The Role of Injections in Recovery From Injury and Pain with Dr Ciaran Cosgrave

Hello everybody, I am Dr Ciaran Cosgrave, Sports & Exercise Medicine Consultant, and I am a Director for UPMC Sports Medicine.

This talk is going to cover ‘The Role of Injections in Recovery from Injury and Pain’.

Sports & Exercise Medicine

As consultants in sports and exercise medicine, we specialize in the non-surgical management of Musculoskeletal (MSK) conditions where a musculoskeletal condition is any injury of the body whether it’s a joint, a muscle, a tendon, a ligament.

While we do treat athletes and sports people, we treat patients of all age groups and all activity levels. whether the injury is a new injury or an old injury, whether it’s wear and tear, the principles of treatment are exactly the same.

One of the treatments that we offer is injections. There’s lots of different types of injection that you can do obviously depending on the conditions and we’ll cover as many of them as we can today.

Understanding MSK Injections

We do a lot of injections in sports medicine. Last year we did over 7,000 injections. Therefore, we do a lot of them and we’ve got good experience with them. I’m sure many of you have had injections and if not I’m sure you certainly known somebody who’s had an injection.

Often patients will ask me and even friends and family will ask me whether a certain injection will help their patient. However, the first thing that you need to get to the bottom of is what’s actually, driving the pain.

What is the diagnosis?

If you don’t know what the diagnosis is, you can’t enter into the discussion about whether or not an injection will help because not all pain is the same. You have to figure out what’s causing the problem.

Pain can be Acute; as in its new, or it can be Chronic; as in it can be old, it can be there for three months or more. That’s the definition of chronic. Patients often think chronic or acute has a degree of severity within it. However, you can have mild acute and mild chronic pain, and you can have severe Acute and severe Chronic pain, that’s just about the duration of pain, but it is different.

Pain might come from arthritis; it might come from inflammation. In terms of what’s actually sore, you can get pain from a joint, from the bone, from tendons, muscles, ligaments, and pain can be nerve related. Quite often patients can have pain from several different sites. Therefore, it might start off with a sore joint, but over time the muscles and the tendons around the joint start to drive some of the pain as well. As a result, it’s really important you figure out what’s causing the pain before you can chat about how to treat that.

Recovery is about more than an injection

Now, regarding injections, injections are just one tool in the toolbox of how to treat something. Therefore, once you’ve established what the diagnosis is, then you need to put in place a management plan, and that management plan is usually multifaceted. That means, there’s lots of different components to the treatment plan all working together to try and get you better.

Treatment will often include a degree of activity modification. Which means, you might need to either reduce some activity or potentially even temporarily stop the activity that’s causing the problem or exacerbating the problem. There’s nearly always a period of rehabilitation required. Therefore, working on range of movement or strength or control of movement which has the benefit of not just treating the current problem but it also helps to build in a degree of robustness so that when you go back to your activity you don’t have a recurrence of the same problem and breakdown straight away.

Once you’ve done all the above, then you can enter into the discussion as to whether or not an injection is needed and if so, what is the most appropriate injection for you and for your condition.

Where can injections help?

Injections can be very helpful in terms of what you’re trying to achieve. Obviously, most patients come to us with pain somewhere. Ideally, you’re going to help to reduce that pain, you might want to reduce inflammation, you might want to try and lubricate the joint, and you might be trying to promote healing. If you manage to achieve any or all of the above, then if the joints more comfortable and it’s moving more freely, then you’ll be able to commit better to your rehab program and hopefully get a much better outcome.

What Injections can not do.

It’s important to note that injections can’t reverse all tissue damage. So, if we’re dealing with something like an osteoarthritis or a wear and tear arthritis, there’s no treatment in the world that can reverse that. Therefore, the target of treatment isn’t to cure the issue. What we’re trying to do is to give you less pain or ideally no pain. We’re trying to give you better function or ideally full function, but we can’t reverse or cure the issue.

