Are Cortisone Shots an Effective and Safe Treatment Option for Running Injuries?
Last time, we looked at the role of non-steroidal anti-inflammatory drugs in running injuries.
Because injuries to tendons, which connect tissue to bone, and fascia, the web of collagen that surrounds muscles and internal organs, seem to be more degenerative than inflammatory, there is not a lot of good evidence that NSAIDs like Advil or Aleve do a whole lot of good in actually helping you recovery from a running injury.
As such, this week, we’ll turn our attention to the more powerful cousin of these drugs: corticosteroids (or more commonly known as cortisone shots).
These types of drugs, as their name suggests, are “steroidal” anti-inflammatory drugs. Despite the name, they don’t share the muscle-building properties of the anabolic steroids bodybuilders take. Steroid is a classification that groups the medications that share a similar chemical structure.
Cortisone and other corticosteroid drugs are usually used as prescription-strength injectable treatment for various musculoskeletal injuries.
When cortisone first came into use in the 1950s and 60s, it became a popular treatment for athletic injuries, from knee injuries in football players to overuse injuries in runners. However, the use of cortisone and other corticosteroids can result in some worrisome side effects. In this week’s article, we’ll review some of the research on corticosteroids and tendon degeneration.
The research behind treating running injuries with corticosteroids
There were concerns about the effects of corticosteroids on tendons as early as 1973, when a paper by Louis Unverferth and Melvin Olix presented five cases of athletically active patients who experienced tendon ruptures in their Achilles, ankle, and elbow following repeated injections of corticosteroids.1
These results were echoed in a paper by Max Kleinman and Allen Gross reported rupture of the Achilles tendon in three sedentary patients following corticosteroid injections for Achilles pain.2 The tendons, which had to be repaired surgically, showed significant degeneration, which is troubling for athletes, seeing as the degeneration could be worse in an active patient.
In a more recent review, Andrew Nichols examined the occurrence of side effects when sporting injuries are treated with corticosteroids.3 While criticizing the lack of concrete data on the rates of occurrence, he nevertheless cautioned that corticosteroid injections around tendons appear to carry a small but notable risk of causing a tendon rupture.
Cortisone shots and plantar fasciitis
The same phenomenon has also been observed in cases of plantar fasciitis.
In a 1998 study, JI Acevedo and JL Beskin at Georgia Baptist Medical Center reported 12 of 112 patients treated for plantar fasciitis with a steroid injection developed a plantar fascia rupture — a rate of about 10 percent.4
In the same study, the authors reported that 44 of 54 patients with a plantar fascia rupture had received at least one corticosteroid injection prior to the rupture.
Because of the difficulties in establishing causality (e.g. did the steroid injection cause the tendon rupture, or simply precede it?) the exact risks to corticosteroid injections are still unclear, but the circumstantial evidence doesn’t look favorable.
The weight of scientific evidence today indicates that corticosteroids are a bad decision for tendon injuries or plantar fasciitis in athletes, seeing as there is some evidence they may cause tendon ruptures, and furthermore these injuries do not appear to have inflammatory causes.
However, they do have a proven success record with injuries like bursitis and joint pain, so some doctors like Ulrich Fredburg, cautiously recommend using steroid injections as an adjunct treatment for some sporting injuries.
They should probably be thought of as a middle ground approach, nestled between truly conservative treatment, like rest, icing, and rehab exercises, and a more extreme option, like surgery.5
Additionally, research shows that a technique called iontophoresis, which transmits small amounts of corticosteroids through the skin using electrical current may be a promising alternative to the standard injection method because it reduces the risk of potential rupture.6
For runners with injuries, it is wise to talk with your doctor about the potential effects of corticosteroid injection before making a decision.
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1. Unverferth, Louis J and Olinx, Melvin L. The effect of local steroid injections on tendon. J Sports Med 1973; 1(4) 31-37
2. Kleinman M, Gross AE. Achilles tendon rupture following steroid injection. Report of three cases. J Bone Joint Surg Am. 1983 Dec;65(9):1345-7.
3. Nichols, Andrew W. Complications Associated With the Use of Corticosteroids in the Treatment of Athletic Injuries. Clin J Sport Med 2005;15:370
4. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. 1998 Feb;19(2):91-7.
5. Fredberg U. Local corticosteroid injection in sport: review of literature and guidelines for treatment. Scand J Med Sci Sports 1997: 7: 131-139.
6. Nowicki K, Hummer CD 3rd, Heidt RS Jr, Colosimo AJ. Effects of iontophoretic versus injection administration of dexamethasone. Med Sci Sports Exerc. 2002 Aug;34(8):1294-301.