Cortisone

The following article appears in the November 1997 issue of Clean Power:

Cortisone (kor’ti-son) A hormone isolated from the cortex of the adrenal gland and also prepared synthetically. It is closely related to cortisol, and is largely inactive in man until it is converted to cortisol. It is important for its regulatory action in metabolism of fats, carbohydrates, sodium, potassium, and proteins. Also used as an anti-inflammatory agent. (From Taber’s Cyclopedic Medical Dictionary.)

That is the medical definition of cortisone. We know it mainly as an anti-inflammatory medication, taken either orally, injected, used as a topical cream, or inhaled. By being an anti-inflammatory, you would think it was a useful, good medication. Something that powerlifters would want to use to help heal minor or major strains or sprains. However, in the last several years there has been mounting evidence to the contrary. Even the USOC has banned the use of it except in special cases.

The USOC has published various documents pertaining to information that is helpful and informative to athletes. One such document, Drug Control Education (on the web at http://www.olympic-usa.org/inside/in_1_3_7_1.html ) states the following about corticosteroids: “The naturally occurring and synthetic corticosteroids (i.e., cortisone, prednisone) are mainly used as anti-inflammatory drugs which also relive pain. When administered systemically, they also influence the natural production of corticosteroids in the body. Corticosteroids may produce mood changes, including euphoria, and other side effects. Their medical use, except when applied topically, demands medical control.

The use of corticosteroids is prohibited except for topical use (in the ear, the eye or on the skin), inhalation therapy* (asthma, allergic rhinitis) and local or intra-articular injections*. Rectal use is prohibited.

*Note: Oral and rectal administration and intramuscular and intravenous injections of corticosteroids is prohibited. Any doctor wishing to administer corticosteroids intra-articularly, locally or by inhalation to an athlete must give prior notice to the IOC, NADP, NGB or Relevant Medical Authority [author’s note: Sports Medicine/Drug Testing Committees] (whichever is responsible for the competition.)”

That is the official policy of the USOC. As an organization we follow their banned substance list and policies, including the above.

At one time, cortisone was reputed to be a miracle drug or “cure-all,” but was found to be much more complex than initially thought. Serious side effects and multiple injuries occurred. High dosages must be quickly tapered; or the adrenals could quit producing natural cortisol.

Some of the conditions cortisone is used to treat are asthma, arthritis, head injuries and even cancer. However, lately it has been discovered that cortisone also has a nasty side effect: it causes bones to die, damaging hips, shoulders and arms. For example, in Canada alone, 5,000 hip replacements per year could be due to cortisone. Here in the United States, it is estimated that 25 percent of the 500,000 hip replacement surgeries performed annually are a result of prescriptive corticosteroid use. Some other estimates are that it accounts for 10% of all joint replacement surgeries. It usually attacks the weight-bearing joints, such as the hip, but it can also destroy the wrists, shoulders, and ankles. What seems to happen is that near the end of the bone, the blood supply gets cut off, causing it to degenerate and crumble and eventually die. This is commonly called avascular necrosis (AVN). How it does this is still currently a mystery. Topical creams and inhalers that contain cortisone seem to be less of a risk to damaging bones when used.

A paper in the Journal of Bone and Joint Surgery (November 1995) showed that the standard treatment of injecting cortisone-type medications into injured tendons and ligaments delays healing and tends to weaken tissue. Medical Doctors often treat these musculoskeletal chronic injuries by injecting them with cortisone-type drugs because they can reduce swelling and lessen pain, but several recent studies show that cortisone injections weaken the tendons for more than 84 days and that exercisers can get more serious injuries if they exercise their injured part vigorously within a couple of months after being injected with cortisone-type drugs. (from the Mirkin Report.)

The results of a recent study that looked at epidural corticosteroid injections (corticosteroid injections in the back) and the effects of the injections on sciatica due to a herniated nucleus pulposus (the inside of a disc that has herniated out) were recently in the New England Journal of Medicine (1997;336:1634-40). The authors concluded: “Although epidural injections of methylprednisolone (a form of corticosteroid) may afford short-term improvement in leg pain and sensory deficits in patients with sciatica due to the herniated nucleus pulposus, this treatment offers no significant functional benefit.”

An attorney from La Jolla, California, Linda Robinson, who is co-counsel in a number of corticosteroid-induced AVN cases around the country, stated, “We’ve known for years that long-term steroid use can cause osteoporosis and other bone diseases. But there are two new areas of concern: reported medical research shows that even short-term, low-dose steroid use can cause AVN. In addition, combining a prescription for steroids with one for antibiotics – a very common practice – is known to potentially double the strength of the steroid.”

Antibiotics increase the potency of steroids by slowing their rate of elimination from the body. According to Paul Watkins, director of the General Clinical Research Center at the University of Michigan, steroids and antibiotics compete for a enzyme that helps metabolize them. “The result of this competition, which is known as a drug/drug interaction, is..the drug remains in the body longer and at greater levels than normal,” said Watkins. The increased exposure increases the risk of adverse effects.

There are two ways steroids attack a person’s bones:

  1. Steroids combine with calcium in food, making it difficult for blood to absorb calcium. The body corrects its blood calcium deficiency by drawing calcium from bones, leaving them fragile
  2. Steroids also inhibit the growth of new bone cells.

Like everything else alive, bone is not a inert substance. Cells are constantly dying and being replaced by others. Inhibiting new cell growth allows the process of deterioration to overtake the process of renewal, and the bone dies. When a person is on a course of corticosteroids, consumption of more calcium and Vitamin D is prudent. According to guidelines recently published by the American College of Rheumatology, people on corticosteroid therapy should consume at least 1,500 mg of calcium and 800 iu of Vitamin D every day, either through diet or supplements, to offset the likelihood of bone deterioration. (NY Times, 1/29/97 at B10)

The above information is important for all athletes. We have many athletes that come into our clinic that have had or are thinking about corticosteroid/cortisone therapy for an athletic injury. After digesting the above information and realizing that the use of cortisone is against USOC regulations and policy* (see above note), they usually decide to go a different route. Other routes to take to help reduce inflammation, swelling and chronic injuries are:

  1. The use of proteolytic enzymes (natural anti-inflammatories), such as bromelain, papain, etc.
  2. The use of NSAIDS, such as ibuprofen, etc., however, cautious use of these must exercised as they can have various bad side effects if taken often
  3. Use of ice and later ice/heat combination
  4. Stretching – this will take the tension off the muscle and corresponding joint and allow it to function properly
  5. Strengthening – to make the muscles and tendons surrounding the injured area stronger to take the stress off of it
  6. Chiropractic manipulative treatments to restore proper joint mechanics and remove any neuromuscloskeletal involvement that could help prolong the injury/inflammation
  7. Use of various therapies and adjuncts to treatment: Active Release Technique, myofascial release, massage, interferential, ultrasound, tranverse friction massage, etc.

There are many other treatment options besides the use of cortisone that are just as or more effective without the bad side effects.

Please send your questions for the Sports Medicine Committee to:

Dr. Michael Hartle
3835 W. Jefferson Blvd.
Ft. Wayne, IN, 46804.

If you would like a personal response, please send a SASE with $2.00 to cover additional postage and other expenses. I also welcome your comments on the committee/column.