(August 2017)

Chronic tendon and soft tissue injuries are extremely common, not only for high-level athletes but for weekend warriors and the sedentary.  Injuries such as tennis elbow, plantar fasciitis, and tendinitis of the achilles, shoulder, and hip, can greatly affect the quality of life for patients and can be exceedingly difficult and frustrating to treat.  A common treatment is to offer a steroid or cortisone injection to help alleviate pain in stubborn cases; however, science has taught us more about the underlying causes for these conditions and I have all but abandoned cortisone as a treatment.  Admittedly, cortisone is attractive to doctors and patients because it holds the seductive promise of near immediate pain relief.  In today's blog, I’m going to explain why the short-term gratification that cortisone provides can potentially cause more harm than good.

Cortisone has been used for musculoskeletal injuries since the 1950’s.  Cortisone is an anti-inflammatory medication that can be extremely effective in reducing inflammation and pain in muscles and joints.  The suffix “-itis” means inflammation, so, an inflamed tendon or "tendinitis" should logically respond to a cortisone injection, right?  Well, it's not that simple.  We have recently learned that your chronically injured tennis elbow or plantar fascia really isn’t an inflammatory condition at all.  Numerous studies over the years have proven that chronic tendon or soft tissue pain is actually a degenerative and not an inflammatory process.  When scientists examine tissue samples from chronically injured tendons, they find that the usual markers of inflammation are not absent. Instead, the tendons appear disorganized and frayed.   What we have referred to for years as an inflamed tendon or tendonitis is really a completely different process.  The tendon is diseased and breaking down, not inflamed.  We now refer to these injuries as a "tendinosis" or "tendinopathy".  In fact, true tendinitis is uncommon.  Tendinopathies and tendinosis can respond initially to cortisone due to cortisones ability to calm the pain signals of local nerves.  Thus, cortisone dulls your perception of the pain but does nothing to heal the tissue.  In the long term, cortisone may prevent the injury from healing.  

Recent studies have supported the notion that treating a degenerative tendon injuries with cortisone sometimes causes more harm than good.  One landmark review article from the Lancet consistently showed cortisone to be effective in the short-term but not in the long term.  In fact, in the case of tennis elbow, cortisone seems to make patients worse.  We now believe that cortisone impedes the tissue from healing by halting the natural healing process.  It turns out that the swelling you get after an ankle sprain is good and part of how an injury heals.  Mother nature rarely does things without a purpose.  So, even though relieving pain and swelling (ice, Ibuprofen, cortisone) makes an injury initially feel better, it may impede the healing process itself.   Studies for various tendinopathies of the shoulder, achilles tendon, or plantar fascia, also suggest cortisone shots effects are typically short-lived. 

What do you do if you have been suffering for months from one of these annoying and often debilitating injuries?  The good news is that there are still treatments that can help.  The simplest takes patience and it is called “benign neglect”.  Many of these injuries will heal on their own without any intervention!  Observational studies indicate that tennis elbow and plantar fasciopathy are often these types of "self-limiting" injuries which heal in approximately 80% of patients within one year.  Even more, the vast majority of patients with tendinopathy will respond to conservative or non-operative care.

But what if you haven’t improved or don’t have the patience to wait a year to get better?  There are options!  As a physician, my goal is to alleviate discomfort with treatments that will cure the condition, not just alleviate pain.  The simplest and most commonly prescribed way to regenerate diseased tissue is through strength-based exercise.  Resistance rehab training exercises cause micro trauma to the diseased tendon.  The microtrauma created by exercise alerts the body to initiate the healing process.  The goal is to transform the degenerative tissue into something stronger, more functional, and ultimately less painful. (Think weightlifter who gets bigger stronger muscles with resistance training).  We are attempting to enable the body to restore normal tendon appearance and function.  The healing process requires patience but is often very successful.  In fact, for something like Achilles tendinosis, exercises are the best initial treatment and has proven to be very successful. 

More stubborn injured tendons will need more direct stimulation of the tissue to initiate the healing response.  With various minimally invasive procedures, doctors can restore a dormant, degenerative tendon back into its physiologically and functionally normal state.  Again, we do this by carefully creating a new injury in the tendon to give the body a "second chance" to heal!  Although no single treatment has proven to be a "silver bullet", having more options to offer can often result in spectacular outcomes.  Many procedures I offer hold great promise for curing even the most stubborn chronic soft tissue injuries.