Alternatives to cortisone shots: Updated reviews of corticosteroid options. Ross Hauser MD

Ross Hauser, MD

Is Cortisone the only option for you?

If you are reading this article, you are likely looking for answers for your long time pain problems that may offer some hope that you can get pain relief today, avoid a hip, knee, or shoulder replacement surgery, or get some pain relief until you can get a joint replacement. You have been on a long journey of degenerative disease, you may have been told joint replacement is the end of the line. Joint replacement can help a lot of people. But it may not be the type of help you are looking for or can get right now.

For many people, the options for pain relief right now are limited to cortisone and medications.

In this article, we will discuss being pain managed with cortisone until surgery becomes an option., we will discuss new research including troubling findings which say that:

  • Corticosteroid triamcinolone acetonide increases knee cartilage destruction.
  • Cortisone injections increase the risk of joint surgery.
  • Cortisone injections increase the need for secondary surgery and possibly higher risk for post-surgical infections in the joint.
  • Corticosteroids can alter the healing environment of the joint by effecting damage on the native stem cells in cartilage.

And we will look at the recent research which suggests in its title: “Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?”

Article outline:

  • Is the increase in the number of hip and knee replacements a direct result of the injection of corticosteroids into these joints.
    • “Steroid injections may lead to joint collapse or hasten the need for total hip or knee replacement.”
  • The fact that new research is pouring in on the detrimental effects of cortisone injections should not convince anyone that suddenly medicine is being alerted to the risk of corticosteroids.
  • Cortisone can work in the short-term and make the problem worse in the long run.
  • Corticosteroid damaged knee cartilage and provided no significant pain relief after two years.
    • Although surgery and cortisone are common, randomized trials have failed to produce evidence for their effectiveness.
    • Cortisone can make bone on bone worse by thinning out the meniscus. But one injection appears okay.
  • The cortisone debate goes on.
  • Cortisone injections. Did they cause a greater risk of need for knee replacement?
  • Secondary adrenal insufficiency.
    • An understanding of cortisol in chronic pain
  • Cortisone disrupts natural healing and hurts native joint cells.
  • “A direct correlation between increased steroid concentration and increased chondrocyte apoptosis (cartilage death).”
  • Cortisone injection risks, side effects, and tissue toxicity.
  • “a positive effect on joint pain may also be associated with accelerated joint destruction.”
  • Cortisone injections can predispose a joint to infection. Patients have reported severe pain, including muscle pain, and burning after a cortisone injection.
  • Treatment options: Prolotherapy.
    • How does Prolotherapy repair a joint in ways cortisone cannot?
    • Prolotherapy brings oxygen to the joint to help provide healing cells energy and a clean, safe work environment.
    • Prolotherapy feeds healing cells the food they like and helps make more of these cells.
    • Comprehensive Prolotherapy and Platelet Rich Plasma. More comparisons to Cortisone

If you are already looking for treatment options beyond cortisone – contact us and we will help with information on our regenerative joint repair treatments.

It is my opinion, the increase in the number of hip and knee replacements is a direct result of the injection of corticosteroids into these joints. This is an opinion now shared by many.

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 urinary excretion of calcium. Bone also shows a decrease in calcium uptake, 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 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).

Cortisone, even one shot, may cause irreversible damage to the joint and cartilage.

The title of the research above “Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?” comes from a study with an October 2019 publication date. This paper, published in the medical journal Radiology (1) lists as its essential messages the following:

A list of side-effects following cortisone injection:

  • Adverse joint events after intra-articular corticosteroid (IACS) injection, including accelerated osteoarthritis progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction with bone loss, are becoming more recognized by physicians, including radiologists, who may consider adding these risks to the patient consent.
  • The radiology community should actively engage in high-quality research to further understand these adverse joint findings and how they possibly relate to IACS injections to prevent or minimize complications.

In other words, back to what the researchers titled their paper: “Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?”

“Steroid injections may lead to joint collapse or hasten the need for total hip or knee replacement.”


