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Managing the Battle Between Good Inflammation and Inflammation… Cortisone and NSAIDs
By Dan Osuch (Orthopedics New England in Natick)
(To see Dan's introduction video please click here...)
What follows is not necessarily a full and thorough medical review, but instead a useful synopsis of how I think about musculoskeletal pain, and how/when non-steroidal anti-inflammatories (NSAIDs, e.g. ibuprofen, naproxen, etc.) and cortisone injections are useful.
Inflammation can be our friend, and it can be our foe. In the setting of normal muscular training/post exercise soreness, or post injury, our body initiates the inflammatory cascade to facilitate healing. This inflammation may cause swelling and pain, cues to the body that it needs time to heal (from an evolutionary perspective, this is actually useful). These are examples of “good inflammation”, and I generally recommend against NSAID use and cortisone in these situations, as stopping this inflammation may actually be counterproductive. However, at some point, good inflammation, can become chronic and “bad”, causing pain without really fixing the underlying problem. I most commonly see this in the setting of arthritis, bursitis, and tendinitis. In these settings, it may make more sense to use NSAIDs and/or cortisone to decrease the bad inflammation and alleviate pain. Sometimes it is difficult to figure the difference between good and bad inflammation/pain, and that is where the help of a professional (physical therapist, sports medicine doc, etc.) can be helpful. The causation of the inflammation is also important to explore, to get a better understanding of how to achieve a more long-standing solution.
NSAIDs and cortisone are generally pretty safe, but are not completely medically benign. Chronic NSAID use has been linked to gastrointestinal ulcers, cardiac disease, high blood pressure, and kidney disease. Repetitive and nonselective cortisone injection can cause tissue deterioration and impact/delay the normal healing response. Therefore, as with anything in life, I consider these medicines useful in selected situations and in moderation. They should also be used in conjunction with things that are considered to be safer interventions (rest, ice, compression, elevation, activity modification, physical therapy, etc.). Furthermore, I often tell people in the office that NSAIDs and/or cortisone are the short term solution, but we also need to understand the underlying causes of the problem to make changes for the long term solution. Often, the problem stems from overtraining and/or poor movement patterns, which is where rest, activity modification, and physical therapy are very important to helping fix the problem. If someone has a true anatomic problem (e.g. a rotator cuff tear), then surgery is an option as well, though I prefer to leave that as a “last resort”.
With all of that as a background, here is my general philosophy on NSAIDs and cortisone: If a problem appears to be more of the bad inflammation category, rest, ice, gentle stretching/mobility work, and modified training are the foundation to recovery. NSAIDs are an important part of the treatment program provided they are used with consistency at reasonable dosing for a relatively short period of time (7-10 days). I usually recommend people try naproxen 220mg tablets, 1-2 tablets twice a day, always with food in your stomach, for 7-10 days. This is easiest to do after breakfast and after dinner to minimize stomach ulcer risks. Putting the pill bottle behind the sink is a great way to remember too (assuming you clean up your own dishes of course…). The consistency is key to decrease the inflammation more thoroughly, as intermittent NSAID use is less likely to be effective. If someone has performed this NSAID trial and the problem still persists, that’s when cortisone may be an option. Cortisone is a potent, locally delivered (i.e. injected with a needle ideally where it’s needed) way to decrease inflammation. Cortisone injections can be both diagnostic (any response helps to localize the source of the pain) and therapeutic (they provide long standing relief). It is generally safe to repeat cortisone in the same location after 4-6 months, although if people are in need of the injection with some regularity, it is my opinion that we need to take a harder look at the underlying problem or diagnosis.
There are also a number of interventions thought to promote “good inflammation”, but that is a topic for another post.