Cortisone Injection or Physical Therapy?

English: A scene in the Atchafalaya Basin in Louisiana, USA. (Photo credit: Wikipedia)

It was recently suggested that I provide another blog on cortisone injections.  I wrote one of my earlier blogs to address the topic of cortisone injections because of the number of questions I get about them from my patients.  I answered questions about how they work, my opinion on their use, and the side effects you would expect in my earlier blog.  Now, I’d like to talk about potential reasons for having cortisone injections, how physical therapy can help, and research in regard to the effects of cortisone injections.

As a physical therapist that practices in an outpatient setting, my patients with orthopedic problems such as arthritis, bursitis, and tendinopathies tend to have questions about these injections.  Cortisone injections are powerful anti-inflammatory treatments administered by Medical Doctors that can be used for a wide variety of problems.  One thing I stress to my patients is that if they have questions about cortisone injections, they should share them with their doctor.  It’s important to discuss the reasons for having a cortisone injection and the potential side effects.  Some of the known side effects can be serious and include such problems as infection, tendon rupture, and osteoporosis to name a few.  The doctor may be using the injection to make a diagnosis, to determine a course of treatment, or to provide pain relief, and it is important for you to understand why he or she is recommending it so you, the patient, know what to expect.  In making a diagnosis, cortisone injections may differentiate one condition from another, thus making further treatments more likely to succeed.12  For instance, sometimes relief from cortisone injection can be used to help predict the success of a possible surgery.34

Many people want cortisone injections to alleviate pain.  For pain relief, the success of cortisone injections varies and can be affected by the presence of other contributing factors including other medical conditions.56  If you have a medical condition that impairs healing or a compromised immune system, the risk of side effects may be increased and the success rate may be decreased.78 Be sure your physician is aware of your preexisting conditions since there are many factors that could impact cortisone injection effectiveness.

But before I continue, let’s talk about why you’re here on my blog reading about cortisone injections.  Are you in pain? Are you having trouble moving and going about your normal day due to pain and stiffness?  Do you have arthritis, bursitis, tendinitis/tendinosis/tendinopathy, plantar fasciitis, rotator cuff problems, labral tears, degenerative joint disease, a bad back, or other painful orthopedic condition?  Are you having trouble moving or being in certain positions?  Because if you are, step one of treatment should be physical therapy.  If your doctor hasn’t suggested physical therapy as an option for you and your condition, you should ask him or her why not.  Physical therapy is beneficial to all of the conditions I just mentioned and more, plus there are several added bonuses.91011

• Taking a more natural approach, avoiding the side effects of injections and medication
• Learning how to take control of your own situation through a plan that you can do at home
• Physical therapy helps you find and treat the problems that are contributing to your condition.  Physical therapy is not a temporary bandage.  PT supports long-term healing, reduces strain and stress, and can slow down degenerative conditions while improving your freedom of movement.1213

Cortisone injections are helpful for some conditions and you should discuss with your doctor whether your condition is one in which cortisone is shown to be effective.  Most of the research I have found shows cortisone injections are most effective in the short-term and this mimics what I have seen in the clinic with my clients.141516  The injection can be helpful to the therapy process when the pain is unbearable and exercise is not tolerable.  Where I have seen them to be especially helpful is with knee arthritis and with persistent hip bursitis.

There is research since that first blog in regard to cortisone injections that is worth mentioning.  For shoulder impingement and rotator cuff tendinitis, it is unclear whether injections are beneficial.1718  For some other conditions, specifically tendinopathies, research either shows injection ineffectiveness or that it may actually worsen the condition.192021  Recent research into tendinopathies has shown that many times inflammation is not even present and the painful condition is due more to degeneration of a tendon and improper healing.2223    Cortisone works by decreasing inflammation and if this is not present, there should be no reason for it to work.  Due to the side effect cortisone has on weakening connective tissue, it seems this should not benefit the natural course of the disease in the already weakened tendon.  There is not much research on the long-term effects of cortisone injections for the most common conditions I mentioned at the start of the post, though for tennis elbow, or lateral epicondylitis  (which is a tendinopathy), there is research showing that those who had cortisone injections actually do worse at 3 and 12 month long term follow up compared to those who did not have the injections.2425

Are you debating whether to have a cortisone injection or physical therapy?  My biased opinion is to try physical therapy first.  Cortisone injections have side effects that shouldn’t be taken lightly.  The success of cortisone injections varies by condition and for certain tendinopathies, there are studies that show it can actually make the condition worse.   You should always discuss treatments with your healthcare providers and weigh the risks and benefits.  A physical therapist is going to look at how you are moving, educate you about your body’s characteristics that are contributing to your problem, and develop a plan to improve your body in order to reduce stress and strain to an area and promote healing.  I’ve helped people with the conditions I mentioned above reduce their pain, improve their strength and flexibility, and return to their usual activities.  Need a physical therapist?  Find one here.

And to end on a personal note… it has been a while since I’ve written… but there are good reasons.  #1 A move from Wisconsin back to Louisiana to be closer to my family and #2 (the driver for #1), my first baby, a son Lucas. 🙂

• NPR: With Elbows, Cortisone Shots May Hurt More Than Help (Link added 02/06/2013)
• Chicago Tribune: Repeat Cortisone Injections…
• NYT: Do Cortisone Shots Actually Make Things Worse?
• USA Today: Cortisone Is it Worth the Shot?
• Rhon DI, Boyles RE, Cleland JA, et al.  A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial  BMJ Open 2011;1:e000137.

