Cortisone Shots For The Treatment Of Tennis Elbow: Dangerous Damaging AND Ineffective?

When it comes to the treatment of Tennis Elbow, the Cortisone shot is the epitome of the quick fix cure – It can often wipe away pain like magic, sometimes providing complete relief in the short term.

Research reveals, however, that the powerful but often fleeting benefits of Cortisone can come at a very high price in the form of long-term and sometimes very serious consequences... Is the pain relief worth it? – And does it actually have anything to do with healing the injury?...

Podcast: Cortisone Shots For Tennis Elbow Treatment: A Bad Idea

Here's a podcast version of the Cortisone Shots video above. It's downloadable at SoundCloud.

The Dark Side Of Corticosteroid Injections

Here are the key points you need to know if you’re considering getting an injection or if you’ve already had one or more:

Photo of syringe: Cortisone Shots poor treatment for Tennis Elbow

The Cortisone Shot: Absolute Worst Treatment For Tennis Elbow Ever

  • Cortisone shots are NOT an effective treatment for Tennis Elbow: They certainly don’t help your tendons heal (they only mask your symptoms),

     

  • Not only are they ineffective at healing they can have the opposite effect; actually damaging your tendons –  delaying your recovery by months or even years, (among other serious side-effect risks),

     

  • Medical researchers have known about the damaging effects of Corticosteriods for decades, yet despite this fact, Doctors continue to give these damaging shots – often without informing you of the full risk involved.

These are well-documented, easy-to-find facts. Here’s a key quote about the shot's worst effects from a very often-cited paper I consider “The Bible” on tendon injuries:

"It is clear that, corticosteroid injection into tendon tissue leads to cell death and tendon atrophy. …[Cortisone injections] inhibit collagen synthesis and decrease load to failure"

Histopathology of Common Tendinopathies, Khan, et al

So, Cortisone shots given directly into the tendon can cause cell death (self-explanatory, right?) and tendon atrophy, which simply means shrinking and weakening.

With this understanding they’re not supposed to inject it right into the tendon any longer, rather “around” it – but how much safer can this be!? (And does your doctor know this and follow it to the letter? How accurate can they be with that needle?)

And more importantly, do you really want a substance that has been shown to kill cells under your skin, around your tendon or anywhere NEAR it!?

As also noted, Cortisone can inhibit collagen production, which is another very bad thing because collagen is the protein that your tendon is made of, and you absolutely MUST be able to make more of it to repair and heal your tendon.

And “decrease load to failure,” is another way of saying the tendon is weaker and can’t handle as much stress or weight “load” on it - before it fails and possibly even ruptures (this has been know to happen, especially with athletes.)

I first discovered and wrote about this research in my “Tendonitis” ebook about 10 years ago in 2003, when hardly anyone was talking about it.

The big, “MD-type” websites sadly still recommend the shot and perpetuate the inflammation myth, which we’ll get to, but it’s encouraging to see the truth about Cortisone going mainstream.

I was delighted to stumble on a post by Gretchen Reynolds, in the NY Times “Well Blog” asking…

“Do Cortisone Shots Actually Make Things Worse?”

This refreshingly direct article from 2010 begins with a brief look at the history of the cortisone shot, how it was lauded as a miracle-cure drug when first used in the 40s, and how it actually produced mixed and in some cases disappointing results in the clinical trials in the 50s.

That minor detail has, of course, done little to slow Cortisone’s meteoric rise to Pharma Superstardom and universal usage.

Gretchen then cites a recent Lancet-published review of over 40 more recent clinical trials involving people with tendon injuries, mostly Tennis Elbow.

The review showed that in the short term it was clear that Cortisone shots did provide quick and significant pain relief – No surprise there.

But in the long term, 6 months to a year later, the people who had the shot were MUCH worse off than those who did nothing, especially those with Tennis Elbow, over 60 percent of whom suffered “a recurrence.”

