A cortisone shot, formally known as a corticosteroid injection, delivers a potent anti-inflammatory medication directly into a localized area of pain, such as a joint, tendon, or bursa. This treatment manages symptoms of musculoskeletal issues like tendonitis, arthritis, or bursitis by suppressing the local immune response and reducing swelling. While often effective, the failure of an injection indicates that the underlying cause of the pain has not been fully addressed. When a cortisone shot does not work, a structured clinical response is required to identify a definitive treatment path.
Re-evaluating the Initial Diagnosis
The initial step after a failed cortisone injection is a thorough re-evaluation. The lack of response suggests the original diagnosis may have been incomplete, or the severity of the condition was underestimated. Corticosteroids primarily target inflammation; therefore, if the pain source is mechanical or degenerative rather than inflammatory, the injection will not provide lasting relief. A failed shot can also indicate that the medication did not reach the precise anatomical target, particularly if the procedure lacked image guidance.
Advanced diagnostic tools are employed to gain a clearer picture of the joint’s internal structure. Magnetic Resonance Imaging (MRI) is valuable for visualizing soft tissues like cartilage, ligaments, and tendons, helping to identify structural issues such as severe tears or bone marrow edema. Ultrasound provides a dynamic, real-time assessment of superficial soft tissues and can confirm if the pain originates from a source a steroid cannot fix, such as advanced arthritis progression.
Further assessment is necessary to rule out referred pain, which is felt at a location different from the actual source. Pain originating from the spine, such as a pinched nerve or facet joint irritation, can be perceived in the hip, shoulder, or leg. If the injection was given to a peripheral joint but the true issue lies in the spine, the treatment targeted the wrong pathology. Accurately pinpointing the origin of the discomfort is the foundation for all subsequent treatment decisions.
Non-Invasive and Pharmacological Alternatives
Once the diagnosis is confirmed or refined, the next line of defense focuses on conservative, non-injection-based therapies. Physical therapy (PT) is a cornerstone of this approach, aiming to address underlying biomechanical issues contributing to pain. PT focuses on strengthening surrounding musculature, improving joint stability, and correcting movement patterns that place excessive stress on the affected area.
Pharmacological alternatives can target aspects of pain beyond local inflammation. If nerve involvement is suspected, specialized medications are introduced, even if non-steroidal anti-inflammatory drugs (NSAIDs) are continued. These agents include gabapentinoids (like gabapentin or pregabalin) and certain tricyclic antidepressants (TCAs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications modulate pain signals within the central nervous system and manage neuropathic symptoms like tingling, numbness, or shooting pain.
Supportive devices are often integrated into the treatment plan to offload the painful joint or tendon. Specialized orthotics, braces, or splints stabilize the joint, redistribute pressure, and absorb shock during activity. For instance, a custom foot orthotic can correct alignment issues affecting the knee or hip, reducing mechanical strain. These non-invasive methods focus on sustained functional improvement rather than temporary pain masking.
Advanced Targeted Injection Therapies
If pain persists despite conservative management, the focus shifts to advanced, non-corticosteroid injection therapies tailored to the specific pathology. For joints affected by osteoarthritis, viscosupplementation is an option, involving the injection of hyaluronic acid into the joint space. Hyaluronic acid is a natural component of healthy synovial fluid; the injection restores the fluid’s viscoelastic properties, improving joint lubrication and shock absorption. This procedure also modulates the biochemical environment by inhibiting inflammatory mediators.
For chronic tendon or ligament issues where inflammation has subsided but healing is incomplete, Platelet-Rich Plasma (PRP) therapy is often employed. PRP is derived from the patient’s own blood and contains a high concentration of growth factors. When injected, these growth factors initiate a localized healing cascade, stimulating cellular proliferation, collagen synthesis, and the recruitment of reparative cells to promote tissue repair.
For pain determined to be primarily neuropathic, targeted interventions can interrupt the pain signal transmission. A nerve block involves injecting a local anesthetic and sometimes a small amount of steroid near the irritated nerve to temporarily block the signal. If a diagnostic nerve block provides significant but temporary relief, the next step may be radiofrequency ablation (RFA). RFA is a longer-lasting procedure that uses thermal energy to create a small lesion on the nerve, disrupting its ability to send pain signals for a period that can last months or longer.
Considering Surgical or Minimally Invasive Procedures
When all conservative measures and advanced injection therapies have failed to provide lasting relief, consultation for surgical or minimally invasive intervention is the final step. Surgery is reserved for cases where advanced imaging confirms a structural defect that is mechanically correctable and directly responsible for functional impairment. This includes conditions like a significant tendon rupture, irreversible joint damage, or nerve compression that risks permanent injury.
The decision to proceed with surgery is made when the pain is unmanageable and severely limits the patient’s quality of life. Procedures vary widely depending on the anatomical location and underlying issue. Arthroscopy, a minimally invasive technique, allows a surgeon to use small incisions and a camera to repair or remove damaged tissue within a joint, such as repairing a torn meniscus or stabilizing a ligament.
For advanced joint destruction from conditions like severe osteoarthritis, a joint replacement procedure, such as a total knee or hip replacement, may be recommended to restore function. Other procedures include open or minimally invasive tendon repair for chronic tendinopathy, or decompression surgery to relieve pressure on a nerve root in the spine. These surgical options represent a definitive treatment approach to address the physical cause of pain that non-surgical methods could not resolve.