What are the alternatives to cortisone injections?

There is no single answer, because each person differs, though the internet offers a very specific one, which is exactly what makes it misleading. Your clinical team will tell you what to expect after the procedure: which changes are normal, and which symptoms should bring you back.

The reason no single answer exists is what the injection actually is. Cortisone is the common name for a strong anti-inflammatory medication called a corticosteroid. An injection delivers the medication to one specific place, unlike a pill, which reaches the whole body. Some people will have injections into a joint, or into a tendon sheath, or near a bursa that is irritated. A bursa is a small pocket of fluid that acts as a cushion for tissues that rub against one another. The medication does not work the same for everyone and symptoms can get worse before they get better. Some injections are mixed with local anesthetics that wear off on a separate schedule. This is the reason people may be told not to drive or limit activity for the rest of the day. Before you leave, ask how long to limit activity and what to expect from your specific injection.

Cortisone is a strong anti-inflammatory medication. A cortisone injection can help with many painful musculoskeletal conditions. The idea behind a cortisone shot is that it delivers a potent anti-inflammatory directly to the site of the pain. Inflammation drives pain, so reducing it can reduce pain quickly.

Cortisone injections may be used for trigger finger, thumb side wrist tendonitis, tennis elbow, hip bursitis, thumb arthritis and arthritis of the knee, to name just a few. When a joint, bursa or tendon sheath is inflamed and irritated, a cortisone injection usually helps the problem right away because it reduces inflammation which decreases pain. For many of these problems, a cortisone shot is often the first recommended treatment before surgery is considered.

The downside: no one knows in advance how long the relief will last, and it differs between patients. A cortisone injection helps control pain, but it does not restore the joint. It will not make worn-away cartilage regrow, and that matters most where arthritis concentrates, knee pain above all. A patient's health and other conditions also shape the response. For example, patients who are diabetic, who have long-standing symptoms, or who have multiple digits involved tend to do worse with injections for trigger fingers. On the thumb side of the wrist, the tendon anatomy itself sometimes blocks the injection, rather than the steroid failing. None of that argues against the injection; it argues for realistic expectations. How many shots came before also matters: a fourth injection is a very different decision from a first. Steroid injections can help, and they can also injure the joint when given again and again.

Steroid injections are also different from steroids taken in pills. Injections deliver the medications to the area locally, but the body absorbs some of the medication systemically. How much steroid reaches the rest of the body, and for how long, depends on what is injected, where, how much, and the patient's overall health. Whether an injection is risky for you specifically is your prescriber's call, not this page's.

There are four kinds of alternatives to a cortisone injection, and which applies depends on your diagnosis rather than on the shot you are trying to avoid. Some of what follows sits inside regenerative medicine; some of it does not.

• Change what the tissue is being asked to do. Most conditions start with conservative care. That means rest from aggravating activities, physical therapy to stretch and strengthen the muscles pulling on the tender area, braces or splints, oral anti-inflammatories, and ice.

For conditions like bursitis of the hip, it is important to avoid activities like sitting with your legs crossed or lying on the affected side of your body.

For conditions like tennis elbow, taking a short break from work or sport-related activities is the primary treatment.

• A different injection. It's also a misconception that any injectable joint treatment is a steroid. Biologic injections and lubricating injections (hyaluronic acid) are not steroids.

Biologic injections use the patient's own blood or tissue instead of a medication, and the lubricating gel is not an anti-inflammatory at all: it works on joint-fluid quality and often takes a series. Of the biologic options, PRP injections are the most thoroughly studied. When a blood sample is centrifuged, the platelets concentrate, and they carry proteins that signal healing.

However, the strength of clinical evidence varies by diagnosis. Success in one joint does not carry over to a different joint.

• An office procedure that puts nothing into the tissue. Other options for thumb-side wrist issues include therapeutic ultrasound and acupuncture, though there is limited evidence to support them.

For a trigger finger, shockwave therapy (which delivers pulses of sound energy to an inflamed tendon) is still being studied and is not considered a standard treatment.

Needles can be used not just to inject medication, but also as simple mechanical devices. Examples include using needles to cut a palmar cord, or release a pulley in a finger.

• A procedure that changes the mechanics. Conversely, some pain can be from structural problems that won't be addressed by an injection. A surgeon can release a thickened pulley around a finger tendon, open a wrist tendon sheath, or free a ligament pressing on a nerve at the wrist. Loose bodies in the knee can be removed although this won't replace any cartilage. This is not the first resort; it is the conversation after injections have not helped.

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The commonest versions of the question are the knee and the hip, and a list alone cannot answer either: the diagnosis decides. Take hip pain, where the same ache can come from an irritated bursa or from a muscle pressing on the sciatic nerve, two problems with two different alternative paths. The list above is a menu, not a match.

The most common injected drug is a corticosteroid, a strong anti-inflammatory that dials down pain from inflammation. The relief is often quick, and the temptation is to read it as proof of healing. The tissue has not been repaired and the original disease is still there: a knee can still be bone on bone, and the cartilage has not regrown. The corticosteroid injection has simply altered the pain signal and the patient is now feeling a decrease in the signal. This can lead patients to feel they need another injection, and the wish for a repeat is understandable. The more useful question is how long the first one lasted. This information can be used during your medical visits to discuss further management and help the doctor and patient know if something has changed in the joint. If the next shot works but fades sooner, something in the joint may have changed, and that belongs in a visit rather than in booking another injection.

Evaluating pain has an order, and treatment has more options than an injection each time pain shows up. The default should not be walking in, pointing at what hurts, and getting an injection; even the pointing is not enough on its own.

An appropriate evaluation will determine what happened with previous treatment, whether it was completed or given up prematurely. Treatment options should be considered, relative to a diagnosis (not just where it hurts). Goals get set, along with a return date to re-evaluate.

The cortisone injection's real role is a question of order, and reading that order is trained judgment, on the record. Completed three advanced orthopedic fellowships. Double board-certified in Orthopaedic Surgery and Orthopaedic Sports Medicine.

Opposing steroids-by-default is not the same as opposing steroids. Whether another shot is the right move in your particular case is not something this page can decide. Request an appointment, and bring the history in writing rather than in your head: what was injected, where, when, and how long it lasted. Many Atlanta patients arrive without that list, and it is the single most useful thing to carry in.