After a Cortisone or Gel Joint Injection: Rest, Flares, Exercise, and Warning Signs

The knee that felt brand new on the table is aching again by dinner. It is one of the most common calls we get after a joint injection, and the answer is almost always the same. A cortisone injection also contains a numbing medicine. The numbing medicine works in minutes and wears off within hours. Cortisone takes days to build. The first evening sits in the gap. A gel injection is slower still, and its effect builds over weeks.

These are the instructions Dr. Alex Movshis gives patients after an image-guided cortisone (corticosteroid) injection into the knee, hip or shoulder, or a hyaluronic acid (“gel”) injection into the knee, at Modal Pain Management, with the evidence behind each one and a plain note wherever no study exists. If you had your injection somewhere else, the timeline is the same, but follow your own physician’s discharge instructions where they differ, especially about blood thinners.

The first few hours tell us something. The first night does not.

After a cortisone injection, while the joint is numb, it is giving an answer to a question we care about: is this joint the main source of your pain? In a study of 220 hip injections, 68% of hips had immediate relief from the numbing medicine, and 94% of those still had relief at two weeks (Deshmukh 2011). When the numbing medicine changes nothing, the pain is often coming from somewhere else. In a group of patients whose hip pain did not respond to a diagnostic hip injection, most did not go on to hip surgery, and another cause was found in most of those (Yoong 2012).

So, in the first hour or two after the injection, do the movement that usually hurts. Stand up from a chair, take the stairs, reach overhead. Write down roughly what share of the familiar pain is gone. Then expect it to come back as the numbing wears off that evening. That return is not a sign that the injection failed.

Pain worse after a cortisone shot: the steroid flare

Some people have more pain, not less, for a day or two. This is usually a steroid flare, an inflammatory reaction to the tiny crystals that some cortisone preparations are made of. It starts within hours of the injection and lasts two to three days, and reported rates range from 2% to 25% of injections (Duarte-Monteiro 2023). The steroid used matters. In 436 shoulder injections, a flare in the first week followed 22.8% of injections with methylprednisolone acetate and 4.0% with triamcinolone acetonide (Eason 2023). For joint injections at Modal Pain we use triamcinolone or betamethasone, not methylprednisolone.

A flare is managed like any sore joint: ice for 15 to 20 minutes at a time, your usual pain reliever, and a lighter day. It should be easing by day three. Pain that is still climbing after three days, or a joint that becomes hot, red and swollen, is not a flare to wait out. Call us, and see the warning signs below.

Still sore at one week? That is common, and it is not yet a verdict. Judge a cortisone injection at about two weeks, for the reasons in the last section.

How long to rest, and when to exercise, by joint

The evidence on rest after a joint injection is thinner than most instruction sheets suggest. The one trial that found a benefit studied knees with inflammatory arthritis, such as rheumatoid arthritis, not osteoarthritis. Patients kept on bed rest for 24 hours after a knee injection did better over six months than patients who went straight home (Chakravarty 1994). Trials at the wrist and elbow found no benefit from keeping the joint still (Weitoft 2003, Weitoft 2010). The European guideline weighed these and settled on a middle course: avoid overusing the injected joint for 24 hours, but do not immobilize it (Uson 2021). We found no trial of rest after a cortisone injection for knee, hip or shoulder osteoarthritis.

That is the basis for our instructions.

• Knee. Walk around normally the day of the injection, and use stairs as you need to. Skip running, jumping, squats and long walks for the rest of that day. Return to the gym and sport from the next day, building back up over a week if the knee has been bad.
• Hip. The same as the knee. Walking after a cortisone injection in the hip is fine, including the walk home. Leave running, long hikes and heavy leg work until the next day.
• Shoulder. Move the shoulder normally. Do not wear a sling. Leave heavy lifting, overhead pressing and throwing until the next day. If you were injected for frozen shoulder, start or restart your stretching program within a few days. A review of the trials suggests the injection does more when it is paired with a home exercise program (Challoumas 2020).

After a gel injection in the knee, the rule is longer. The product labels for knee gel injections tell patients to avoid strenuous activity, such as jogging, tennis and heavy lifting, and prolonged weight-bearing, such as standing for more than an hour, for 48 hours after the injection (Genzyme Corporation 2025, Anika Therapeutics 2023).

Cortisone side effects in the first week

Some of the cortisone injected into a joint reaches the bloodstream. Most of these effects are short-lived.

