Steroid Injections in Sport: A Complete Guide for Athletes

This article was written by Dr. Sandeep Khosla, who is a GP partner and works at our Derby clinic. He is also the Lead Doctor for Leicester Tigers Rugby and Derby County Football Club, working at the top of his field in elite sports medicine.

This article is designed for athletes who may require or are considering glucocorticoid treatment for injury management. It specifically focuses on the use of glucocorticoid injections, outlining what athletes need to know about anti-doping regulations and how to navigate these rules safely.

In this article, you’ll learn:

  • What glucocorticoids are and how they’re used for medical treatments, including cortisone and corticosteroid injections.

  • The importance of ultrasound guidance to ensure accurate, safe cortisone injections with minimal risk.

  • Key responsibilities as an athlete, including understanding anti-doping rules and ensuring that your treatments comply with sport regulations.

  • Practical advice for athletes: how to plan treatments around competition schedules and what steps to take to avoid potential doping violations.

  • Frequently Asked Questions (FAQ) to clarify the essential points about using glucocorticoid injections in sports.

What Are Glucocorticoids?

Glucocorticoids are a class of steroid hormones used to treat a variety of medical conditions due to their anti-inflammatory and immune-suppressive properties. Conditions that benefit from glucocorticoid treatment include asthma, hay fever, inflammatory arthritis, ulcerative colitis, Crohn’s disease, and eczema.

Glucocorticoids can be administered in several ways:

  • Pills or tablets (oral route)
  • Creams or lotions (topical route)
  • Rectal suppositories (rectal route)
  • Eye drops (ophthalmic route)
  • Multiple injectable formats, such as:
    • Intramuscular injections (into the muscle)
    • Intravenous injections (into a vein)
    • Subcutaneous injections (under the skin)
    • Intra-articular injections (into joints)
    • Epidural injections (into the spinal column)

There are over-the-counter glucocorticoid preparations, such as hydrocortisone creams for eczema, nasal sprays like Beconase for hay fever, and rectal creams like Anusol-HC for piles.

The administration of glucocorticoids by topical routes such as inhaled, intranasal, and dermal remain allowed both in and out of season. (UKAD).

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At Complete, we specialise in ultrasound-guided steroid injections, which offer precise targeting for various joint and soft tissue injuries such as bursitis, synovitis, arthritis, tendinitis, and many more. This technique allows for enhanced accuracy and effectiveness of the treatment, minimising discomfort and optimising recovery. Our experienced team utilises state-of-the-art ultrasound technology to ensure that the injections are administered safely and effectively, providing relief from pain and inflammation to help you return to your active lifestyle.

For further information or to book an appointment, feel free to contact us via email info@complete-physio.co.uk or call us on 020 7482 3875.

Common Glucocorticoids

At Complete, we commonly use two specific glucocorticoids for the majority of our ultrasound-guided injections. These glucocorticoids are aslo commonly known as steroids, corticosteroids or cortisone injections. These are:

  • Methylprednisolone, commonly known as Depomedrone
  • Triamcinolone acetonide, commonly known as Kenalog

These are effective for managing joint, tendon, and soft tissue injuries.

Other commonly used glucocorticoids include:

  • Beclometasone
  • Betamethasone
  • Budesonide
  • Ciclesonide
  • Dexamethasone
  • Fluticasone
  • Hydrocortisone
  • Mometasone
  • Prednisolone
  • Prednisone

If you’re unsure whether a medication contains a glucocorticoid, it’s best to consult your pharmacist or doctor.

Rules for the Use of Glucocorticoids in Sport

The World Anti-Doping Agency (WADA) has strict rules regarding the use of glucocorticoids in sports. Certain routes of administration (e.g., oral or injectable) can result in significant levels of glucocorticoids circulating in the blood, potentially enhancing performance or causing harm.

Since January 1st, 2022, all glucocorticoid injections are prohibited during the in-competition period. This includes glucocorticoids injections into joints, bursa, and the epidural space. While out-of-competition injections are still allowed, athletes are advised to stay updated on regulations as they are revised annually.

For more information on your medication and route of administration, we recommend checking the Global DRO to ensure compliance with anti-doping rules.