“Physicians do not commonly tell patients about the possibility”

The press information released by the Radiological Society of North America, the publishers of the journal Radiology, listed these important points:

  • “Steroid injections may lead to joint collapse or hasten the need for total hip or knee replacement.”
  •  Ali Guermazi, M.D., Ph.D., professor of radiology and medicine at Boston University School of Medicine, and lead researcher of the study, found that “corticosteroid injections may be associated with complications that potentially accelerate the destruction of the joint and may hasten the need for total hip and knee replacements. . . “We’ve been telling patients that even if these injections don’t relieve your pain, they’re not going to hurt you,” Dr. Guermazi said. “But now we suspect that this is not necessarily the case.”
  • In a review of existing literature on complications after treatment with corticosteroid injections, Dr. Guermazi and colleagues identified four main adverse findings: accelerated osteoarthritis progression with loss of the joint space, subchondral insufficiency fractures (stress fractures that occur beneath the cartilage), complications from osteonecrosis (death of bone tissue), and rapid joint destruction including bone loss.
  • “Physicians do not commonly tell patients about the possibility of joint collapse or subchondral insufficiency fractures that may lead to earlier total hip or knee replacement,” Dr. Guermazi said. “This information should be part of the consent when you inject patients with intra-articular corticosteroids.”

Let’s point out, that physicians who see cortisone as a valuable tool do not necessarily embrace these findings, responding to this research was a letter to the editor titled: “Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Dangerous as They Want You to Believe?” (2) The “they,” is the research author of the piece published in the journal Radiology. Let’s be fair, some people do get relief from cortisone. Some people do not. Cortisone will not cause immediate joint destruction in everyone. However, there is a very good chance that if you are reading this article, you have had cortisone injections in the past and you are here looking for options.

The fact that new research is pouring in on the detrimental effects of cortisone injections should not convince anyone that suddenly medicine is being alerted to the risk of corticosteroids.

The fact that new research is pouring in on the detrimental effects of cortisone injections should not convince anyone that suddenly medicine is being alerted to the risk of corticosteroids. The dangers of cortisone injections have long been known. But in eagerness by health professionals and the patients themselves to get instant relief, the dangers were accepted as part of the treatment, in other words, “let’s manage the pain until the patient is ready for joint replacement treatment.”

In 2009, I wrote in the Journal of Prolotherapy “It is my opinion that there is no doubt that the rise of osteoarthritis, as well as the number of hip and knee replacements, is a direct result of the injection of corticosteroids into these joints.”(3)

My evidence then was a summary of the effects of cortisone on articular cartilage which included:

  • a decrease of protein and matrix synthesis (the nutrient and healing bed that cells grow in),
  • mutation of (cartilage) cell shape
  • growth of new cartilage inhibited,
  • cartilage destruction risk and enhancement
  • cartilage surface deterioration including edema, pitting, shredding, ulceration and erosions, etc, etc.

In ten years since the evidence has grown.

Cortisone can work in the short-term and make the problem worse in the long run

The idea that cortisone can cause damage was not an easy sell for some researchers. Corticosteroid injections have been used for a very long time. Their anti-inflammatory and pain relief properties made its use a common practice within the medical community. Further, they are effective.

Corticosteroid injections have been shown to be effective in decreasing the inflammation and pain of ligament injuries for up to 8 weeks; however, these same properties lead to the destruction of cartilage as mentioned above. Simply, the body heals via inflammation, cortisone inhibits inflammation and healing by disrupting the three characteristic phases: inflammatory, proliferative, and remodeling.

Simply, healing comes in phases. The first phase, the inflammatory-reparative phase, sets the foundation for the other phases of healing including repairing and remodeling connective tissue. This inflammatory phase of healing is critically affected by the treatment options chosen. These options can either block or stimulate the healing process. Cortisone, as it has been well shown, blocks and retards this initial healing phase. Cortisone is the “feet of clay” upon which the whole healing structure crumbles upon.

