When You Should Get a Cortisone Shot—and When to Say No
A cortisone injection is an anti-inflammatory treatment that works to provide rapid pain relief, but could it be too much of a good thing?
Whether it’s due to a sports injury or an arthritis flare-up, you may have heard your doctor mention the possibility of a cortisone shot. This anti-inflammatory steroid injection can be a powerful treatment against pain and inflammation. It’s important to note that it is not a painkiller, but the pain tends to subside after the initial injection.
A study in The Journal of Bone & Joint Surgery suggests that cortisone injections are becoming increasingly common in the United States. (Note that this study is specifically about epidural injections of the back.) But when it comes to cortisone-fueled pain relief, can you have too much of a good thing? Some patients have been found to experience faster osteoarthritis progression after getting cortisone injections, according to a 2019 study in Radiology.
California-based osteopathic doctor and Monarch Athletic Club medical director Ryan Greene, DO, offers insight on the benefits and risks of cortisone shots, while fitness author and TEDx speaker Melissa Kathryn, RD, discusses how to ease inflammation without an injection.
What is cortisone?
Cortisone is a type of steroid known to ease pain, swelling, and itching. It is actually a general term based on the natural hormone cortisol, and not a specific medication. Despite its name, cortisone is not the same as performance-enhancing anabolic steroids, which are drugs that mimic the hormone testosterone.
Cortisone is what’s known as corticosteroid injection, powerful medications that mimic the hormone cortisol and fight inflammation in the body. Cortisone is used to treat a variety of ailments, from carpal tunnel syndrome and cystic acne to asthma and arthritis. In most cases, triamcinolone (Kenaog) is injected.
Because of its potency against the body’s natural immune responses, cortisone is not available over the counter. Depending on the source and type of inflammation you have, your doctor will offer cortisone either as a prescription injection or pill. (Learn about the accidental history of cortisone and other common drugs.)
How cortisone works in the body
Think about the last time your knee smashed into the corner of a chair or the side of a doorway. First, you felt a sharp pain. Next, throbbing. Perhaps your knee even started to swell.
Dr. Greene explains that cortisone “significantly reduce(s) inflammation and pain by prohibiting or ‘dampening’ an immune system response to an area in which some sort of damage has occurred.”
Though unpleasant, pain and swelling are part of your body’s response to injury and infection. When a cortisone shot reduces your inflammation, it also reduces your body’s immune response, which makes you more susceptible to viruses and fungal infections
The widespread use of cortisone shots
Doctors likely prescribe cortisone shots so often because they treat such a wide variety of symptoms and issues. Cortisone also provides fast pain relief, which is attractive to patients in distress.
According to Dr. Greene, cortisone is very effective when administered properly. But he cautions, “It is almost always a temporary solution, providing a ‘Band-Aid’ of sorts. The effect will wear off and the underlying issue contributing to the pain may not always be addressed. It is commonly used in today’s medical setting because it provides a quick result and temporary pain relief.”
A cortisone shot may do more harm than good
Cortisone is not the same kind of steroid that is used and abused in the area of professional sports. But that doesn’t mean frequent cortisone injections are healthy.
Dr. Green recommends getting no more than three steroid shots per year. He says, “The issue with repeated and long term use of injected cortisone is the medication can cause localized tissue damage … contributing to a worsening of the underlying condition.”
In 2017, a two-year clinical trial in JAMA focused on 140 patients with symptomatic knee osteoarthritis accompanied with joint inflammation. Researchers found those injected with the corticosteroid triamcinolone every three months did not see a long-term benefit.
In fact, in a statement, Timothy E. McAlindon, MD, of Tufts Medical Center, Boston, lead author of the study, acknowledged the cortisone injections could potentially speed up cartilage damage in the knee. This led him to conclude these injections may end up doing more harm than good.
When to say ‘no’ to a cortisone shot
For most people, there are at least three situations in which it’s best to decline a cortisone injection.
