SPORTS INJURIES
Knee Injury and Cortisone
The quickest way for an athlete to lose strength at the ligament-bone
junction (fibro-osseous junction) is to inject cortisone to
that area. Cortisone and other steroid shots ALL have the same
detrimental effects on articular cartilage.
Corticosteroids, such as cortisone and Prednisone, have an adverse effect on
bone and soft tissue healing. Corticosteroids inactivate vitamin D, limiting
calcium absorption by the gastrointestinal tract, and increasing the urinary
excretion of calcium. Bone also shows a decrease in calcium uptake with cortisone
use, ultimately leading to weakness at the fibro-osseous junction. Corticosteroids
also inhibit the release of Growth Hormone, which further decreases soft tissue
and bone repair. Ultimately, corticosteroids lead to a decrease in bone, ligament,
and tendon strength.
Corticosteroids inhibit the synthesis of proteins, collagen, and proteoglycans
in articular cartilage, by inhibiting chondrocyte production, the cells that
comprise and produce the articular cartilage. The net catabolic effect (weakening)
of corticosteroids is inhibition of fibroblast production of collagen, ground
substance, and angiogenesis (new blood vessel formation). The result is weakened
synovial joints, supporting structures, articular cartilage, ligaments, and tendons.
This weakness increases the pain and the increased pain leads to more steroid
injections. Cortisone injections should play almost no role in sports injury
care. Although anti-inflammatory medications and steroid injections reduce pain,
they do so at the cost of destroying tissue. In a study conducted by Siraya Chunekamrai,
D.V.M., Ph.D., steroid shots, of a substance commonly used in humans, were given
to horses. The injected tissue was looked at under the microscope. The steroid
shots induced a tremendous amount of damage, including chondrocyte necrosis (cartilage
cell damage), hypocellularity (decreased number of cells) in the joint, decreased
proteoglycan content and synthesis, and decreased collagen synthesis in the joint.
All of these effects were permanent.
Dr. Chunekamrai concluded, “...the effects on cartilage of intra-articular
injections of methylprednisolone acetate (steroid) were not ameliorated at eight
weeks after eight weekly injections, or 16 weeks after a single injection. Cartilage
remained biochemically and metabolically impaired.” (Chunekamrai, S. Changes
in articular cartilage after intra-articular injections of methylprednisolone
acetate in horses. American Journal of Veterinary Research. 1989; 50:1733-1741.)
In this study, some of the joints were injected only one time. Even after one
steroid injection, cartilage remained biochemically and metabolically impaired.
Other studies have confirmed similar harmful effects of steroids on joint and
cartilage tissue. A cortisone shot can permanently damage joints. Prolotherapy
injections have the opposite effect—they permanently strengthen joints,
ligaments, and tendons.
The problem with athletes is that they look for quick relief. The problem with
cortisone is that the athlete may get pain relief, but it may be at the expense
of permanent inability to participate in athletics. Athletes often receive cortisone
shots in order to play. They go onto the playing field with an injury of such
significant magnitude that they received a cortisone shot to relieve the pain.
Unfortunately, they cannot feel the pain anymore so they play as if there was
no injury. We know that the injury could not possibly be healed because of the
tremendous anti-healing properties of cortisone. Thus the athlete is further
injured from the cortisone, as well as playing with an injury, thereby worsening
the already bad injury.
Cortisone is so dangerous to the athlete because it inhibits just about every
aspect of healing. Cortisone inhibits prostaglandin and leukotriene production.
It also inhibits chondrocyte production of protein polysaccharides (proteoglycans),
which are the major constituents of articular ground substance. Behrens and colleagues
reported a persistent and highly significant reduction in the synthesis of proteins,
collagen, and proteoglycans in the articular cartilage of rabbits who received
weekly injections of glucocorticoids. They also reported a progressive loss of
endoplasmic reticulum, mitochondria, and Golgi apparatus, as the number of injections
increased.
Exercise has the opposite effect. Exercise has been shown to positively affect
articular cartilage by increasing its thickness, enhancing the infusion of nutrients,
and increasing matrix synthesis. However, the effects of doing them together
were not studied until recently.
Dr. Prem Gogia and associates at the Washington University School of Medicine
in St. Louis, Missouri, did an excellent study bringing out the dangers of an
athlete exercising after receiving a cortisone shot. (Gogia, P. Hydrocortisone
and exercise effects on articular cartilage in rats. Archives of Physical Medicine
and Rehabilitation. 1993; 74:463-467.) They divided animals into three groups:
1.
Group One: received a cortisone shot
2. Group Two: received a cortisone shot and exercised
3. Group Three: control group, received no treatment
This study was done in 1993 and was the first study to
look at the effects of exercising after receiving a
cortisone shot. The authors performed this study because
it is common practice in sports medicine to give an
athlete a cortisone shot for an acute or chronic injury.
Athletes are typically returning to full-intensity
sports activities within a few hours to one to two
days after receiving the shot. The results of the study
were unbelievable. The animals receiving the cortisone
shots showed a decrease in chondrocytes, but when they
received the cortisone shot and exercised, the chondrocyte cell count
decreased by another 25 percent. Degenerated cartilage
was seen in all of the cortisone-injected animals,
but severe cartilage damage was seen in 67 percent
of the animals that exercised and received cortisone.
The cortisone and exercise group also showed a significant
decline in glycosaminoglycan synthesis compared to
the other groups. The authors concluded, “...the results suggest that running exercise in combination
with intra-articular injections results in damage to the femoral articular cartilage.”
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