A December 2022 paper in the journal Skeletal radiology (29)  reviewed previously published studies on the use of image-guided corticosteroid injections in the treatment of patients with knee and hip osteoarthritis. In this paper 10 hip osteoarthritis and 12 knee osteoarthritis and one study on both were evaluated. The researchers observed “hip injections were found to be effective in treating short- and long-term pain and more effective than hyaluronic acid, Mepivacaine, NSAIDs, and normal saline in terms of improvement in pain and/or function. There was less impact on Quality of Life.”  Knee injections were found either to have little or no impact or were similar or inferior to comparison injections (intra-articular hyaluronic acid, PRP, NSAIDs, normal saline, adductor canal blocks). ” The researchers concluded: “Our systematic review found generally positive outcomes for the hip, but overall negative outcomes for the knee, although hip injections may carry a risk of serious adverse outcomes.”

Corticosteroid damaged knee cartilage and provided no significant pain relief after two years.

In 2017, doctors from Tufts Medical Center in Boston asked, “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?”

Writing in the Journal of the American Medical Association, (JAMA) (4) they published their answer:

“Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”

  • Corticosteroid damaged knee cartilage and provided no significant pain relief after two years.

In other words, cortisone can either work or make the problem worse.

In February of 2020 a review study with the title “Medical Reversals in Family Practice: A Review,” (5) published in the journal Current Therapeutic Research, Clinical and Experimental offered these points:

Although surgery and cortisone are common, randomized trials have failed to produce evidence for their effectiveness.

  • “Despite inconsistent recommendations for more invasive treatments, hundreds of thousands in the United States are treated with corticosteroid injections and surgery. Although these practices are common, randomized trials have failed to produce evidence for their effectiveness.”
  • Because corticosteroids have an anti-inflammatory effect and because osteoarthritis is an inflammatory condition, intra-articular corticosteroids have has been used for several decades, and as many as 95% of rheumatologists use them for osteoarthritis; however, in a randomized trial of patients with symptomatic knee osteoarthritis, in which 140 patients were treated with an injection of either triamcinolone or saline every 12 weeks for 2 years, there were no differences in pain between patients treated with triamcinolone or saline. Further, patients assigned to the triamcinolone treatment had a greater loss in cartilage thickness. (This study is cited above). (3)
  • Many patients are likely better off with a less-is-more approach of low-impact physical activity and strength training exercises than cortisone or surgery.

Moving forward on research surrounding knee osteoarthritis:

Cortisone can make bone on bone worse by thinning out the meniscus. But one injection appears okay

One of the reasons that you are considering a knee replacement or are thinking about getting a cortisone injection is because you have been told you have a bone on bone knee. So the idea that cortisone may make this worse by thinning out your meniscus is concerning doctors.

In August of 2020 in the journal Scientific Reports (6) doctors expressed concerns about damaging the meniscus tissue with cortisone injections. It should be noted that this research’s main findings were that it was okay to get one cortisone injection. For many people, one injection would be considered safe. Here are the learning points of that research:

  • Although intra-articular corticosteroid injections are commonly used for the treatment of knee osteoarthritis, there is controversy regarding possible side-effects on the knee joint structure.
  • In this study, the effects of intra-articular corticosteroid injections on worsening the knee structure and creating greater pain were examined.
  • Findings: No significant effect of the intra-articular corticosteroid injections were found on the rate of cartilage loss nor on any other knee structural changes or patient-reported pain scores. In conclusion, a single intra-articular corticosteroid injection for the treatment of osteoarthritis-related knee pain was shown to be safe with no negative impact on structural changes, but there was a transient meniscal thickness reduction, a phenomenon for which the clinical relevance is at present unknown.

The cortisone debate goes on

A December 2020 (7) study published in the medical journal Rheumatology gives this overview assessment of the debate surrounding the use of cortisone for a bone on bone knee. Here are the summary learning points:

  • “Existing data indicate that intra-articular corticosteroids in knee osteoarthritis provide short-term pain relief and functional improvement which may last from one to several weeks.
  • At present, synovitis (inflammation) is the most important predictor of treatment response, and also a target for anti-inflammatory treatment for intra-articular corticosteroids.”

