Episode 77: Cortisone Injections for Chronic Pain: What They Help, What They Hurt, and When to Avoid Them

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• Joe Gambino
• Joe LaVacca

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Summary

In this episode of the Beyond Pain podcast, Joe LaVacca discusses the complexities of pain management, particularly focusing on the role of injections, especially corticosteroids. 

He emphasizes the importance of understanding pain as a system that involves various interacting parts and the need for a holistic approach to treatment. 

The conversation covers the potential benefits and risks of corticosteroid injections, the distinction between short-term relief and long-term solutions, and the significance of lifestyle factors in managing pain effectively.

Takeaways

• Injections may provide short-term relief but not long-term solutions.
• Understanding pain as a system is crucial for effective management.
• Corticosteroid injections can lead to degeneration of tissues.
• Lifestyle factors like weight management and sleep are vital in pain management.
• Consulting with healthcare providers is essential before opting for injections.
• Pain management should consider both physical and emotional aspects.
• Injections should be used sparingly and with caution.
• Not all pain is due to inflammation; proper diagnosis is key.
• Patient education is critical in making informed decisions about treatment.
• Holistic approaches often yield better long-term outcomes.

Chapters

• 0:00 Introduction to Injections and Pain Management
• 2:52 Understanding Pain as a System
• 5:46 Corticosteroid Injections: Benefits and Risks
• 9:13 Short-term Relief vs. Long-term Solutions
• 12:07 Lifestyle Factors in Pain Management

Transcript

Joe LaVacca (00:00)
Hello everyone and welcome back to the Beyond Paint podcast. My name is Joe LaVacca and I am once again, your only host this week. I do apologize for that. Joe is feeling better. He is healthy. However, he is on a work trip to Portugal. So that means it is just you and I again. So.

If you do not want to just listen to me banter, please do yourself a favor and turn this off right now. If you're okay hanging out with me for a few minutes, we got a nice episode for you. And I thought we might touch on, or at least begin the conversation of injections and pain mainly around the idea of corticosteroids. As always, you can find me

on Instagram at strength in motion underscore PT. You can find Mr. Gambino on Instagram at Joe Gambino at DPT. You can follow the Beyond Pain podcast on Instagram by using the same title, Beyond Pain podcast. And don't forget to check this out on YouTube if you prefer to watch instead of listen. If you wouldn't mind dropping us.

a comment, a review, a share, we'd greatly appreciate it. And that will help us reach more people, grow the podcast and continue to give you free information. Now let's talk about this idea of injections and pain. It does come up quite frequently. I work with many people as does Joe in the chronic pain sphere.

And as pain continues, it seems like there is no way out of it. So more and more treatments are offered and it could range from things like injections to alternative therapies to completely far out fringe therapies and maybe all the way up to surgery. Now, I think when we come around to this idea of injections,

for people in pain. Again, there's a lot of context here. And I used to just probably be on the fence or on the side of the fence that was just anti, anti, anti. And while I still don't necessarily support injections, I think it's going to be very dependent on you. What is happening in your life? How is it affecting you? And what have we tried in the past that did not give us the results that we wanted?

So I think where my approach coming from this is viewing pain as a system. Now, a system has parts. You can talk about your tendons and your joints or other tissues, but systems also interact in their environment and systems generally have a purpose. Now, when it comes to us as human beings, we are made up of all of these parts.

We interact socially because we are social creatures. We form relationships and then our purpose is to thrive as a species, to reproduce, to make meaningful connections. The list goes on and on. When we're thinking about pain, our pain system is designed or its purpose is to protect us. So in so facto sometimes it limits a lot of our social behaviors, our interactions,

or how we just naturally behave as a species. So we have two maybe competing systems at work. And I think it's worth starting with the parts, the things that we typically label as the cause of all of our dysfunctions, tendons, joints, ⁓ muscle tissues, fascial tissues, you name it. Oftentimes, these are the least important parts of a system. And we'll go with two examples here.

I'm sure if you're a clinician or if you're a client, you know someone who has gotten a joint replacement. You know someone who's gotten a tissue repair or a tendon repair, and yet they still have pain. So the parts have been fixed or replaced, yet the signal that was there before is still present. If we think about our economy, our nation, our country,

which as of this recording is still standing, we can think that over the last hundred years or so, definitely 125, there's been a complete turnover of people who live in this country. I do not know the oldest person in United States, but I would venture to guess they're not older than 125. So let's say despite there being a completely new population, we are still remotely bound by the same.

laws, the same structure, the same rules, the same states, you name it, right? So the parts are not generally as important as our interactions and our purposes when we think about systems. So how does this relate to injections? Well, if you are looking for short-term relief of a painful problem, yes.

there is some research to suggest that when you choose an injection at a site, like your elbow or your shoulder or maybe even your back, there is some reported improvements in pain. Now, we're not gonna go down the rabbit hole of comparing corticosteroids to placebos and what that might mean, because that's a different conversation. We'll come back to it.

But typically when you expect something to work and you are told it will, and maybe you haven't had the outcomes that you were hoping for, then a lot goes into short-term relief when it comes to treatment. And you can even see that probably with your hands-on therapies or your manual therapies, whether you do them or receive them. Wow, I feel really great or my client feels really great. And then what happens an hour later, a day later, you know, the pain comes.

