"In the late s the steroid cortisone an antiinflammatory drug was first synthesized and hailed as a landmark. It soon became a safe reliable means to treat the pain and inflammation associated with sports injuries as well as other conditions. Cortisone shots became one of the preferred treatments for overuse injuries of tendons like tennis elbow or an aching Achilles which had been notoriously resistant to treatment. The shots were quite effective providing rapid relief of pain. Then came the earliest clinical trials including one published in  that raised incipient doubts about cortisones powers. In that early experiment more than half the patients who received a cortisone shot for tennis elbow or other tendon pain suffered a relapse of the injury within six months. But that cautionary experiment and others didnt slow the ascent of cortisone also known as corticosteroids. It had such a magical immediate effect against  pain. Today cortisone shots remain a standard muchrequested treatment for tennis elbow and other tendon problems. But a major new review article https published last Friday in The Lancet should revive and intensify the doubts about cortisones efficacy. The review examined the results of nearly four dozen randomized trials which enrolled thousands of people with tendon injuries particularly tennis elbow but also shoulder and Achillestendon pain. The reviewers determined that for most of those who suffered from tennis elbow cortisone injections did as promised bring fast and significant pain relief compared with doing nothing or following a regimen of physical therapy. The pain relief could last for weeks. But when the patients were reexamined at  and  months the results were substantially different. Over all people who received cortisone shots had a much lower rate of full recovery than those who did nothing or who underwent physical therapy. They also had a  percent higher risk of relapse than people who adopted the timehonored waitandsee approach. The evidence for cortisone as a treatment for other aching tendons like sore shoulders and Achillestendon pain was slight and conflicting the review found. But in terms of tennis elbow the shots seemed to actually be counterproductive. As Bill Vicenzino the chairman of sports physiotherapy at the University of Queensland in Australia and senior author of the review said in an email response to questions There is a tendency among tenniselbow sufferers for the majority  percent of those following a waitandsee policy to get better after six months to a year. But this is not the case for those getting cortisone shots he wrote they tend to lag behind significantly at those time frames. In other words in some way the cortisone shots impede full recovery and compared with those adopting a waitandsee policy those getting the shots are worse off. Those people receiving multiple injections may be at particularly high risk for continuing damage. In one study that the researchers reviewed an average of four injections resulted in a  percent worse outcome when compared to one injection Dr. Vicenzino said. Why cortisone shots should slow the healing of tennis elbow is a good question. An even better one though is why they help in the first place. For many years it was widely believed that tendonoveruse injuries were caused by inflammation said Dr. Karim Khan a professor at the School of Human Kinetics at the University of British Columbia and the coauthor of a commentary in The Lancet https accompanying the new review article. The injuries were as a group given the name tendinitis since the suffix itis means inflammation. Cortisone is an antiinflammatory medication. Using it against an inflammation injury was logical. But in the decades since numerous studies have shown persuasively that these overuse injuries do not involve inflammation. When animal or human tissues from these types of injuries are examined they do not contain the usual biochemical markers of inflammation. Instead the injury seems to be degenerative. The fibers within the tendons fray. Today the injuries usually are referred to as tendinopathies or diseased tendons. Why then does a cortisone shot an antiinflammatory work in the short term in noninflammatory injuries providing undeniable if ephemeral pain relief  The injections seem to have an effect on the neural receptors involved in creating the pain in the sore tendon Dr. Khan said. They change the pain biology in the short term. But he said cortisone shots do not heal the structural damage underlying the pain. Instead they actually impede the structural healing. Still relief of pain might be a sufficient reason to champion the injections if the pain were severe Dr. Khan said. But its not. The pain associated with tendinopathies tends to fall somewhere around a  or so on a point scale of pain. Its not insignificant but its not kidney stones. So the question of whether cortisone shots still make sense as a treatment for tendinopathies especially tennis elbow depends Dr. Khan said on how you choose to balance shortterm pain relief versus the likelihood of longerterm negative outcomes. In other words is reducing soreness now worth an increased risk of delayed healing and possible relapse within the year Some people including physicians may decide that the answer remains yes. There will always be a longing for a magical pill the quick fix especially when the other widely accepted and studied alternatives for treating sore tendons are to do nothing or more onerous to some people to rigorously exercise the sore joint during physical therapy. But if he were to dispense advice based on his findings and that of his colleagues systematic review Dr. Vicenzino said he would suggest that athletes with tennis elbow and possibly other tendinopathies think not just once or twice about the wisdom of cortisone shots but  three or four times."