(“Recurrence” sounds a little mild to me, but this is dry medical lingo. What I hear is: “The pain returns with a vengeance”)

Quoting the summary of the Lancet article directly:

"…Corticosteroid [Cortisone] injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms."

Efficacy and Safety of Corticosteroid Injections... The Lancet, Vol 376, Iss. 9754, 20 Nov. 2010, Coombes et al
Link to study on G+

Here’s another paper published two years earlier (which may be included in the Lancet review) saying basically the same thing, "No proof that they work."

"…Corticosteroid injections have been used for decades in the treatment of tendinopathy. [tendon problems like Tennis Elbow] There is strong evidence they relieve pain in the short term up to 6 weeks, but there is no evidence they provide any benefit in the long term (beyond 6 months)"

Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon; Andres and Murrell – ncbi.nlm.nih.gov/pmc/articles/PMC2505250/
Link to source (G+)

Now, switching back to The Times Article, here’s the kicker:

"Those people receiving multiple injections may be at particularly high risk for continuing damage…"

Dr. Bill Vicenzino, University of Queensland, Australia

This is something I’ve been convinced of for many years as a practitioner. I’ve treated many people with Tennis Elbow and have seen first hand (well, more like felt first hand) the damage done.

I believe I’ve seen the effect Cortisone has on the healing process. It stops it dead in it’s tracks. This is anecdotal, of course, and no kind of medical proof, but I can tell you the people who’ve had the shot (especially those who’ve had more than one) always take at least twice as long to recover – if they recover at all.

Slideshow: Cortisone Shots For Treating Tennis Elbow: Friend Or Foe?

Brief slideshow glance at the controversy over Corticosteroid injections as a way of treating Tennis Elbow (YouTube video on slide #2)

What Is Cortisone And Why Is It Used?

Cortisone is the man-made version of a Corticosteroid hormone called Cortisol that our bodies naturally produce.

The 'Anabolic' Steroids usually get all the attention and notoriety. They’re the "builder" hormones; they build tissues up, especially muscle.

And then there are 'Catabolic' Steroids, which is the class that Cortisone belongs to. These steroids have the opposite effect – They break your tissues down.

They are also very powerful inflammation suppressors and that’s theoretically why they’re used to treat Tennis Elbow and other 'Tendinopathies' (tendon conditions) but there’s a big problem with this idea…

Inflammation: Chasing A Ghost That Isn't There

There are two things you need to know about inflammation, when it comes to Tennis Elbow (and most other tendon conditions.)

The first is that most of the time there isn’t any! In other words, it’s not “Tendonitis” – (The ITIS suffix suggesting an inflammatory condition.)

“Numerous investigators worldwide have shown that the pathology underlying these conditions is tendinosis or collagen degeneration. One factor that may interfere with optimal treatment is that common tendinopathies [including Tennis Elbow] may be mislabeled as tendinitis. …An increasing body of evidence supports the notion that these overuse tendon conditions do not involve inflammation.”

Overuse tendinosis, not tendinitis part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed. 2000 May;28(5):38-48 - Khan, Cook, Taunton, Bonar - ncbi.nlm.nih.gov/pubmed/20086639

The inflammation “story” is a tired, old myth and the Orthopedic-Surgeon authors of this second paper (and I suspect most of them in general) know the research and see for themselves no significant signs of inflammation in the tendons they perform surgery on:

“As orthopaedic surgeons, we are besieged by myths that guide our treatment of lateral epicondylitis, or "tennis elbow." …The term epicondylitis suggests an inflammatory cause; however, in all but 1 publication examining pathologic specimens of patients operated on for this condition, no evidence of acute or chronic inflammation is found

Lateral tennis elbow: "Is there any science out there?" Boyer MI, Hastings H 2nd; J Shoulder Elbow Surg. 1999 Sep-Oct;8(5):481-91 – ncbi.nlm.nih.gov/pubmed/10543604

The research clearly shows that most cases of Tennis Elbow (and other so-called TendonITIS cases) are degenerative NOT inflammatory. And they reclassified it as TendinOSIS decades ago – (See my article and video on Tendonitis Vs Tendinosis for more on this.)

