you take oral steroids, it will be absorbed and then distributed throughout your body. There are multiple reasons to do this, but typically not in orthopaedics with the exception of short bursts (and we even try to avoid those). Systemic steroids (oral) do have multiple side effects.
Second thing is that not all injections are the same. An injection into a joint is different than an injection into a bursa area which is different than a “trigger point” injection which is typically in muscle. Because the joint is a distinct area, very little of the injection leaves the joint. The vast majority of the injection stays in the joint where we want it to act. Injections into bursa or other soft tissue areas (like trigger point injections into muscle) can spread locally and may have more system wide effects. Okay, now that we got that out of the way, let’s tackle some of these topics.
Topic #1: You can only have 3 (or however many) injections in your life.
This is a myth. There is no limit on the number of injections a person receives. I do believe that injections should be carefully considered and there is benefit to spreading identical injections apart by a period of time. We typically tell patients to wait at least 3 months between injections, but this may be different between physicians.
Topic #2: It softens (destroys) bones and deteriorates tendons and joints.
Partly myth and partly fact. Mostly misconception. So, oral steroids can cause osteoporosis especially if taken over a long period of time or in very high doses. This isn’t true of cortisone injections. Very little of the injected cortisone will leave the joint and therefore has minimal risk of osteoporosis. There is risk to the other soft tissues around the joint. If the injection is placed incorrectly and the cortisone is injected into a tendon, it will cause damage. Similarly, there has been some basic science research that suggests some toxicity to the cartilage cells in the joint but it is not completely worked out yet. In fact, the local anesthetic (lidocaine, Marcaine, etc) can also cause some damage to cartilage. So, our advice is to use these injections judiciously, space them apart in time, and make sure they are placed correctly.
Topic #3: It will destroy your liver (or other organs)
Myth. So again, of the total cortisone injection placed into a joint, only a small fraction will leave the joint and access the rest of the system. This is why the injections of cortisone are, in fact, safer than oral steroids.
Topic #4: You will get used to it and it will become less effective
Myth. We do not build up a tolerance to these types of medications. It’s not like opiates (narcotics) where a person will require more and more of the same medication to achieve a result. Each time an injection is placed, it works there locally. If it is not placed correctly, then the patient may not feel the same benefit from one injection to another. Over time, the disease process may also be getting progressively worse (worsening arthritis in the joint) which can also make an injection less effective as it is battling a greater degree of inflammation in the area it is placed.
Topic #5: My injection did not work and so I’m “immune” to it
Several years ago, I would have said this is complete myth. There is no immunity build up to cortisone injections. However, over the years, I have met several patients where cortisone injections did not work where we expected them to. I have had to admit to these few patients that they are very much “non-responders” to the cortisone medications. We have even tried to change the type of cortisone and tried other joints as well, without benefit. So, while I do not believe in the “immunity” concept, I do know patients that do not respond to these medications.
Tell me what other questions or concerns you might have about these injections in the comments and we will address them!