Samuel G Oltman, ND, RMSK
Cortisone injections are often the first therapy offered for joint pain, yet few patients get an adequate explanation on what it is, when it should be used, and the alternative therapies available. Even fewer providers have the knowledge and/or time to sufficiently counsel a patient toward the best possible outcome. Simply put, cortisone is a tool in the toolbox. It is neither the only option nor automatically destructive. It requires wisdom, experience, and nuance to properly navigate what the best treatment is for you, at this time, with your current goals.
What is “Cortisone”?
Cortisone refers to corticosteroids, which are a class of anti-inflammatory medications chemically similar to our naturally occurring hormone, Cortisol. Importantly, cortisone is NOT a “pain-killer” as many people think. It simply reduces inflammation, which is why it doesn’t work for all pain. If the pain is not inflammatory, it won’t do much.
The Evidence On Cortisone Injections For Joint Pain
Cortisone works well to reduce pain in the short term (1-2 months) for inflammatory conditions (1).
The more cortisone that is injected into a joint, the quicker that joint degrades and the worse the arthritis becomes (2,3).
Subsequent cortisone injections tend to work less and less well compared to the first and are no better than placebo (4,5)*.
Most studies comparing PRP to cortisone head-to-head show that pain relief is superior for PRP beyond the 2-3 month timeline and the gap widens with time, i.e. people treated with PRP do better at 4 months and even better at 12 months compared to cortisone (see all our references for PRP here).
*Reference #5 is especially enlightening because it was a 2-year placebo controlled study published in JAMA, one the top journals in the world, showing cortisone is no better than placebo for pain and worse for cartilage using MRI confirmation. Yet providers still accuse therapies like PRP of being “not evidence based” and offer cortisone.
How To Decide What Is Best For You
The first question is: What is the diagnosis and what are the options? Joint issues are different from tendon issues and the application of cortisone differs in each.
The next question is always: Is there a compelling reason to prefer short term pain relief over long term joint health? If the answer is “no, long term joint health is the priority” then cortisone is out and we’re talking about PRP and MFAT.
However, there are many compelling reasons to prioritize short term relief: competition (upcoming race), vacation, or psychological (the break from the pain is the point). If there are good short term goals, then we ask if the patient has had any cortisone before. The more they’ve had and the more recent it was, the less likely it’s a good idea to do it again. If we do move ahead, we plan for afterwards. What was the underlying cause and how do we address that while the inflammation is lowered? This will often include PT and strengthening to maximize the therapeutic window that cortisone provides.
Lastly, with my expertise in ultrasound-guided injections, if we do utilize cortisone, it’s always ultrasound-guided in order to get the smallest dose possible exactly into the correct location.
I don’t use cortisone very often because after working through this decision tree with my patient, it’s not indicated most of the time. The evidence is clear that if you are prioritizing long term joint health we want a regenerative therapy like PRP or MFAT. I don’t shy away from it because of a dogmatic aversion to pharmaceuticals. I use it sparingly because that’s what the evidence dictates.
If This Is True, Why Will My Insurance Cover Cortisone and Not PRP?
Cortisone will be covered because insurance companies are concerned with short term outcomes and the most cost-effective way to get you to not seek more care. You probably won’t be on your current insurance by the time you need a joint replacement. You will likely have switched jobs, switched to a different carrier, or became eligible for Medicare. This is a classic misalignment of incentives that plagues our entire healthcare system. It is one of many reasons why US healthcare performs so poorly treating chronic disease.
We all need to fully understand the pros and cons of every medical decision we make. You need a provider with expertise in the full array of options available. You also need the time to move through the decision process. Cortisone can be a great one-time option for short term relief but is unquestionably detrimental for long term joint health. If you aren’t having this conversation with your orthopedic provider you aren’t getting adequate care. Come see what comprehensive, person-centered care looks like at Cascade Regenerative Medicine.
Effects of recurrent intra-articular corticosteroid injections for osteoarthritis at 3 months and beyond: a systematic review and meta-analysis in comparison to other injectables. Osteoarthritis and Cartilage. 2022;30(12):1658-1669.
Shazeen Ayub and others, Efficacy and safety of multiple intra-articular corticosteroid injections for osteoarthritis—a systematic review and meta-analysis of randomized controlled trials and observational studies, Rheumatology, Volume 60, Issue 4, April 2021, Pages 1629–1639.