10
Injection therapies for soft-tissue disorders

https://doi.org/10.1016/S1521-6942(02)00122-5Get rights and content

Abstract

Local injection therapies are used in the management of a variety of musculoskeletal pain syndromes and include the local infiltration of substances such as corticosteroid and/or anaesthetic, dry needling and neural blockade. Although commonly used, the rationale for their use in many conditions is arguable and evidence of efficacy is often lacking. In this chapter, a number of common injection therapies for soft-tissue-mediated pain are described. The reasoning for their use, potential mechanisms of action and unwanted effects are discussed. The literature relating to their documented effects is critically reviewed. Practical suggestions for their utilization in the management of soft-tissue conditions are given and proposals are made for future research in this important area.

Section snippets

Corticosteroid injections

Steroid hormones were initially recognized as potent anti-inflammatory substances in the 1930s and a flurry of activity during that decade resulted in the isolation of a number of steroids, most importantly ‘Compound E’, later known as cortisone.2 This was administered in 1948 to a patient with rheumatoid arthritis with dramatic results, and the evolution of steroid therapies for a spectrum of disorders swiftly followed.2., 3. Administration of local corticosteroid injections for

Local anaesthetic injections and dry needling

Injections of local anaesthetic alone are used for both diagnostic and therapeutic purposes in soft-tissue conditions. Local anaesthetics reversibly block sodium channels and hence nociceptive impulses. In some cases, the duration of analgesia obtained can exceed the duration of action of the local anaesthetic, for reasons that are not fully understood.

Subacromial injection of short-acting local anaesthetic (e.g. 2–5 ml 2% lignocaine) was recommended by Neer for the evaluation of the patient

Other agents

A number of other substances are used in local injections of soft-tissue complaints.

Neural blockade in the management of soft-tissue disorders

Neural blockade is used for the diagnosis and treatment of a variety of chronically painful conditions. Such procedures aim to reduce nociceptive input into the dorsal horn on the hypothesis that, if a nerve is quiescent for some time, peripheral sensitization can be reduced or reversed.58 Techniques can divided into peripheral somatosensory nerve blocks and neuraxial blockade.

Summary

A number of local injection therapies are available for the management of soft-tissue mediated pain. They should be reserved for the treatment of chronic soft-tissue lesions and as part of a programme that includes identification and correction of provocative factors. Although an increasing number of techniques and injectates are available, the current evidence for the use of many is scant. Accuracy of diagnosis and injection appears to be important for maximum benefit to be achieved.Box 4

References (70)

  • A.N Gam et al.

    Treatment of frozen shoulder with distension and glucocorticoid compared with glucocorticoid alone

    Scandinavian Journal of Rheumatology

    (1998)
  • S.A Paget

    Clinical use of corticosteroids: an overview

  • S.A Rodeo et al.

    Immunolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder

    Journal of Orthopaedic Research

    (1997)
  • H Sakai et al.

    Immunolocalization of cytokines and growth factors in subacromial bursa of rotator cuff tear patients

    Kobe Journal of Medical Sciences

    (2001)
  • G.P Riley et al.

    Tendon degeneration and chronic shoulder pain: changes in collagen composition of the human rotator cuff tendons in rotator cuff tendinitis

    Annals of the Rheumatic Diseases

    (1994)
  • M.D Chard et al.

    Rotator cuff degeneration and lateral epicondylitis: a comparative histological study

    Annals of the Rheumatic Diseases

    (1994)
  • J Josza et al.

    Overuse injuries of tendons

  • H Alfredson

    In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic achilles tendon pain

    Knee Surgery, Sports Traumatology & Arthroscopy

    (1999)
  • M Gotoh et al.

    Increased substance P in subacromial bursa and shoulder pain in rotator cuff disease

    Journal of Orthopaedic Research

    (1998)
  • K.M Khan et al.

    Where is the pain coming from in tendinopathy? It may be biochemical, not only structural in origin

    British Journal of Sports Medicine

    (2000)
  • C.A Speed

    Fortnightly review: corticosteroid injections in tendon lesions

    British Medical Journal

    (2001)
  • C.A Speed

    Local injections for soft tissue lesions

  • W.J Assendelft et al.

