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Home > Do Cortisone Injections Cause Weak Bones?

Do Cortisone Injections Cause Weak Bones?

Jeffrey R. Carlson, MD, CPE

Jeffrey R. Carlson, MD, MBA, CPE, FAAOS

The number one question I get from patients with painful orthopedic problems is “What is the best option for eliminating my pain”?  While we may discuss oral medications, physical therapy, bracing and even surgery, I must tell them the significant role that cortisone injections have in the rapid improvement of painful and inflammatory conditions.

Cortisone or corticosteroid works by 1) stopping the inflammation from an injury, as well as 2) decreasing the swelling caused by that injury. The combination of inflammation and swelling causes pain related to an injury or inflammatory condition.  “Well, Doc, aren’t inflammation and swelling the same thing”?  Yes and no.  Swelling occurs either from an abnormal build-up of fluid or from inflammation but doesn’t need inflammation to occur.   Inflammation is a specific part of the immune response to an injury, infection or irritation and indicates healing has begun.  It is characterized by redness, pain, loss of function and swelling.  Now you know!

By decreasing both the inflammation and swelling, cortisone will also decrease the pain at the area of the injection. These steroid injections can be placed in a joint, the spinal canal, tendon sheath, muscle, nerve and around tissues that are swollen. Because these injections provide local cortisone, they act at the source of the pain, helping patients feel better within a few hours. In fact, we use these types of injections in our athletes to help them quickly recover from injuries.

There are always risks from medications and cortisone is no exception. Injections of cortisone have risks locally, which include:

  • skin irritation
  • loss of pigmentation at the injection site
  • bleeding at the injection site
  • increased blood sugar levels (A1C) – an issue for diabetic patients

A concern I often hear is that cortisone will weaken the bones, resulting in conditions called osteopenia or osteoporosis. The thought is that too many cortisone injections will make the bones collapse or fracture. This is borne out of fear of fractured bones that are seen in patients that have certain diseases that are treated with long-term steroids and subsequently have a tendency toward osteoporosis and fractures.

This concern was studied by doctors at the Mayo Clinic and the results were published in the May 31, 2024, issue of JAMA. These doctors were able to evaluate more than 7000 patients that had received, on average, three injections over a four-year period. They separated those patients (by the quality of their bones) into osteoporosis and non-osteoporosis groups. This study found no difference in the number of fractures between the groups or in relation to the number of steroid injections. Their conclusion was the number of cortisone injections (cumulative amount of cortisone) did not produce an increased risk of fractures.

The theory is that cortisone from injections may stay in the local tissues and not cause other systemic effects that may lead to weakness in the bones. On the other hand, oral pills are absorbed in the gut and distributed throughout the body through the bloodstream, so they can cause detrimental effects in the bones. If you are having an orthopaedic issue, you should not be concerned about osteoporosis caused by injections. There are limits to cortisone injections and your orthopaedic physician will carefully monitor the number of injections that are given to you for your safety.

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