Injections aren’t there to replace rehabilitation. Unfortunately, the only thing that can rehabilitate a joint is hard work by yourself to try and build up the strength and the control of movement. When I’m chatting to patients about the treatment, it’s always rehabilitation plus or minus an injection. It’s never rehabilitation or an injection. Therefore, it’s important to bear in mind that injections aren’t there as a replacement for the rehab.

In terms of the injections themselves, so we do all of our injections under ultrasound guidance. This has a couple of benefits. Number one, we can see the area that we’re trying to inject and that helps us to guide the needle into the right spot. That makes things a lot easier for me. It also makes it a lot easier for you undergoing the injection.

There’s also a safety benefit as well. Therefore, we can identify the blood vessels, the nerves on that ultrasound that then allows me to know the areas where I need to avoid.

Corticosteroid Injections

Some of the common injections that we do then are corticosteroid injections also often called steroid injections or cortisone. These are by far the most common injections globally. Therefore, I would say at least 95% of the time when a patient has had or is going to have an injection, they’re going to have a steroid injection. They are the best anti-inflammatory that we have they’re brilliant at reducing pain they’ve been around for over 70 years, and we know they’re very safe.

In terms of how they work, they reduce inflammation and quite often your pain is driven by inflammation. Therefore, if you reduce the inflammation, you reduce the pain. They help to reduce the stiffness in the joint, that then improves the movement.

Where we use Corticosteroid Injections

In terms of where we use them, we use them a lot in joints, whether it’s an injured or inflamed joint. It can be used in arthritis if that’s wear and tear or osteoarthritis, and it can also be used in inflammatory arthritis like rheumatoid.

If you have inflammation around the lining of the tendon, that’s called tenosynovitis, and it’s very effective at reducing that. It is also used very effectively in patients with back pain.

Important considerations with Steroid Injections

Some important considerations with steroid injections are that benefits may be temporary and that’s entirely dependent on what’s actually driving the problem; What’s the diagnosis? If you’ve had trauma to a joint, you’ll get inflammation to promote the healing. That healing will happen, but sometimes the inflammation hangs around afterwards.

A steroid injection is fantastic at reducing that inflammation and providing there’s no further injury, that steroid injection should be permanent. Therefore, it should be a one-off but as we talked about osteoarthritis, that’s not reversible. As a result, if we inject steroid into that joint, hopefully you’ll get a benefit, but that benefit will almost certainly just be temporary.

Everybody asks, how long is it going to last? That’s the variable bit. On average, you’re talking about six months relief. There are some people who are very lucky and they might get a few years out of the injection, but at the other end of the spectrum, you have people who might only get a few weeks, you don’t know from the outset. Essentially, you do the treatment and then you see what the response is like. Some patients and some injuries are not suitable for steroid injection. Therefore, it’s important to know what the diagnosis is and to know your history so we can talk about whether steroid injection is suitable.

And following on from that, there’s good research now that shows if you do a lot of steroid injections over a long period of time, it can actually lead to more cartilage wear, so, you might end up doing more harm than good. Also, research shows us that if you inject steroid into a tendon that can actually inhibit the healing of the tendon and might actually lead to more tendon damage. As a result, we’re very reluctant to inject steroid into tendons.

Hyaluronic acid injections

Now the next injection then is Hyaluronic acid often called hyuronate. This is the lubrication fluid injection. So, we inject this into joints commonly knees, but it can be injected into any joint as well as lubricating the joint, it helps to improve shock absorption, it helps to reduce inflammation and by doing all of the above, it helps to reduce pain and stiffness in the joint.

Important considerations:

We use it mostly for arthritis and it seems to be most effective for that mild to moderate arthritis with less benefit the more severe the arthritis is. The improvement is more gradual and arguably more dramatic compared to a steroid.

Whereas, with a steroid injection you might get a very noticeable improvement within a few days with a hyaluronate injection it’s more like somebody turning down the volume of your pain and stiffness over a period of a few weeks. Then for the exact same reasons as we talked about with the steroid the benefits may be temporary. On average patients get six to nine months relief from the Hyaluronic acid injections.