    Corticosteroid injections for lateral epicondylitis: a systematic overview

    British Journal of General Practice

    (1996)
  • E.M Hay et al.

    Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care

    British Medical Journal

    (1999)
  • S Green et al.

    Interventions for shoulder pain

    Cochrane Database of Systematic Reviews

    (2000)
  • C.A Speed et al.

    Shoulder pain

    Clinical Evidence

    (2002)
  • D.J DaCruz et al.

    Achilles paratendonitis: an evaluation of steroid injection

    British Journal of Sports Medicine

    (1988)
  • F Crawford

    Plantar heel pain (including plantar fasciitis)

    Clinical Evidence

    (2002)
  • D Atkins et al.

    A systematic review of treatments for the painful heel

    Rheumatology

    (1999)
  • F Crawford et al.

    Steroid injection for heel pain: evidence of short term effectiveness. A randomised controlled trial

    Rheumatology

    (1999)
  • J.R Sellman

    Plantar fascial rupture associated with corticosteroid injection

    Foot and Ankle International

    (1994)
  • P.D Fadale et al.

    Corticosteroid injections: their use and abuse

    Journal of the American Academy of Orthopaedic Surgery

    (1994)
  • R.J Nevasier et al.

    The frozen shoulder. Diagnosis and management

    Clinical Orthopaedics & Related Research

    (1987)
  • H Berry et al.

    Clinical study comparing acupuncture, physiotherapy, injection and oral anti-inflammatory therapy in the shoulder

    Current Medical Research Opinion

    (1980)
  • T Rizk et al.

    Corticosteroid injections in adhesive capsulitis: investigation of their value and site

    Archives of Physical Medicine

    (1991)
  • Cited by (21)

    • Corticosteroid injections compared to foot orthoses for plantar heel pain: protocol for the SOOTHE heel pain randomised trial

      2017, Contemporary Clinical Trials Communications
      Citation Excerpt :

      Betamethasone sodium phosphate combined with betamethasone acetate has been selected for use in this trial due to the combination of a long-acting acetate, which will increase potency, and a short-acting sodium phosphate which will increase solubility. This combination will balance the potency required for an anti-inflammatory action [46], against greater solubility which will decrease the likelihood of adverse effects such as plantar fascia rupture or fat pad atrophy [50]. An ultrasound-guided injection has been chosen as ultrasound-guided injections have been found to be more effective than palpation guided injections [51].

    • Ultrasound-guided versus palpation-guided local corticosteroid injection therapy for treatment of plantar fasciitis

      2016, Egyptian Rheumatologist
      Citation Excerpt :

      It was recommended for soft tissue injections [34]. However, it was considered by some authors to be inadequate for periarticular injection [35]. It was assumed that it is associated with greater risk of local complications as heel fat pad atrophy.

    • Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes

      2016, Acta Orthopaedica et Traumatologica Turcica
      Citation Excerpt :

      During the rehabilitation process reducing the activity of the gastrocnemius muscle, deep ankle muscle strengthening exercises and proprioceptive exercises may alleviate the symptoms.13 Dry needling with physical therapy was suggested to accelerate healing via improving blood flow to injured area and collecting local inflammatory mediators to the region.14 In agreement with reported studies the symptoms of almost two thirds of our patients relieved with non-surgical treatment methods.15

    • The role of ultrasound guided peri-tendinous injection in the treatment of non-calcific tendinopathy

      2015, Egyptian Journal of Radiology and Nuclear Medicine
      Citation Excerpt :

      We have never experienced this mixing as a major problem. Many studies (10,11,16,17), suggested adequate time between injections, generally a minimum of four to six weeks, however in our study the time interval was about 2 weeks. In all previous studies, blind method of injection was done that carries the risk of tendon injury, mainly due to lack of direct visualization of needle position, that is avoided in ultrasound guided methods.

    • Glucocorticoids and sport's performance

      2006, Revista Clinica Espanola
    View all citing articles on Scopus
    View full text