Current Insights On Using Cortisone Injections For Athletes

Cortisone normally is not the quick fix that athletes may hope for but it can speed the return to a high level of athletic activities when one gives the shots appropriately. A runner patient recently asked me for a general explanation of the role of cortisone shots in her care. I decided to write up my views for her and my blog followers. I hope it is helpful.

Cortisone shots are either short-acting or long-acting. Short-acting shots normally are beneficial for three days and can quickly reduce inflammation. They are commonly betamethasone (6 mg/mL) or dexamethasone (4 mg/mL) formulas. Since even short-acting cortisone can cause damage/weakness to tendons, if one administers injections into tendon sheaths, the injected body part should be immobilized for the three days.

It is the long-acting shots that are the true healers when the inflammation is out of control and normally what people are talking about when it comes to a cortisone shot. Long-acting shots have a crystalline base that slowly dissolves over a nine-month period. These shots commonly involve Kenalog (Bristol-Myers Squibb) (10 mg/mL) or Celestone Soluspan (Merck) (6 mg/mL) brands. Any shot after the first long-acting cortisone shot within the aforementioned nine-month period is considered a booster shot.

One normally mixes long-acting cortisone shots with a five-hour local anesthetic. There is a diagnostic aspect to this approach. The long-acting cortisone itself takes three to seven days before it begins to work. This is why you wait two weeks to see its effectiveness. I ask patients to tell me how much pain relief they received in the first five hours and then how much relief they have over the next three to 14 days. The initial five hours tell me if the shot deposited the cortisone in the right place.

Following a long-acting cortisone shot and after the local anesthetic has worn off, there can be a period of two to seven days where there is more pain due to the added swelling produced by the shot. This is why I encourage patients to ice the area of the shot three times daily during the first week and twice daily during the second week. I tell patients to come back in two weeks if they have less than 80 percent pain relief (normally no pain walking and greatly diminished pain from before the shot).

I usually give long-acting cortisone shots routinely to diminish inflammation for bursitis and neuritis situations.

Never give long-acting cortisone shots into tendon or tendon sheaths since they are associated with tendon ruptures. It is important to keep the cortisone as far away from the neighboring tendons as possible.

Only give long-acting cortisone injections into joints when magnetic resonance imaging (MRI), not X-rays, have documented no bone/cartilage damage to be of concern or when the only alternative is surgical treatment. For example, one can perform up to five cortisone injections a year for an arthritic joint to calm down the inflammation, but if the injections stop working, surgery in some form will be the only alternative. The patient must know this going forward with the shots.
Never inject long-acting cortisone into the plantar fascia itself but into the bursitis under it. Tears of the plantar fascia can occur with direct injections into the plantar fascia.

Do not permit patients to participate in running/high-demand/weightbearing sports for two weeks after they have received a long-acting cortisone shot. This is why athletes run from the thought of cortisone shots, even when they are limping, and vow they will ice hourly as long as they can still run. It is more realistic to try three to four weeks of physical therapy to cool off the inflammation and then maintain their relief with a daily icing regimen.

Most cortisone injections in the foot are 10 mg of cortisone each. Most cortisone injections in the knee are 40 mg each. Most epidurals (spinal) are 80+ mg of cortisone for each injection.

When it comes to plantar fasciitis, I recommend giving cortisone injections until 80 to 90 percent relief has occurred. This may require one, two or three shots, spaced a minimum of two weeks apart.

What is an 80 to 90 percent improvement? It is crucial to understand this concept. Eighty to 90 percent improvement occurs when athletes can resume full activity with only mild symptoms and easily maintain activity with non-invasive conservative treatments like icing, contrasts, activity modifications, stretching, anti-inflammatory medication, etc.

Most of the time, in my experience, only two cortisone injections (and a month of no weightbearing athletics) are needed to achieve 80 to 90 percent improvement. However, more than 20 percent of patients need one injection and an equal percentage of patients need all three injections.

There should be no predetermination as to how many shots are needed. Give the first shot and have the athlete return in two weeks. Evaluate the area. The doctor and the patient independently can give an estimate on what improvement (if any) has occurred. It is crucial that the patient ice the area three times daily during these two weeks. This can accentuate the anti-inflammatory aspect of the shot, hopefully eliminating any need for further shots.

When patients call me wanting an appointment for another shot, I normally have them icing three times a day for three days to see if they really need the shot. Over 50 percent of the time, they do not need the next shot. After the two weeks, if it is hard for whatever reason to determine how much improvement has happened, before giving another shot, I have the patient gradually return to full activity with anti-inflammatory oral medicine (after, not before, activity), icing, stretching, etc. If full activity is not allowed and the patient has not experienced 80 percent improvement, give a booster shot and continue the process for two more weeks. You can see how once cortisone injection therapy begins, it can take a while to finish.

In the worst-case scenario, three injections may not bring the inflammation down to achieve the aforementioned 80 to 90 percent improvement. One must then decide on further diagnostic tests or removable casts for immobilization. Normally, one, two or three shots do bring down the inflammation in combination with icing three times a day. With the 80 to 90 percent improvement, weightbearing physical activity can begin.

Hopefully, during the time of inactivity, some level of cross-training has happened so returning to activity at a higher level will not be too stressful on the body.

Once the cortisone shot(s) provide initial 80 to 90 percent improvement occurs, I will see patients at three months. If all is okay, I will see them again in three months before I will determine they are cured. If the symptoms reoccur and icing does not diminish the symptoms greatly, one can give booster shots one shot at a time.