A cortisone shot involves injecting a corticosteroid, a potent anti-inflammatory medication, often combined with a local anesthetic, directly into a painful area like a joint, tendon, or bursa. This treatment primarily reduces localized inflammation and provides temporary relief for conditions such as tendinitis, bursitis, or arthritis. While these injections are frequently effective, they are not a cure for the underlying condition. When the injection fails to provide meaningful pain reduction, it signals that the initial treatment plan needs adjustment and requires a deeper look into the true source of the discomfort.
Causes of Treatment Non-Response
Failure of a cortisone shot often stems from either a misidentification of the pain source or a technical issue with the procedure. Corticosteroids suppress inflammation, so if the pain is not primarily inflammatory, the medication will have limited effect. For example, pain caused by purely mechanical issues, such as advanced structural joint damage or nerve compression, requires more than just inflammation reduction.
Accuracy of the injection is another common reason for non-response, especially when treating deeper tissues without guidance. If the steroid misses the precise target area, its therapeutic effect is diminished or nonexistent. While many providers use ultrasound or fluoroscopy (a type of X-ray) guidance to ensure accurate placement, this is not always done.
The severity of the underlying condition can also overwhelm the medication. In cases of severe, end-stage degenerative joint disease or a large tendon tear, the structural damage is too extensive for an anti-inflammatory drug to overcome. A patient might also experience a brief increase in pain, known as a cortisone flare, which is a temporary reaction and should not be mistaken for treatment failure unless the pain persists beyond a few days.
The Medical Re-Evaluation Process
If a patient does not experience noticeable pain relief within seven to fourteen days, the medical team initiates a comprehensive re-evaluation. This first involves a detailed review of the physical examination, focusing on changes in range of motion, strength, and the exact location of the persistent pain. This helps determine if the diagnosis was inaccurate or if the condition has progressed.
The next crucial step often involves advanced diagnostic imaging, such as a magnetic resonance imaging (MRI) scan or a follow-up ultrasound. An MRI provides detailed images of soft tissues, revealing issues like an undetected meniscal tear, nerve impingement, or a larger tendon rupture that a standard X-ray might miss. Ultrasound can also help confirm if the steroid was accurately delivered to the intended anatomical space.
The re-evaluation may also include consultation with a specialist, such as an orthopedic surgeon, rheumatologist, or pain management physician. These specialists offer a second opinion on the imaging and clinical findings, potentially identifying a less common source of pain or a complex biomechanical issue. This methodical approach ensures that a new, evidence-based treatment plan is developed.
Non-Invasive Alternative Therapies
Once the underlying issue is clarified, the focus shifts to conservative, non-surgical treatments.
Physical Therapy
Physical therapy is often the most recommended next step, addressing mechanical and movement problems that cortisone does not affect. A physical therapist develops a targeted program to improve joint stability, strengthen supporting muscles, and correct poor movement patterns causing irritation and pain.
Alternative Injection Treatments
Alternative injection treatments offer a non-invasive pathway distinct from corticosteroids. Hyaluronic acid injections (viscosupplementation) can be used for osteoarthritis, acting as a lubricant to improve joint function and reduce friction. Another option is Platelet-Rich Plasma (PRP) therapy, which involves injecting a concentrated solution of the patient’s own platelets and growth factors into the damaged tissue to promote healing.
Oral medications are also adjusted to manage persistent pain and inflammation, often moving to prescription-strength non-steroidal anti-inflammatory drugs (NSAIDs) if over-the-counter options failed. Lifestyle and activity modifications become paramount, including bracing or splinting to support the affected area. Weight management is also a long-term strategy that significantly reduces mechanical load on joints like the knees and hips.
Considering Surgical Intervention
Surgery is typically the final step, reserved for when all non-invasive therapies, including conservative measures following a failed cortisone shot, have been exhausted. Criteria for surgical consultation are based on the severity of pain, functional impairment, and progressive structural failure confirmed by imaging. Debilitating pain that significantly interferes with daily life, despite previous management attempts, is a strong indicator for surgical review.
Structural issues requiring mechanical repair often necessitate surgery. These include a large, non-healing tendon rupture, a severely unstable joint due to ligament damage, or advanced joint degeneration. For example, severe osteoarthritis may lead to total joint replacement, where damaged surfaces are replaced with prosthetic components. Nerve compression threatening motor function, such as severe carpal tunnel syndrome or a disc herniation, also makes surgery a time-sensitive necessity.
The decision to proceed requires a thorough discussion between the patient and the orthopedic surgeon. This conversation covers the specific procedure, potential benefits, inherent risks, and the expected recovery timeline, which often involves significant physical therapy. Surgery offers the potential for long-term correction of the underlying anatomical problem that conservative treatments could not address.