Cortisone injections (CSI) are a common medical procedure used to treat localized inflammation in joints, tendons, and bursae. These injections deliver a powerful anti-inflammatory corticosteroid directly to the site of pain, aiming to reduce swelling and discomfort. While often successful in providing temporary relief, it is a recognized clinical scenario that the injection may not provide the expected benefit, leaving patients frustrated. Understanding the reasons for this lack of efficacy and the appropriate next steps is paramount for effective pain management.
Understanding the Timeline for Relief
Cortisone injections typically contain a combination of a corticosteroid and a local anesthetic. The local anesthetic works almost immediately, providing a rapid but temporary numbing effect that lasts for several hours. This immediate relief is often mistakenly attributed to the steroid itself.
The corticosteroid takes a few days to interact with the cells in the joint lining and initiate its anti-inflammatory action. Studies indicate that most patients who experience relief feel better within one week. Therefore, an injection should not be considered a true “failure” until at least seven to ten days have passed without any significant, lasting improvement.
Technical and Diagnostic Causes of Failure
One primary reason a cortisone injection fails involves technical issues related to the procedure itself. Cortisone must be delivered precisely to the inflamed tissue, such as the joint space or bursa, to be effective. If the medication is injected outside the intended target area, its therapeutic concentration may be too low to resolve the localized inflammation.
To mitigate this risk, many practitioners now use imaging guidance, such as ultrasound or fluoroscopy (a type of X-ray), to confirm accurate needle placement. Without this guidance, especially in deep or complex joints, the medication may miss its mark. Rapid clearance of the medication can also be a factor in highly vascular areas, or if the patient engages in strenuous activity too soon after the procedure.
The most significant cause of a failed injection is often a diagnostic limitation, meaning the pain source was incorrectly identified. Cortisone works by controlling inflammation, so if the patient’s pain is not primarily inflammatory, the injection will not help. For example, pain may be mechanical, stemming from bone-on-bone contact in advanced osteoarthritis, or structural, caused by ligament instability or nerve entrapment.
Furthermore, the severity of the underlying disease can overwhelm a single dose of steroid. If the inflammation is too extensive or long-standing, the amount of medication delivered may be insufficient to overcome the body’s inflammatory response, leading to minimal change in symptoms.
Next Steps When Cortisone Provides No Relief
Once the initial ten-day period has passed and the injection is deemed unsuccessful, the focus shifts to a thorough re-evaluation of the pain source. The failure provides valuable diagnostic information, strongly suggesting the pain is not driven by inflammation alone. This warrants a deeper investigation to uncover overlooked mechanical or structural issues.
Targeted physical therapy is often the first non-pharmacological intervention, starting the process of addressing the root cause. A physical therapist can identify faulty movement patterns, muscle imbalances, or joint mechanics that are irritating the tissue. A structured program focusing on strengthening and stability can address the root cause, which a cortisone injection cannot.
Systemic medications may also be considered to manage persistent pain and inflammation throughout the re-evaluation process. Non-steroidal anti-inflammatory drugs (NSAIDs) can provide generalized relief. For pain with a significant neurological component, nerve-blocking medications or specialized nerve treatments may be explored. For conditions involving widespread inflammation, such as certain forms of arthritis, a physician might consider advanced medications like disease-modifying antirheumatic drugs (DMARDs).
Considering Repeat Injections or Advanced Intervention
If the initial injection failed, repeating the procedure requires careful consideration. A second injection may be warranted if the practitioner suspects the first was technically inaccurate, especially if imaging guidance was not used. However, if the first injection confirmed the pain was not inflammatory, a repeat injection is unlikely to succeed and carries unnecessary risks.
Healthcare professionals recommend limiting cortisone injections in a single joint to no more than three or four times per year. This limit mitigates the risk of side effects, including cartilage damage, tendon weakening, and bone changes. Physicians typically recommend a minimum gap of three months between injections.
For persistent pain that has not responded to conservative alternatives, advanced interventions offer specialized care. These may include other injection types, such as hyaluronic acid, which acts as a lubricant for joint pain, or Platelet-Rich Plasma (PRP) therapy. In cases of severe structural damage or advanced arthritis, consulting an orthopedic surgeon to discuss surgical options is the necessary next step.