If you’ve had repeated injections in the same spot
Because cortisone shots can lead to slow tissue and cartilage damage, it is wise to avoid injecting the same area again and again.
“Getting cortisone injections frequently to the same joint can be highly detrimental, as frequent injections in the same joint can damage it, as well as the surrounding soft tissue,” Kathryn cautions. “This may lead to the softening of the cartilage in joints or weakening of the tendons. (Here’s how to slash your risk of osteoporosis.)
If you have upcoming surgery
Dr. Greene says most surgeons will refuse to operate if you’ve had a cortisone shot within the last three months.
“It significantly inhibits the body’s innate ability to heal. Thus, if surgery is a possibility in the near future, I would recommend avoiding the temporary pain relief via cortisone injection,” he says.
If you have chronic pain and inflammation
If you experience constant aches and swollen joints, it is natural to want a quick fix. But Dr. Greene cautions against this.
“Pain and inflammation are innate signals the body utilizes to indicate something needs to be addressed. Muting those signals, although it will provide temporary relief, is often problematic because we are not focusing on the root cause,” he says.
So instead of requesting another cortisone shot, ask your doctor to help you identify the underlying cause of your pain.
Alternatives to cortisone shots
The good news is that skipping a cortisone shot doesn’t mean living with pain and swelling forever. There are plenty of other treatment options. Deciding how to address your pain will depend on the root cause.
Simple joint overuse injuries could benefit from RICE: rest, ice, compression, and elevation. For more severe inflammation, both Dr. Greene and Kathryn recommend platelet-rich plasma (PRP). PRP injections are a therapy in which a patient’s platelets are collected from blood samples and used instead of a cortisone shot. Note that PRPs are not usually covered by insurance in comparison to steroid injections.
“PRP injections use the patient’s own innate healing factors to be injected similar to cortisone, allowing actual healing to occur versus reduction of an immune response to mitigate pain,” says Greene. The exact mechanisms of benefit are still being explained, so this is still considered an alternative or complementary treatment.
Kathryn adds, “Licorice root … contains a plant compound called glycyrrhizic acid, which stimulates an anti-inflammatory effect by mimicking the actions of steroids in the body.” She also notes that alternative therapies such as acupuncture, hypnotherapy, and more can soothe the emotional and mental stress that contributes to physical pain.
A 2018 study in Frontiers and Pharmacology also indicates that local anesthetics and hyaluronic acid can also reduce joint- and back-related pain.
Cortisone shots are a quick, effective treatment for localized pain. If you have chronic pain, Kathryn suggests addressing inflammation with your diet.
She says, “Decrease your omega-6 intake by reducing your consumption of oils like sunflower oil and corn oil. Then your goal is to increase your consumption of foods that are high in omega-3, including flaxseed, oily fish such as salmon, walnuts, chia seeds, and avocado.”
Whether you choose to tackle your strained knee with RICE or a cortisone shot, your health decisions are very personal. Both Dr. Greene and Kathryn agree that cortisone shots offer fast relief—but that they’re not intended as a repeated, long-term solution.
Next, learn about good pain management.
- Ryan Greene, DO, MS, osteopathic doctor and medical director of Monarch Athletic Club, Santa Monica, California
- Melissa Kathryn, RD, a certified holistic nutritionist, fitness author and TEDx speaker
- Journal of Bone & Joint Surgery: "Geographic Variation in Epidural Steroid Injection Use in Medicare Patients"
- Radiology: "Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?"
- MedLine Plus: "Steroids"
- National Institute on Drug Abuse: "Who uses anabolic steroids?"
- Oncotarget: "Inflammatory responses and inflammation-associated diseases in organs"
- Centers for Disease Control and Prevention: "Medications that Weaken Your Immune System and Fungal Infections"
- JAMA: "Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial"
- National Institute of Arthritis and Musculoskeletal and Skin Diseases: "Long-term Benefit of Steroid Injections for Knee Osteoarthritis Challenged"
- Frontiers in Pharmacology: "Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain?"