What this means is not only do Cortisone shots “chase” something that probably isn’t even there, (inflammation) they risk making a problem that probably IS there worse.

Recalling that Cortisone is a ‘Catabolic’ Steroid; a steroid that breaks tissues down… And that Cortisone shots into tendon tissue can cause: “cell death and tendon atrophy,” and they can “inhibit collagen synthesis and decrease load to failure.”

What we seem to have here is a perfect recipe for worsening or outright causing degeneration and long-term weakness, pain and suffering.

The other thing you should know about inflammation is that it’s a normal, healthy part of your healing process – At least when it comes to normal muscle and tendon healing.

I know I say this a lot, but it needs to be repeated and fully accepted: The simple fact is you can’t have healing and repair of your injured tendon without going through the inflammation process.

Tendons have a hard enough time healing without us trying to chase away with a dangerous drug one of the very things required in that healing process. Which leads us to the obvious question…

How do you support healing rather than getting in its way?

That’s what Tennis Elbow Classroom is all about.

Learn To Treat Your Own Tennis Elbow Here In The Membership Program:

Tennis Elbow Classroom Membership Card Image

You'll get instant access to a complete video program designed by a professional therapist to help you take charge and break your vicious elbow pain and injury cycle...

I'll be your personal tutor guiding you through easy-to-follow video lessons, where you'll learn all the therapy techniques, key stretches and essential exercises you need to treat and recover from your injury at home. (No special equipment or gimmick devices needed!)

Just watch the videos, follow along and start putting an end to your elbow pain today.

Learn more, join and get started here: Tennis Elbow Classroom Self-Help Program

Comments

  1. helen mcqueen says

    Hi, I have had tennis elbow for several years and have about two cortisine jabs per year. It has returned again and I am booked in for another jab today to tide me over till I get surgery. afrer reading your very informative article I have decided to take your advice. I am going to ask my Dr about “shock wave therapy” in the hope that will help.

    • says

      Wow, Helen – That sounds like a lot of shots you must have had! Glad to hear you’ve decided to say “No Thanks!” to another jab, though. I wish you a speedy recover, but also must encourage you to be patient, as that many shots can significantly delay tendon healing.

      (Unfortunately, in my experience, the damage seems to increase exponentially with multiple shots over time.) Hang in there!

  2. mike says

    I had tennis elbow about six months ago and was desperate to get it solved as I am an avid tennis player and do many other activities. I bought a special brace, theraband exercise bar, electric accupuncture and finally a cortisone shot. Completely healed… or so I thought. four months later it started to hurt again. Not much, but i could tell it was coming back. I did not know then what I know now about cortisone and was convinced to have one more injection. Disaster! Hurt a ton for the next two days but thought that was normal. Within a week I could see a valley forming on the back of my forearm caused by atrophy. Doctor sent me to physio, had fifteen sessions and was just getting worse. The pain is very different from the original tennis elbow, very specific, very sharp and very painful. Not only can I not do sports, I cant hold a cup of coffee, open a jar or do just about anything with my arm, which is starting to whither away from non use. (I use to work out 5 days a week). I am not afraid of hard work and will do what i need to get my arm back, but I fear I am going in the wrong direction. I think I am hurting it at physio and I recently read a post that some tennis elbow cases cannot be fixed after severe atrophy. Help!

    • says

      Thank you for posting, Mike. That sounds terrible. I’m really sorry to hear you’re having such a tough time.