Platelet Rich Plasma injections (PRP)

Now the next injection, Platelet Rich Plasma or PRP. This is our most common injection, so, this is the one that we do most commonly in the clinic. Last year we did over 4,000 PRP injections.

PRP concentrates your own platelet. Therefore, we take a blood sample from you, we spin that blood in the centrifuge which then separates the blood into different layers depending on the density of the cell. The platelets are the Lightest, so they float at the top in that yellow fluid that you see on the screen. That’s called the plasma, you’ve got all the platelets concentrated in that one volume of plasma. We can then take that volume out and that’s what gets injected into the injured area.

Your platelets contain your growth factors. Therefore, they help to reduce inflammation and pain, and they also help to promote repair. As a result, for those two reasons, we like it, and we find great results with it and obviously patients like it as well.

It’s got a lot of different use cases. Most commonly we use it in joints, it can be used in any joint. The most commonly used joints would be knees, ankles, hips and shoulders.

It can be used for Tendinopathy which is an overload condition of the tendon often called tendinitis. So, around the elbow you might have tennis elbow or golfer’s elbow, at the knee you might have quads tendinopathy or patellar tendinopathy. at the ankle and Achilles tendinopathy and then around the buttock you’ve got hamstring and gluteal tendinopathy, and we find that a PRP injection combined with rehab is an effective treatment for tendinopathy.

PRP injections are also very effective for planter fasciitis which is a very stubborn cause of heel pain.

Important considerations with PRP

Now some important considerations with PRP, it may need to be repeated so our protocol for tendons is to do one injection and then six weeks later review to decide if a top up injection is needed. Whereas our protocol with joints, just because of the research and our own experience, is to book two injections from the outset, so, two injections a few weeks apart and then review six weeks later to decide if any further injections are needed.

PRP is certainly not an overnight fix. Whereas with steroid, you might get a benefit within a few days. PRP doesn’t even start working for a couple of weeks and it takes up to six weeks to work fully which is why we wait that period before deciding if any further intervention is needed.

Botox injections

Now the next injection you might be a bit surprised to see in here. This is Botox injections. You’re probably familiar with them from cosmetic medicine where they inject them to the face to reduce wrinkles, but it can

be very effective in musculoskeletal medicine as well. Botox works at the neuromuscular junction, so, it works at the point where the nerve meets the muscle, and it blocks transmission of signals going to the muscle.

It then reduces the activity of that muscle. It works in the skin by stopping you from being able to move the skin repeatedly which is what causes the wrinkle. Therefore, if you stop the muscle activation, the skin essentially repairs itself.

Uses of Botox Injections

In musculoskeletal and sports medicine, we use it in a few different areas. We see a lot of patients who have exercise related leg pain, for example that might be in the calf. Usually running re-education combined with rehab gets on top of this but where it hasn’t Botox can be very effective at reducing the activity of that muscle to provide a period where rehab can then take over.

It’s very effective for tendinopathy. As we talked about tendinopathy is an overload of the tendon. Usually rehab plus PRP gets on top of that. However, if that’s not been successful, injecting Botox to the muscle helps to detention the tendon, take the pressure off it, and give it a period of time to heal.

It’s also a very effective treatment for plantar fasciitis, which has not responded to the rehab and to the PRP.

Arthrosamid

Now the last treatment then is Arthrosamid. That’s the newest treatment we have. It’s called a Polyacrylamide Hydrogel, often just shortened to hydrogel. Many people hear that and they assume it’s a hyaluronic acid or it’s just a different type of Hyaluronic acid.

However, it’s actually very different, what happens is you inject it into the knee joint, and it gets integrated into the lining or the synovium of that knee joint, and it stays there permanently, and because it stays there permanently, it doesn’t get absorbed. It’s actually not classified as an injection. It’s classified as an injectable implant.

What Arthrosamid does then is it stops the inflammation from crossing through the lining of the joint into the knee. When pain is driven by inflammation, it’s a really effective way of reducing that. Therefore, patients who get those recurrent fusions or fluid collections in the knee or patients who have a really dramatic but temporary benefit with the steroid injections, they seem to be the patients who respond best to Arthrosamid and because when it’s injected it’s there permanently. The benefits are much longer lasting.

