Why Are Doctors Still Giving Cortisone Injections?

by: Robin Dufour

Knee pain can stop you in your tracks. It also continues to be surprisingly mishandled by many healthcare practitioners. People with knee pain would do anything to be rid of it, so following a doctor’s advice for a cortisone (steroid) injection or two is often a no-brainer.

Unfortunately, there’s a problem with that.

Despite mounting evidence that they do no good, steroid injections are among the most common ‘treatments’ for knee pain. The research has been clear for years — steroid injections do not lead to good outcomes for joint pain. A 2017 Journal of American Medicine (JAMA) article raises the stakes and brings the Hippocratic Oath to mind — ‘do no harm’.

Numerous researchers have proven that steroid injections have a placebo effect at best. The 2017 JAMA article goes one crucial step further — the steroid injected into your joint causes your cartilage to degrade. That’s exactly the opposite of what we want.

Doctors at Tufts Medical Center in Boston did a two year blind study with two groups of patients with arthritic knee pain. They also had what’s called synovitis — a type of inflammation in the joint, verified by ultrasound. If anyone is going to respond to steroids, these people should.

Each group got injections every 12 weeks for 2 years. One group had saline (placebo) injected, the other a steroid. An MRI was done at the beginning, after one year, and again at the end.

The dismal results are no surprise to Physical Therapists, who often see these patients at some point in time after injections. In my 25 years as a PT, I’ve heard a version of these 12 words more times than I could possibly count, “It seemed to help for a little while, but it didn’t last.”

The results of the JAMA study should NOT be surprising to doctors who continue to inject. This information is widely circulated in journals.

Here are the conclusions of that revealing study:

For pain it was a net zero effect. No difference in pain between the two groups. Thanks to the placebo effect, both groups did experience some decrease in pain.

No difference in function in either group. No improvement in stiffness. No improvement in walking.

Remember, one group got the steroid, the other got saline.

There was one significant difference discovered between the two groups, and it’s bad news for the cortisone recipients.

The steroid group had definitively less cartilage in their knees after two years. That’s BAD. The steroids sped up the rate of arthritic changes. The saline group had no change in thickness — that’s GOOD.

This is exactly the opposite of what patients (I like to call them people) and their doctors would want to happen.

Will this 2017 JAMA study change the recommendations from doctors and surgeons who’ve been giving them for years? We could assume it should, but assumptions are dangerous.

A Google search for information on cortisone shots brings up the current Mayo Clinic recommendations:

There’s concern that repeated cortisone shots might cause the cartilage within a joint to deteriorate. So doctors typically limit the number of cortisone shots into a joint. In general, you shouldn’t get cortisone injections more often than every six weeks and usually not more than three or four times a year

The JAMA study was within those current guidelines of a shot every twelve weeks or four times a year.

My advice would be to simply ask your doctor what they think about this and other studies or find a good Physical Therapist to consult with first. All 50 states allow direct access between you and your Physical Therapist — meaning you don’t need a referral.

One last thing, in 2018, a year after the JAMA study was published, there was an increase in supply and demand of cortisone shots. According to MarketWatchCortisone Shots Market 2018 Receives a Rapid Boost in Economy due to High Emerging Demands with CAGR of 5.2% by Forecast to 2023

America acquires the first position in the market for cortisone shots owing to the rising prevalence of various types of allergies, arthritis, tendinitis, and others, and rising demand for corticosteroid injection in the U.S. According to the Center for Disease Control and Prevention, an estimated 78 million i.e. 26% of the U.S. adults aged 18 years or older are projected to have doctor-diagnosed arthritis by 2040. Additionally, the prevalence of tendinitis among athletes is found to be increasing from last few years in the U.S.

Despite years of researchers — and patients — telling us that cortisone injections don’t really do the job, the market tells a different story. They are being purchased in even higher quantities. They are still being given liberally and usually before any Physical Therapy. They are causing more harm than good.

We need to handle joint pain differently. We’ve been discussing the knee here, but the same goes for hips, shoulders, spine and any other joint that gets injected. All treatment and advice should be geared toward getting a good outcome for the person experiencing pain and difficulty.

Any practitioner helping you with joint pain should be looking at you when you talk (not checking boxes on their computer), listening and asking questions, watching you perform the tasks/movements that cause pain, strategically finding moves that don’t, and giving you new cues and habits to build into your day. Habits based on mindset and movement.

If your doctor is still giving cortisone injections, ask them why. Perhaps they have a convincing argument, I just haven’t heard one yet.