      How large was that “valley?” Is it in your muscle or your tendon? That sounds like very dramatic atrophy. I’ve been doing a little researching and it looks like there are many more medical references to Corticosteroid-induced muscle atrophy (in many muscles at once) when it comes to taking the drug orally, rather than injection. (Atrophy refers to muscles – Tendon shrinkage is usually degeneration, from my understanding.)

      The research I’ve seen on the long-term effects of the injections seems to focus on the damage to tendon it’s injected into or around, but it would seem to make that sense that local muscle atrophy could result from an injection (or more likely a series of them.)

      I have seen one case in my practice where the person had a very bad reaction to the shot, and it caused a crater-like, crystalline-feeling depression (can’t seem to find the right term for this side-effect if there is one other than degeneration) in their tendon (but not the muscle connected to it.)

      My thoughts on this is that despite the dramatic sudden onset of your muscle shrinkage / atrophy (if it is in your muscle and not your tendon!) muscles have a much, much larger capacity to heal and recover. So, I hope it’s muscular.

  3. Anthony says

    Hi, two days ago I had my second cortisone injection in my elbow in the past six months per advice of my orthopedic physician. After reading the research you provided, I regret my decision. My elbow feels better, but I have more tenderness this time around in the area. He suggested trying a PRP injection if this one didn’t do the trick. I just hope I haven’t already done irreparable damage.

  4. Patti says

    I hit my elbow on the corner of my husbands dresser in the middle of the night. RIGHT below my joint above my forearm.. apparently right were people get tennis elbow.. I thought I just bruised it but it lasted for 4 months so I went to an orthopedic dr. He gave me a cortisone shot in March.. my pain returned about two weeks go, just got another shot today and it hurts WAY worse than it did the first time. I can not bend my arm up to my face or straighten it all the way.. I am sure it will feel better in a couple of days but I am assuming it hurts worse this time because I used my arm normally and did nothing to help it heal. He did mention surgery if it keeps flairing up…. scary!!

  5. Tim Mason says

    I have been suffering for 9 months with cronic tennis elbow. So far I;ve had 2 physio treatments lasting 8 months
    and 1 cortisone injection. I was re-assessed yesterday and the doctor is recommending another cortisone
    injection which I am going to refuse.This is not an easy decision for me as the Workers Safety Insurance
    Board here in Canada will probably cut off my funding. The first injection I had did nothing to help my
    condition and I feel another injection is just plain stupid. i am contacting my family doctor to get a referal for
    a sports injury specialist to get a second poinion. I feel that the Canadian health system is way behind other countries in dealing with tennis elbow injuries. My research into Platelet Rich Plasma injections has me
    convinced that this would be a better option for me. The problem is that this treatment is not recognized by
    the Canadian health system and will not pay for it. it is my opinion that more research is needed to determine
    a better method for the treatment of tennis elbow in Canada as cortisone is not the answer.

  6. Elba Grossling says

    I have been suffering from tennis elbow for the last three months, it has been very painful, even to blow my nose, hold a cup of coffee, etc. I am receiving teraphy right now. Since I have not improved yet, today the Orthopedic doctor injected me with two injections of steroids (top and bottom part of elbow), I am having tremendous pain in the right arm and elbow area and do not know what to do. I do not know if I could take a pain killer. I cannot get hold of my doctor. I am getting for a nite of pain. Any suggestions?Can you reply? It will be very much apreciated.

  7. Heidi says

    My son had some elbow issues this season in football throwing he had to miss three games. Now he is able to throw and has no pain but his arm is still bent. Is this normal for recovery or should we be doing something, he is stretching and massaging it and he wants to play basketball but Im not sure about it??