Returning to the research study:

  • “(A) subgroup of patients with the inflammatory phenotype (simply people with pain and other characteristics attributed to knee swelling) with clinical features of pain, stiffness, joint swelling, and effusion are expected to be more responsive than other phenotypes (those people who do not have chronic knee swelling) who do not display clinical manifestations of inflammation.”
    • Our explanatory note: If you do not have chronic knee swelling, cortisone may not be an answer for you.

Cortisone injections. Did they cause a greater risk of need for knee replacement?

As we are seeing, when it comes to corticosteroid injections numerous research studies will report contradictory findings. In a March 2022 paper in the journal Arthritis & rheumatology (28) researchers noted that recent research that intra-articular corticosteroids injections caused harmful side effects when injected into knees with osteoarthritis. As we have seen in this article, that includes the breakdown of cartilage and advancing osteoarthritis.

  • This study sought to prove or disprove the risk of knee osteoarthritis progression in patients who received intra-articular corticosteroids injections over a 5-year follow-up.

Among the 564 patients in this study who suffered from knee osteoarthritis, 51 (9.0%) and 99 (17.5%) received intra-articular corticosteroids or intra-articular hyaluronan injections, respectively, and 414 (63.1%) did not receive any injection during follow-up.

  • Compared with untreated knees, those treated with intra-articular corticosteroid injections had a similar risk of incident needing total knee replacement or osteoarthritis worsening. Intra-articular hyaluronan injections injections had no effect on the risk of total knee replacement or or osteoarthritis worsening.

Conclusions: In this study, intra-articular corticosteroid injections for symptomatic knee osteoarthritis did not significantly increase the 5-year risk of incident total knee replacement  or cause radiographic worsening osteoarthritis on MRI. These findings should be interpreted cautiously and replicated in other cohorts.  In other words – the researchers suggest that they found no significant side effect but they remind others to interpret these finding cautiously.

Secondary adrenal insufficiency

University researchers in the United Kingdom publishing in March 2022 in the journal Clinical orthopaedics and related research (27) examined whether corticosteroid Injections are associated with secondary adrenal insufficiency in adults with musculoskeletal pain.

  • Secondary adrenal insufficiency is described when the adrenal glands do not make enough cortisol, a hormone that when low levels are in the body will cause symptoms of weakness, fatigue, and low blood pressure (and accompanying symptoms of lightheadedness, dizziness, nausea). It is called secondary adrenal insufficiency because it is caused by lack of production of the hormone ACTH (adrenocorticotropin) in the pituitary gland.

Here are the learning points of this study:

  • While corticosteroid injection is a common treatment for individuals experiencing musculoskeletal pain, there is concern about corticosteroid injections side-effects and the possibility of secondary adrenal insufficiency.
  • Seventeen previously published studies were reviewed to help answer the question of secondary adrenal insufficiency risks in patients receiving cortisone injection.
  • Findings:
    • Concern with spinal steroid injections: “Clinicians offering spinal injections should discuss the possibility of short-term secondary adrenal insufficiency with patients, and together, they can decide whether the treatment remains appropriate and whether mitigation strategies are needed.”
    • Concern with hip, shoulder, knee injections: “Clinicians offering appendicular skeleton injections (injections into arms, legs and pelvis) should not limit care because of concerns about secondary adrenal insufficiency based on the best available evidence, and clinical guidelines could be reviewed accordingly.”

Spinal injections caused the most concern with the authors calling for more research to understand whether age and/or sex determine risk of secondary adrenal insufficiency and what clinical impact secondary adrenal insufficiency has on patients undergoing spinal injection.

An understanding of cortisol in chronic pain

Pain not only decreases one’s enjoyment of life, it creates stress in the body. Stress is the worst detriment to good health. A body under stress triggers the “fight or flight” response, which means the adrenal gland begins excreting hormones such as cortisol and adrenaline.

