No guideline sets a safe number. The one randomized trial that tested four a year in the knee found more cartilage loss than saline and no better pain relief. A 2024 review found guidelines on how often, how long and how many lifetime corticosteroid injections are safe still lacking. A 2022 meta-analysis of 10 randomized trials found repeat steroid injections for osteoarthritis no better than placebo for pain or function at 12 to 24 months. The 2026 four-society guideline puts the relief at a few weeks to a few months. In our practice, we reassess when a shot helps for less time than the last.
If you are asking this, you have probably had one or two already, and the last one did not last as long as the first. That is the right moment to ask. Here is what the trials found about repeating steroid shots in knees, tendons, shoulders and wrists, how far apart and how many at once, and what to ask before the next one.
What the evidence says about repeating the shot
Where the three-or-four-a-year number comes from
No guideline sets a safe number of cortisone shots. A 2023 debate article in Osteoarthritis Imaging summarizes systematic reviews as showing a modest effect over saline in osteoarthritis lasting 2 to 4 weeks on average, and notes that, potentially as a consequence, repeated injections are often given up to 4 injections annually. A 2024 review in the American Journal of Roentgenology states the gap plainly: guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. The 2026 joint-injection guideline from the American Society of Regional Anesthesia and Pain Medicine and three other pain societies found triamcinolone 40 mg as effective as 80 mg in the knee, and that ultrasound guidance increases the accuracy of injections. Dr. Garg makes the case in the podcast episode on steroid injections.
In an arthritic knee, repeats cost cartilage
The direct test of repeat injections is a 2017 randomized, placebo-controlled trial in JAMA. 140 patients with knee arthritis and ultrasound-detected synovitis received 40 mg of triamcinolone or saline every 12 weeks for two years. The steroid group lost more cartilage, a mean of 0.21 mm against 0.10 mm, and knee pain was no different. The authors concluded the findings do not support the treatment. A 2022 meta-analysis in Osteoarthritis and Cartilage pooled 10 randomized trials of repeat joint injections, eight in the knee, and found the other injectables compared, including PRP, often gave greater improvement in pain and function up to 24 months. An observational 2025 Radiology analysis of 210 people from the Osteoarthritis Initiative associated steroid injections with greater MRI progression over two years: an association, not proof, but it points the same way. The week-by-week picture is in our knee arthritis comparison.
In a tendon, the risk is weakness, and the relief reverses
A tendon is a different tissue with a different risk. A 2023 review in American Family Physician states that corticosteroid injections are not recommended for intratendinous injections, and that repeated injections can cause cartilage and tendon degeneration. Rupture itself was rare in trials: in a 2010 Lancet review of 41 randomized trials, one of 991 people who received a steroid injection (0.1%) had a tendon rupture. The larger cost was time. Steroid reduced pain in the short term, and that effect was reversed at intermediate and long terms. In tennis elbow, doing nothing was favoured over steroid at the intermediate and long-term marks. For tendon pain, see how focused shockwave and a steroid shot do different jobs.
When we reassess the plan
In tennis elbow, a 2024 meta-analysis of 11 randomized trials (730 patients) found steroid better before two months and PRP better at six months and beyond, though a 2021 Cochrane review (moderate certainty) and a 2026 meta-analysis of 6 randomized trials found PRP no better than placebo for tennis elbow. In plantar fasciitis, a 2025 meta-analysis of 24 randomized trials found PRP gave better pain scores at three and six months, with no difference at one month or one year. No source sets a number of shots. In our practice, we reassess when a shot helps for less time than the last. That is when a different treatment deserves a look.
When a shot fits, and when to change the plan
Here is how we sort it at the evaluation.
- A flare you need settled now: the 2026 four-society guideline puts the relief from a joint injection at a few weeks to a few months
- A frozen shoulder or tenosynovitis, where a 2023 review says steroid injections help
- In our practice, when each shot helps for less time than the last: we reassess the plan, not the interval
- Not when a tendon has torn through or the joint is unstable: that is a surgical conversation first
Before you book, ask
- How many steroid injections have I had in this spot, and how long did each one last?
- Will the needle go into the tendon or beside it, and will it be placed under ultrasound?
- What is the plan if this one fades faster than the last?
What you are really counting
Nobody counts shots for fun. You are counting because the season, the trail or the grandkids’ visit keeps getting interrupted, and each shot buys a little less time. The goal is not the next quiet month. It is getting back to the things you planned, and staying there.
Frequently asked questions
How many cortisone shots can you have in a year, or in a lifetime?
