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Cortisone injections are possibly the most common treatment that doctors prescribe for tendon pain conditions like tennis or golfer’s elbow and RSIs such as carpal tunnel syndrome. But do they really work?

I’ll answer that question below, but let’s start off with: what exactly is cortisone anyway? Cortisone is a hormone produced by the adrenal gland. It is technically a cortico-steroid (not to be confused with the anabolic steroids that bodybuilders often use), and it is essential to maintain proper function of your body. Except for certain people who have Addison’s Disease, it is naturally produced by every human being, so there isn’t anyone who’s allergic to it.

If you decide to get a cortisone shot, you probably won’t be injected with the pure stuff. Instead, cortisone derivatives such as Kenalog or Celastone, which last longer and create fewer side-effect issues, are more commonly used. Also, there is usually a pain reliever included in the shot. People who suffer allergic reactions to the shots are generally allergic to the pain reliever rather than the cortisone derivative itself.

Cortisone can be effective in suppressing inflammation for short periods of time. This will provide some pain relief, but without addressing the underlying cause of the condition, the pain will return after the effects of the shot have worn off. Also, there is a limit to the number of shots that can be performed within a given time period, since animal studies have shown that cortisone can weaken tendons and cartilage in joints when over-administered via local injections. (This is not a problem with oral cortisone doses, which are absorbed by the body gradually over a period of time.) This possible adverse effect is more worrisome in younger people, as their joints and tendons are still healthy, so patients below the age of 25 especially are encouraged to exhaust all other forms of treatment before getting cortisone injections. With older patients, whose joints generally have already experienced significant damage, it is not as much of a concern. Also, certain tendons – the Achilles tendon in particular – are prone to rupture even when the injections are performed with the utmost care.

Inflammation, while often a useful physiological reaction, can actually hinder healing when it is present in excess. The idea behind a cortisone shot is that by helping to suppress unnecessary inflammation, it will thereby aid in healing. However, the most recent medical studies are increasingly showing that tendonitis, RSIs (tennis elbow and runner’s knee; carpal tunnel syndrome and related conditions suffered by data entry professionals) and so on are not actually caused by inflammation, but by some other mechanism — the most likely suspect being direct damage to, and/or fraying of, the tendon. Naturally, this calls into question the whole rationale for the shots in the first place since cortisone has absolutely zero demonstrated effect on repairing tendon collagen.

So why do patients report a decrease in pain? The fact is that not all of them do; cortisone shots are reported as being effective in only about 50% of the people who receive them. For those that do experience relief, the most likely explanation is that the analgesic included in the shots has a temporary deadening effect on the pain. Also, the placebo effect can be very powerful and should never be discounted.

Although cortisone shots are admittedly a very effective treatment for certain conditions such as arthritis in older patients, there are serious concerns as to their effectiveness when it comes to conditions like RSIs, tendonitis, tendonosis and the like. In younger patients and runners suffering from Achilles tendonitis in particular, it seems that there are more effective tendonitis treatments available, with a much better cost/benefit ratio and better success rates. Granted, cortisone shots are relatively inexpensive, easy to administer, and don’t take a lot of time. Furthermore, they fit very well into the usual medical paradigm of addressing the symptoms of a condition rather than the condition itself. (In other words, even if you experience some temporary “relief” the shot won’t help heal your tendon.) And, of course, doctors are able to monitor their use. But when you think about the discomfort of receiving an injection directly into damaged tissue, the questionable mechanism by which it is supposed to work, the coin-toss percentage of patients who report even temporary pain relief, and the possibility of potentially severe side effects, it makes sense to try other treatments first.