The adrenal gland, also known as the stress gland, secretes cortisol to increase the amount of white blood cells that are activated, as in cases of allergic or infectious stress. It puts the body “on alert.” Chronic pain causes the adrenal gland to be in a continual “alert mode,” secreting cortisol as would occur with an infection or when a person is being robbed. As the chronic pain lingers, cortisol is continually produced. Cortisol levels are supposed to be low at nighttime, putting the body in the sleep mode.

The adrenal gland also secretes adrenaline, more properly named epinephrine, which is the hormone that stimulates the sympathetic nervous system. When adrenaline is secreted it causes the body to produce free radicals, causing oxidative damage to the body. Long-term stress from chronic pain results in long-term oxidative damage. This is one reason that people who suffer from chronic pain are ill more frequently and age prematurely. This can also explain why they seem “stressed-out.”

Cortisone disrupts natural healing and hurts native joint cells

Cortisone as well as other anti-inflammatories, and the RICE (rest, ice, compression, and elevation) protocol– which has very recently been rescinded by its author due to its detrimental effect on healing all are considered “non-healing,” and whose long-term usage will make the patient’s condition worse.

Cortisone disrupts and hurts healing cells

Recent research from the Mayo Clinic says cortisone may hinder the native stem cells in cartilage. (Mesenchymal stem cells (MSCs) are the building blocks of cartilage other musculoskeletal tissue.) Cortisone threatens their innate regenerative capacity in exchange for temporary analgesia. (8)

“A direct correlation between increased steroid concentration and increased chondrocyte apoptosis (cartilage death)”

It becomes perplexing then, that these medications continue to be routinely injected into people’s joints “therapeutically” for pain.  While corticosteroid and analgesic injections have the potential to temporarily relieve pain by shutting down the body’s inflammatory mechanisms, these medications are toxic to cartilage cells.  Results of bovine cartilage studies from the University of Pittsburgh School of Medicine revealed the following:

“A direct correlation between increased steroid concentration and increased chondrocyte apoptosis (cartilage death) as well as increased chondrocyte toxicity (cartilage poisoning) with increasing time of exposure to methylprednisolone. The addition of lidocaine to methylprednisolone significantly increased the rate of chondrocyte cell death.”(9)

In the American Journal of Sports Medicine, university medical researchers in Japan demonstrated a case history in which a patient received high-dose cortisone treatments for a case of Bell’s Palsy, the same patient was also a volunteer subject in a study to test a stem cell-based Tissue Engineered Construct for cartilage and bone defect. Stem cells were harvested from the patient to “build a scaffold patch.”

  • At three weeks after the cortisone treatment, the patient’s stem cells could not help generate the construct needed for the cartilage/bone patch.
  • At seven weeks after steroid therapy the stem cells could, the stem cells had successfully withstood a direct attack from the cortisone, but it did take 7 weeks to recover. (10)

This single piece of research published by French doctors in the journal Clinics in orthopedic surgery should be enough to convince anyone that cortisone makes healing with stem cells difficult. Patients seeing doctors who insist on cortisone first, should research this treatment decision.

  • “Following corticosteroid therapy in osteonecrotic patients, abnormalities have been demonstrated in the bone marrow of the iliac crest, with a decrease in the stem cell pool.”(11). 

It is the message over and over – When injected into joints, corticosteroids not only trigger cartilage cell death but also completely suppress healing by their innate mechanism of action, which is to suppress the immune system and block inflammation.

Cortisone injection risks, side effects, and tissue toxicity

Despite the research, the first trip to the joint pain specialist is usually a recommendation to cortisone. Shortly after doctors started injecting cortisone and other steroids into knee joints in the 1950s, researchers began noting severe problems of joint degeneration and so discouraged the use of cortisone injections. Today, despite the dangers, cortisone use remains widespread as a standard of care.