No guideline sets a safe number. A 2024 review in the American Journal of Roentgenology found that guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. A 2023 debate article notes that repeated injections are often given up to 4 injections annually, about one every three months, potentially because each one works briefly. The one randomized trial that tested four a year in the knee found more cartilage loss than saline and no better pain relief, and a 2022 meta-analysis found repeat joint injections no better than placebo for pain or function at 12 to 24 months. In our practice, we reassess when a shot helps for less time than the last.
How long should you wait between cortisone shots?
No trial we read compared one interval with another, so there is no tested minimum. The two-year randomized knee trial tested a shot every 12 weeks, and that schedule resulted in more cartilage loss than saline and no better pain. A 2024 scoping review of 65 studies on cartilage toxicity found that results seem significantly influenced by the dosage and frequency of injections. The 2026 four-society guideline puts the relief from a joint injection at a few weeks to a few months. In our practice, shrinking relief is when we reassess the plan rather than shorten the wait.
Can you get two cortisone shots at the same time in different areas?
The effects are not only local. The 2026 four-society guideline lists an increase in blood glucose and adrenal suppression among the adverse events of joint steroid injections, and a 2024 review lists hypertension and hyperglycemia among the systemic side effects. Two sites in one visit means a larger total dose. The same guideline found 20 mg of triamcinolone as effective as 40 mg in the shoulder, and recommended effective doses lower than those clinicians currently use. None of the sources we read set a rule for two sites at once; ask the physician giving the injection about the total dose and your blood sugar.
How many cortisone shots in the knee are too many, and can they make knee pain worse?
In a randomized trial that tested a shot every three months for two years, 140 patients with knee arthritis and ultrasound-detected synovitis lost more cartilage on triamcinolone than on saline, a mean of 0.21 mm of cartilage thickness lost against 0.10 mm, with no difference in pain, and the authors concluded the findings do not support the treatment. An observational analysis of 210 people linked steroid injections with greater MRI progression over two years. As for making it worse, a 2024 review lists a post-injection flare and accelerated progression of osteoarthritis among the local side effects. One shot for a flare is a different decision from a standing schedule.
Is the limit different for a shoulder, wrist or back injection?
The 2026 four-society guideline addresses the shoulder, elbow, hand, wrist, hip and knee, with dose findings that differ by joint. For the wrist, a hand-surgery follow-up of 689 carpal tunnel injections found short-lived local pain after 13%, all resolved within 3 weeks, and no tendon rupture even after repeated injection, though 13 hands kept skin lightening or thinning. Spine injections fall under a separate guideline from the same work group. And in a small sacroiliac joint trial of 26 patients, steroid gave lower pain scores than PRP at one, three and six months.
What are the side effects of a cortisone shot, and how long do they last?
A 2024 review sorts them as immediate or delayed. Local effects include a post-injection flare, skin lightening and thinning, and infection; systemic effects include facial flushing and raised blood sugar, which matters if you have diabetes. In the follow-up of 689 wrist injections, local pain resolved within 3 weeks in every case, but some skin changes persisted. The 2026 multisociety guideline notes that publications showed adverse events from single corticosteroid injections, so one shot is not risk-free. The same 2024 review states that corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint.
What do repeated cortisone shots do to a tendon?
A 2023 review in American Family Physician states that corticosteroid injections are not recommended for intratendinous injections and that repeated injections can cause cartilage and tendon degeneration. A 2024 radiology review lists tendon rupture among the local side effects. In trials, rupture was rare: one of 991 people who received a steroid injection in a 2010 Lancet review. The bigger issue is durability. Steroid reduced tendon pain in the short term, and that effect was reversed at intermediate and long terms. Placement matters, which is why we ask whether a shot goes into the tendon or beside it.
What can I do instead of another cortisone shot?
It depends on the tissue. In tendon trials, a 2025 meta-analysis of 27 randomized trials found PRP’s mid-term results better than steroid, with long-term results still unproven. In knee arthritis, a 2026 meta-analysis of 62 trials found PRP better than steroid at six and twelve months, with substantial heterogeneity and moderate to very low certainty, while a 2025 meta-analysis found no significant difference between PRP alone and steroid. In plantar fasciitis, a 2023 meta-analysis of 236 studies found shockwave therapy was the only intervention with a significant pain effect against control at medium and long term; the abstract does not separate focused from radial devices. The evaluation decides which, if any, fits.
Find out what to do instead of the next shot, and get back to living
Each shot buys relief for a while and keeps costing you time. Book the 90-minute evaluation with Aneesh Garg, DO, CAQ, fellowship-trained at the American Sports Medicine Institute, and get a plan aimed at the version of you that is not counting injections.
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