IT Band Syndrome Runners

Cortisone Shots: The Right Choice to Treat Inflammation?

Despite very wide usage, cortisone shots are poorly understood by the general public. Frequently applied for a wide variety of problems, they are unfortunately often applied without proper diagnosis. While they can be useful as a treatment, they also provide a lot of diagnostic information. These fall into three categories, and begin with the information that anesthetic is often a second ingredient along with the cortisone. This anesthetic offers the first, and most important detail:

  • Does the pain go away immediately?
    • If yes, you know the injected area is the pain-generator.
    • If no, you do not know what the pain generator is yet. This immediately suggests a second shot to the same location is unhelpful.
  • If the pain has gone away immediately, we get to the second important detail:
    • How long is the pain relieved for? The anesthetic will last for a matter of hours, and then the cortisone is able to take effect.
      • If the pain goes away for days to weeks, we know that the pain-generator is affected with inflammation, because cortisone is a powerful anti-inflammatory.
      • If the pain returns unaffected after the anesthetic wears off, we know what the pain generator is, but we also know inflammation isn’t the problem.
  • Does the pain return after a few weeks?
    • If it does, this strongly suggests that there is a biomechanical problem, essentially creating friction. The body is responding the friction with inflammation
    • If it doesn’t: Congratulations, you’re done! This is the ideal scenario for a cortisone shot, and occurs most commonly when the problem came on because of an unusual physical activity. “Unusual” is important because it means the provoking activity is not being repeated.

This brings us to the other issue. Assuming for a moment that we are not in Category 3b, the problem will recur. And importantly, there is a growing body of literature demonstrating that cortisone injections have a destructive effect on bone, essentially creating degenerative arthritis. This means that if a cortisone shot is used for poorly diagnosed “arthritis”, it will ultimately contribute to the very condition that it was supposed to treat! This is not to say that cortisone shots should never be used. They can be very useful in a situation that has been properly diagnosed already as inflammatory due to unusual circumstances, or in the case where the joint is dynamically unstable.

I define stability as being able to keep a joint in neutral. Static instability is something I see rarely as a chiropractor. It usually has to do with severe trauma, and these patients are generally in a surgeon’s office. Dynamic instability is therefore difficulty to keep a joint in neutral while moving. This essentially means that the more you move, the more the symptoms will occur. This can result in severe inflammation that is very difficult to treat by any other means. Addressing the inflammation directly with a cortisone shot in this situation allows treatment of the underlying problem, the instability, with exercise rehab.

The bottom line here is that cortisone shots have their use, but it is more limited that presently applied. An individual needs proper evaluation by a profession skilled in musculoskeletal diagnosis, not by reading Google reviews. Furthermore, this discussion underlines one more important fact: mechanical problems need mechanical solutions. Chemistry is a poor solution to free a stuck bolt. It should also be noted that cortisone shots have additional side effects which can be severe.

McAlindon, T. E., LaValley, M. P., Harvey, W. F., Price, L. L., Driban, J. B., Zhang, M., & Ward, R. J. (2017). Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients with Knee Osteoarthritis: A Randomized Clinical Trial. JAMA, 317(19), 1967–1975.
Kompel, A.J., Roemer, F.W., Murakami, A.M., Diaz, L.E., Crema, M.D., and Guermazi, A. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought? Radiology 2019 293:3, 656-663
Seshadri V, Coyle CH, Chu CR. Lidocaine potentiates the chondrotoxicity of methylprednisolone. Arthroscopy. 2009 Apr;25(4):337-47.