The Difficulty with Cortisone Injections

To some, cortisone injections are a miracle. The can play a crucial role with adhesive capsulitis, for example. I have had patients that tell me of past injuries that were "healed" with cortisone injections. For those of you unfamiliar with their use, the typical benefit involves reduction of inflammation and/or pain. Sometimes, patients come to you following an injection. Sometimes, they get them during the course of the treatment. And sometimes, patients get the injections as a result of failed physical therapy.

That being said, there are several problems with the procedure and its impact on our job.  As many of you know, cortisone injections can do an excellent job with pain reduction, but does not do much with any impairments that may have contributed to the original injuries. The issue with this is that patients come to us thinking they are "healed" but their body is still very much at risk for reinjury. When it comes to our testing, some patients are extremely sensitive to even ROM assessment. Coming out of school, I would still do my normal assessment of these patients (ROM, MMT, special tests, etc.) and they would come back in pain. With the patient thinking they have regressed as a result of the evaluation, it's possible the trust in the clinician-patient relationship will be shaken, affecting their prognosis. Some patients, especially with various biopsychosocial factors, may be affected by even the least aggressive stimulation of the affected region.

So how do we assess and treat these patients? Personally, I try to keep things as minimal as possible with assessment. I'll usually do a ROM assessment while having the patient keep it in a range that is comfortable. And I'll assess strength of joints away from the affected region. That is typically it for patients after an injection. I'll begin with some lighter manual treatment and exercise to improve the mobility in a non-threatening way. I do absolutely no special tests looking for pain provocation. Once the patient starts moving better, I'll continue with further assessment and progress my treatment. Even in taking these precautions, every once and awhile I'll have a patient that is so hypersensitive that they will have an increase in pain. At that point, it is essential that we educate our patients on pain science in order to calm their nervous system. Personally, I think that cortisone injects can be a very beneficial tool in managing our patients, especially when the pain restricts them from fully participating in rehab. But I would prefer the injections be performed after a trial of therapy in order to not risk the clinician-patient relationship.

-Chris

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