Blood sugar in people with diabetes. This is the side effect most worth planning for. In a controlled study of patients with controlled diabetes and knee arthritis, every patient given a triamcinolone knee injection had a significant rise in blood sugar. Readings peaked about one to one and a half days after the injection, at a median of about 240 to 290 mg/dL depending on the preparation, and were back to normal in about two and a half to four days. A gel injection did not have this effect (Habib 2011). A systematic review found the rise in every study, usually appearing within 24 to 72 hours, and advised monitoring for up to a week (Choudhry 2016). Check your blood sugar more often than usual for a week, and call your diabetes doctor if readings run well above your usual range.

Facial flushing. Redness and warmth of the face can appear within about a day and a half of a cortisone injection, and it passes on its own (Duarte-Monteiro 2023).

Appetite and mood. A bigger appetite or mood changes can follow a cortisone injection. One study, in children, put the rate at about 3% (Duarte-Monteiro 2023). Some people also notice a restless night.

Skin changes at the needle site. A small dent from thinning of the fat under the skin, or a patch of lighter skin, is reported after roughly 1% to 7% of injections in the studies available, most of them in children. It is more common in older patients and usually fades, though not always (Duarte-Monteiro 2023). Show us if you notice one.

Your body’s own cortisol. A joint injection can quiet the adrenal glands for a time. Cortisol falls within hours, is lowest at one to two days, and recovers over one to four weeks, sometimes longer, depending on the steroid, the dose and how many joints were injected (Habib 2009). This rarely matters in daily life. It does matter if you need surgery or become seriously ill in the following month, so tell your surgeon and anesthesiologist about the injection.

Flu and COVID vaccines. A 2026 multisociety position statement recommends, for a non-urgent injection, leaving at least one week between a cortisone injection and a flu or COVID vaccine. For healthy people it allows skipping that gap after a discussion of the small risk of a weaker vaccine response (Benzon 2026). If your vaccine is due soon, mention it and we will plan around it.

After a gel injection: what is normal, and how long it takes

Gel (hyaluronic acid) injections are approved for knee arthritis, and they do not contain cortisone, so they do not raise blood sugar (Habib 2011) and do not cause steroid flushing. The common reaction is mild to moderate pain and swelling of the knee that passes, usually on its own or with ice and a pain reliever (Genzyme Corporation 2025).

The less common reaction is the one to know about. A knee can become much more swollen, warm and painful in the days after a gel injection. In one small study of a single gel product, this happened to 1 of 42 patients on their first course and 4 of 19 who had had more than one course (Leopold 2002). It is not an infection, but it looks like one, and the only way to tell them apart is often to draw fluid from the knee. So a knee that swells hard after a gel injection gets a call to us the same day, not a week of waiting. If you have fever or chills, or the pain keeps climbing, go to the nearest emergency room.

Gel works slowly. In a pooled analysis of the trials comparing the two, cortisone was ahead at two weeks, the two were level at four weeks, and gel pulled ahead after eight weeks, clearly by twelve (Bannuru 2009). The Cochrane review found the benefit of gel strongest between 5 and 13 weeks after the injection (Bellamy 2006). Judge a gel injection at 8 to 12 weeks, not in the first month. The major guidelines also disagree on how much gel helps. The American College of Rheumatology recommends against it for most people with knee arthritis (Kolasinski 2020), and the American Academy of Orthopaedic Surgeons does not recommend it for routine use (Brophy 2022). We offer it when the trade-offs make sense for you, and we will tell you plainly if it is not working.

Infection: rare, and why it is the one to act on fast

A joint infection after an injection is rare. In a Danish region, 11 infections followed 14,118 cortisone joint injections, or 0.08%, counting any infection within 14 days (Petersen 2019). It is also serious, which is why the warning signs are on the first page of these instructions. An infected joint usually becomes hot, red, swollen and steadily more painful over the days after the injection. Do not wait for a fever. In a national study of septic arthritis in Iceland, 42% of adults did not have a temperature of 37.8°C (100°F) or higher when they were admitted (Geirsson 2008).

A joint that turns hot, red and swollen with pain that keeps getting worse, especially with fever or chills, goes to the emergency room the same day.