Research shows it benefits can last as long as five years after one injection. It’s currently only licensed for knee osteoarthritis, but I’m confident that over time with more research, benefits will be shown in other large joints like hips, ankles, and shoulders. I’m sure we’ll start to see it being used in other areas of the body.

Important considerations for Arthrosamid

Now, some important considerations for Arthrosamid. As I’ve said here it’s relatively new. It’s actually, been used in different areas of medicine for over 20 years. It’s used in patients with incontinents as a bulking agent and it’s been used in cosmetic medicine as a filler. Therefore, we know it’s very safe, but it’s actually only got a license for its use in knee osteoarthritis 5 years ago.

As a result, the evidence for its benefit is still relatively light. Yes, it’s growing, but it’s still light. There’s also not a lot of head-to-head comparison evidence where we can compare Arthrosamid versus steroid versus PRP.

Therefore, we need to keep an eye on that as things grow. What we do know is that patient selection is key. As I said, it seems to work best when inflammation is the main driver of pain. So that’s your mild to moderate Osteoarthritis, as the Osteoarthritis starts to get more severe, bone is a major driver of pain and Arthrosamid isn’t effective for bone pain, and if you’ve got a lot of bone pain, then Arthrosamid probably isn’t the treatment for you.

The other consideration is it’s not covered by insurance because it’s relatively new and there’s not a huge body of evidence for it. The insurance companies aren’t cover covering the injection. Therefore. there is a cost to you which needs to be factored into the conversation.

That’s all of the injections that I wanted to talk about. There’s a lot of information in there. Therefore, I’m just going to recap it all in this one slide.

Recap

Step one is always to establish what is driving the pain. What is the diagnosis? And once you have that, you put in place a management plan, and that management plan is nearly always multifaceted. It’ll involve some activity modification, some rehabilitation.

Then depending on the diagnosis and what treatments you’ve had before, then we can enter into the discussion around what injections might be suitable.

Steroid injections are a brilliant anti-inflammatory. They’re very effective at reducing pain, very quickly but the benefits are often temporary.

Hyaluronic acid injections or the lubrication fluids they get injected into the joint and they seem to be very effective at reducing the pain and stiffness in the joint particularly for the mild to moderate arthritis.

PRP or Platelet Rich Plasma injections, these are the injections that we do most commonly in the clinic and we can use them in joint arthritis, Tendinopathy and Plantar Fasciitis.

The Botox injections are the ones that reduce the muscle activity. Therefore, they’re very effective at reducing the activity in a muscle when patients are overusing that muscle during a particular activity like running. They’re also effective in tendinopathy and plantar fasciitis.

Then finally, our newest treatment, the Arthrosamid, which gets injected into the joint, gets integrated into the lining of the joint, prevents the inflammation from getting into the joint, and then is very effective at reducing pain that is driven by inflammation, and it seems to be most effective in that mild to moderate range.

So, that is everything from me., if you would like to get any further information on any of the injections that we talked about, then feel free to contact us there with the details on the screen by email or phone. And if you’d like to get an opinion as to whether any of the injections might help you then through the same details, you can contact us to book in with one of the sports medicine consultants to confirm your diagnosis, put in place a management plan, and then we can chat about injections as and when needed.

There’s no need for referral. You can book in with us directly. thanks a million for your attention and I’d be very happy to take any questions.

First thing just to make sure that the pain is coming from the knee. Sometimes it can refer from another area like the hip or the back. However, if you’re confident that it is a knee problem, then you just want to, delve into what treatment has she had before.

What’s worked, what hasn’t worked. Any of the injections that I talked about, maybe barring the Botox would be suitable. Therefore, the pros and cons of all of them could be discussed. If she was just needing some quick relief for a specific reason, steroid would be a good option, but if it’s more of a longer-term plan, then you’d maybe look at your PRP or your Hyaluronic acid.

Yes, you judge the dose of the steroid based on mostly the joint size. Obviously, the larger the joint, the more steroid you can safely put in there. The diagnosis obviously impacts on it; past medical history is relevant. With certain conditions like diabetes, you might not want to put in too much of a dose.

