For a variety of orthopedic problems, patients frequently can benefit from “cortisone” shots, but every day I hear lots of the misconceptions about what they involve, how much they hurt, and how bad they are for you. On the whole, they’re probably not as terrible as your friend made them out to be, nor are they as perfect as a “free lunch.” “Cortisone” shots are a generic name for an injection with a combination of local anesthetic (like Novocaine) and a corticosteroid. The anesthetic is used to provide immediate pain relief and also to dilute the small volume of steroid used so the medications can spread around more. The local anesthetic usually works within minutes and lasts from 1 to 8 hours, with the steroid taking effect more gradually over the course of about a week to powerfully reduce the inflammation. They’re used to help with pain and inflammation from tendinitis, bursitis, an arthritic or inflamed joint, or nerve compression in the spine. Most injections in an orthopedic office can be done just by knowing the anatomy and guiding the needle to the right spot by feel, but some deeper injections are often guided by ultrasound or live x-ray. The discomfort of the injection is typically dulled by using a topical sprayed anesthetic on the skin, or sometimes by injecting a local anesthetic separately into the skin prior to the cortisone shot. The medications themselves are typically not terribly painful to have injected, but rather patients feel a “strange” sensation from the volume of liquid that is quickly injected in typically just a few seconds. I find that patients often are surprised at how little pain there is—with comments from, “I didn’t feel anything,” to “that hurt less than a flu shot.” In general, the smaller the joint that gets injected, the greater the discomfort. Fingers and toes and feet hurt a lot more than big joints like shoulders and knees. If your doctor knows the anatomy and routinely deals with orthopedic problems, it’s a largely painless procedure. I think that some docs who inject and aren’t as familiar tend to fuel that legend of the “excruciatingly painful cortisone shot”. The steroid medication itself can damage joint cartilage and tendons, so we limit the injections in one site so the benefit tends to far outweigh the negative. For an arthritic joint, I will do as many as 3 shots per year per joint, but for most injections around tendons, I tend to only do those twice in a lifetime. The beauty of an injection is that most of the medication stays where you put it, so side effects tend to be limited and the effect is much stronger than what a pill can provide. There can be a flare of discomfort that can last 24-48 hours and is best treated with ice and Tylenol or Advil. Resting for 24-48 hours is also recommended. It can raise the blood sugar in diabetics for several days, or when injected in an area close to the skin can sometimes cause bleaching of the skin pigment. At some point, the problem may worsen and be greater than what cortisone can treat, so the best option may become surgery to fix the problem. So, if your doctor suggests a cortisone shot, there’s no need to be afraid. Chances are, it’s not nearly as painful as you might have heard, and its effect can be amazing relief.
by Daniel E. Thompson and M.D.