1. Grumet, Robert and Rubin, Benjamin. Injection Therapies in the Management of Shoulder Injuries.  Oper Tech Sports Med 20:114-123. [↩]
2. Wysocki, Robert W.; Biswas, Debdut; Bayne, Christopher O. Injection Therapy in the Management of Musculoskeletal Injuries: Hand and Wrist. Operative Techniques in Sports Medicine 20. 2 (2012): 132-141. [↩]
3. Grumet, Robert and Rubin, Benjamin. Injection Therapies in the Management of Shoulder Injuries.  Oper Tech Sports Med 20:114-123. [↩]
4. Wysocki, Robert W.; Biswas, Debdut; Bayne, Christopher O. Injection Therapy in the Management of Musculoskeletal Injuries: Hand and Wrist. Operative Techniques in Sports Medicine 20. 2 (2012): 132-141. [↩]
5. Grumet, Robert and Rubin, Benjamin. Injection Therapies in the Management of Shoulder Injuries.  Oper Tech Sports Med 20:114-123. [↩]
6. Wysocki, Robert W.; Biswas, Debdut; Bayne, Christopher O. Injection Therapy in the Management of Musculoskeletal Injuries: Hand and Wrist. Operative Techniques in Sports Medicine 20. 2 (2012): 132-141. [↩]
7. Grumet, Robert and Rubin, Benjamin. Injection Therapies in the Management of Shoulder Injuries.  Oper Tech Sports Med 20:114-123. [↩]
8. Wysocki, Robert W.; Biswas, Debdut; Bayne, Christopher O. Injection Therapy in the Management of Musculoskeletal Injuries: Hand and Wrist. Operative Techniques in Sports Medicine 20. 2 (2012): 132-141. [↩]
9. Fedorczyk, Jane M. Tendinopathies of the Elbow, Wrist, and Hand: Histopathology and Clinical Considerations. Journal of Hand Therapy 25. 2 (Apr-Jun 2012): 191-200. [↩]
10. Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009; 43: 247-52. [↩]
11. Kon, Elizaveta; Filardo, Giuseppe; Drobnic, Matej; Madry, Henning; Jelic, Mislav; van Dijk, Niek; Della Villa, Stefano. Non-surgical management of early knee osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy 20. 3 (Mar 2012): 436-49. [↩]
12. Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009; 43: 247-52. [↩]
13. Kon, Elizaveta; Filardo, Giuseppe; Drobnic, Matej; Madry, Henning; Jelic, Mislav; van Dijk, Niek; Della Villa, Stefano. Non-surgical management of early knee osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy 20. 3 (Mar 2012): 436-49. [↩]
14. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010; published online Oct 22. DOI:10.1016/S0140-6736(10)61160-9. [↩]
15. Roh, Young Hak; Yi, Seung Rim; Noh, Jung Ho; Lee, Sung Yup; Oh, Joo Han; Gong, Hyun Sik; Baek, Goo Hyun. Intra-articular corticosteroid injection in diabetic patients with adhesive capsulitis: a randomized controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy 20. 10 (Oct 2012): 1943-8. [↩]
16. Mcgarry, James G; Daruwalla, Zubin J. The efficacy, accuracy and complications of corticosteroid injections of the knee joint. Knee Surgery, Sports Traumatology, Arthroscopy 19. 10 (Oct 2011): 1649-54. [↩]
17. Johansson, Kajsa; Bergstromb, Anna;  Schroderb, Karin and Foldevi, Mats. Subacromial corticosteroid injection or acupuncture with home exercises when treating patients with subacromial impingement in primary care–a randomized clinical trial. Fam Pract August 2011 ; 28:355-365. [↩]
18. Koester, Michael; Dunn, Warren; Kuhn, John; Spindler, Kurt.  J Am Acad Orthop Surg, January 2007 vol. 15 no. 1 3-11. [↩]
19. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010; published online Oct 22. DOI:10.1016/S0140-6736(10)61160-9. [↩]
20. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006; 333: 939. [↩]
21. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2009; 1: CD004016. [↩]
22. Fedorczyk, Jane M. Tendinopathies of the Elbow, Wrist, and Hand: Histopathology and Clinical Considerations. Journal of Hand Therapy 25. 2 (Apr-Jun 2012): 191-200. [↩]
23. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006; 333: 939. [↩]
24. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010; published online Oct 22. DOI:10.1016/S0140-6736(10)61160-9. [↩]
25. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006; 333: 939. [↩]

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MoniqueSerpasPT

Physical Therapy Orthopaedic Specialist at Southeast Louisiana Veterans Health Care System

Follow @MoniqueSerpasPT
My name is Monique Serpas, PT, DPT, OCS. I am a physical therapist and board-certified Orthopaedic Clinical Specialist practicing at the Southeast Louisiana Healthcare System in New Orleans, LA. I realize how difficult it can be to overcome an injury or manage a chronic condition and am focused on helping my clients achieve wellness through a physically active lifestyle. I treat orthopaedic, balance, and vestibular disorders and practice using a combination of hands-on manual therapy, therapeutic exercise, and education. This enables my patients to assist in their own recovery and injury prevention. I also have developed fall prevention and golf-related rehab programs in the past. I hold a Doctor of Physical Therapy from Concordia University Wisconsin (2008) and a Bachelor of Science in Kinesiology from Louisiana State University (2004). I am a member of the American Physical Therapy Association (APTA), Louisiana Physical Therapy Association (LPTA), and the Orthopaedic and Neurology sections of the APTA.

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