Some injuries and joint problems can benefit best from a combination of physiotherapy and medication. Other injuries are more stubborn and fail to respond to this. In this situation, after careful consideration and explanation, injection therapy can be a powerful adjunctive treatment for you to consider, to work alongside physical and exercise therapy.
Some injuries are in places that are usually fairly easily identified and accessed without needing to use ultrasound - for example into a painful knee joint with arthritis. However, other injuries may be deeper down (or very focal), and to precisely put the needle (and the medicine) in the correct spot to have the best chance to be effective, these are usually best done by guiding the needle in place using ultrasound. Dr Robertson is trained and experienced in a wide range of ultrasound-guided injections, and has been doing these procedures since 2003. This includes the hip, shoulder, carpal tunnel, wrist, foot, achilles, elbow - as well as tendon injuries, bursitis, muscle tears and superficial focal injuries around the knee and ankle.
FYSICL prides itself in making sure our Injections for non-insured patients are affordable and accessible.
Rest assured you will only be offered a guided injection if it is advised this matches your choice of best treatment options. Injections always come with a choice - they are not always guaranteed to work and the clinic is careful to make sure all the options are discussed and explored first. For example, if you assessment indicates that a surgical (or other) opinion is you best option, this will be made clear to you.
HIGH VOLUME INJECTION (HVI)
High volume injection (HVI) is a procedure performed to treat a painful tendon injury that occurs as a result of persistent strain being placed on the tendon. During the healing process following a tendon injury, tiny blood vessels grow into the tendon bringing with them new nerves as well. These nerves are thought responsible for most of the pain related to the tendon injury. Chronic achilles tendinopathy that has not responded to other therapies (or rest) is one of the commonest indications to consider having HVI treatment.
What is the procedure?
The procedure involves injecting a high volume (around 30ml) of a solution of saltwater (normal saline) and a local anaesthetic into the space between the tendon sheath and tendon. The solution strips off the new blood vessels and nerve endings that have grown into the tendon. You will feel a pressure or stretching sensation when the solution is injected. Any discomfort should last for no more than a few seconds. You will also notice swelling due to the high volume of fluid being injected which should resolve within 24 hours. The entire procedure should be completed within 30 minutes. The aim of high volume injections is to reduce pain and allow individuals to move and exercise the tendon comfortably.
What injuries is it mainly used for?
High volume injections are used for the treatment of Achilles tendon or patellar tendon pain as well as other tendinopathies.
Following the procedure you may experience numbness for a day. Or a day or two or increased pain (which occurs in about one in 25-50 patients). There may also be a slight risk of bruising. Infection is always a small possibility – as with any medical procedure, but is very rare (1 in 20,000) and treated by antibiotics.
Later on, after a few days rest, you should recommence good work with your physio to get the tendon to heal naturally. In most cases, you should be able to resume your normal activity again once the tendon is completely healed.
Corticosteroid injection (sometimes referred to as “steroid” or “cortisone”) are safe, well tried and tested and commonly used for the treatment of joint and soft tissue disorders. They are the same medicines used for hay fever, arthritis, skin conditions and severe inflammatory conditions. In the past these medicines were sometimes over-used in sport, and justifiably received bad press in the past when some retired footballers complained about having been given too much too often.
However, cortisone remains a good, safe and carefully considered treatment option for stubborn injuries where there is persistent pain and inflammation. And when used correctly (at the right time, in the right place and in the right amount), cortisone can be a great ally for patients with persistent demoralising and painful injuries. Examples are shoulder impingement, bursitis over a joint or tendon or inflammation of a joint such as in rheumatoid or osteo-arthritis or gout. For those who are trying to get better and regain fitness, it can help you to start moving better again, exercise safely with professional supervision and complete your recovery.
Most commonly Dr Robertson uses Triamcinolone or Methylprednisolone acetate - but if you have another preference for a specific reason, then normally this can be arranged.
Corticosteroid injections are often used in conjunction with local anaesthetic, and this can help confirm the diagnosis as well. As with all medication, an individual’s response to a steroid injection cannot be predicted. Some patients get great benefit, others not so much.
Depending upon the medication used, patients will usually experience an improvement in their pain lasting anything from several weeks to six months or longer. Injections can be repeated up to 3-4 times a year – if this is not sufficient then it is good practice that the doctor will discuss alternative options that are in your best interests (such as a different treatment or a possible opinion by a surgeon).
For more information, please go to the Patient Information Leaflet (PILs) resource section or ask the clinician.
PRP (PLATELET RICH PLASMA) INJECTIONS
Platelet Rich Plasma (PRP) is blood plasma with concentrated platelets (the body’s repairmen for damaged tissue). It is a safe treatment option that is increasingly used nowadays in sports medicine to improve healing and get back to fitness. There is also evidence it can reduce and help control (but not cure) arthritic joint pain. Blood is taken from your arm and put in a centrifuge machine which separates the different types of blood cells. The doctor will inject this into the area of your injury.
