Cortisone shots suck.
Unless you are a high level athlete where returning to the playing field is critical, taking cortisone shots for joint pain absolutely, positively sucks.
Say your shoulder has been bothering you for 6 months. You walk into your primary care doctor and they do some asinine examination on your shoulder acting like they know what the hell they’re doing,
The doctor says you have tons of inflammation based on your pain levels, and recommends a cortisone injection. You ask what that’s for. They tell you, “to reduce the inflammation.”
First off, most people are prescribed a cortisone injection for some type of chronic pain they are suffering. The first issue with this is not all people suffering from chronic joint pain are experiencing inflammation. In fact, most chronic joint pain is from tendinosis, not tendonitis.
“Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.”
From: http://bjsm.bmj.com/content/36/6/392.long
That is, the pain is due to chronic degradation of the tendon (-osis), not chronic inflammation (-itis). Chronic inflammation with joints is actually pretty rare as the inflammatory response is much more common in a traumatic injury during the acute stage.
In other words, considering your shoulder has been bothering you for 6 months or longer, you are no longer in the acute stages of an injury. You may not have ever had an acute stage to begin with. Typically the pain just slowly starts and gets worse and worse.
This is why some people get a cortisone shot and don’t notice any difference in their pain: they never had any inflammatory issues to begin with.
But what about those who do get pain relief? They’re even more screwed.
While the cortisone will get rid of the inflammation, which will then get rid of the pain, the cortisone isn’t getting rid of what’s causing the inflammation.
For example, say someone has poor posture so they experience shoulder pain when lifting their arm(s) overhead due to excessive impingement. The cortisone isn’t helping correct their posture, so it’s not preventing the excessive impingement, thus it’s not helping what’s causing the pain. It’s only treating the symptom.
In fact, in the long-term it’s going to make the situation worse. Pain is a survival tactic by the body and joint pain is a sign you are damaging the joint. So it causes you to stop what you’re doing, as you obviously don’t enjoy the pain.
-> Pain can obviously be more complex than this. For instance, a person may have pain due to fear of damaging their joint, even if no actual damage is occurring. Perception, false or correct, can drive sensation. (We’ve all heard of the placebo effect.)
Due to the effects of the cortisone though, you can no longer feel the pain. But that doesn’t mean you’re not still damaging the joint when you’re lifting your arm overhead. Again, your posture is still bad and you’re still experiencing that excessive impingement. It just doesn’t feel as bad as it used to.
This is why you see some people get a cortisone shot and 6 weeks later, or whenever that shot starts to wear off, they feel worse.
Furthermore, when you are trying to get someone out of pain you use pain as a guide as to when they should stop a movement. Or a sign they’ve become too fatigued. It serves as a guide as to whether the treatment prescribed is working or not. If the person can’t feel pain in the joint regardless (due to the cortisone) you have no idea whether or not the prescribed treatment is helping to alleviate their pain. Again, you might just be messing the particular joint up even more.
Not to mention there seems to be a good amount of evidence suggesting taking the shot will actually increase your chances of weakening, and possibly rupturing, the injected tendon. One example: http://ebm.bmj.com/content/16/4/116.full
Back to tendinosis- during tendinosis a tendon is chronically degraded, which means it has likely already become weak due to there being less of it…why would you want to inject a substance with evidence for weakening tendons into an already weak tendon???
How this rant was inspired: A few days ago a client came in for a training session and it had been about a week since I had seen her. She has arthritis in various joints throughout her body that typically feel decent. Namely her right knee acts up sporadically.
Anyways, she tells me she felt some knee pain while playing racquetball and subsequently experienced a good amount of swelling the next day or so. So she goes into see her doctor, her primary care doctor mind you (who probably specializes in cardiology), gets an x-ray, is diagnosed with “some arthritis” and is told she should come back in a few days to get a cortisone injection.
SOMEBODY KILL ME!!!!! WHAT THE HELL KIND OF TREATMENT IS THIS?!?!?!
No wonder “chronic pain has no solution” when crap like this somehow qualifies as helping someone in pain.
For the love of god at least refer her out to an orthopedist or physical therapist. Somebody who actually sees this type of thing everyday. Someone who can perform some testing or order an MRI to see if she tore anything. After all, she did get hurt while playing a sport involving a lot of cutting and twisting at the knee.
Seriously, if your doctor starts prescribing cortisone shots for a chronic condition you are on the path to a joint replacement. Your doctor is only going to be able to prescribe 3-4 shots per year. Eventually they are going to wear off. Or the pain is just going to exceed what the shot does for you. Either way, you’re screwed.
Figure out what’s causing the chronic pain to begin with and go from there. No more band-aids!
Adam
May 26, 2018
Great article Brian. Treating the symptom and not the cause feels like a re-occurring theme. I’d be curious to hear a counterpoint from a general practitioner giving out shots regularly. I suspect it’d be something like “I have 2000 patients and only get 20 minutes with each one, you know, because of the nature of our health care system.. And patients rarely complain about getting rid of pain quickly, cheaply and effortlessly, albeit temporarily.”
b-reddy
May 29, 2018
To some degree, hey, that’s a fair argument.
It’s not much different than how a general practitioner goes about handling high blood pressure. Rather than go after e.g. the cause of a person’s obesity, which requires more than 15 minute visits every 6 months, they instead give medication.
A glaring issue with this example though -high blood pressure medication vs cortisone shots- is cortisone is known to wear off. The second, third, etc. shot is often not as beneficial as the first. So you’re really just kicking the can down the road. And not very far. Cortisone doesn’t usually last too long. (Though I have had some clients who got a shot and the issue never came back.)
To your point, in a more ideal system GPs would be, say, referring patients out to regular care. Or providing it themselves. For instance, when a person is on the cusp of needing blood pressure medication, instead of only telling the patient “I recommend you lose weight” and calling it a day, they’d also be sending them to a personal trainer for multiple times per week care. Or they’d schedule more regular checkups. Granted, there are limitations to this. Most obviously cost, as insurance doesn’t currently pay for personal training and largely dictates how many visits a patient gets with a doctor too. (Though rich people have the many of the same issues with obesity as poor people.)
Like you said, we’re getting into a broader discussion about the healthcare system. I will say though, doctors have more power here than they either realize, or want to admit. Especially in America, it’s not like there is some system giving them a decision tree for what to do in every scenario. I’d recommend Atul Gawande’s writing for more about this. Particularly these two articles,
https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
https://www.newyorker.com/magazine/2004/12/06/the-bell-curve
With the main takeaway being if we were so strict with how care was given, there wouldn’t be such enormous disparity in complication rates between doctors and hospitals.
Back more specifically to cortisone- from my experience, one counterargument I’ve routinely heard is “Well, the patients push us for some kind of treatment.” This goes for cortisone, but also, notably, antibiotics and opiates. This isn’t an argument I’m sympathetic towards. You don’t give your kid a knife just because they want to touch it. (And it’s also in opposition to the doctors saying they are too confined in what they can give treatment wise. You can’t say you have limited freedom yet also say you’re caving into patient requests so easily.)