Now what we know about corticosteroid injections in general, when they do work, they probably work because there is some sort of inflammation in the tissue or the site of where the injection happened. Now that makes sense. It's supposed to target inflammation. However, when there is no inflammation, they typically don't work. It is pretty hard to determine what the root cause of pain is despite our best efforts.

There's not a lot of tissues that are super close to the surface where we might actually see redness, warmth, swelling. So we think about maybe something like an Achilles tendon. You might see an Achilles tendon in your foot, be really red, be really hot, be really swollen. And we might all come to the conclusion that, yeah, this seems like there's an inflammatory response here. However, at the hip or the back, or in some cases, even the shoulder,

these structures are a little bit deeper. So it's kind of more challenging to know if there actually is inflammation present. And sometimes a lot of clients aren't getting blood work done, aren't getting imaging done beforehand. They're just offered these injections kind of willy nilly. So we can sort of see why maybe they don't have as great an outcome for some people as they do others. The other thing we have to think about is what are we injecting when it comes to tendons?

there does seem to be worse long-term outcomes with corticosteroid injections, mainly because it causes a little bit more degeneration in that tendon itself, because it breaks down a lot of the pieces that fill the tendon, which is what we refer to as collagen. Now, when we're thinking about a spinal injection, well, this is where it gets a little bit trickier. It doesn't seem to be any long-term benefit at all.

there does seem to maybe be a little bit of risk just because we're putting needles close to very sensitive nerve tissues and spinal tissues. But the spinal injections are strongly recommended against. They usually lead to repeat procedures and high cost. Whereas the tendon injections or maybe more of these soft tissue injections are

kind of dependent on where you are, but still recommended to be used sparingly. So again, this is just being guided by the research. So let's think about what this might mean for someone with chronic back pain, hoping to get relief from a corticosteroid injection because they have a big event coming up, a big race. I don't know, maybe they're getting married, their kids getting married. They're probably not going to see the same benefit in the short term as somebody who might have a really inflamed tendon.

Now, in short-term situations, this is up to you. My job as a clinician is not necessarily to make decisions for you, it's to give you information so you can make informed decisions about what you think is best for you. Now, if you're okay taking a little bit more risk later on in a soft tissue because what's in front of you right now is the most important, I probably won't stand in your way.

If you've gotten repeated injections though, in an area, I might be a little bit more adamant on pushing back to you because if we are going to then load that area after your wedding or after your major life event, we might be risking more harm and still might set you up for failure in the long term. If again, we're looking at back stuff, it's just not there from an evidence perspective.

And what I've seen with clients and even family is you get an injection on one level, it doesn't work. So you get an injection on another level, it doesn't work. So then you go to the other side, it doesn't work. And then you try a different procedure like an ablation or something like that. And again, the cost is going up and up and up. There's repeated invasive procedures. So again, we don't really love the idea of spinal injections for anyone. These sort of short term ones for tendons.

You know, again, I think it's really something that you and I have to sit down or you and your provider have to sit down with and have a meaningful discussion. So injections aren't offering really long-term pain relief. They aren't really offering any relief for chronic spine pain. The more you expose yourself to these procedures, the higher the risk. ⁓

This is including everything from infection to maybe structural breakdown of tendon and cartilage. And, you know, again, even when they are helpful in the short term, if we go back to our idea of pain being a system, human beings, a system, if we're viewing the parts as the most important piece of your pain and your doctor is viewing the parts as the most important pieces of pain, then this can be a very defeating

intervention as well when it doesn't work. And, or if it does, to just think you are quote unquote cured and don't have to change your behaviors or your purposes in life, then this is where you're going to probably come right back to needing more interventions like that. So what else do we know that kind of drives inflammation or drives tendon pain? Well, it's being more connected to metabolic disorders, obesity, high blood pressure, high cholesterol.

These are systemic effects. So even if an injection helps you in the short term, your better option, your long-term option for success is probably weight management, sleep management, nutrition management, don't smoke, don't drink, right? These are all behaviors that are going to drive you back into pain and potentially leave you scratching your head of

what's happened, I just got this injection, if you're not thinking about the big picture. So if we're going to wrap this up, and again, just kind of come away with some practical advice here. If you're a client seeking an injection, my major question would be, what have you tried? Why do we think that there is an active inflammation into the area?

Have we gotten imaging or blood work or the like to support that claim? Have you given lifestyle education, exercise, a meaningful opportunity to show improvement? Have you discussed other options with your PT or your doctor? Sometimes things just need a little bit of offload and that's okay. We can make modifications to your running technique, your lifting technique, maybe even how much your training or moving during the week and

Just let tissues calm down. That is part of the healing process and there's nothing wrong with that. talk to your PT, talk to your physician, make an educated decision. Am I looking for short term relief? Am I looking for a quick fix? Do I care about any long term ramifications that are possibly associated with this injection?

If you have spinal pain, maybe consider avoiding all of these things all together. So I hope this was helpful. I don't want to take up too much of your time, but I hope to give you some things to think about, discuss with your healthcare provider, discuss with me or Joe if we are your healthcare providers so that way you're always making the best decision in your care.

Next week, I'll be back with Joe again. We have lots of exciting guests coming up. So stay tuned and don't forget next Friday, another episode of the Beyond Pain podcast. Take care everybody.