Sex isn’t necessarily something you would change your dose on, but body size you might and obviously men are generally larger than women. Therefore, if you were modifying the dose, it might be more on size rather than sex.

Stem cells are interesting. The theory behind stem cells is you inject them into the area of interest, usually a joint, and then the stem cell you would hope would then grow into cartilage cell and then help to regrow the cartilage.

A few issues with stem cell treatment:

First of all, you can’t control what the stem cell grows into. Therefore, you can’t specifically ask that stem cell to grow into cartilage. The assumption is that that’s what it will do, but there’s always the risk that it will grow into another type of cell.

There are also different types of stem cells. Therefore, you can isolate stem cells from body fat, or you can take it from bone marrow, and you can take it from other areas. Despite stem cells being around for probably 10 years now, there’s still not a huge amount of evidence for it, and there is a significant cost.

As a result, at the minute, we’re just watching it, I’m not saying we wouldn’t ever go down the route of stem cells, but at the minute, I don’t think there’s enough evidence to justify the cost and potential risk with it.

There’s no absolute limit. Most people would agree that it is safe to inject a joint up to three times in a year. Therefore, there’s a bit of a myth out there that says you can only have three steroid injections in your lifetime. That’s definitely not the case. but it is generally accepted you wouldn’t want to inject a specific joint more than three times in a year, so roughly every four months for a knee for example.

My preference is to try and stretch it out as long as you can. Therefore, if you can get 12 months great. If it’s only six that’s okay but if you’re looking at getting it done every four months, it’s probably not the treatment for you and you might look at alternatives.

There’s no absolute time point, with the steroid, you probably want to leave it at least three or four weeks just to make sure that it’s had enough time to work.

With the Hyaluronic acid, you probably look at five or six weeks to make sure it’s had enough time to work, and if after the four weeks with the steroid or the six weeks with the Hyaluronic acid and you haven’t noticed the benefit, then you’re probably into looking at the other options, whether that’s PRP or Arthrosamid or even potentially surgery.

46 is still young. The compartment of the knee doesn’t really change which option you go for. As a result, all of the injection options barring maybe the Botox would be viable for Unicompartmental Osteoarthritis, but if it is very isolated to the one compartment and you weren’t responding to the injection options then absolutely a Unicompartmental replacement would be a safer more functional quicker recovery option for you.

That would be a chat with the surgeon obviously, but most surgeons would look at the injection options before going down the route of a Hemi knee replacement.

Yes, what we know with the meniscus tears is if you’re a young athletic person, say you’re in your 20’s, there’s great healing potential on that meniscus. Therefore, an operation to either repair or remove the torn bit is generally very successful and we’d be much more inclined to operate on that age group with a meniscus tear.

The older you get, the poorer the condition of the meniscus and you’re more dealing with a degenerative knee, and we know that the success with the operations is much lower. Even surgeons themselves will tend to try out a couple of injections before going down the route of an operation for that. Again, all the injections that we talked about would be suitable considerations for even meniscus tears with degeneration.

There is some light evidence to say that they can be helpful. The way I think about supplements like that and glucosamine and chondroitin, if there was good evidence for good benefit, then everybody in the world would be on them because they would save us a lot of hassle as patients and they would save health systems an absolute fortune in terms of joint replacement. Therefore, the fact that they’re not being promoted by health services and governments would show that there’s probably not that great evidence out there.

They’re generally safe and the worst they can do is nothing. As a result, a lot of people try them in the hope that it will help but there’s not great evidence that they do.

Yeah, I think exercise is a good solution with any sore joint of any cause. The way I frame it is if the joint is strong and better supported, then those muscles will do more of the work, and if they’re doing more of the work, it means the joint has to do less work. Therefore, it’s just a very simple transfer of load. So, I’d get all of my patients, regardless of the diagnosis, if they’re going for an injection, I’d always follow up with some rehabilitation, which would nearly always involve a strengthening program around the joint and even the muscles above and below as well.