Episode 9: Can Cortisone Injections Really Help with Joint Pain? Debunking Myths and Clearing Up Misconceptions

In this episode, Dr. Karmy dives into the facts and misconceptions surrounding cortisone injections. Often misunderstood, these powerful anti-inflammatory treatments can offer significant relief for joint pain, tendon issues, and nerve inflammation.

Join Dr Karmy as he explores when cortisone is most effective, its potential risks, and why it may not be the silver bullet for chronic pain that many expect.

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Chapters

• 0:49 What are Cortisone Injections?
• 2:13 Differences between Tablet vs Injection Form
• 3:48 Medical Indications: Arthritis, Inflammatory Conditions, Disc Herniation
• 5:13 Pros: Onset of Action, Response Rate, OHIP Coverage
• 6:01 Cons: Complications, Weakened Immune System, Discolouration, Muscle Atrophy
• 7:42 Debunking Myths: Limitations, Contraindications, Landmark vs Guided Injections
• 12:10 Dr Karmy's Final Thoughts

Transcript

Dr Karmy: 0:00

I would also say that of all the treatments that we have for pain, cortisone has the highest response rate. I would say that about 70 percent of patients respond to cortisone injections.

Raveena: 0:18

Welcome to Chronic Pain Chronicles with Dr. Karmy. In today's episode, we'll be discussing cortisone injections, what they are, how they work, and why they're a useful option for treating joint pain. I'm Raveena, your host, here to guide you through today's discussion. This topic is important for pain management because while cortisone can offer significant relief, understanding its limitations and risks is crucial for making informed treatment decisions.

