Cortisone / Trigger Point Injections

What is cortisone?
It is a hormone produced by a small gland on top of the kidney called the adrenal gland. It is essential to the proper functioning of your body, particularly when under stress. Its absence is known as Addison’s Disease, which without treatment is fatal. Cortisone is a normal body product therefore; there are no allergic reactions. In cases of people with severe allergies, it is one of our most effective treatment tools. Cortisone by itself is rarely used today as it is relatively short acting and of low potency. Semi-artificial cortisone derivatives, such as DepoMedrol, Celestone, Kenalog, and a number of others, are used with increased benefits and fewer side effects.

What are the different types of injections?
Cortisone falls into a group of chemicals called steroids. It is very different from anabolic steroids commonly abused by weight lifters or competitive athletes. The cortisone/steroid injections, used in medical practice, fall into three broad categories, articular injections, “trigger point” injections, and epidural steroid injections.

• Articular or joint injections are preceded by an aspiration withdrawing joint fluid or blood. Joints commonly injected are the shoulder, knee, ankle and small joints of the hand and foot. Most of the injections can be followed by a booster injection 2 to 4 weeks later. A good limit is three injections over a three-month period of time (an injection to another location can be done at any time).
• The “trigger point” injection is done to a tendon area or into the bursa surrounding such joints as the shoulder, knee, or the hip. These follow the same guidelines as articular injections as far as frequency.
• An epidural steroid injection is another category. It is neither a joint nor “trigger point” injection but, rather an injection inside the bony column of the spine surrounding the dura (the sac that encloses the spinal cord and spinal nerves). Lumbar epidural injections are a relatively simple technique. They are done several inches from the spinal cord and are unlikely to be accompanied by complications except, perhaps a headache. Cervical (neck) epidural injections are a very specialized technique done in our office only by skilled and experienced anesthesiologists. Epidural steroid injections are useful for a variety of back conditions including sciatica, arthritis, degenerative disc problems, and spinal stenosis.

Is the injection painful?
Some cortisone injections can be painful. Injections into an area that is already inflamed are more sensitive. Some areas, such as the hand and foot are particularly sensitive and a freeze block is used before injection. Other areas, such as the knee and shoulder are only moderately uncomfortable.

Cortisone shots are generally accompanied by an anesthetic such as Carbocaine or Lidocaine. This deadens the area and indicates where the shot should be placed (the pain will go away about an hour while the anesthetic works). Most people who have reactions or allergies to cortisone really have the reaction to the anesthetic agent of the epinephrine (adrenaline), which may be in some forms of the injection. Epinephrine can cause tachycardia (rapid heart beat) in some patients. For others, the sight of a needle will cause this reaction and the feeling of being faint is often misinterpreted as an allergic reaction.

How is cortisone effective?
Cortisone is useful in suppressing inflammation in the short term, and in the long term, dissolving scar tissue, stabilizing the body’s defenses, speeding the healing process, and is very effective in causing certain cysts to disappear. It does however, have a weakening effect on tendons if injected directly into them. It can also soften cartilage when injected into a joint. (Information comes from experiments on animals and not human beings.)

How many injections are needed?
In spite of surrounding folklore, there is no specific limit to the number of cortisone shots that can be given. Practical concerns are, if the shot does not work, then why repeat it? If it does work, cortisone is extremely effective and not too many shots are needed. There is a limit to the amount of cortisone given in one dose, even if injected in several areas of the body; this varies depending on the size and physical condition of the person.

Published Clinical Evidence

Treatment of chronic low back pain incorporating active patient participation and chiropractic: a retrospective case report.

A prospective randomized trial comparing the effectiveness of one versus two (staged) corticosteroid injections for the treatment of stenosing tenosynovitis.