In Issue 1 of this newsletter I introduced the broad case against reflexive cortisone use. This week I want to go further, because the story of how I changed my own practice is more honest and more useful than a summary of the evidence. For the first decade or so of my surgical career, cortisone was a tool I reached for readily — not recklessly, but without the caution I now apply. Patients came in with elbow pain, shoulder pain, trigger finger, carpal tunnel symptoms. Injection was fast, effective in the short term, well-tolerated, and reliably produced a satisfied patient walking out of the office. That feedback loop reinforces behavior. It reinforced mine.
"The problem with cortisone is not that it doesn't work. It's that it works so well in the short term that it obscures whether the underlying problem is actually being addressed."
What the evidence accumulated
What the literature accumulated over time, and what my own long-term follow-up of patients confirmed, is that the picture is considerably more complicated for tendinopathy specifically. Repeated injections into degenerating tendons — tennis elbow, rotator cuff tendinosis, Achilles tendinopathy — produced temporary pain relief followed by recurrence at a higher rate than conservative loading programs. And in some cases, particularly with multiple injections into the same structure, the tendon tissue itself was compromised.
I have operated on tendon ruptures in patients who had received four or five injections into the same site. The connection is not always causal, but the pattern is real and the literature supports caution with repeat injection into the same tendon in a short time window.
What I do now
For true inflammatory conditions — rheumatoid flares, acute bursitis, De Quervain's tenosynovitis, trigger finger — cortisone remains a highly effective and appropriate first-line tool and I use it without hesitation. For tendinopathy, I have largely replaced reflexive injection with a structured eccentric loading program, reserving injection for cases with significant acute pain that is preventing the patient from engaging in that rehabilitation.
The injection in that context is not the treatment. It is the bridge to the treatment. That distinction took me years to fully internalize, and it changed my outcomes. Evidence over ego applies to what we do in the clinic the same way it applies everywhere else — including when what we need to revise is our own previous practice.
Watch the cortisone reel on Instagram — the one that sparked the most comments of any medical post I've made.
@formandfunctionmd →- Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333:939. doi:10.1136/bmj.38961.584653.AE
- Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751–1767. doi:10.1016/S0140-6736(10)61160-9
- Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis. Lancet. 2002;359(9307):657–662. doi:10.1016/S0140-6736(02)07811-X