Monday, May 29, 2017

Steroid Injection Not Better Than Placebo For Low Back Pain

Picture by Army Medicine from Flickr
It seems like another of my patients has been asked if he wanted a cortisone (or corticosteroid) injection for his low back pain after I wrote about my shoulder pain patient last week who was asked by another doctor to get a steroid injection.

Evidence that they (cortisone or corticosteroid injections) work no better than placebo is mounting though.

The article referenced below is a systematic review. A systematic review is a computer aided search for all randomized and clinical controlled trials, meaning it's top of the line in terms of quality.

Researchers pooled data together from 30 placebo controlled studies of epidural steroid injections for radiculopathy (back pain that radiates to legs) and eight studies for spinal stenosis (back/ neck pain caused by narrowing of the spinal canal).

For radiculopathy, the steroid injections provided only short term relief. Over time, they were not more effective compared to placebo injections. They also did not reduce the need for surgery later for patients with more severe conditions.

The pooled data was similar for spinal stenosis.There was only some moderate temporary pain relief after the corticosteroid injections. There were no differences between steroid injections and placebo injections in pain intensity or functional ability lasting six weeks or longer after the injections.

The authors did note that some studies did not have many subjects while others had shortcomings their methodology.

The researcher in charge also suggested that there was probably some financial motivation to carry on using steroid injections despite the lack of evidence for its effectiveness. There is also a worry among professional societies (for doctors) due to implications for insurance coverage.

Other mentioned less selfish reasons is that doctors see their patients in horrible pain and concede that they do get some pain relief after the injections.

Please come to our clinics if you need help with your low back pain. We definitely do not give steroid injections.


Chou R, Friedly J et al (2015). Epidural Corticosteroid Injections For Radiculopathy And Spinal Stenosis: A Systematic Review And Meta-analysis. Ann Intern Med. 163(5): 373-381. DOI: 10.7326/M15-0934.

Sunday, May 21, 2017

Shoulder Pain From Swimming? Treat Your Neck

Yes, your shoulder pain is coming from your neck
I had a really interesting case this past week. A patient who's an elite swimmer comes in to our clinic complaining of shoulder pain.

An ultra sound scan and MRI that was done confirms the diagnosis of shoulder subacromial impingement (usually the tendon of the supraspinatus muscle gets irritated from hand above head activities under the acromium).

The doctor my patient saw the the Singapore Sports Institute suggested a steroid (or cortisone) injection to "solve the problem".

R shoulder impingement
Well, the Physiotherapists reading this must be thinking "yeah, what's the big deal". All elite swimmers (or athletes involved with overhead sports like badminton, tennis etc) always get shoulder pain from subacromial impingement at some point of other in their sporting career.

Well, here's the thing, I got the swimmer better just be treating the swimmer's neck. This swimmer did not have any neck pain or signs of nerve root irritation.

I've seen other cases of shoulder impingement when the patient had obvious clues suggesting it was the neck and/ or nerve root irritation causing the shoulder impingement.

This swimmer did not have any neck pain or nerve root irritation signs. The patient did have a forward head posture which can contribute to a C5 nerve root involvement.

Similar to the article referenced below, the swimmer got better very quickly just by cervical retraction, as taught by Gwen Jull. Of course treatment also included other things and not just cervical retraction.

My swimmer went back to full training in three days with no recurrence of symptoms. Good thing my patient said no to the steroid or cortisone injection.


Pheasant S (2016). Cervical Contribution To Functional Shoulder Impingement: Two Case Reports. Int J Sports Phys Ther. 1196): 980-991.

Saturday, May 6, 2017

Eccentric Exercises

I was talking with a patient of mine earlier who exercised by climbing up and going down the stairs at his 40 storey flat while carrying a 16 kg backpack. He knew about my past results climbing stairs and wanted to know why walking down a flight of stairs seems to be more effective at building his muscle strength than walking up the same flight of stairs.

Going down the stairs with his 16 kg backpack meant he had to really control his step and lower himself down slowly rather than just letting himself go. This meant that he was doing an eccentric exercise.

Say you want to train your biceps (arm muscles). When you bring the dumbbell up, the muscle is shortening, that is also known as a concentric muscle action. If you lower the dumbbell slowly (which is more difficult), the muscle is lengthening or an eccentric muscle action.

Eccentric exercises are more demanding on the muscles and fatigues then far more than concentrically. It also damages (or breaks down the muscle) to a greater extent, so there is greater stimulation and subsequent growth.

Try this if you want get better leg strength in a shorter time. Bend your legs more deeply when going down stairs of hills. Your legs will be sore from DOMs or delayed onset of muscle soreness. Once your muscles recover (after a few days), they'll be stronger and it will require much more eccentric exercises to get the same effect.

In fact, this was exactly what researchers found in a group of elderly men with chronic heart failure. Going down stairs appeared to be easier and more pleasant compared to the climbing stairs which the subjects found to be more demanding.

Changes in muscle strength were similar or even greater when going down stairs compared to going up stairs after six weeks of training.

To put this into practice, try bending your legs more deeply when going down stairs or slopes, lower your body more slowly doing push ups or pull ups. You'll be amazed at the results ..... after recovering from  the soreness.


Theodoru AA, Panayiotou G et al (2013). Stair Descending Exercise Increases Muscle Strength In Elderly Males With Chronic Heart Failure. BMC Res Notes. 6:87. DOI: 10.1186/1756-005-6-87.