Athlete’s Responsibility

It is the athlete’s responsibility to ensure any medications they take are allowed in their sport, even if prescribed by a healthcare professional. Athletes should always verify the medication and its administration route on Global DRO or with their sport’s anti-doping agency.

Definition of In-Competition Period:

The in-competition period starts at 11:59 p.m. on the day before a competition and lasts until the end of the competition and any related sample collection process.

For example, a football player competing in a 3 p.m. match on a Saturday enters the in-competition period at 11:59 p.m. on Friday, lasting until the end of the match and sample collection.

The in-competition period may differ for some sports, so athletes should confirm the specifics with their sport’s governing body or national anti-doping organisation.

Washout Period

It is important to remember that when glucocorticoids are taken, whether it is oral or injected, they will remain within the body for a certain length of time until metabolised and removed in the urine.

This means that a glucocorticoid injection could be given by a clinician out of competition but the urine sample may contain evidence of glucocorticoids use even though this took place out-of-competition, and an adverse analytical finding (AAF) may be reported leading to potential sanctions.

A washout period is recommended by WADA as the minimum time an athlete should allow between the end of the treatment and the next competition.  The wash out period will vary depending on the type of glucocorticoid used and the route of administration. If an athlete participates in a competition during the washout period, the substance is very likely to be detected during doping control. If the next competition is after the washout period, there is still a small chance that the active ingredient will still be present in the body.

WADA recommends clinicians and athletes observe the minimum intervals between the end of the glucocorticoid use and the next competition (see table) to reduce the risk of a positive in-competition doping test.

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As you can see from the table, the majority of joint and soft tissue injections will have a washout period of 3 days. However, triamcinolone acetonide, which we do use at Complete, commonly known as Kenalog, has a potential washout period of 10 days. This is a very common glucocorticoid used in soft tissue and joint injections, Therefore, this may need to be considered by your clinician depending on how close your competition is to the injection.

Athletes receiving glucocorticoid injections into or around joints or tendons should be aware that such procedures may accidentally result in some intramuscular injection/absorption. If intramuscular injection/absorption is suspected during a procedure, then the intramuscular washout periods should be followed. An advantage of having an ultrasound guided injection is that this risk is minimised due to improved accuracy of the injection.There are no concerns of an athlete being tested out-of-competition (i.e. at training) within a wash out period since local glucocorticoid injections are only prohibited in-competition.

The best way to keep safe as an athlete is to avoid any glucocorticoid injection within the washout period before a competition.

Therapeutic Use Exemption (TUE)

Athletes who require the use of a glucocorticoid by local injection are only required to apply for a retroactive TUE if they are subject to doping control in-competition and they subsequently return an adverse analytical finding (AAF) for the presence of that glucocorticoid. A therapeutic use exemption (TUE) form can then be completed retrospectively by the clinician administering the injection.

This is most likely to occur if the injection was done within the washout period before competition. Further information about WADA’s decision to make changes to the way glucocorticoids are regulated in sport can be found in a review article published in the British Journal of Sports Medicine.

Athletes receiving a local injection within a washout period should ensure that a medical file is compiled prior to proceeding with the injection in case there is a need to apply for a retrospective TUE.

Medical File  – Documentation Required for Retrospective TUE Applications for Local Glucocorticoid Injections

  1. Diagnostic Investigations – supporting evidence, such as the results from imaging scans (e.g., ultrasound, MRI) and other relevant diagnostic tests that were used to confirm the medical condition, must be provided with the application.
  2. Clinical Review Letter – a detailed clinical review letter from the overseeing doctor must accompany the application. This letter should include:
    • A comprehensive clinical history, detailing when the injury or condition first occurred, the symptoms the athlete experienced at the time, and the severity of these symptoms.
    • A description of the clinical examination findings that led to the decision to administer a glucocorticoid injection.
    • A summary of previously tried permitted medications and/or non-drug treatments. This should include names, dosages, dates, durations, and the effects of each treatment. If no alternatives were tried, the prescribing doctor must provide a clinical justification explaining why there were no suitable permitted alternatives.
    • An explanation of the consequences for the athlete if the treatment had been withheld.

Your health professionals should complete thepre-application checklist prior to administering the injection if it is within the washout period so that they can fulfil all the criteria should a retroactive TUE be required.

