How Many Cortisone Injections is Too Many?

Lance Armstrong does it.  Baseball players do it.  Professional lifters do it.  That’s right, I’m talking about steroids, baby!  What better way to instantly vault to the top of a professional sports field and right into the history books?  However, in this case, we are talking about steroids that are far less exciting – the corticosteroids, or cortisone injections.  Since we have spent the last few weeks talking about different forms of arthritis and the treatments, it seems appropriate to discuss injections, and specifically answer the question – How many cortisone injections is too many?

As we have discussed in the past, cortisone is a synthetic form of the glucocorticoids that are synthesized by the adrenal glands.  In the body they act as a stress hormone and functionally mobilize glucose stores and decrease immune function- all important features at stressful times such as while running from a charging bear.  As an injectable material, cortisone is great for reducing inflammation in conditions such as arthritis, heel pain, Morton’s neuroma, and various other inflammatory conditions of the foot and ankle.  This is a treatment that has been used with great success and minimal side effects since the 1950’s and in fact, the discovery of corticosteroids earned a Nobel Prize in 1950.

However, as much as I am a big fan of the cortisone injection, so much so that I have injected my own plantar fasciitis – physician, heal thyself indeed! – with great success.  It worked so well that I waived my copay and wrote myself a great review on Yelp.  But anyway, many of my NYC podiatry patients have varying opinions on how many cortisone injections are considered safe.  And the answer is – I really don’t know, and neither does anyone else.  I also have heard the three-cortisone injection limit, but have never heard a consistent time frame within which the said injections can be safely given, and suspect that someone made up the three-injection limit because it’s an easy number.  After a moderately exhaustive search through the internet and the scientific literature, there seems to be no real consensus.  In my NYC podiatry office, I tend to limit injections to three for a particular condition, only because after three injections and minimal relief, it’s time to question the treatment and diagnosis.  However, if patients experience complete relief after a number of injections and the pain recurs after a reasonable time frame, I generally initiate a new round of injections.  Similarly, some conditions, such as neuromas, seem to commonly take more than three injections to resolve, and 4 or 5 injections seems to be a more viable option than surgery for my patients and myself.

So, my dear patients, I hope this is somewhat helpful and not just more confusing.  If your foot or ankle hurts, don’t hesitate to limp in for a soothing and not so painful cortisone injection, and don’t be concerned about the oft quoted, yet thoroughly misunderstood “three-injection limit”. Trust me, I’m a doctor…

See you in the office.

Ernest Isaacson