This is what cortisone does:

  • Cortisone has a harmful effect on soft tissue healing by inhibiting blood flow to the injured area, suppressing new blood vessel formation, suppressing the growth of immune cells like leukocytes and macrophages, preventing protein synthesis, fibroblast proliferation, and ultimately collagen formation.
  • Cortisone inhibits the release of growth hormone, which further decreases soft tissue and bone repair.
  • Cortisone weakens collagen and therefore soft tissue such as ligaments and tendons.

“a positive effect on joint pain may also be associated with accelerated joint destruction”

This is what research says about it:

  • Research: Cortisone works well for some but not for others and no one seems to be able to identify why:
    • From the journal Seminars in Arthritis & Rheumatism: “Previous research has not identified reliable predictors of response to intraarticular corticosteroid injections, a widely practiced intervention in knee and hip osteoarthritis. Further studies are required if this question is to be answered.”(12)
  • The Journal of the American Academy of Orthopaedic Surgeons (2009) Researchers concluded that corticosteroids reduce knee pain for at least 1 week and that intra-articular corticosteroid injection is a short-term treatment of a chronic problem. (13)
    • (My comment, good for one week, damages stem cells for three weeks, referring to above research).
  • From the International Journal of Clinical Rheumatology, a paper entitled: “Future directions for the management of pain in osteoarthritis”. (2014) Dangers of cortisone injections include cartilage and joint destruction, especially in those with osteoarthritis of the joint. “Corticosteroid therapy, as well as NSAIDs, can lead to the destruction of cartilage, suggesting that a positive effect on joint pain may also be associated with accelerated joint destruction, which is an extremely important factor in a chronic, long-term condition such as osteoarthritis.”(14)
    • (My comment: Cortisone is clearly not part of the Future directions for the management of pain in osteoarthritis).
  • In March 2017, Italian researchers publishing in the medical journal Expert Opinion in Drug Safety noted: local glucocorticoid injections have shown positive results in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures have been reported. (15). 
    • The was a confirmation of a study that appeared 40 years earlier in 1977. Here Stanford University Medical Center and Kaiser-Permanente Medical Center researchers suggested that cortisone injections can lead to painful tendon and ligament ruptures. They compromise tendon and ligament strength, a scary finding considering that many athletes return to the game or the sport shortly after an injection. (16)
  • The evidence for the effectiveness of intraarticular epidural steroid injection for Sacroiliac joint dysfunction treatment is poor (17).

Cortisone injections can predispose a joint to infection. Patients have reported severe pain, including muscle pain, and burning after a cortisone injection.

In research from doctors at the University of Toronto (18) wrote of the problem of injection infection.

Intraarticular hip injections of corticosteroids and hyaluronic acid may be used to treat hip osteoarthritis. Although the sterile technique is recommended to avoid infiltration of the joint with microorganisms normally found on the surface of the skin there remains a risk of infection. (All injections can carry the risk of infection, this includes our injection techniques of Prolotherapy PRP Prolotherapy and stem cell Prolotherapy)

HERE IS THE DIFFERENCE -Patients prior to hip replacement surgery may typically receive hip injections of corticosteroids and hyaluronic acid to manage their pain until surgery day.

Intraarticular hip injections of corticosteroids and hyaluronic acid may increase the risk of infection because of the immune system suppression characteristic of cortisone.

Therefore, in the setting of total hip replacement, preoperative receipt of a hip injection may increase the risk of infection, leading to early revision arthroplasty.

While the researchers were unable to determine what agent was injected into the joint prior to surgery, they concluded that the most likely therapies were corticosteroids and hyaluronic acid, with or without a local anesthetic.

As hyaluronic acid has no proven benefit for hip osteoarthritis, it is likely that most of the injections were of corticosteroids.

  • Corticosteroid joint injection may have local immunomodulatory effects that may increase the risk of infection following hip replacement.

If so, there may be a period of time required for these effects to be “cleared” before a hip replacement can be safely implanted into the joint. Regardless of the solution injected, intraarticular injections expose the joint to the external environment and may allow seeding by microbes, particularly when an improper sterile technique is used. Further research is warranted to determine whether the documented increased risk of infection following hip injection differs according to the solution used (corticosteroids versus hyaluronic acid).