Case Example: A Powerlifter’s Subacromial Bursitis

A powerlifter visited our clinic with shoulder pain that had been affecting his training for weeks. After a thorough clinical assessment and a comprehensive diagnostic ultrasound exam, we diagnosed subacromial bursitis, an inflammation of the bursa located beneath the acromion (shoulder blade).

Given the diagnosis, we advised a glucocorticoid injection using triamcinolone acetonide (Kenalog). We ensured the injection was performed 10 days days prior to his next competition, safely outside the in-competition period according to WADA regulations. The athlete was reassured about the procedure, informed of potential concerns at the competition, and guided on what to do if any issues arose.

For further information or to book an appointment, feel free to contact us via email info@complete-physio.co.uk or call us on 020 7482 3875.

Frequently Asked Questions (FAQs)

Why should corticosteroid injections be carried out under ultrasound guidance?

Ultrasound-guided injections improve accuracy and help minimise the risk of complications, such as accidental intramuscular injection, which can result in a positive doping test if mismanaged. At Complete, we always use ultrasound for precision and safety.

Do elite athletes have steroid injections?

Yes, elite athletes may receive glucocorticoid injections for injury management and to reduce inflammation. The benefits include faster recovery and pain relief. However, as discussed in this article, there are risks, including side effects and regulatory concerns under WADA rules. A proper diagnosis and careful planning are essential to ensure that injections are both safe and compliant with anti-doping regulations.

What is the in-competition period?

The in-competition period typically begins at 11:59 p.m. on the day before a competition and lasts until the competition has ended and sample collection is completed. It is important for athletes to avoid banned substances during this period. Out-of-competition use is more flexible but should still be managed carefully.

What is the washout period?

The washout period is the recommended minimum time between the end of glucocorticoid treatment and the next competition to avoid detection in doping tests. The length of the washout period varies depending on the glucocorticoid type and administration route. For example, most joint injections require at least 3 days before competition, however certain products can take up to 10 days. It is essential for athletes to time their treatments to avoid a positive doping test in-competition.

Do I need a Therapeutic Use Exemption (TUE) form filled out before receiving a glucocorticoid injection?

No, athletes do not need to apply for a TUE before receiving a local glucocorticoid injection. A TUE form can be completed retrospectively if the athlete returns an adverse analytical finding (AAF) in-competition due to the presence of glucocorticoids in their system. This is typically required if the injection was administered during the washout period before competition.

What should I do if I receive a glucocorticoid injection during the washout period?

If you receive a local glucocorticoid injection during the washout period, it is important to compile a medical file with supporting documents, including diagnostic imaging and clinical notes. This will assist in applying for a retrospective TUE in case of an adverse analytical finding (AAF) following a doping control test in-competition.

Are there alternatives to glucocorticoid injections?

At Complete we also offer alternative treatments such as:

  • Platelet-Rich Plasma (PRP): A regenerative treatment where platelets from the patient’s own blood are injected to stimulate healing. PRP is not on the WADA prohibited list and can be a good alternative for treating soft tissue and joint injuries.
  • Hyaluronic Acid: A substance that is injected into joints, commonly used for conditions like osteoarthritis to provide cushioning and pain relief. Like PRP, it is not prohibited by WADA and can be a suitable alternative for athletes.

Timing is crucial when using these alternatives, as sufficient time is needed to ensure therapeutic effects before competition.

Are glucocorticoid injections worth it?

Yes, corticosteroid injections can provide rapid pain relief and reduce inflammation, particularly when used for the right diagnosis, such as joint or tendon inflammation. At Complete, we always conduct an ultrasound scan and consider all investigations before proceeding with treatment.

Where can I get more information about glucocorticoid injections?

Consult your clinician or refer to the World Anti-Doping Agency (WADA) regulations. You can also check the Global DRO website for specific medication details.

If you would like to make an inquiry or book an appointment, please email info@complete-physio.co.uk or call 020 7482 3875.

Resources & References

For further information, please contact the UKAD Science and Medicine team at tue@ukad.org.uk. Athletes and support personnel are also guided to the Medicine Hub on UKAD’s website for frequently asked questions about this policy.

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