How much cortisone can a human arm take before falling off?
July 27, 2021 1:08 PM   Subscribe

Briefly: I know there are guidelines on how many cortisone shots a person should get within the space of a single year. I do NOT know if there are guidelines on how many a person may have over a lifetime. But are there? Are the side effects potential or assured, are they cumulative over many years, and does a steroid-weakened tendon never heal if left alone long enough? One million details follow.

You are not my doctor, and I know this to be true because my doctors will not answer these questions. if you have relevant medical knowledge, please give me as much information as you are willing to. Technical language & links to studies are welcome.

Background:

I need (=want) a cortisone shot in the vicinity of my bicep tendon where it attaches to my shoulder. That tendon was undamaged when I went in for a supraspinatus repair some years ago and damaged when I came out, for reasons never investigated or disclosed to me. The surgeon told me directly after he was finished that my bicep tendon was in fine shape; this had not been clear from the pre-op imaging and I had consented to have it stapled back on during the course of surgery if it turned out to need it: but he said he had done nothing to it; this was meant to be good news.

However, it was pain-free before surgery and very painful both immediately after surgery and ever since. he did not offer an explanation when I asked why this might be; he did not refer me for another MRI; he did not respond to the alarmed letter from my physical therapist describing my unusual rehab difficulties and requesting a consult.

SInce that time it has gone in cycles of pain, worse whenever I use my right arm. which I do regrettably often. Cortisone shots helped substantially for months at a time. however, the last doctor I saw for this cut me off after 2 injections 2 years ago. He did not tell me I could have more cortisone after enough time had passed, and I am reluctant to start another round of begging unless I have reason to believe I might succeed.

as noted above, I do understand that there is some risk of the tendon tearing after repeated injections. but...I do not know, and am not able to find out, whether it is torn already. it very well could be! whether my surgeon missed a pre-existing tear or himself did the damage I do not know. Furthermore, it is my understanding that if the tendon was unquestionably torn, I could have it surgically repaired - and as long as it is presumed to be only irritated, I cannot. for this reason -- but mainly for the reason that it hurts - I would like another cortisone shot. In my layperson's ignorant opinion, it is not clear that I have anything to lose. but if there is some universal policy or guideline preventing me from ever having another, I will not waste my time persecuting more innocent doctors over it. especially if there is a good reason.

Secondarily: same question, but about oral steroids (methylprednisolone specifically, for nerve pain from osteoarthritis and/or inflammation.) How long between dose packs must a person wait, and how many packs may safely be taken per year? I have variously heard that 2 or 3 may be prescribed in a calendar year, either back-to-back or months apart. But I do not know how severe the risks are, or how much worse it is to take 3 vs. 2 (or 4 vs. 3) in one year. As with the injection problem, I am willing to take a flat No for an answer (to the question Please, may I have some more?) but need to understand the rationale. I do know that steroids are prescribed in other amounts & schedules for other conditions. How is risk/benefit calculated for this drug? and/or is 2-3 packs per year the official maximum that all responsible doctors follow? To be clear, this is not in reference to the bicep tendon -- separate issue.

[to pre-empt two obvious questions: 1. yes, I have consulted several very good physical therapists over the years and am about to restart PT again. All of the standard rotator cuff exercises & stretches make things worse. yes, I overuse OTC anti-inflammatories and ice packs already. no, topical diclofenac doesn't do anything. 2. I recently had spine surgery and the offending nerves are officially Decompressed. I had held onto some sliver of hope that the bicep tendon pain was actually nerve-related, not a rotator cuff issue at all, as it clusters with the nerve pain in my neck and shoulder blade and the origin is sometimes difficult to distinguish. sadly, it does appear to be a separate problem.

In conclusion, I have already allowed both a shoulder and a spine surgeon to do their worst and their best, respectively. The official messaging to me has consistently been that life-altering major surgery is much safer for me than either temporary steroids or any other useful pain medication. this is extremely hard for me to believe, but I am, after all, not a doctor.

If you are also not a doctor, please do not advise me to push for another shoulder MRI at this time. I would like one, but we cannot always get what we want. If you are a doctor, feel free to advise anything at all. even if it's mean.]

thank you for reading.
posted by queenofbithynia to Health & Fitness (12 answers total) 2 users marked this as a favorite
 
A family friend recently had a similar treatment and had cortisone after manipulation under anaesthetic. He says the MUA seems to help much more than the cortisone. I believe his doctor told him cortisone can be injected up to three times each year.
posted by parmanparman at 1:12 PM on July 27, 2021 [1 favorite]


I believe his doctor told him cortisone can be injected up to three times each year.

My 80 year old mother-in-law goes in for a 3-5 cortisone shots in different places on her body every 6 weeks or so. Her doctors say she is too old to operate on and that plus strong pain killers are the only option. it might be different if you are younger.
posted by The_Vegetables at 1:53 PM on July 27, 2021 [1 favorite]


This is one of those frustrating situations where there seems to be a lot of information & yet not nearly enough information to really be able to say one way or another. Are you set on it being a torn tendon, or why do you think that this must be the case? Could it be inflammation from the autoimmune disorder or scar tissue build-up from the initial surgery or one or both of the aforementioned? What is the range of movement? PT is great but has the drawback of usually being provided by people with less training in internal medicine than the doctors you'd hope would know.
https://www.future-science.com/doi/full/10.2144/fsoa-2020-0145
This article mentions intra-articular sodium hyaluronate injections, something I know nothing about, but appears to be another option.
Sometimes strengthening the tissue around the offending region helps with pain management, too, though you would need to find a coach who is pretty specialized in this kind of training.
posted by erattacorrige at 2:59 PM on July 27, 2021


