Sports Medicine physicians can administer cortisone injections

Ballarat Sports Medicine physician can administer a range of injections to assist with pain, injury, and recovery. One of these is cortisone injections. The following provides an insight into cortisone. Patients should always be guided by a medical professional on the advantages and disadvantages of cortisone use.

Dr Greg Harris and Dr Bryn Savill are qualified to be able to assess your pain, injury and determine the best course of action for recovery, including if required the use of cortisone.

What is cortisone?

Cortisone is the name used to describe a group of drugs commonly known as corticosteroids. The types of cortisone used at BallaratOSM include Celestone (Betamethasone) and Depo-Medrol (Methylprednisolone). Cortisone is used to treat pain in various parts of the body where inflammation is felt to be the cause of this pain. The reason why cortisone is effective in treating such pain is because it is a powerful anti-inflammatory. It is not purely a painkiller. Cortisone is NOT an illegal steroid medication, such as those steroids used by some disqualified body builders and athletes.

Why inject cortisone?

In regard to musculoskeletal problems, cortisone injections are performed in order to reduce or even eliminate pain associated with a variety of disorders, such as:

  • Bursitis (most commonly subacromial and trochanteric bursitis)
  • Arthritis (any joint may be injected, including joints of the spine)
  • Nerve pain (most commonly for sciatica and carpal tunnel syndrome)
  • Some tendon conditions, such as plantar fasciitis, trigger finger, DeQuervain’s tenosynovitis). In pure tendon injuries cortisone is best avoided, as it can worsen a tendon tear.
  • Other miscellaneous conditions where inflammation is a contributor to the pain, for example frozen shoulder/adhesive capsulitis, Morton’s neuroma, ganglion cyst injections and Dupuytren’s contracture.

How is cortisone administered?

  • The skin is prepared using an antiseptic agent.
  • Many of the injections performed at Ballarat Sports Medicine will be done using ultrasound, with the needle being guided into the relevant body part. Some injections do not need guidance and can be done without the ultrasound.
  • The degree of discomfort during the procedure is generally mild, as the needle used is fine and local anaesthetic is mixed in with cortisone. If only one pass is planned (meaning that the needle will only penetrate the skin once) then local anaesthetic is usually NOT injected into the skin. It is our experience that injecting local anaesthetic into the skin in a single pass procedure is actually more painful, as local anaesthetic stings a little prior to taking effect. Also, the needle used to inject the local anaesthetic results in similar discomfort as the needle delivering the cortisone. Local anaesthetic is only injected into the skin if more than one pass is made through the skin. Of course, if you wish for local anaesthetic to be injected despite our recommendation, we are happy to do this.
  • A greater degree of discomfort may occur if:
    • the underlying inflammation is severe
    • the area to be injected is severely painful
    • the needle tip requires to be repositioned several times in order to distribute the cortisone effectively
    • a previous bad experience has resulted in a fear of needles, or there is a general anxiety/phobia of needles and other medical procedures.
  • In cases where a cyst, ganglion, bursa or joint is distended with fluid, the cortisone will be injected after an attempt to aspirate (remove) the fluid in order to improve comfort.

Benefits, Risks, Complications and Side-Effects of Cortisone

  • As for all medical procedures, there are risk associated with the administration of any medication, including cortisone. The chances of cortisone providing you with the benefit of pain relief in most patients outweighs the risk of experiencing a side effect(s) (discussed below). The decision to inject cortisone is not taken lightly and is carefully made by your referring doctor and based on your signs, symptoms and past medical history, as well as the suspected diagnosis. Frequently, a trial injection is made where the diagnosis is not clear, however the body region that is to be injected is suspected of causing your pain.

    The side effects and risks of a cortisone injection include:

    • Allergy to any of the substances utilised during the procedure, such as the cortisone, dressing, local anaesthetic or antiseptic. This is usually minor and self-limiting.
    • The cortisone may result in palpitations, hot flushes, insomnia, and mild mood disturbance. This usually resolves within 24 hours and no treatment is necessary.
    • Infection is a rare but serious complication (<0.1%), especially if injected into a joint. Most infections take at least a day or two to manifest, so pain at the injection site after 48 hours is considered to be due to an infection until proven otherwise. Even if not definitively proven, you may be commenced on empirical antibiotic treatment.
    • Local bruising.
    • Localised skin and subcutaneous fat atrophy (thinning resulting in dimpling).
    • Hypopigmentation (whitening of the skin) at the injection site. This most commonly happens in injections of the palm of the hand or sole of the foot.
    • Mild increase in blood sugar levels in diabetic patients for several days and may last up to a week.
    • Transient increase in pain at the injection site before the cortisone takes effect. Occasionally this may be severe, however usually lasts only 24–48 hours and is treated with a cold pack, paracetamol and anti-inflammatory medication. If this occurs and you are concerned, especially if the pain is not settling despite the above treatment, then please call contact your referring doctor so that they are able to examine, assess and manage you appropriately.
    • Cortisone injection administered directly into a tendon has been reported to weaken and damage the collagen fibres, thus carrying a risk of delayed rupture. For this reason, cortisone is only injected around the tissue surrounding a tendon and the tendon is rested for one week.
    • An extremely rare complication is avascular necrosis (bone death) which some doctors suspect may rarely occur when cortisone is injected into a joint, though this has not been proven.
    Remember that the side effects of cortisone that are commonly reported in the media, such as osteoporosis, weight gain, acne and diabetes only occur when taking cortisone tablets for at least several weeks (typically many months to years). These side effects do not occur with the careful use of cortisone injections.

Are there any alternatives to a cortisone injection?

Of course, there are. Since a cortisone injection is used for treating pain, it is an optional procedure. Other options should be discussed with you referring doctor and may include anti-inflammatory medications, exercise, physiotherapy and surgery to name a few.

How many cortisone injections are permitted?

There is no scientifically proven limit for cortisone injections, however as a general rule, three injections into the same body part are permitted over a twelve-month period. Injections more frequent than this are felt to place the injected tissue at risk of softening/ weakening, which may be an issue in a joint for example, as this may accelerate arthritis. Also, if you have failed to respond to a series of three injections, then it is probably time your condition was reassessed to find out if the diagnosis is correct. Has your condition worsened and are other forms of treatment, such as surgery, more appropriate?

If you do require more than three injections in a year, then the risk of the injection must be carefully balanced against the benefits of pain relief.

Management of concussion for AFL players

Management of concussion for AFL players

Sport related concussion is a topical injury particularly at AFL and NRL elite level, but an injury that can happen at any level of these sports. The Ballarat Football and Netball league utilise “THE MANAGEMENT OF SPORT-RELATED CONCUSSION IN AUSTRALIAN FOOTBALL – With Specific Provisions for Children and Adolescents (Aged 5-17 Years): for trainers, first-aid providers, coaches, club officials, players, and parents” as their concussion management tool, released by the AFL in April 2021.

Many sports at the elite level are moving to the use of specialist doctors in Sports Medicine rather than general practitioners as team doctors. Ballarat Sports Medicine physicians, Dr Greg Harris, Specialist in Sport & Exercise Medicine and Dr Bryn Savill, Registrar in Sport & Exercise Medicine, are both team doctors at elite level sport and conduct training at local AFL level for team trainers.

If you or your children have suffered a concussion injury or suspected concussion injury, both Greg and Bryn can assess your injury and provide specialist guidance for recovery and return to exercise, training and competitive sport.

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AFL Concussion

Head impacts can be associated with serious and potentially fatal brain injuries. In the early stages of injury, it is often not clear whether you are dealing with a concussion or if there is a more severe underlying structural head injury. For this reason, the most important steps in initial management include:

  • Recognising a suspected concussion;
  • Removing the player from the match or training; and
  • Referring the player to a medical doctor for assessment.

Any player who has suffered a concussion or is suspected of having a concussion (i.e. in cases where there is no medical doctor present to assess the player or the diagnosis of concussion cannot be ruled out at the time of injury) must be medically assessed as soon as possible after the injury and must NOT be allowed to return to play in the same match/training session. There should be an appropriately accredited first aid provider at every match and the basic rules of first aid should be used when dealing with any player who is unconscious or injured.

Important steps for return to play following concussion include:

  • A brief period of complete physical and cognitive rest (24-48 hours);
  • A period of symptom-limited activity to allow full recovery; and
  • A graded loading program (with monitoring).
  • Clearance by a medical doctor

Players should not enter the graded loading program until they have recovered from their concussion. Recovery means that all concussion-related symptoms and signs have fully resolved (for at least 24 hours) at rest and with activities of daily living, and they have successfully returned to work or school, without restrictions.

Any concussed player must not return to competitive contact sport (including full contact training sessions) before having moved through the graded recovery process and have obtained medical clearance.

The earliest that a player may return to play (once they have successfully completed a graded loading program and they have obtained medical clearance) is on the 12th day after the day on which the concussion was suffered.

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