A cortisone shot is a common medical procedure that involves injecting a corticosteroid medication combined with a local anesthetic directly into the source of pain, such as a joint, bursa, or tendon sheath. Corticosteroids are synthetic versions of the hormone cortisol, which effectively suppresses the immune response and reduces localized swelling and irritation. While often providing significant relief, an injection’s failure to alleviate symptoms requires a systematic re-evaluation and a new treatment strategy.
Reasons the Initial Injection May Not Provide Relief
The lack of improvement following a cortisone injection often signals that the underlying cause of pain was not what the injection was intended to treat. Corticosteroids are powerful anti-inflammatory agents, so if inflammation is not the primary driver of discomfort, the medication will have little effect. Pain caused by mechanical instability, nerve compression, or advanced tissue degeneration will not respond well to an anti-inflammatory treatment alone.
Another common issue is an error in the physical placement of the medication, where the injection misses the intended target structure. This is a particular concern when injections are performed without the use of real-time image guidance, such as ultrasound or fluoroscopy. If the corticosteroid is not precisely delivered, its concentrated effect is diffused, resulting in minimal or no pain reduction. The severity of the underlying condition can also overwhelm the medication’s effect, especially in cases of advanced osteoarthritis or large, structural tendon tears.
The timeframe for expecting relief also plays a role in the perception of failure. Many injections include a local anesthetic that provides immediate numbing, but this is temporary. The anti-inflammatory action of the cortisone takes time to fully develop, with most patients noticing maximum improvement within seven to fourteen days after the procedure. A lack of immediate relief should not be interpreted as a complete failure.
The Re-evaluation Process and Necessary Diagnostics
After a failed cortisone injection, the first step is to wait for the expected two-week window to ensure the corticosteroid has had sufficient time to reach its peak anti-inflammatory action. Once this period has passed without significant change in symptoms, the physician initiates a thorough re-evaluation. This process involves a detailed update to the physical examination, focusing on changes in range of motion, muscle strength, and specific pain patterns. The physician is essentially looking for evidence that the pain is mechanical or structural in nature, rather than inflammatory.
This diagnostic refinement often requires the use of advanced imaging techniques beyond standard X-rays. Magnetic Resonance Imaging (MRI) is frequently ordered to visualize soft tissues, which can reveal conditions not visible on plain films. An MRI can clearly show the extent of a tendon tear, look for nerve root compression, or assess the integrity of ligaments and cartilage. A Computed Tomography (CT) scan may be used to provide a more detailed look at bone structure. The goal is to confirm or refine the original diagnosis by identifying an underlying structural issue.
Conservative Treatment Options After Injection Failure
Once the re-evaluation is complete and a structural issue that does not immediately require surgery is identified, the focus shifts to alternative conservative therapies. Physical therapy (PT) becomes a primary treatment, as it directly addresses mechanical issues like muscle weakness, poor joint mechanics, and faulty movement patterns that often contribute to chronic pain. A targeted PT program will focus on specific exercises to strengthen the stabilizing muscles and improve overall flexibility and posture.
Therapeutic exercises are frequently combined with manual therapy techniques performed by the physical therapist, such as joint mobilization and soft tissue manipulation, to reduce pain and restore normal joint function. Pharmacological adjustments may also be considered, which involves switching to a different class of oral medication, such as a different nonsteroidal anti-inflammatory drug (NSAID) or nerve-specific medications.
Alternative injection therapies offer another non-surgical path, especially for persistent joint or tendon issues. These regenerative injections address the underlying tissue health, rather than just the inflammation. For instance, hyaluronic acid injections (viscosupplementation) may be used for mild to moderate osteoarthritis to improve the lubricating and shock-absorbing properties of joint fluid. Platelet-Rich Plasma (PRP) therapy is another option that involves injecting a concentration of the patient’s own platelets, which contain growth factors, into the injured tissue to stimulate natural healing and repair.
Lifestyle modifications also play an important role, particularly weight management, as excess body weight significantly increases the mechanical load on joints. The use of bracing, splinting, or custom orthotics can provide mechanical support and offload stress from the injured structure, allowing for a better healing environment. These conservative measures are designed to treat the root cause of the pain, offering a comprehensive approach to recovery.
When Surgical Consultation Becomes Necessary
A surgical consultation is typically considered when a patient has exhausted all appropriate conservative treatment options, including physical therapy, alternative injections, and pharmacological management, without achieving a satisfactory reduction in pain or improvement in function. The persistence of severe, debilitating pain that significantly interferes with daily life is a strong indication that the underlying issue requires surgical intervention.
Another clear criterion for surgical referral is the presence of progressive neurological deficits, such as worsening muscle weakness, numbness, or loss of reflex function. Imaging that reveals structural damage requiring mechanical correction, such as a large rotator cuff tear or severe spinal stenosis, also warrants a surgeon’s opinion.
If surgery is planned, a waiting period of at least three to six months following the cortisone shot is often recommended to minimize the potential risk of post-operative infection.