She thought she had found the answer after the first injection.

She was a physical therapy assistant, someone who understood musculoskeletal care better than most patients walk in with. The cortisone injection to her wrist worked. The pain reduced, she could do her job, and she figured she had found a manageable long-term solution. “Oh, we’ll just have to get an injection every year and it’ll be fine.”

Then the second one did not work. And the third did not either.

She had gotten a total knee replacement specifically to return to tennis. The knee healed. Then the wrist became the wall between her and the thing she had worked so hard to get back. Now her pain management provider was recommending nerve surgery. She did not want it.

When she came to COSJ, she was at Awareness Level 3, she knew exactly what she needed, she was choosing a provider, and she had a specific question: is there a conservative path left, or is surgery the only option?

This article is for her, and for anyone who has had one injection that worked and subsequent ones that did not, and who wants to understand what that pattern actually means.

 

What Cortisone Does and Why It Works (At First)

Cortisone is a corticosteroid, a powerful anti-inflammatory agent. Injected locally, it reduces the inflammatory cascade in the surrounding tissue, which relieves pain and often improves function, sometimes dramatically.

For acute tendinopathy or tendinitis (where the tissue is genuinely inflamed) cortisone is addressing the primary driver of the pain. That is why it works well in the early stages. The tissue is in an inflammatory state, cortisone suppresses inflammation, pain reduces.

The problem is that most tendinopathies, when they have been going on for several months or more, are no longer primarily inflammatory. They have transitioned into a degenerative state, the tissue structure has changed, the collagen organization has broken down, the blood supply to the area is poor. This is called tendinosis, or more broadly, tendinopathy. The pain is real. The biology has shifted.

When cortisone is injected into degenerative tissue, it still suppresses whatever residual inflammation is present, which can produce some short-term relief. But it does not address the degenerated tissue structure. It does not stimulate new collagen formation. It does not improve blood supply. And research suggests that repeated cortisone injections into tendon tissue may actually weaken the structure over time, reducing the mechanical integrity of the tendon.

This is why the first shot worked and the subsequent ones did not. The first addressed an inflammatory component. By the second and third, the biology had already moved past inflammation as the primary driver.

 

What Shockwave Does That Cortisone Cannot

Extracorporeal shockwave therapy (ESWT) works through a fundamentally different mechanism than cortisone. Rather than suppressing a biological process, it initiates one.

The acoustic pulses delivered by shockwave stimulate three things that degenerative tendon tissue needs and cannot generate on its own:

New blood vessel formation. New blood vessel formation. Degenerative tendon and fascia tissue is typically poorly vascularized, this is part of why it cannot heal without intervention. Shockwave induces the formation of new blood supply, which delivers the nutrients and cells required for repair.

Cellular activation. Shockwave activates the cells responsible for producing collagen. These cells were present but dormant in the degenerative tissue. The acoustic energy essentially wakes them up and puts them to work producing new collagen to replace the disorganized scar tissue.

Pain modulation. Shockwave reduces the density of local pain receptors (substance P and CGRP) in the treated area, interrupting the chronic pain cycle that has often become self-sustaining by the time a patient reaches this stage.

The result is a tissue that is genuinely healing, not just less inflamed.

For the patient I described (wrist tendinopathy, three failed cortisone injections, surgery on the table) shockwave was the appropriate next step before any more invasive intervention. The tissue had transitioned to a degenerative state. She needed a treatment that addresses degeneration.

 

The Evidence Comparison

The research literature on this comparison is not subtle.

Cortisone injections for tendinopathy show consistent short-term benefit (four to eight weeks) and neutral to negative long-term outcomes compared to waiting or conservative treatment. A 2010 systematic review in the British Medical Journal found that for lateral elbow tendinopathy (tennis elbow), cortisone injections produced superior short-term outcomes but significantly worse long-term outcomes than physiotherapy or wait-and-see. The short-term effect reliably returned to baseline or worse by twelve months.