But, cortisone is being recommended and you are being pain managed until such time as you can get a joint replacement. Are there options?

At Caring Medical, our option is to fix the joint or spine by rebuilding and repairing damaged tissue with regenerative injections. We can accomplish this with Prolotherapy and Platelet Rich Plasma Injections used together.

  • Comprehensive Prolotherapy is an injection technique that uses a simple sugar, dextrose, and in some cases, it is combined with Platelet Rich Plasma Therapy (blood platelets) to address damage and micro-tearing of the ligaments or soft tissue in the knee. A series of injections are placed at the tender and weakened areas of the affected structures of the knee. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction.

The localized inflammation causes healing cells to arrive at the injured area and lay down new tissue, creating stronger ligaments and rebuilding soft tissue. As the ligaments tighten and the soft tissues heal, the knee structures function normally rather than subluxing and moving out of place. When the knee functions normally, the pain and swelling go away.

  • Nature’s way is for chondrocytes (healing and rebuilding cells in our body) to repair the damage. Our therapies can assist in this process and accelerate healing.
  • During this healing, the body produces its own specialized inflammatory process that acts as a protective barrier to protect the new cartilage that is being built.
  • Once the repair is complete, our body shuts down the inflammation. The inflammation is no longer needed.

In the above scenario, the repair of the joint has shut down the inflammation. This is not so in the second scenario where medication and steroids are used to shut down inflammation.

The second way to shut down the inflammation does not involve healing or repair

  • The pharmaceutical industry has made billions and billions producing anti-inflammatories to try to get the inflammation to shut off.
  • The anti-inflammatories the industry produces simply attacks the natural inflammation, they do not repair or change the course of the disease.
  • Since the repair mechanism in your body has been shut off, you now become a pain management patient until such time as you can get a joint replacement.

You are told to have a cortisone injection. Is Prolotherapy an option?

In this video, Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical gives a brief explanation of the differences between Prolotherapy and Cortisone 

  • The difference between Prolotherapy and Cortisone is extensive.
  • Cortisone when injected into the joint can successfully mask pain. Many people have very successful treatments with Cortisone. We typically see patients who have a long history of Cortisone injection and these injections are no longer effective for them.
  • Cortisone has been shown, in many studies, to accelerate degenerative osteoarthritis through cartilage breakdown.
  • Over the years we have seen many patients who have received corticosteroid (cortisone) injections for joint pain. Unfortunately for many, excessive cortisone treatments lead to a worsening of chronic pain. Again, while some people do benefit from cortisone in the short-term – the evidence however points to cortisone causing more problems than it helps.
This chart demonstrates that cortisone injections, acting as an anti-inflammatory, decreases circulation and repair to damaged joints as its primary means to reduce pain. Prolotherapy injections are shown to act in a different way, by repairing joint damage, Prolotherapy can reduce inflammation by repairing the damage causing the inflammation.
This chart demonstrates that cortisone injections, acting as an anti-inflammatory, decreases circulation and repair to damaged joints as its primary means to reduce pain. Prolotherapy injections are shown to act in a different way, by repairing joint damage, Prolotherapy can reduce inflammation by repairing the damage causing the inflammation.

How does Prolotherapy repair a joint in ways cortisone cannot?


Prolotherapy removes damaged tissue and debris from the joint – clean up

When Prolotherapy is injected into the joint, it stimulates the production of leukocytes (an immune cell that absorbs and gets rid of diseased tissue) and macrophages. The term macrophage is from the Greek meaning, “Big Eaters.” They eat debris and damaged tissues in the joint.

Prolotherapy brings oxygen to the joint to help provide healing cells energy and a clean, safe work environment.

