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Monday, May 3, 2010
Cortisone Shots: The Thought Process Behind
• Cortisone shots can be divided into short-acting or long-acting.
• Short-acting shots normally are beneficial for 3 days and are used to quickly reduce inflammation. They are commonly betamethasone (6mg/ml) or dexamethasone (4mg/ml) formulas. Since even short-acting cortisone can cause damage/weakness to tendons, if given into tendon sheaths the body part should be immobilized for the 3 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.
• This post shows that cortisone normally is not a quick fix as some athletes hope, but it can speed the return to a high level of athletic activities when given appropriately.
• Long-acting shots have a crystalline base which slowly dissolves over a 9 month period. They are commonly Kenalog (10mg/ml) or Celestone (6mg/ml) brands. Any shot after the first long-acting cortisone shot within the 9 month period is considered a booster shot.
• Long-acting cortisone shots are normally mixed with a 5 hour local anesthetic. This way the shot also becomes very diagnostic. The long-acting cortisone itself takes 3 to 7 days before it begins to work. This is why you wait 2 weeks to see its effectiveness. I ask the patient to tell me how much pain relief they received in the first 5 hours, and then over the next 3 to 14 days. The initial 5 hours tell me if the cortisone was deposited in the right place.
• Following a long-acting cortisone shot, and after the local anesthetic has worn-off, there can be a period of 2 to 7 days where there is more pain due to the added swelling produced by the shot. This is why patients are encouraged to ice the area of the shot 3 times daily during the first week, and twice daily during the second week.
• Patients are told to come back in 2 weeks if they have less than an 80% pain relief (normally no pain walking, greatly diminished pain from before the shot).
• Long-acting cortisone shots are given routinely to diminish inflammation for bursitis and neuritis situations.
• Long-acting cortisone shots should never be given into tendon or tendon sheaths (the covering of the tendon) since they are associated with tendon ruptures. It is important to keep the cortisone as far away from the neighboring tendons as possible.
• Long-acting cortisone should only be given into joints when MRI s (not x rays) have documented no bone/cartilage damage to be of concern, or when the only alternative is surgical treatment. An arthritic joint, for example, can have up to 5 injections per year 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.
• Long-acting cortisone is never injected into the plantar fascia itself, but into the bursitis under it. Tears of the plantar fascia can occur with injections into the plantar fascia directly.
• No running/high-demand/weight-bearing sports are allowed for 2 weeks after a long-acting cortisone shot is given. 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. More realistic is to try 3 to 4 weeks of physical therapy to cool off the inflammation, then to maintain their relief with a daily icing regimen.
• Most foot injections are 10mg of cortisone each. Most knee injections are 40mg of cortisone each. Most epidurals (spinal) are 80+mg of cortisone each.
• Injections are given until 80-90% improvement is noted. Golden Rule of Foot: Never Give A Shot You Are Not Sure Is Needed. This may require 1, 2, or 3 shots, minimally spaced 2 weeks apart.
• What is an 80-90% improvement? It is crucial to understand this concept!! Golden Rule of Foot: 80-90% improvement is when full activity can resume with only mild symptoms easily maintained with non-invasive conservative treatments like icing, contrasts, activity modifications, stretching, anti-inflammatory medication, etc.
• Most of the time 2 injections are needed to bring about this 80-90% improvement (a month of no weight-bearing athletics). However, 20%+ need 1 injection, and equal number need all 3.
• There should be no pre-determining how many shots are needed. The first shot is given and the athlete returns in 2 weeks. The area is evaluated, and the doctor and the patient independently give an estimate on what improvement (if any) has been achieved. It is crucial that the patient ice the area 3 times daily (see post on icing) during these 2 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 3 times a day, if they have not, for 3 days to see if they really need the shot. Over 50% of the time, they do not need the next shot.
• If after the 2 weeks, it is hard for whatever reason to determine how much improvement was attained, before giving another shot, the patient gradually returns to full-activity with anti-inflammatory oral medicine (after, not before, activity), icing, stretching, etc. If full activity is not allowed, thus not a the 80% improvement level, a booster shot is given and the process continues for 2 more weeks. You can see how once Cortisone Injection Therapy is initiated, it can take a while to finish.
• In the worse case scenario, 3 injections may not bring the inflammation down to achieve this 80-90% improvement expected. The decision must be made on further diagnostic tests or removable casts for immobilization.
• But normally, 1, 2, or 3 shots do bring down the inflammation, coupled with the 3 times a day icing, and with the 80-90% improvement, weight-bearing physical activity can begin.
• Hopefully, during the time of inactivity, some level of cross-training has happened, so return to activity at a higher level will not be too stressful on the body.
• Once the initial 80-90% improvement is attained, I will see patients at 3 months, then 6 months. If a re-flare of symptoms occurs, and icing does not diminish greatly, booster shots can be given one shot at a time.