  8. jennifer goodrich says

    I had a rotator cuff tear. Got kenalog injected into my left shoulder…the tendon sheath to be exact. Six months after the injection i am still experiencing side effects. I had a period for 40 days straight. Hair loss that still continues, steriod psychosis, atrophy…everything you name it. I went to 5 doctors all of them told me i was just stressed out and one even offered me more kenalog. Im now getting surgery bc ive lost my range of motion and am so weak it hurts to put my shirt on in the morning. This stuff is poison and im glad someone realizes cortisone is bad and not the miracle drug docs claim it to be
    If anyone would like to talk about my experience or share yours feel free to email me

  9. Victor Rivera says

    I started your program today hoping to get better soon. I have been lifting weigths for 15 years and all my prior minor injuries have been at the elbow tip which have been told by my orthopedic surgeon was a bursitis. Afrer Celebrex and rest it finally got better and I was able to resume weight lifting for 1 year, but now comes this new injury that was told by the same orthopedic surgeon that was a lateral epicondilitis (tennis elbow) I have had my tennis elbow for 2 months and have been taking Celebrex on-off combined with totally been off exercising with weights for 2 full months without much sucess. He then suggested a cortisone injection when I complained of persistent pani. I got scared of this therapy so decided to consult a physiatrist. She ordered a elbow sonogram that revealed a 8 mm interstitial tear at the tendon area just were it reaches the lateral epicondile so the diagnosis was correct but she does not like steroid shots for the same reasons that you mention in your web site and videos. She told me to use Celebrex daily for 10 days and gave me exercises very similar to your web site as well as stretching. She also recommended a portable TENS UNIT and physical therapy with sonography and gels. Here is the thing. She told me that if I dont get better in 6 weeks instead of steroid injection she has had good results with dextrose injection (Prolotherapy) . Do you have an opinion on this dextrose injection? She says sugar is less likely to cause the bad rap of the steroids. She says sugar WILL CREATE an inflamation rather than decrease inflamation and that this will help better than steroids. Here is a link for a site I found: http://www.ncbi.nlm.nih.gov/m/pubmed/23291605/ Your response woud be apperaciated on this therapy.

    • says

      Sounds like you have a sensible Physiatrist, Victor.

      I like the theory behind Prolotherapy (Thanks for the link to the study. I hadn’t seen that yet.) but it’s still an injection. I’m sure you’ve done some searching for yourself on it and have found that people sometimes have bad reactions to it – even though it’s a totally benign substance.

      I’m not about to tell you what to do, but I will say that I wouldn’t do it myself unless it was a last resort. (Glad to see you joined as a member – Thank you and welcome to Tennis Elbow Classroom! I’ll be looking forward to hearing about your progress.)

  10. Mina says

    Thank you so much. I had pain in different parts of my elbow since last May. This morning and to my sorrow my elbow specialist just gave me a Cortisone injection. I was actually improving with physical therapy but the progress was very slow. Should I expect my case to get worse now and my tendons become weaker. Will I be able to go back to weight lifting? My Dr. didn’t mention any of the side effects of a cortisone injection.

    • Mina says

      Also would PRP fix this mess the cortisone creates. I can’t believe that Drs would do something that make your case worse. I am honestly freaking out after reading all of this negative reviews.

      • says

        PRP sounds good in theory to me so far. Definitely moving in the right direction toward supporting and stimulating the healing process – and away from just “symptom suppression at the expense of healing!” (which is what I think of as the very essence of Cortisone.)

    • says

      Mina, I’m sorry to hear your Doctor didn’t mention anything about the downside of Cortisone. (It seems they seldom inform people – I wonder how many really know about all the medical studies.)

      I have no way of knowing if your tendons will get weaker – but the upside is that it was only one shot, right? (It’s the multiple injections over weeks/months that seem to have a cumulative, negative effect.)

      I would try to put it behind me, if I were you – You didn’t know any better and had no opportunity for ‘informed consent’ – so, all you can do is make your decision about whether to have any more shots (I’m guessing, no? ! ) and do your best to move forward and support your healing process.

      I don’t see any reason why you wouldn’t be able to get back to weight lifting (you’ll have to be careful, of course) but to help you with that question I would definitely suggest my post and video: Can You Still Work Out When You Have Tennis Elbow?

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