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Despite risks, cortisone still a familiar remedy

Phil Bradley is a former All-Star outfielder who played for four Major League teams. Before that, he was the starting quarterback at Division I Missouri. So, yes, he knows something about playing with pain -- and methods of dealing with it.

Lance Berkman is an All-Star outfielder/first baseman for the Cardinals who has a .296 career average and 360 home runs in 14 seasons. After appearing in 1,806 games, he knows about playing hurt, too.

"I used cortisone," Bradley, now a special assistant for the Major League Baseball Players Association, said recently, after it was reported that Yankees shortstop Derek Jeter had received a cortisone injection to help him continue to play through a bone bruise in his left foot, before fracturing his left ankle in Game 1 of the Championship Series against the Tigers.

"I've known a lot of guys who have taken a lot of cortisone shots, including myself," Berkman said.

Dr. Matthew Roberts, a foot and ankle orthopedic surgeon at the Hospital for Special Surgery in New York, who has worked with professional sports teams, fully understands the pluses and minuses of cortisone as a treatment.

"Cortisone is a very powerful anti-inflammatory," Roberts said. "It's a steroid. So when you hear the word NSAIDs like aspirin, Advil, ibuprofen, those are non-steroidal anti-inflammatories. So the ultimate anti-inflammatory is a steroid.

"I think its effects are variable, but clearly one or two injections isn't going to cause harm. If you keep injecting a joint over and over again, it can certainly soften the cartilage or the cushion in that joint. So there are pros and cons. When you're injecting it locally, it can significantly decrease inflammation. But it can also cause harm, if you inject a single site over and over and over again."

That's straightforward enough, and every indication is that teams have become much more conservative in prescribing treatments that could have negative long-term implications. The bigger issue is that cortisone does not heal injuries. It reduces or eliminates pain, which could lead a player to push his body to the breaking point.

"Correct," Dr. Roberts said. "Cortisone decreases inflammation. And it's inflammation that causes pain. So, yes, you will decrease inflammation, but it may not fix the underlying problem. Usually what fixes an underlying problem is time and allowing things to heal."

Further complicating the picture is the fact that many players willingly accept the risk of a more serious injury if it allows them to play in the short term.

"Guys aren't real smart, and I'm including myself in that," Berkman said with a laugh. "For whatever reason, the need to be out there and feel like you're not letting your teammates down, not letting your organization down, those feelings far outweigh what you know in your heart to be [in your personal best interest]. I think it's part of this culture. We try to get on the field. We get paid a lot of money by these organizations. Most of us feel an obligation to get on the field if we can drag ourselves out there. So I think guys will continue to do whatever it takes to get on the field.

"I read some comments [Nationals third baseman] Ryan Zimmerman made about his shoulder. He's like, 'Hey, it's professional sports, this is what we do.' And he's exactly right. He's got a shoulder issue, but take some shots and keep going out there until it falls off.

"I think that's part of professional sports that not many people see. Not many people appreciate the sacrifice that guys make with their bodies to be able to do what we do. And, obviously, don't cry for us. We're being well-compensated for it. But you always hear, 'Aw, these guys are spoiled, they make so much money, they're not worth it.' But there's a level of commitment, a level of self-sacrifice that goes with that, that not many people get to see."

Some of the biggest names on teams that made the playoffs this season reportedly took cortisone to help play through injuries, including Zimmerman, Carlos Beltran of the Cards and Brian McCann, Freddie Freeman and Tim Hudson of the Braves.

Bradley agreed that players tend to look for a way to play.

"Within reason, I think so," Bradley said. "Especially during the era I played where we didn't have [many] multiyear contracts," he said. "It was very important to be on the field. Because if you weren't on the field, you weren't able to generate numbers to merit [the next contract].

"I'm not as close to it today, but I think human nature is that players were made to play. It's important to them, it's important to the team, it's important to everyone. The players do all they can to perform, within limits. Without jeopardizing your career or jeopardizing the team."

The problem is that it's sometimes difficult, if not impossible, to determine what is an acceptable risk.

"The line is never clear, and you don't ever know how far you're pushing the envelope," Bradley said. "It's hard to say when you play injured. Obviously, you're not 100 percent. But you've heard the old adage, 'Just give me 100 percent of what you've got.' Because sometimes a certain guy's presence on the field is just as important as his performance."

Cardinals general manager John Mozeliak said he goes strictly on the opinion of the medical staff.

"We rely solely on what our medical staff recommends," Mozeliak said. "I don't try to play doctor. If a player can't play, then we just play a different hand. We don't go in demanding shots or telling our staff to get these guys back on the field. What we try to do is treat them with the best medical care we can provide.

"And I feel we do a very good job of that. I don't feel we're overly aggressive with that and I don't think it's a tool we use unless we feel it can really help."

Said Dr. Roberts: "Teams are much more conservative, and they think about their long-term future with the player. There are certainly a lot of doctors and trainers out there who are looking after the best interest of the athlete. Their athletes being healthy in the long run is better for the team than maybe getting through one more game and being injured."

Roberts also appreciates that using cortisone is part art and part science, and he noted that even the time of year can play into the decision about whether or not to use it.

"With any intervention, you have to weigh the pros and cons and what you're trying to do," Roberts explained. "We're dealing with high-level athletes. Maybe it's the Super Bowl and you're trying to get through one more game, which maybe changes your decision pattern versus something done early in the season."

Said Berkman: "It does matter, because what are you saving yourself for in October? You go until you can't go at this time of year. Whereas in May, live to fight another day. In October, there isn't another day. You're out there or you're not."

Even that's not always clear-cut. Phillies first baseman Ryan Howard ruptured his left Achilles tendon on the final play of Philadelphia's 2011 postseason after taking multiple cortisone shots in that ankle over the previous two years. That led the Philadelphia Inquirer to run a lengthy article exploring the possibility of a connection between the injections and Howard's catastrophic injury.

"I can say unequivocally that cortisone had nothing to do with Ryan Howard's Achilles tendon," said Phils general manager Ruben Amaro Jr. "I think it has a beneficial effect. But just like anything else, anything in excess can cause complications. Cortisone has its place. I don't think it causes injuries."

An important point to remember, especially for a sport like baseball, in which the use of steroids has been such a hot-button issue over the past two decades, is this: Cortisone is legal.

"[Illegal] steroids can affect your whole body," Roberts said. "We're talking about a systemic steroid, which affects your whole body, versus a localized steroid used purely for an anti-inflammatory effect and not as an enhancing effect."

On balance, Berkman is a proponent of cortisone.

"Obviously, it helps you feel better," Berkman said. "But if you're not careful, it can mask your body's natural tendency to protect itself. It's a risk-reward type thing. Obviously, in the [Jeter] situation, he got a shot. He felt better than he probably would have. You can play that game until the cows come home.

"If you're talking about general joint inflammation, whether it be a knee or ankle or shoulder, that's really beneficial. I would never take one for a muscle injury, but I would take one for joint inflammation."

Carlos Beltran, Lance Berkman, Freddie Freeman, Ryan Howard, Tim Hudson, Brian McCann, Ryan Zimmerman