It is important to realise that adrenal cortical hormone injection for sports injuries is only an adjunct to the main part of treatment, which is load reduction and slowly increasing rehabilitation within the pain threshold to strengthen the injured tissue. If the triggering cause (the overload) is not removed, there is a significant risk that the symptoms will return.
Adrenal cortical hormone injections cannot treat training errors!
While local injection of adrenal cortex hormone in joints in patients with rheumatoid arthritis is a proven effective, widely used and recognised treatment, no other legal treatment for sports injuries has been as controversial as local injection of adrenal cortex hormone, as some believe it increases the risk of tendon ruptures.
Whether tendon ruptures are caused by the adrenal cortex hormone injection taking away the pain so that rehabilitation is accelerated too quickly, or whether it is a direct result of the injection, is still being debated.
However, there is no evidence in the literature that injecting adrenal cortical hormone around tendons, in joints or in bursae results in an increased risk of rupture. Some studies have shown a reduced production of the connective tissue that makes up the tendons (collagen synthesis) and thereby weakening of the tendon (Haraldsson BT, et al. 2009). Injections directly into the tendons are not recommended as some animal studies suggest an immediate weakening of the tendon tissue shortly after the injection (Fredberg U. 1997), which human studies do not suggest (Koenig MJ, et al. 2004).
There are many scientific studies documenting the short-term effects of injecting adrenal cortical hormone around overuse tendon injuries (tendinopathy) almost anywhere in the body. Most people experience a reduction in symptoms and (partial) normalisation of the chronically thickened tendons, while the inflammation-related blood vessel growth in the tendons disappears. The increased fluid in the joints disappears.
However, a significant proportion of people experience a relapse of symptoms, possibly due to overly rapid rehabilitation (Fredberg U, et al. 2005). It is therefore crucial that treatment with corticosteroids is accompanied by long-term rehabilitation (even if the symptoms subside within 1-2 months), which should often last for (more than) ½ year. See the iceberg theory.
However, other randomised studies have shown that adrenal cortical hormone injection around thickened tendons (e.g. hollow foot tendon) enhances the rehabilitation effect for at least 6 months (Johannsen FE, et al. 2019).
Indications: Adrenal cortex hormone injection in sports medicine is used for the following indications:
Reduction of long-term ‘inflammation’ (inflammation) in e.g. mucosal inflammation, tendonitis, inflammation of the synovial membrane with fluid accumulation in joints (traumatic arthritis/synovitis), and in certain long-term tendon overloads (tendinitis/tendinopathy) that do not improve with long-term rehabilitation (Fredberg U, Stengaard-Pedersen K. 2008).
If there is no effect (or the effect is transient despite regular rehabilitation) from the first ultrasound-guided injection, there is no indication to repeat it. If there is definite progress that stops before the discomfort has completely subsided, the injection can be repeated at a minimum interval of 4-6 weeks.
Side effects: The risk of infection is extremely low if simple sterile rules are followed (rinsing at least twice, sterile equipment, non-touch technique). Skin discolouration and reduction in subcutaneous fatty tissue (fat atrophy) over the injection, resulting in visible skin vessels and slightly altered sensitivity in the area are common, but only cause discomfort in very rare cases. Most discomfort resolves spontaneously after a few months, but in rare cases can last for years. The risk of systemic effects after injection of adrenal cortex hormone is seen in the form of facial flushing (about 10%), menstrual irregularities and blood sugar fluctuations, which are relatively common, while serious side effects (hypersensitivity shock) are extremely rare. Thus, there are significantly fewer side effects with local injections than with long-term tablet therapy.
In our experience, the biggest risk with adrenal cortical hormone injections is that athletes too quickly resume the load that triggered the injury after they have become pain-free, but before the tendons have been trained to the necessary strength. This often results in relapse (see above).
Accidental injection directly into the tendons or around partially (and totally) ruptured tendons can happen. It is therefore advisable that all injections around the large weight-bearing tendons (Achilles tendon, patellar tendon, hollow foot tendon, iliopsoas tendon) are preceded by an ultrasound scan to ensure diagnosis and rule out partial ruptures. If the injections are ultrasound-guided, correct injection is ensured for optimal effect and minimised risk.
In most other cases, your GP can safely perform the injections without ultrasound guidance as the risk is minimal.
It is necessary to inform the athlete of the risk of increased soreness/pain in the area a few hours after the injection (‘flair up’), which usually disappears within a few hours (days).
Contraindications: Suspected infection near the injection site and active tuberculosis. Known hypersensitivity to adrenal cortical hormone or local anaesthetic. There is little experience with injecting children, so this treatment is very rarely indicated in children.
Administration: The adrenal cortical hormone is mixed with a local anaesthetic before injection. This reduces the risk of side effects and the temporary reduction in pain (due to the local anaesthetic) helps to confirm (or deny) the diagnosis.
Doping: Local injection treatment with adrenal cortex hormone may not be used during competition and may require a doping certificate (TUE). See Anti-Doping Denmark’s doping list.
Summary: Adrenal cortical hormone injection is only an adjunct to the basic treatment of sports injuries that are slowly increasing rehabilitation within the pain threshold. Used correctly, the medical treatment can reduce the recovery period so that rehabilitation can start faster. If the treatment is misused to continue a harmful sporting activity without waiting for the effects of the necessary rehabilitation, the risk of relapse and exacerbations will increase.
