When it comes to the treatment of Tennis Elbow, the Cortisone shot is the epitome of the apparent quick fix cure – It can often wipe away pain like magic, sometimes providing instant and complete relief in the short term – But at what cost in the long term?...
Research reveals that the powerful but often fleeting benefits of these steroid injections can come at a very high price in the form of lasting and sometimes very serious consequences in the long run (like significant tendon damage.)
Is the pain relief really worth it?... Does that relief have anything to do with healing the injury? – Or is it actually a mirage; a complete falsehood?...
(The video above contains a playlist of two episodes on Cortisone - The first being shorter and more recent - and the second a longer, older version containing more of the details you'll see below.)
Podcast On Cortisone Injections For Tennis Elbow Treatment
Here's a podcast version of the second, longer Cortisone Shots video above that you can download and keep by clicking the "download" link under the player below:
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:
- 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.
Update: Aug 25, 2016 - Another Cortisone Shot Study And NYT Article
The Cortisone shot came under fire again by Gretchen Reynolds this week, questioning the idea that it's a valid 'Quick Fix' for Tennis Elbow.
In the article, 'For Tennis Elbow, No Such Thing as a Quick Fix' (link below) she begins by affirming the continued popularity of the Cortisone shot as a Tennis Elbow treatment:
"Recent surveys in the United States and Britain show that injections of the steroid, ...are the preferred first line of treatment among many orthopedic specialists."
And then immediately raises the issue of the risks involved with these shots, referring to the:
"...growing evidence suggests that the injections, while effective in the short term, can frequently worsen the condition in the months that follow..."
Cited in the article is a study from Norway published in BioMed Central's Musculoskeletal Disorders Journal, which suggests that Cortisone injections, while effective in the short term for Tennis Elbow (in relieving pain) frequently worsen the condition in the months to come:
Isn't it sad and unfortunate to hear that Cortisone shots are STILL "the preferred first line of treatment" among numerous Orthopedists, considering this growing body of evidence suggesting they do more harm than good?
Not THIS one, apparently, though! Check out this video from an Orthopedist, frankly sharing his views on Cortisone shots here
And here's more evidence from more recent studies:
“Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences.”
“Use of corticosteroid injections to treat lateral epicondylalgia [Newer term for Tennis Elbow] is increasingly discouraged, partly because evidence of long-term efficacy has not been found, and due to high recurrence rates.”
Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia: Brooke K. Coombes, PhD; Leanne Bisset, PhD; Peter Brooks, MD, FRACP; et al - JAMA. 2013;309(5):461-469. doi:10.1001/jama.2013.129 https://jamanetwork.com/journals/jama/fullarticle/1568252
“CONCLUSIONS: Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis.”
“There is increased collagen disorganisation and necrosis as shown by in vivo studies...”
“This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.”
The Risks And Benefits Of Glucocorticoid Treatment For Tendinopathy: A Systematic Review Of The Effects Of Local Glucocorticoid On Tendon Semin Arthritis Rheum. 2014 Feb;43(4):570-6. doi: 10.1016/j.semarthrit.2013.08.006. Epub 2013 Sep 26. Dean BJ; et al https://www.ncbi.nlm.nih.gov/pubmed/24074644
("Increased collagen disorganization" meaning the tendon protein fibers are losing their strong, parallel alignment and becoming more random - And "collagen necrosis" means that the proteins are breaking down and degenerating - Rotting, essentially = Very bad results.)
Shockingly, collagen disorganization and necrosis/degeneration is the very essence of what's wrong with the tendons in most moderate to severe cases of Tennis and Golfer's Elbow, in the first place! (Known as Tendinosis, which we'll cover more about shortly.) So, it appears that the steroid shots are making this worse!
So, What Is Cortisone And Why Is It Used?
Cortisone is the man-made / synthetic 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 - https://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.
If you're going to inject something, at least consider ProloTherapy or Platelet-Rich Plasma injections, which might actually encourage and kick-start a failed healing process - rather than suppress healing even further!
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.
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