Cortisone Injections - pain relief at what cost?
Note: This is an update of an earlier article.
Let me present the case of a very fit woman who, by anybody's terms, completely overdid the exercise for a few months towards the end of last year. She developed left ankle pain that would not resolve. She was referred to a sports medicine physician who injected the spot with hydrocortisone. Being a sports physician, he would have been well aware of the risks associated with these injections and would have exercised due care with the procedure.
The relief was immediate and she was able to resume normal activities several days later.
About 6 months later, she developed diffuse ankle joint pain when running. It refused to respond to treatment, including rest. The ankle would throb while sitting. Running out of options, she came to see me.
Her case is quite typical of what I see months after cortisone injections and long after the patient has been declared "cured" of their musculoskeletal pain.
Photo One shows the left ankle appearing to be less meaty in appearance as compared to the right.
Photo Two shows a hollow towards the front margins of the ankle bone
Photo Three shows a marked hollow where there should normally be fat and ligaments
So, what is going on here?
What hydrocortisone does
Hydrocortisone is a means of doing a "chemical exision". In other words, it is a way of removing tissue without the need to cut. The chemical literally dissolves tissue. This is very effective at removing spots of persistent pain - it makes the problem literally disappear!
The problem
While it removes the pain, it invariably leaves the structure weakened. Furthermore, wherever the fluid leaks, tissue is killed off. In this case, healthy tissue - including shock absorbing fat and gristle and protective ligaments were damaged and even disappeared altogether!
It would also appear that some cortisone leaked into the joint itself, causing arthritic changes that now show as diffuse pain throughout the ankle joint, including the other side and general throbbing.
These complications are common. The first instance I can recall was of a running mate who was just on the heels of elite milers like Dixon, Quax and Walker. He developed plantar fasciitis of the foot and had a cortisone injection that fixed the problem. A few months later, he was out for a training run when he felt something snap in his foot. The plantar fascia had completely detached from the heel bone. His foot catastrophically collapsed. When I examined his foot, the arch was absent, he had knee pain due to altered foot mechanics and there was no fatty pad under the skin of his heel - it had been completely dissolved! That was the end of his running career.
Once the tissue is gone, it aint ever coming back.
I have seen plenty of cases of delayed complications. Possibly the most common is cortisone injections to relieve tennis elbow types of pain. This can result in complete avulsion of the wrist extensor muscle where it attaches at the elbow.
In these kinds of cases where there is a delayed complication, the treating doctor may forever remain blissfully unaware and will have chalked the case up as a treatment success.
Sometimes, the cure can be much worse than the ailment itself.
Labels: ankle pain, cortisone
9 Comments:
do these problems come about through a single injection or from a course of injections, I think we've all come across someone who will swear by cortisone in helping them, so i wondered it if was more protracted use or a matter of luck if a single shot helped or hindered
In the case presented here, it was a single shot done by a highly qualified and respected sports medicine physician.
Generally, the limit is no more than 2-3 to an area and spread over time.
Whyt take the risk of catastrophe when there are very safe and effective alternatives? I will cover some of these in a followup article.
Your article has completely freaked me out. I had a cortisone injection after extensive physio failed to relieve a very painful ankle which hurt any time I was walking or running over uneven surfaces. The cortisone injection was a "last resort" and I too was referred to a highly respected sports doctor and athlete for the treatment. More than 6 months has passed since I had that treatment and things seem to be fine. I've had lots of friends and colleagues though who've subsequently warned me about having this treatment ever again. Needless to say, after having read your article - won't.
Julie,
Do not get too freaked out. These injections can and often do work; but they sure can go wrong now and then. That you have remained symptome free is encouraging and you will probably be fine as and never look back. I am going to do a followup that covers some of the alternatives, including what I have recommended for the case presented in this article.
makes me wonder about any injection, given the large hard sore lump on my shoulder (no not my head) from my tetanus shot a week ago
When I read your article it could have been about me. I had a cortisone injection into the posterior tibialis tendon in November of last year. It did the trick initially - allowing me to compete in several more races before starting to play up again. I am now left with a hollow above the left ankle and am on a waiting list to see an orthopaedic surgeon to see what he can do. Needless to say I'm not running an am missing it sorely.
Debra,
I am sorry to hear of your ongoing foot problems, I guess it is of little comfort that you are not alone.
If you are able, you might like to have me take a look at your injury. Surgical solutions (of which cortisone is one) should be last resort options only to be exercised after other less radical and risky options have been thoroughly tried and exhausted.
Hi Gary,
Back on New Years Day I came of my bike and landed on my shoulder. This seemed to flair up an ongoing problem with my Rotator Cuff so I went back to my Physio for some treatment (yes, covered by ACC). After extended treatment I had achieved some relief but it had plateaued so my Physio sent me for an Ultrasound, the result - "a large full thickness tear which involves all but the anterior border of the supraspinatus tendon".
My Physio suggested surgery to be the likely treatment but referred me to my doctor. My doctor has suggested that the appropriate treatment is most likely Cortizone and has provided me with a choice of referral to one of two specialists. The first a Sports Medicine Specialist who is more than competent to carry out the surgery (also my Physio's preference) and the other a general Orthopaedic Specialist competent to give a Cortizone injection but "not someone he would recommend me to if he thought surgery was required".
I have been trying to set up an appointment with the first surgeon and, having waited a month already, have finally received an appointment for mid-July. I don't think I can wait another 6 weeks but am loathe to go down the Cortizone track if it is not going to give me complete mobility back in my shoulder and arm.
Your advice or comments appreciated.
Regards
Paul Leslie
Paul, without seeing you in the flesh and properly evaluating the shoulder, it is hard to be specific with advice. Are you in Wellington?
While I am very cautious about cortisone, it does have its uses. However, in most cases where it may used there are often good alternatives. In the case of a shoulder, this may be a mix of massage, exercises and manipulation.
I recommend that you consult a specialist in shoulders. If you are in NZ I may be able to make a recommendation for you.
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