If you race often enough, over enough years, someday it will happen to you. At that critical time when you should be peaking for a marathon or pushing speed for a 5K, some tendon, joint or muscle will start giving you problems that don't quickly respond to ice, rest or other conservative treatment. You'll wonder what you can do to salvage the training cycle, and the word "cortisone" will come to mind.

"Cortisone is a wonderful, terrible drug," says physician Cathy Fieseler, president of the American Medical Athletic Association. "It can do a lot of great things, [but] it's easy to abuse." After you've experienced it, every time you have an ache, you want it again.

Medically, cortisone is an anti-inflammatory drug that can be injected directly into damaged tissue to reduce inflammation and allow a quick return to normal function. It has the advantage of being fast-acting and, even though it's technically a steroid, legal under U.S. and international anti-doping rules. It's not a performance-enhancing drug because all it does (when it works) is reduce inflammation and allow normal function. "Preparation H has hydrocortisone in it," Fieseler says.

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But the ease with which you can get a cortisone injection isn't entirely good. One concern with relying too heavily on it is that it doesn't cure what caused your injury. It merely buys you time to address an underlying strength, flexibility or biomechanical problem. If you relax and view no pain as the same thing as being cured, the problem is likely to return.

Two-time New Zealand Olympian Kim Smith wonders if that's what happened to her last spring. Ten days before the London Marathon, Smith hurt her foot on a 10-mile tempo, badly enough that it was painful to walk. Following an MRI and a consultation with her doctor, she had cortisone injected into the sheaths of two inflamed tendons.

"I ran two days later and it felt OK, [then] did a very short tempo to test it and it felt good," she says. But by the time she got to London, she was back to square one. "It was back to the point where I couldn't walk on it again--much worse even than before the cortisone. I'm not sure if the cortisone wore off or I just irritated it further by masking the pain, but I don't think I would get one again."

ERODING TISSUES
Cortisone also carries risks. The biggest of the potential negatives, Fieseler says, is that repeated use of cortisone into the same joint can erode cartilage. "We know this from guys in the National Football League in the 1960s and '70s who got shots weekly," she says. If you want a formula for destroying your knees, that's it.

Cartilage isn't the only thing that's vulnerable to cortisone-induced damage. "It can also weaken tendons and increase the risk of rupture," Fieseler says. "Nobody should do it for a weight-bearing tendon."

William Roberts, medical director for the Twin Cities Marathon and past president of the American College of Sports Medicine, agrees. "I don't inject around major tendons that, if they rupture, the results are disastrous," he says, noting that over the years he's come to use cortisone injections less frequently.

Another potential side effect of cortisone is the atrophy of subcutaneous fat, which can take years to get back to normal. For most parts of the body, that's just a cosmetic issue, but for plantar fasciitis, it means that cortisone injections are problematic because a critical patch of fat, the heel pad, is located close to the most likely injection site.

"I ignored my podiatrist's advice not to have cortisone injected into my heel and asked my family doctor, who obliged," says Christine Byers, a Boston-qualifying masters runner from Valparaiso, Indiana. "I now have no fat remaining under that heel and can no longer walk barefoot. Custom orthotics are the only reason I'm able to walk or run reasonably comfortably."

Yet another risky use is for the treatment of a Morton's neuroma (a painful nerve inflammation in the webbing between the toes). Although major medical websites still list injections as a possible treatment, the risk, Fieseler says, is that stray cortisone could degrade the metatarsal capsule, which is "like Saran Wrap that goes around the joint."

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The obvious situations are for upper-body problems or arthritic knees. "A longtime runner, with arthritis of the knee, with a major event coming up--I would consider that," Fieseler says. "Not a 20-year-old or 30-year-old. Somebody in their late 40s or 50s, doing their last Boston."

Cortisone can also be useful for IT band syndrome or bursitis, she says, for which the risk of damage to peripheral tissues is lower. But it's not a good idea for high hamstring or piriformis injuries, she says, because there's too much risk of affecting the sciatic nerve, which runs nearby. "That would really mess you up, even as far as walking normally," she says.

Dathan Ritzenhein, a 2:07:47 marathoner, says he's had "quite a few" cortisone injections over the years. "Some worked and some didn't," he explains. "I have had them in my Achilles sheath, hip joints, knee joints and feet."

That said, he doesn't recommend jumping into it too quickly. "Sometimes just a couple of days of cross-training can knock it out without the need for a shot," he says. "But there are cases when it [is] necessary to try. For me it has always been if the next option is surgery or if my season is in jeopardy."

Ritzenhein adds that if you decide to have the shot, it's a good idea to have it administered under ultrasound guidance, so the drug goes into exactly the right place.

If you're going to use cortisone, he adds, he's found that sooner is better than later. "Cortisone injections have worked best for me before the condition becomes chronic," Ritzenhein says. But Roberts warns that knocking down inflammation too aggressively, too soon, can be counterproductive. "The inflammatory response is necessary for some parts of the healing process," he says. "You want to time the injection so it doesn't interfere with the good parts, which occur early in the injury process. So it's a two-edged sword."

In general, Ritzenhein says he tries to see a doctor whenever pain hasn't gotten any better in three days. "You have to be proactive," he says. "Find a doctor you can trust and get to quickly." And whether it's for cortisone or anything else, there might be no better overall advice for any situation in which your short-term running goals and your overall health could conflict.