Dr Karmy: 0:49

Hi, this is Dr. Karmy, and today I wanted to discuss cortisone injections. Perhaps it's a little bit redundant, because most people have heard of cortisone shots. However, I feel like there are some misconceptions about them, and I wanted to clarify these misconceptions. First of all, what are cortisone injections? Cortisone is a hormone. It is a glucocorticoid, which is a very different hormone from sex hormones, like estrogen or testosterone. Some people confuse the two. Estrogen and testosterone, affect things like muscle size or the size of the breasts or how much facial hair a person has. Cortisone, on the other hand, is a hormone that's involved in stress response and metabolism. But the reason we use it in chronic pain is because it also reduces inflammation. It is one of the most powerful anti inflammatory injections that we have. Generally speaking, there are two forms of cortisone. There's cortisone that comes in the pill form called Prednisone, which is sometimes taken for weeks, but often is taken for months or years. And injectable form, often called Depo-medrol or Kenalog. When taken for months or years, cortisone can cause all sorts of side effects, including bone loss, diabetes, skin atrophy, weight gain. You name it. When cortisone is administered as an injection, you can get all the same side effects. However, chances of a person getting them are much, much lower. The reason for that is that when cortisone is injected, it mostly stays in the joint that it was injected into. Some cortisone does leak out and spreads throughout the whole body, but majority of cortisone stays put. Also, the cortisone that does leave the joint is typically gone within a week or two. So, what type of medical conditions respond to cortisone injections? The most common application of cortisone is to treat joint pain due to arthritis. In addition to that, cortisone is used to reduce inflammation in tendons or around nerves. Such common conditions as tennis elbow or plantar fasciitis will respond very well to cortisone. Also, in cases where disc herniates in the back and compresses a nerve, often injecting cortisone into epidural space, so it spreads near the nerve and reduces inflammation around the nerve, can help with symptoms of sciatica or radiculopathy. It is, however, not used for every medical condition. It is not helpful for muscle pain, and generally speaking, doesn't help much for headaches. So what are the pros and cons of this approach? The pros of cortisone is, it's relatively rapid onset of action. It can start helping within two days to two weeks after the injection. I would also say that of all the treatments that we have for pain, cortisone has the highest response rate. I would say that about 70 percent of patients respond to cortisone injections. It is also an OHIP covered treatment, so patients don't have to worry about coverage. So, what are the cons of cortisone injections? Well, first of all, it can cause bone damage and cartilage damage. It can suppress immune system and also it can cause clots to form, leading to strokes of the spinal cord. To put this in perspective, chances of some of these more serious complications are extremely low. I have only seen two cases of osteonecrosis or bone damage in 20 years of practice, and I have never seen an instance of a stroke post cortisone injection. Other more minor side effects include skin pigment loss in the area of injection. It is not a medical issue, however, it can be a cosmetic issue for individuals. Typically the pigment loss is just in the area of injection, so it's typically a very small area. Cortisone can also cause muscle atrophy in the area of injection, which is one of the reasons that it's not used to treat muscle pain. So, how often or, and for how long can you use cortisone? There is some sort of impression in some circles that you're only allowed to have two cortisone injections in your lifetime. There's no evidence for that. anywhere. There is, however, limitation on frequency. You shouldn't inject cortisone more often than once every three months. And perhaps limitation on total dose per year, especially in postmenopausal women. There is some evidence that one shouldn't inject more than eighteen milligrams of the depo-medrol every three months, as this treatment entails some risks. If somebody responds for six months or a year, obviously they do not repeat the treatment in three months. Then there's some discussion as to whether or not one needs ultrasound or x ray guidance in order to perform a successful cortisone injection. The idea being that if you are not in exactly the right place, you will be treated differently. It may somehow make the injection more dangerous or ineffective. In my opinion, the answer is empathic no. I think that if you have a physician who is well versed in landmark based injections of cortisone, he will do well with landmark based injections, while if you have a physician who is well versed in ultrasound or x ray guided injections of cortisone, he will do well with ultrasound or x ray guided injections. So, I think the most important factor is the level of expertise and comfort of your physician, rather than the approach they use. Cortisone is one of those medications that spreads, so even if the needle tip is not exactly, on top of the target, generally speaking it'll spread and the clinical effect will be as good. To go into more detail, there are some areas where guided injections provide more consistent results and other areas where I feel that they are unnecessary and if anything cause additional risk. First of all, for structures that are close to the surface like joints, one can easily feel the edges of the bones. In which case, landmark based procedure is often easier to perform. The problem with guided procedures for surface joints is that first of all, you have to have ultrasound probe located very close to the area that's being injected, and it is potential source for contamination. Second of all, in order to see ultrasound tip, often thicker needles are required, which can cause additional tissue trauma and post injection pain. As mentioned, there are some areas where ultrasound or x ray guidance has an advantage, College of Physicians and Surgeons of Ontario, which is our regulatory body, mandates that epidural injections in clinics, but oddly enough, not hospitals, have to be done under x ray or ultrasound guidance. So we have no choice but to do these procedures under x ray or ultrasound guidance if we want to protect our license. Also, some of the deeper joints where edges of the bones are hard to feel can benefit from guided injections. In particular, shoulder joint injections and hip joint injections will sometimes do better with guidance. In terms of nerves, brachial plexus blocks and sciatic blocks, again, will often have more consistent results if ultrasound guidance is used. The reason I'm pointing out these particular situations is because they are the exceptions rather than the rule. For the vast majority of locations and targets, be it nerves or joints, it is questionable whether ultrasound and x ray guidance really provides better results. So, what are my final thoughts on cortisone injections? Overall, I think that cortisone is an incredibly useful approach to pain management. It is often my go to treatment in patients who come in with excruciatingly severe flare up of pain. In the back, or in patients who come in with gout flare up, it is also not the right treatment for every condition in every situation. Cortisone can slow down healing of an injury. Is not used for muscle pain. Because it suppresses immune system, I try not to administer cortisone within two weeks of immunization. And also, I try to avoid injecting cortisone, if the patient is anticipating surgery, especially orthopedic surgery within the next one or two months. I would also avoid cortisone injection within one or two months of a stroke or a heart attack because there is some suggestion that it can predispose to clots in rare circumstances. As stated earlier, the less frequently you take cortisone, the better. So, if it helps a patient for a year, I won't repeat it any earlier than that. So, overall, I think it's a very useful tool in chronic pain management, as long as it is used wisely. It is not a silver bullet. Thank you.

Raveena: 15:26

Thank you for listening to Chronic Pain Chronicles with Dr. Karmy, where we explore chronic pain from a physician's point of view. In our upcoming episodes, we'll continue to delve into some of the most effective and widely used approaches to managing chronic pain. We'll also investigate the causes of chronic pain and where the field is heading in the future. Furthermore, Dr. Karmy will interview seasoned professionals and leading researchers in the field, sharing their insights and expertise in our discussions. Disclaimer, when it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.