Restarting blood thinners

Restart any blood thinner on the schedule you were given, not on a general rule from the internet. Joint injections are classed as low-risk procedures in the multisociety guideline on pain procedures in patients taking blood thinners, but the right timing still depends on the drug, the dose and why you take it (Narouze 2018). That is why this page gives no drug-by-drug timings. If you are not sure when to restart, call us before you take the next dose.

When to go to the emergency room

For any of the emergency signs on this page, call 911 or go to the nearest emergency room. Do not call the office first. Tell the emergency team that you had a joint injection, which joint, and on what date. The signs are a joint that turns hot, red and swollen with pain that keeps getting worse, especially with fever or chills, a joint you suddenly cannot move or stand on, trouble breathing or swelling of the lips or throat, and very high blood sugar with vomiting, confusion or heavy drowsiness.

Judging whether it worked, and what happens next

Give a cortisone injection about two weeks. In the knee trials, the benefit of cortisone was clearest at one to two weeks and faded over the following months, with no clear benefit left at six months on average (Jüni 2015). The hip trials showed the same early pattern (McCabe 2016). Give a gel injection 8 to 12 weeks (Bannuru 2009).

What to note for your follow-up visit:

• after cortisone, what share of the familiar pain was gone in the first hour or two, while the joint was numb
• what share is gone now, as a rough percentage
• what you can do now that you could not do before, such as walking farther, sleeping on that side or reaching overhead
• when relief started, and if it faded, when

Those notes decide the next step. Repeating a cortisone injection is reasonable when the first one gave real relief that has since worn off. The European guideline describes avoiding more than three to four injections into the same joint per year as a common rule while noting it is not based on research (Uson 2021). In a two-year trial, knee injections every three months caused slightly more cartilage thinning than saline, with no difference in pain (McAlindon 2017). Not every study has found this, but it is one reason we look for a longer-lasting option when injections are needed often.

Planning surgery? Wait at least three months between a cortisone or gel injection and a joint replacement or shoulder surgery on the same joint. In large national and state databases, injections within three months before knee replacement raised the odds of a joint infection, for cortisone and gel alike (Richardson 2019). The same three-month pattern appeared before hip replacement (Schairer 2016) and shoulder surgery (Werner 2016). Before rotator cuff repair, the extra infection risk was limited to injections within one month of surgery (Forsythe 2019). One large Medicare study found no extra risk before knee replacement (Kurtz 2022). The European guideline still advises three months before joint replacement (Uson 2021), and we apply the same wait to shoulder surgery.

The joint injection page explains when cortisone, gel or PRP makes sense for each joint, and the hip joint injection page covers the hip in detail.

If the injection did not help: what that usually means

A well-placed joint injection that changes nothing is useful information, wherever it was done. These are the patterns we see most often when patients come in for a second opinion after a cortisone or gel shot elsewhere. Bring your X-ray or MRI and the procedure note.

Knee: cortisone or gel helped for a while, the same pain is back, and you are not ready for a knee replacement

Usually: Knee osteoarthritis that responds to injections but not for long

At Modal Pain: Genicular nerve block, then radiofrequency ablation if the block works

Hip: the groin went numb, but the pain on the outside of the hip, worse lying on that side, did not change

Usually: Greater trochanteric pain syndrome (hip bursitis or gluteal tendon pain), outside the joint

At Modal Pain: Ultrasound-guided injection at the tendon or bursa

Hip: pain running from the buttock or groin down the leg, below the knee, that a hip injection did not touch

Usually: A pinched nerve in the lower back that mimics hip pain

At Modal Pain: Epidural steroid injection at the level that matches the exam and MRI

Shoulder: the deep ache eased, but reaching overhead or lying on that side still hurts

Usually: Subacromial bursitis or rotator cuff pain, outside the joint that was injected

At Modal Pain: Ultrasound-guided subacromial injection and a rotator cuff program

Shoulder: stiff and losing motion, worst reaching behind your back, even after the injection

Usually: Frozen shoulder (adhesive capsulitis), where the injection is usually paired with a home stretching program

At Modal Pain: Image-guided injection with a supervised stretching program

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References

Every figure on this page comes from the sources below. Where no study exists, the page says so and explains the reasoning instead.

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These are general instructions after a joint injection (cortisone or hyaluronic acid). If the instructions you were given at discharge differ, follow the ones you were given, because they account for your medications and your procedure. For anything you are unsure about, call (646) 290-6660. See the joint injection (cortisone or hyaluronic acid) page for how the procedure works and who it helps, or the aftercare instructions for other procedures.