Shockwave therapy shows different long-term data. Multiple randomized trials and systematic reviews for plantar fasciitis, Achilles tendinopathy, calcific shoulder tendinitis, and lateral epicondylitis show meaningful improvement at three-month and twelve-month follow-up, with effect sizes that hold. A 2005 Cochrane review and subsequent high-quality trials consistently support its use for chronic presentations.

The honest summary: cortisone wins the short-term comparison. Shockwave wins the long-term comparison for chronic, degenerative tendinopathy. The appropriate choice depends on the chronicity and the biological state of the tissue.

 

When Cortisone Is Still the Right Tool

I am not arguing that cortisone is never appropriate. There are presentations where it is the correct first-line intervention.

For acute tendinitis (new onset, clearly inflammatory, duration of weeks rather than months) cortisone can provide meaningful short-term relief that allows the patient to begin loading the tendon. In this context, it is a bridge, not a destination.

For calcific tendinitis of the shoulder (where calcium deposits within the rotator cuff are driving the inflammation) a targeted cortisone injection is part of the standard of care, often combined with shockwave to break up the deposits.

For patients who need immediate function restoration before a significant event, cortisone’s short-term efficacy may be the right choice with clear eyes about its limitations.

The decision depends on an honest assessment of where the tissue is in its biological timeline.

 

The Full Protocol at COSJ for Chronic Tendinopathy

When we treat a chronic tendinopathy presentation, shockwave is one component of a complete plan.

Repair

Shockwave to the affected tendon, typically three to five sessions spaced one week apart. Combined with dry needling of the surrounding musculature to address the secondary trigger point activity that develops around chronically painful tendons. For the wrist, this includes the forearm flexors and extensors.

Retrain

Loading the tendon. This is the part most patients skip, and it is the part that makes the tissue durable. Heavy slow resistance loading (the Alfredson protocol for Achilles, eccentric wrist loading for forearm tendinopathies) stimulates the collagen that shockwave has initiated to organize into functional, load-bearing structure. Shockwave without loading is incomplete treatment.

Reinforce

Progressive loading above the demands of the patient’s specific activities. For the PTA who needs to lift and transfer patients and wants to play tennis, the loading goal is specific and measurable. We build toward it.

 

FAQ

How do I know if my tendinopathy is inflammatory or degenerative?

Duration is the most reliable indicator. Pain present for fewer than six weeks is more likely to have a significant inflammatory component. Pain present for three to six months or longer, particularly if it has had partial responses to anti-inflammatories and injections, is more consistent with a degenerative picture. A clinical evaluation can assess the tissue state more precisely.

Can I get both shockwave and cortisone?

Generally, we do not combine them in the same treatment period. There is evidence suggesting that cortisone may blunt the cellular response that shockwave is trying to initiate. The standard protocol is to complete shockwave therapy before considering cortisone, or to wait a minimum of six weeks after a cortisone injection before beginning shockwave.

Is shockwave painful?

The treatment involves noticeable pressure and discomfort in areas of dense trigger point activity or significant degeneration. Most patients rate it as manageable, particularly when the expected outcome is explained. Post-treatment soreness for twenty-four to forty-eight hours is common and indicates the healing response has been triggered.

Does insurance cover shockwave therapy?

Coverage varies by plan. Shockwave is covered by some insurance as part of a chiropractic or physical medicine benefit, but is not universally covered. We can review your specific coverage before your first appointment.

 

If the Shot Has Stopped Working

You have a specific biological reason the injections stopped helping. The tissue moved past the phase where cortisone is effective. There is a treatment that addresses where the tissue actually is now.

If you have been told surgery is the next step and you are not ready to accept that, come in. We will tell you honestly whether there is a conservative path left, what the tissue looks like clinically, whether shockwave is appropriate, and what the realistic expectation is. If there is a conservative path, we will build it. If there is not, we will tell you that too.

You deserve an honest assessment, not just the next procedure.

Schedule at cospineandjoint.com/schedule-appointment

Building better with you,
Dr. Blake Richard, DC
Central Ohio Spine and Joint | Westerville, OH
cospineandjoint.com/schedule-appointment