In a 2017 stem cell study (stem cells are cells native in the body that help remodel damaged tissue) Dr. Ming Pei of West Virginia University publishing in the medical journal Biomaterials (19suggests that while adult stem cells are a promising cell source for cartilage regeneration, they have a hard time in a harsh joint environment when hypoxia (the lack of oxygen) and inflammation have created a toxic soup for the stem cells to work in. As noted above healing cells, like your native stem cells, like a clean, safe work environment. Chronic inflammation slowly and steadily brings about a low oxygen environment in joints because the body feels that diseased tissue will die in a low oxygen environment. Oxygen deprivation is designed to be a short-term drastic measure to healing a wound. But chronic inflammation means a slow strangulation of the joint

Sometimes we forget the cells of the body obtain their energy via aerobic metabolism.  The primary substrates or substances that are needed for aerobic metabolism are oxygen and glucose. The body breathes to get oxygen and we eat to break down the food into sugar. Even if a person just eats protein, ultimately the body finds a way to break down the protein into individual amino acids and eventually into glucose. Without glucose, the cells and the body cannot live.

Prolotherapy feeds healing cells the food they like and helps make more of these cells

One important published paper on stem cell research from Purdue University confirmed the notion that dextrose, especially hypertonic (extra) dextrose is a significant factor in the ability of mesenchymal stem cells from bone marrow to proliferate. What is in a Prolotherapy injection? Hypertonic dextrose (20)

The mesenchymal stem cell consumption of glucose increased proportionally with the glucose concentration in the medium. (The more food the stem cells were given, the more they ate). The primary results note that the higher glucose and serum concentrations appear to produce higher stem cell populations over time.

This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.

In this video Prolotherapy treatments are demonstrated by Ross Hauser, MD:

  • This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.
  • This patient has a suspected labral tear and ligament injury.
  • The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
  • The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
  • From the front of the hip (1:05), we can treat the pubofemoral ligament and the iliofemoral ligaments.
  • From the posterior approach, I’m going to inject some proliferant within the hip joint itself, and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also treat the attachments of the smaller muscles  too including the Obturator, the Piriformis attachments onto the Greater Trochanter
  • Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.

Comprehensive Prolotherapy and Platelet Rich Plasma. More comparisons to Cortisone

  • Patients with chronic gluteal tendinopathy for more than 4 months, diagnosed with both clinical and radiological examinations, achieved greater clinical improvement at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection. (21)
  • Autologous blood injection, a derivative of Platelet Rich Plasma where the blood is reintroduced without the platelet concentration improved pain and function patients with chronic lateral epicondylitis (Tennis elbow), who had not had relief with a cortisone injection. (22)
  • Journal of Clinical and Diagnostic Research, a 2015 study reveals PRP as a superior treatment option to cortisone in cases of tennis elbow. (23)
  • Doctors in Pakistan have shown the effectiveness of platelets rich plasma versus corticosteroids or the “tennis elbow steroid injection.” The doctors looked at 102 patients in the study and divided them into two groups of 51(50%) each.
    • In the patients in the cortisone group 53% improvement
    • In the patients in the PRP group 82%
    • Their conclusion: PRP is an effective alternative to corticosteroid in the treatment of lateral epicondylitis (tennis elbow). (24)
  • International Orthopaedics (2012) Compared with cortisone injections, PRP showed significant clinical benefit for patellar tendinopathy. Additionally, the PRP benefit worked best when the patient did not have a PREVIOUS CORTISONE INJECTION.(25)
  • Doctors in the United Kingdom found that PRP is as effective as Steroid injection at achieving symptom relief at 3 and 6 months after injection, for the treatment of plantar fasciitis, but unlike Steroid, its effect does not wear off with time. At 12 months, PRP is significantly more effective than steroids, making it better and more durable than cortisone injection. (26)

In summary, while cortisone shots weaken an injured area even further, Prolotherapy stimulates the body to repair it. Prolotherapy stimulates blood flow to the area, protein synthesis, fibroblast proliferation, and ultimately collagen formation. The choice is simple: cortisone shots that lead to proliferative arthritis of joints or proliferative injections (Prolotherapy) that stimulate the repair of the injured tissue.

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This page was updated on December 23, 2022

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