Cortisone: Is it worth the shot?

• Shots help ease pain
• Short-term benefit for sure; long-term effects uncertain
• General rule is no more than three or four a year

Carlos Beltran put on an impressive display of power Monday in the St. Louis Cardinals' 12-4 victory in Game 2 of the National League Division Series, hitting a pair of home runs to continue a surge in which he's hit four homers in his last six games.

Across the diamond, Washington Nationals third baseman Ryan Zimmerman continued his own, more sustained pattern, crushing a home run among his two hits as he rides a hot streak that began in late June.

Their respective teams owe their production — perhaps even their mere presence in the lineup — to what's arguably the wonder drug of athletics: Cortisone.

Long a staple of trainers' rooms, cortisone — in its natural state, a steroid hormone produced by the human adrenal gland — has been available in synthetic form since 1950, and weekend warriors are as likely to tap into its anti-inflammatory powers as pro athletes.

But the quandary professionals encounter with cortisone is not its use, but its frequency — and the short- and long-term damage possibly created from too many shots.

Zimmerman, slowed by inflammation in the AC joint of his right shoulder, had already received two cortisone injections by June 24 this year, when he was hitting .224.

So he opted for a third shot, and the results were almost instantaneous.

In 74 games between his third cortisone shot on June 24 and another one Sept. 16, he hit .330 with 19 homers, 61 RBI and a .995 OPS.

Medical experts are loathe to suggest an athlete take four cortisone injections in one season. Athletes are loathe to struggle in the unrelenting grind of a 162-game season.

"It's professional sports," Zimmerman says. "You do what you need to do to play and, at the end of the season, you get cleaned up."

And this year's playoffs are filled with players who will mask pain now, and deal with medical fallout later.

***

'An athlete's best friend'

When Johnny Cueto walked off the mound with back spasms after facing one batter in the Cincinnati Reds' first playoff inning Saturday, David Wells had a simple solution to what looked like damaged playoff hopes.

"Nothing a shot of cortisone can't take care of," said Wells, whose major league career lasted 21 years thanks in part to what he called in his TBS commentary "an athlete's best friend sometimes."

The Reds won't reveal what Cueto's treatment has been. But they say he's feeling better and could pitch again as soon as their current NL Division Series with the San Francisco Giants.

Cortisone is becoming as big a factor in this year's playoffs as scouting reports and umpires' calls, and it had a significant impact on the mere composition of the field.

Atlanta lasted one game in the postseason but got there in part because catcher Brian McCann, first baseman Freddie Freeman and pitcher Tim Hudson were able to continue playing after cortisone treatment.

The Cardinals were in a taut battle with several teams for the National League's second wild-card spot. Beltran, slowed by a hand injury, had a cortisone shot in late August.

While it didn't have an immediate effect — he had six hits in his first 52 at-bats — it provided comfort, which eventually led to production. And a starring role in Tuesday's playoff game.

"I couldn't bend my (index) finger. I got the shot and three days later it was as good as a new," Beltran said Monday as the Cardinals celebrated their Game 2 win. "I could do everything I needed to do with my finger. It really helped me a lot when I might have had to go on the disabled list."

Nowhere has it been more crucial than in Washington, where Nationals regulars Ryan Zimmerman, Danny Espinosa and Michael Morse have seen improvement in their ability to not only stay on the field, but also produce.

***

'Not a miracle cure'

It's so big in Washington that Duffy's Irish Pub there offers its version of a cortisone shot to patrons watching Nationals games in the bar. There's no official word yet on the pain-killing or healing powers of the concoction of Jack Daniels, Jameson Irish whiskey, apple schnapps and cranberry juice.

Actually, healing powers aren't part of the cortisone regimen. The players understand. They just want to play.

That's the crucial point, especially this deep into a potential championship season.

"It's not a miracle cure," says San Francisco Giants head athletic trainer Dave Groeschner. "It's something that helps aid in reducing the inflammation and getting the guy back, but they don't always work. It's not like you get one and you're going to feel great right away. I wish it were that easy."

But an injection can help within a couple of days — if the doctor's aim is good.

"My first couple didn't make a difference," Zimmerman says. "They've done it a million times so they're pretty good at it, but they've got to get the right spot."

Zimmerman says a numbing agent masks the pain for the first day, "and then you start to feel better. It's more feeling the movement to be able to do the things you know you can do."

Cortisone differs from anabolic steroids in that cortisone does not return the body to a non-injured level. It is a medical treatment that relieves or masks pain rather than heal.

That makes it legal but creates other issues.

***

Three or four shots a year

Matthew Matava, head physician for the NFL's St. Louis Rams and team physician for the NHL's St. Louis Blues, says there is a general rule when it comes to the number of injections: No more than three to four in a year.

"I suppose there are always exceptions to any rule," says Matava. "These are guidelines. They're sort of based on expert opinion as opposed to any hard and fast scientific data consisting of randomized, controlled trials.

"Certainly if you start getting into six to eight shots into a joint, that's where it becomes problematic.'' The biggest concern, says Matava: cartilage damage, or rupturing a tendon.

Groeschner says one danger of repetitive use is weakening cartilage in the joints. Research by Massachusetts Institute of Technology and the Mayo Clinic, among others, has shown cortisone can be even more detrimental if used on ligaments and tendons.

Zimmerman says that was part of the information he learned while deciding whether to try the injections.

"And it's masking pain. If something's hurt and you're masking pain," Zimmerman says, "sooner or later you're going to have to do something a little more than a cortisone shot."

For players and teams in a playoff series or the struggle to get there, there often seems like little choice.

McCann, who suffered with shoulder issues that eventually forced him to miss Atlanta's wild-card playoff loss to St. Louis, was skeptical of cortisone at first, chalking up his physical woes to the normal wear and tear .

"We all pretty much wake up every day sore," he says. "The shot really did help reduce the inflammation. Other guys had told me they worked but I had never experienced one and I'm glad I did it."

Still, McCann understands the shot he had in early September did not cure anything. He's scheduled for tests this week to determine if he'll need shoulder surgery.

Zimmerman is wary of long-term effects. He met with trainers, doctors and general manager Mike Rizzo before deciding on his treatment.

That balancing act of short-term glory, perhaps at the expense long-term health, figures to always permeate the game.

"Everybody's always looking for the quick fix, and so are we if it's appropriate," Groeschner says. "Guys come to us and ask if they can get one, and we may say no. You have to take into account the player, the injury, is it going to be detrimental to the player, not just today or tomorrow but three or four years down the road.

"Which gets hard, because you're living for today's game, and so are they."

Contributing: Jorge L. Ortiz, Bob Nightengale, Gary Mihoces and John Perrotto