Cortisone Decreases Bone, Ligament and Tendon Strength
Ross Hauser, M.D.
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In my
opinion, the quickest way for an patient or athlete to lose strength at the
ligament-bone junction (fibro-osseous junction) is to inject cortisone to
that area. Cortisone and other steroid injections ALL have the same
detrimental effects on articular cartilage.
Corticosteroids, such as cortisone and Prednisone, have an adverse effect on
bone and soft tissue healing. Corticosteroids inactivate vitamin D, limiting
calcium absorption by the gastrointestinal tract, and increasing the urinary
excretion of calcium. Bone also shows a decrease in calcium uptake with
cortisone use, ultimately leading to weakness at the fibro-osseous junction.
Corticosteroids also inhibit the release of Growth Hormone, which further
decreases soft tissue and bone repair. Ultimately, corticosteroids lead to a
decrease in bone, ligament, and tendon strength.
Corticosteroids inhibit the synthesis of proteins, collagen, and
Proteoglycans in articular cartilage, by inhibiting chondrocyte production,
the cells that comprise and produce the articular cartilage. The net
catabolic effect (weakening) of corticosteroids is inhibition of fibroblast
production of collagen, ground substance, and angiogenesis (new blood vessel
formation). The result is weakened synovial joints, supporting structures,
articular cartilage, ligaments, and tendons. This weakness increases the
pain and the increased pain leads to more steroid injections. Cortisone
injections should play almost no role in sports injury care. Although
anti-inflammatory medications and steroid injections reduce pain, they do so
at the cost of destroying tissue. In a study conducted by Siraya Chunekamrai,
D.V.M., Ph.D., steroid shots, of a substance commonly used in humans, were
given to horses. The injected tissue was looked at under the microscope. The
steroid shots induced a tremendous amount of damage, including chondrocyte
necrosis (cartilage cell damage), hypocellularity (decreased number of
cells) in the joint, decreased proteoglycan content and synthesis, and
decreased collagen synthesis in the joint. All of these effects were
permanent.
Dr.
Chunekamrai concluded, “...the effects on cartilage of intra-articular
injections of methylprednisolone acetate (steroid) were not ameliorated at
eight weeks after eight weekly injections, or 16 weeks after a single
injection. Cartilage remained biochemically and metabolically impaired.”22
In this study, some of the joints were injected only one time. Even after
one steroid injection, cartilage remained biochemically and metabolically
impaired. Other studies have confirmed similar harmful effects of steroids
on joint and cartilage tissue. A cortisone shot can permanently damage
joints. Prolotherapy injections have the opposite effect—they permanently
strengthen joints, ligaments, and tendons.
The
problem with athletes is that they look for quick relief. The problem with
cortisone is that the athlete may get pain relief, but it may be at the
expense of permanent inability to participate in athletics. Athletes often
receive cortisone shots in order to play. They go onto the playing field
with an injury of such significant magnitude that they received a cortisone
shot to relieve the pain. Unfortunately, they cannot feel the pain anymore
so they play as if there was no injury. We know that the injury could not
possibly be healed because of the tremendous anti-healing properties of
cortisone. Thus the athlete is further injured from the cortisone, as well
as playing with an injury, thereby worsening the already bad injury.
Cortisone is so dangerous to the athlete because it inhibits just about
every aspect of healing. Cortisone inhibits prostaglandin and leukotriene
production. It also inhibits chondrocyte production of protein
polysaccharides (proteoglycans), which are the major constituents of
articular ground substance. Behrens and colleagues reported a persistent and
highly significant reduction in the synthesis of proteins, collagen, and
proteoglycans in the articular cartilage of rabbits who received weekly
injections of glucocorticoids. They also reported a progressive loss of
endoplasmic reticulum, mitochondria, and Golgi apparatus, as the number of
injections increased.
Exercise has the opposite effect. Exercise has been shown to positively
affect articular cartilage by increasing its thickness, enhancing the
infusion of nutrients, and increasing matrix synthesis. However, the effects
of doing them together were not studied until recently.
Dr. Prem Gogia and associates at the Washington University School of
Medicine in St. Louis, Missouri, did an excellent study bringing out the
dangers of an athlete exercising after receiving a cortisone shot. They
divided animals into three groups:
1.
Group One: received a cortisone shot
2. Group Two: received a cortisone shot and exercised
3. Group Three: control group, received no treatment
This
study was done in 1993 and was the first study to look at the effects of
exercising after receiving a cortisone shot. The authors performed this
study because it is common practice in sports medicine to give an athlete a
cortisone shot for an acute or chronic injury. Athletes are typically
returning to full-intensity sports activities within a few hours to one to
two days after receiving the shot. The results of the study were
unbelievable. The animals receiving the cortisone shots showed a decrease in
chondrocytes, but when they received the cortisone shot and exercised, the
chondrocyte cell count decreased by another 25 percent. Degenerated
cartilage was seen in all of the cortisone-injected animals, but severe
cartilage damage was seen in 67 percent of the animals that exercised and
received cortisone. The cortisone and exercise group also showed a
significant decline in glycosaminoglycan synthesis compared to the other
groups. The authors concluded, “...the results suggest that running exercise
in combination with intra-articular injections results in damage to the
femoral articular cartilage.”
