As a pain management doctor who performs procedures all day, I have seen Cortisone shot flares in the office. Cortisone is a corticosteroid, which is a fancy way of saying that it’s a very strong anti-inflammatory which can bring down swelling. Cortisone is actually an older brand name, newer brand names more commonly used today include Depomedrol and Celestone. One of the biggest problems that we see in our office is that the commonly dose used of Cortisone is in the milligram range (thousandth of a gram). While this may not sound like much, for orthopedic applications like sciatica, back pain, knee pain, shoulder pain, elbow pain, and other peripheral joints, this dose is about 100,000 to 1,000,000 times more than your body naturally uses to control swelling. As an example, if the 50 nano-gram dose that your joint would use on it’s own to control inflammation is the height of a book of matches, the height of the usual dose used by most physicians to control swelling is the height of the Empire State Building. Why? Unknown, as the science would support that the nano-gram (billionth of a gram) dose is good for the joint, while the milligram dose causes all natural repair function to cease. This is why too many of these very high dose Cortisone shots can cause a joint to degrade. Think of it as you can put in a finish nail with a sledgehammer (the milligram dose), but it isn’t pretty. Steroid shots for sciatica are common, and we only use the giant milligram dose in certain circumstances where we need a huge effect to help the patient, otherwise we have moved to the lower doses. So what’s the biggest cause of a Cortisone shot flare? While the high dose may be an issue, it’s usually the needle. To inject joints, most syringes come loaded with a 20 gauge needle. While this makes drawing up meds very fast and is great for pulling fluid out of a joint (aspirate), its way to large for putting cortisone into a joint. A 27 gauge needle is a better choice and less likely to cause a cortisone shot flare. So to avoid a Cortisone shot flare, make sure your doctor uses a smaller needle (25 or 27 gauge). In addition, we find that cold spray on the skin can help patients tolerate the shot better. In addition, having the doctor wiggle or put allot of pressure on the area to be injected can help reduce the sensation of the needle stick. What if don’t want Cortisone? Alternatives include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the swelling short term.