Sunday, 15 June 2014

Cortisone injections in athletes

It is a well-known fact that many injured athletes get cortisone shots when joint inflammation becomes too painful to play (translation: I'm too lazy to provide a bunch of references).

What's less well-known is that repeated injections lead to no good. Clearly inflammation occurs in joints and other parts of our body for good reason. Except for critical cases like swelling of the brain, one should hesitate alleviating such inflammation, which usually is a sign of bodily repair underway. It's important to know exactly what you're doing and why.

The following two papers are concerning back pain but this is as good a place to start as any since back pain can be crippling, hence the solutions sought provide immediate relief. Let's combine the quest of athletes and back pain in one fell swoop. Browsing Google Scholar I came across an old-ish (1980) paper that stated
Thirty-two young athletes (ages ranging from 17 to 30 years) with a clinical diagnosis of a symptomatic lumbar disc and sciatica [read: back pain] were treated with lumbar epidural cortisone injections. All had had disabling symptoms persisting for a minimum of 2 weeks, with an average duration of 3.6 months. Dramatic abatement of symptoms and a significantly hastened return to competition (a positive response) was seen in 14 (44%) of the 32 athletes following injection.
Fair enough; doctors would never give such painful injections if people didn't show some sort of improvement. However I was looking for longer-term studies, since the point is that reducing inflammation now is likely a tradeoff with full recovery later. What might that tradeoff be? For one, new types of back pain may emerge. One in particular spinal nerve inflammation is known as by technical term arachnoiditis. It turns out taking these injections can potentially lead to this type of complication. And herein lies a shocking observation in a second article from 1996:
The lack of evidence of a relationship between epidural steroid administration and arachnoiditis is quite remarkable. In our review of the literature, we found no case reports documenting such a relationship, and our review of 64 series out steroid epidurals, which included nearly 7000 patients, failed to reveal a single report of arachnoiditis. 
The Wiki entry on arachnoiditis shows doctors have learned to take this problem into consideration:
Steroid injections, administered either intrathecally or epidurally have been linked as a cause of the disease, therefore they are generally discouraged as a treatment and may even worsen the condition. Doctors have different views about this disease so seeking a second opinion may be wise. 
The second article stated in its conclusions that
There are few published reports of serious complications following epidural steroid injections. There are a few published reports of complications following subarachnoid steroid injections, most of which were associated with multiple injections over a prolonged time period.
Imagine the sheer number of people who've received shots (up until 1996) without much long-term consideration of the consequences. As article #1 already pointed out, immediate pain issues are 'solved', but the second review article shows some disturbing recurring side effects in various cohorts: Transient increased pain, severe headaches, exacerbation of pain, and nausea.  There were even cases of bacterial infections.

If something as severe as complications for back pain were this long-ignored, imagine the masking of truth behind using these same steroids for relatively minor problems. A USA Today article titled "Cortisone: Is it worth the shot?" regarding baseball players using cortisone brought such consideration to light:
[T]his year's playoffs are filled with players who will mask pain now, and deal with medical fallout later.
Cortisone differs from anabolic steroids in that cortisone does not return the body to a non-injured level. It is a medical treatment that relieves or masks pain rather than heal. That makes it legal but creates other issues.
Or in this (also-baseball article):
The bigger issue is that cortisone does not heal injuries. It reduces or eliminates pain, which could lead a player to push his body to the breaking point. 
"Cortisone decreases inflammation. And it's inflammation that causes pain. So, yes, you will decrease inflammation, but it may not fix the underlying problem. Usually what fixes an underlying problem is time and allowing things to heal."

The goal of many a doctor is to control the pain now and pay the consequences later. This seems the worst possible solution for an athlete, as athletes most always want immediate results. Some are growing wiser, as in this piece on runner's injuries:
It used to be that cortisone shots, also known as corticosteroid injections, were considered a wonder cure. Doctors would prescribe them for virtually every injury and they were believed to relieve nearly all pain. 
Not anymore. [...] In the long-term, they don’t do better than the group with rest.
But if both doctor and patient show the same blind spot, the end result is an injured athlete. For the pros who already committed to expensive contracts and plan to deal with the fallout later, ok. But for an amateur runner, soccer player, swimmer, etc. the tradeoff appears insane.  Worse still are the thousands of people receiving these injections not involved in any sport, and perhaps entirely unaware of the consequences. 

To each their own. But please, I hope people know what they're doing. 

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