If this were me, I would just get the bicep tenodesis rather than spend any more of my life screwing around with this clearly unhappy bicep tendon. The long-term effects of repeated cortisone injections are still being debated and at any rate you know it's just a bandaid because if it were a permanent cure you'd be cured. I say this as a person who screwed around with cortisone injections before going in for what was supposed to be a bicep tenodesis but instead turned out to be a monster case of adhesive capsulitis. Wasted a good year of my life in pain. All better now. Once they get in there they can see what's actually going on and fix it.
posted by HotToddy at 3:55 PM on July 27, 2021 [2 favorites]


No no no. Make a different ortho MRI the mess the surgeon left. He may have stapled through a nerve, he may have hurt the bicep tendon. The radial ulnar nerve runs through this and sometimes biceps problems are made apparent by discomfort from this nerve. Get a second opinion and get it fixed.
posted by Oyéah at 4:03 PM on July 27, 2021 [3 favorites]


P.S. I have had horrific injuries to both shoulders later in life, I rehabed and I live pain free from these complicated repairs. Way complicated injuries, no pain. Full range of motion, full strength, no pain
posted by Oyéah at 4:05 PM on July 27, 2021


Response by poster: [just one response, to clarify all points raised by recent comments -]

erratacorige, I am not aware of having any autoimmune disorders. the osteoarthritis was explained to me as part of the general degenerative mess that is my spine, & it wasn't bad enough to keep a surgeon from replacing two of my several herniated discs with artificial new ones, although it might be bad enough to explain why the replacements haven't done me much good yet. I got several opinions on that & went with the one that matched what I wanted to hear, as is my custom.

I am not set on believing the tendon is torn, it is my best guess is all. I'd rather have a doctor do the diagnosing, but I do not have what it takes to make them interested. I believe tendonitis is what the last cortisone-injector thought. my physical therapist first refined my description of front shoulder ouches to "sharp pain over the proximal bicipital tendon," & her anatomy is sound even if mine is not. My surgeon claimed it was not torn when he looked at it, but his inspection was the only trauma to the area, it directly preceded the onset of pain, and I was unconscious for whatever it involved.

range of movement is lousy. physically can't pull right shoulder down & back to match the left side. this was all true before repairing the supraspinatus tear & replacing the herniated discs, and is still true now. am pursuing botox for hypertrophied trapezius because why not (and because trigger point injections have been largely useless.)

HotToddy - I have been saving my energy to fight for another MRI / consult another surgeon until such time as I think I can handle even more surgery. " Once they get in there they can see what's actually going on and fix it." - thing is, that is what the first surgeon said. so I think you are right but I am not in a position to do it immediately.

Oyéah - I hope you are wrong bc I definitely do also have some kind of ulnar nerve issue (outside the scope of this question, I think. unless it's not.) in any case I will press the next doctor I see on the relationship of my various problems to each other. they are certainly all mutually reinforcing at the very least. but I have never yet had any luck trying to discuss more than one part of the same arm with a single specialist in a single appointment. I do try...
posted by queenofbithynia at 5:02 PM on July 27, 2021


Response by poster: with all that said, and with apologies for commenting twice and a promise not to continue:
I don't mind extra medical advice but I really am asking specifically about how frequently steroids can be safely administered in the two forms described - without regard to whether it will definitely work for the intended purpose. "what should I do about my many problems" is also a good question but I don't expect it to be answered here.

the cortisone shot anecdotes & opinions are much appreciated, and the academic question of "what is a safe number of Medrol packs [for a non-diabetic person] to take in a year" is still of great interest to me.
posted by queenofbithynia at 5:42 PM on July 27, 2021


"what is a safe number of Medrol packs [for a non-diabetic person] to take in a year

As you note in your question, this is really one of those "it depends" questions, at least based on my anecdata. IANAD, but I do have chronic back pain/joint problems and asthma. I haven't done cortisone shots, but i've recently had several bouts of oral steroids.

My pain management doctor and an urgent care doctor both seemed very set on two medrol packs per year being the maximum.

However, for my asthma flare up, they prescribed a two week prednisone taper that I started less than a week after a 6 day medrol taper.

The doctors I've interacted with all seem pretty wary of the side effects of prednisone, and I guess it really is dose dependent. But I don't think there's a magic number that is too much. And the potential side effects are weighed against the cost. So for pain management, they seem to be much more conservative vs something like acute asthma attacks.

Of course, there are also some conditions where steroids are taken longer term. So it seems to just be a cost benefit analysis.

But this is just my impression from the physicians who have prescribed oral prednisone to me over the past year.
posted by litera scripta manet at 5:47 PM on July 27, 2021 [1 favorite]


According to Mayo Clinic, cortisone shots should not be done more than three to four times A YEAR, and at least six weeks between shots. It is heavily suspected that repeated injection at the same site can damage the cartilage permanently.
posted by kschang at 5:56 PM on July 27, 2021 [1 favorite]


My sister got regular cortisone injections in her spine for years. Her physician told her that she's reached her lifetime limit and can't have any more.
posted by The Underpants Monster at 1:57 AM on July 28, 2021 [1 favorite]


My orthopedist told me I could only get two cortisone injections in my thumb joint in my life. I assume this varies depending on the joint.
posted by metasarah at 12:23 PM on August 4, 2021


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