Steroid injections have become almost reflexive in orthopedic care. Pain in the elbow — injection. Shoulder hurts — injection. And I understand the appeal: they work fast, they're straightforward to administer, and patients walk out feeling better. But twenty-seven years of watching outcomes unfold has made me considerably more selective about when I reach for cortisone. Here's the reasoning I think every patient deserves to hear before they agree to one.
What cortisone actually does
Cortisone is a corticosteroid — a powerful anti-inflammatory agent. When injected into a tissue, it suppresses the local inflammatory cascade: reducing swelling, quieting pain signals, and temporarily restoring function. For conditions driven by acute inflammation, this is exactly what you want. The problem begins when we apply this tool to conditions that aren't inflammatory — or where inflammation is actually part of the healing process you need.
There are two fundamentally different things happening in musculoskeletal pain that are frequently conflated: inflammation and degeneration. Inflammation is an active biological process — the body marshaling resources to heal damaged tissue. Degeneration is a different process — the structural breakdown of tissue over time, often with minimal inflammatory activity. These require different treatments. Treating one as if it were the other doesn't just fail. In the case of tendinopathy, it can accelerate harm.
"Cortisone treats inflammation. But not all pain is inflammatory — and injecting into a tendon that's already degenerating doesn't heal it. It can accelerate the breakdown."
The tennis elbow problem
Lateral epicondylitis — tennis elbow — is the condition where this distinction matters most and where the data is most clearly against reflexive injection. The tissue in established tennis elbow is not inflamed. Histological studies of the degenerated extensor carpi radialis brevis tendon show an absence of inflammatory cells and the presence of disorganized collagen, immature blood vessels, and fibroblast proliferation. This is tendinosis — degeneration — not tendinitis.
A cortisone injection into a degenerated tendon suppresses pain in the short term. In multiple randomized controlled trials, patients who received cortisone for tennis elbow reported significantly less pain at six weeks than those who received physiotherapy or watchful waiting. The problem is what happens next. At one year, those same patients have significantly worse outcomes — higher recurrence rates, slower return to function, and in some cases structural tendon changes. The injection borrowed against the future. The pain relief was real. The trade was not favorable.
When cortisone is the right answer
I want to be precise here because this is not a blanket indictment of corticosteroid injections. They are excellent tools for the right indications. The distinction I follow in practice is straightforward:
- Acute inflammatory arthritis flare in a joint
- Acutely inflamed bursa (bursitis with swelling and heat)
- Carpal tunnel syndrome — especially in pregnancy, where systemic options are limited
- De Quervain's tenosynovitis — the target is an inflamed synovial sheath, not the tendon itself
- Trigger finger — injection into the tendon sheath has excellent efficacy and a strong safety profile
- Tennis elbow (lateral epicondylitis) — short-term gain, worse long-term outcomes in the evidence
- Rotator cuff tendinosis — degenerated tendon, not inflamed; repeated injection raises rupture risk
- Achilles tendinopathy — the risk of tendon rupture following injection is well-documented
- Patellar tendinopathy — same reasoning; the evidence for injection is not supportive
- Any tendon already partially torn — the mechanical risk is significant
The rupture risk is real
Multiple cortisone injections into the same tendon over time compound the risk of structural failure. The mechanism is understood: corticosteroids impair collagen synthesis, reduce the tensile strength of tendon tissue, and in high doses can cause fat necrosis and localized tissue atrophy. A tendon that has received three injections over two years and is then subjected to a sudden load is not behaving like a healthy tendon. I have operated on ruptures in patients whose only risk factor was a history of repeated injections at the same site.
The clinical rule I follow: one injection to establish diagnosis, suppress inflammation, and create a window for rehabilitation. If the problem recurs without the rehabilitation having been done, the injection did not fail — the treatment plan did. If the problem recurs after thorough rehabilitation, the injection is unlikely to be the right answer the third time.
Inject what's inflamed. Load what's degenerated. Those are two different problems requiring two different solutions.
This came from The Form & Function Brief.
Every Tuesday — one clinical question answered, one condition explained, one piece of gear worth knowing about. Five minutes. Evidence over ego.
Subscribe Free →- 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(7575):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. The Lancet. 2010;376(9754):1751–1767. doi:10.1016/S0140-6736(10)61160-9
- Dean BJF, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Seminars in Arthritis and Rheumatism. 2014;43(4):570–576. doi:10.1016/j.semarthrit.2013.08.006