Steroid/ Cortisone Injections Significantly Increase Risk Of Tendon Tears

Picture from BuzzRx

I was asked to do a home visit for a patient who was having some pain in his hip 2 days ago. The patient hurt his knee last year while playing golf and the doctor he consulted did a steroid/ cortisone injection for him. His knee was better for a while but some of the pain came back a short while later. 

Perhaps my patient was not able to weight bear well on that right knee since then and subsequently that caused his right hip to act up. After assessing him, I found that his sore knee was not the main cause of his hip pain, but definitely a contributing factor. 

I shared an article (referenced below) that I just read just a few days ago with my patient and his family regarding steroid/ cortisone injections. There were 1025 patients with shoulder pain in that hospital study. 205 patients received a steroid/ cortisone while 820 did not (they acted as the control group).

Patients in that study who received a steroid/ cortisone injection (for their shoulder pain) significantly increased the risk of having a shoulder tendon tear by 7.44 times compared to those who did not receive a steroid/ cortisone injection! 

Those who had concurrent chronic liver disease were 3.25 times more likely to have a torn tendon while those who smoked by 2.4 times. Another reason to stop drinking and smoking too.

Since my patient is an avid golfer and still very active, I told him he definitely does not need to have any more steroid/ cortisone injections anywhere else on his body. There are high chances of degenerative changes in the surrounding areas where the steroid/ cortisone is injected.

Remember my true story when I used to work at the Singapore Sports Institute (formerly Singapore Sports Council). Back then, I used to treat the badminton players frequently and traveled with them on most of their training trips and competitions. (Ronald Susilo and I pictured below after he beat world number one Lin Dan at the Athens 2004 Olympics).

I'm more excited than Ronald

In 2006-2007, Ronald Susilo had on and off right elbow pain, in his playing arm. He was subsequently injected with steroids (cortisone) a few times to help with the pain so he could train and compete.

Tragedy struck at the 2007 SEA Games in Thailand. He tore a forearm muscle while playing at the Games. I was tasked with accompanying him back to Singapore for a visit to the surgeon to repair it.

I've accompanied Ronald for all his sporting surgeries. His shoulder in 2004, Achilles in 2005 and right forearm in 2007. These were his words to the operating surgeon, "Gino knows my body better than I, he's been around for all my operations."

As usual I was waiting outside the operating theater for Ronald when they operated on his forearm. The first words the surgeon said to me when he came out of the operating theatre was, "We found cortisone still in his arm." My interpretation was that he meant too much steroid/ cortisone had been injected into Ronald's forearm. That probably caused the muscle to tear. Just like what the study by Lin et al (2022) had found.

Yes, there would definitely be occasions where a steroid/ cortisone injection is needed.  However, speaking from personal experience, if you're an athlete or participating in sports regularly like my patient, please reconsider if your doctor suggests a steroid/ cortisone injection. There are definitely other ways to treat your pain/injury besides getting a steroid/ cortisone injection. You definitely do not want to risk tearing any muscle or tendon after that.

Reference

Lin CY, Huang SC, Tzou SJ et al (2022). A Positive Correlation Between Steroid Injections And Cuff Tendon Tears: A Cohort Study Using A Clinical Database. Int J Environ Res Pub Health. 19(8): 4520. DOI: 10.3390/ijerph19084520.

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.


Reference

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.