What If A Cortisone Shot Doesn't Work?

What is Cortisone?

A cortisone shot is an orthopaedic steroid injection (corticosteroids) used to help reduce pain, bursitis, and inflammation symptoms.^1,2 Cortisone is often used to treat conditions such as:

• Rheumatoid arthritis
• Immunity disorders³ 
• Tendonitis
• Asthma
• Tennis elbow
• Trigger finger⁴
• Sports injuries

Cortisone can be used on either a short-term basis or as part of a regular pain relief care plan for chronic conditions. Cortisone shots are prescribed or administered by trained health care professionals, such as orthopaedic surgeons or doctors. The steroid is usually injected as close as possible to the point of inflammation to reduce it.

Cortisone is an artificial steroid that mirrors the natural steroid present in the body, named cortisol. It can be prescribed by injection, creams, orally, liquids, or in tablet form.

How is a Cortisone Injection Given?

Cortisone is usually administered into either the tendon or the soft joint between the bones. Here are some of the parts of the body where cortisone is likely to be injected:

• Shoulder
• Ankles
• Spine
• Wrists
• Knees
• Hands and feet (these areas tend to be avoided because the injection can be felt more in limited areas)

How Long Does Cortisone Take to work?

A cortisone shot usually takes several days before it begins to work to its fullest potential. Some people report noticing changes instantly, while others hardly notice any changes at all. 

How long does cortisone take to wear off?

How long cortisone takes to wear off is different for everyone. Typically, the injection can last from around six weeks to several months before the effects begin to wear off. 

Can a cortisone injection hurt?

The injection has been described as uncomfortable, yet not intolerable. Ultrasound scans and X-rays are regularly used to  administer a cortisone injection better and help prevent unnecessary pain or discomfort. These procedures are becoming more widely used, especially in sports medicine. Ultrasound and X-rays also help with getting to the point of damage more quickly and precisely, thereby limiting the number of potential side effects experienced afterwards. 

How Many Cortisone Injections Can You Have?

The number of injections you can receive to the same part of the body is limited to three. If cortisone is used too frequently, it has the potential to cause serious damage to the tissues near the injection site. In very rare cases, cortisone shots can cause necrosis (tissue death).⁵ 

Does Age Affect Cortisone Treatment?

Age is considered when prescribing cortisone shots. As you age, the less susceptible your muscle mass becomes.

Studies show that older age groups are more likely to already suffer from the more common side effects of steroid injections, including weakened immune system, diabetes and osteoporosis. Therefore, the dosage is usually lowered accordingly to combat these risks.

Side Effects of cortisone shots

Cortisone shots may have several side effects; some of the common reactions to a cortisone shot are listed below:

• Raised blood sugar (especially in people with diabetes)
• Weakened immune system
• Nausea/vomiting
• Pain/swelling around the injected area
• Changes in facial pallors, such as clammy, flushed, or paler than usual
• Gastrointestinal/peptic ulcers and bleeding
• ‘A cortisone flare up’⁶
• Temporary fat atrophy (loss of fatty tissues around the injected area)
• Changes in lactation for breastfeeding mothers
• Changes in menstrual cycle for women
• Excess hair growth
• Changes in appetite (usually become hungrier)
• Weight gain
• Skin changes (thinning of the skin/rashes/dermatitis)
• Increased hair growth
• Trophic disorders⁷

More uncommon side-effects

• Serious infections (especially in those with weakened immune systems)
• Nerve damage
• Anaphylactic shock
• Psychiatric disorders
• Adrenal insufficiency

Cortisone and other conditions

• Diabetes (cortisone shot can increase a diabetic’s blood sugar)
• Patients using blood thinners are more at risk of side effects

Why Might a Cortisone Injection Fail?

The more cortisone injections are used, the higher the risk of side effects. 

• Inflammation: Even though cortisol is a hormone used to reduce inflammation, unfortunately, it does not always help reduce pain symptoms. 
• Inflammation is not the issue: If a cortisone shot has not reduced the inflammation, it is likely that inflammation was not the underlying problem. If you notice that the steroid shot does not seem to have worked after a few weeks, please seek medical attention.
• Sometimes two or more cortisone injections are required to help reduce the inflammation.
• Advanced osteoarthritis (progressive arthritis): The more osteoarthritis progresses, the more tricky the disease is to treat using a cortisone shot. Surgery may be a better option for patients diagnosed with severe osteoarthritis to reduce pain/inflammation. 
• A missed target area: For cortisone shots to be effective, they must reach the correct area. X-rays and ultrasounds ensure that the drugs are delivered into the correct place.
• Infected injection area sight: On rare occasions, the injection area can become infected, preventing the cortisone shot from working to its fullest ability. If the injection site becomes painful, weepy or feels hot to the touch, please get in touch with your local health care provider for more advice.
• Destroyed stem cells: Steroid medication can kill stem cells that help to fight infection. People who already have low immunity are more susceptible to cortisone shots not working.
• Vitamin D deficiency: Too many cortisone shots can cause severe vitamin D deficiency, which stops the treatment from working properly.⁸ 

Adrenal suppression

Frequent use of cortisone shots can make you more susceptible to developing secondary adrenaline insufficiency.⁹  This is usually noticed once the course of steroids is complete and is one of the main reasons cortisone shots should be used sparingly. Symptoms can either gradually build up over time or rush on all at once, causing an adrenal crisis. This is a medical emergency that needs to be treated quickly. Here are some of the most common symptoms of adrenal insufficiency:

• Chronic fatigue
• Low blood pressure
• Feeling dizzy
• Darkening of the skin
• Temperature changes
• Low blood sugar (hypoglycemia)
• Changes in menstruation
• Weight loss
• A reduction in appetite
• Nausea/vomiting
• Loose stools
• Loss of libido
• Craving salty foods 

Pain relief and other treatments

The main purpose of a cortisone shot is to reduce inflammation, but sometimes it can be mistaken for pain relief. Medication for pain is likely to be prescribed alongside a cortisone shot. However, if you continue to experience pain after a few weeks, it could be a sign that the cortisone dose was not strong enough to be effective.

Pain relief 

One type of pain relief medication that might be prescribed alongside steroids is analgesia.¹⁰ These are commonly used for neuropathic pain.

Joint aspiration

Joint aspiration, when fluid is drained away from the inflamed area, can be used to provide relief for joint pain. Joint aspiration is usually performed under general anaesthetic, followed by a cortisone shot.¹¹ 

Surgery

If the cortisone shots are not reducing the inflammation as they should be, then an individual might require surgery. One type of surgery that is common is joint replacement. 

Platelet-rich plasma injections

Platelet-rich plasma (PRP) injection is a modern,  regenerative approach that helps to reduce inflammation by collecting the plasma blood platelets and injecting them into the intended area. This treatment has proved to be beneficial for reducing inflammation and pain. As the PRP is taken from your body, it can not be rejected.^12,13

Summary

Cortisone injections are an effective method to reduce injury or trauma-induced pain in orthopaedics. Cortisone shots have many benefits, but repeated cortisone injections are subject to potentially serious side effects. In addition, cortisone jabs are not always the correct approach to treat inflammation of the joints, meaning other options may be considered by your orthopaedic team, depending on your age, health and response to cortisone treatment.