PRP is still very much at the cutting edge of sports medicine and management of degenerative joint pain or injury. Variables include the correct diagnosis, the type of PRP (we use leucocyte poor). And success can be influenced by the time of the injection and the careful correct placement of the PRP. It is not a pannacea, and needs to be matched to good physio and exercise/rehabilitation treatment programmes. But is is safe, can improve recovery times and tissue recovery, and is a useful option to discuss for many patients and athletes. See the news pieces on Rafa Nadal and John Terry as sports examples.
FYSICL uses the TROPOCELLS PRP system™. It is a safe closed system that is affordable, has excellent biologics and a strong track record in sports medicine. The entire process to prepare your blood to do the guided injection takes about 20 minutes. PRP increases the concentration of platelets and growth factors at the site of injury by up to five.
Some patients respond better than others. PRP aims to stimulate your body’s ability to heal conditions like tennis elbow, jumpers knee, joint inflammation or a muscle or ligament tear. This treatment may eliminate or reduce the need for use of cortisone injection or long term medication or surgery. No foreign substance is used – we use your own growth factors from your own blood. If you are interested that this might be a suitable safe option for your problem, please discuss it with the clinician.
Some patients ask: what is better, PRP or cortisone for a joint pain? Its not a simple answer. But this link provides a nice clear summary of the typical answer.
For more information on PRP, please go to the PILs resource section or ask Dr Robertson if this might be an appropriate option for you to think about for your problem.
Prolotherapy is a second-line treatment where the research indicates that it triggers proliferation of connective tissue for the purposes of regenerating damaged or weak ligaments, tendons, joints, and bones. The clinic uses a solution of 20-25% dextrose for prolotherapy, and normally the amount is around 3-5ml. This treatment can help the injured athlete with chronic injuries where other treatments such as rest, physiotherpay, eccentric exercises and oral medicines have failed; examples include recurrent ankle sprains and chronic painful thickened tendons ("chronic tendinopathy") such as "jumpers knee"and chronic achilles tendon injury.
Such chronic knee and ankle injuries are specially found in football, basketball players and other sports involving repetitive running and jumping - further information (below) shows examples of how these can respond well to prolotherapy. Chronic rock climber shoulder injuries and tennis elbow are also ideal candidates for prolotherapy, and can respond quickly.
How might prolotherapy help your pain and injury? Prolotherapy can promote long-term, sometimes permanent pain relief by stimulating the body’s ability to repair itself. A solution of concentrated dextrose and local anaesthetic (steroids are not used) is injected into the affected ligaments or tendons. An individual plan is devised with prolotherapy treatments scheduled every 3-6 weeks until the healing is complete, and you can return to normal activities without pain.
How long does it take? The total appointment time takes approximately 25-30 minutes, including administration/form-filling, review of consent/understanding, preparation, treatment and recovery time.
As with any treatment, there is a risk that prolotherapy might not work. Complications are very rare. Inflammation around the injection site should be brief and only last a day or so at most. Infection is a small risk with any injection, but again is very rare and quoted less than 1 in 10-20,000 injections.
If you are interested in this option, then feel free to enquire.
Synvisc, Ostenil and Ostenil Plus are called viscosupplements and contain hyaluronic acid (HA). These are injectable agents which are used to treat the symptoms of osteoarthritis.
They can improve the viscosity of the synovial (lubricating) fluid, reduce pain and swelling within the joint, increase the articular cartilage depth on load bearing surfaces. These effects can provide symptom relief and help get you moving again and work on your strength and fitness, this will “buy you time” in osteoarthritic disease process.
How are the injections given ?
They are given for a joint with a lot of “wear and tear”. But viscosupplements do not cure the underlying technique is the same manner as cortisone injections – some are guided, some (like knee joints) do not need guided.
How long do the benefits of Ostenil injections last for?
Patients with mild to moderate osteoarthritis often see improvements in symptoms lasting from 3 to 12 months - mostly longer that cortisone**. However, this can vary from individual to individual. Patients with very severe osteoarthritis may not be suitable to the injection and normally will be referred for an opinion with a trusted surgeon. For patients who do respond to treatment with Ostenil products, injections may be safely repeated. There are no known long term adverse effects with repeated injections of these products.
Can Ostenil be combined with other medicine?
Yes, there are cases where the doctor and patient may consider combing an injection that has a faster pain-relieving action (typically a cortisone) along with ostenil. Also, more evidence is appearing that ostenil can work with PRP to help delay the need for surgery in an arthritis joint**.
What are the possible risks and side effects of the treatment ?
The risk of a complication arising from injection with Ostenil or Synvisc (or other products such as Durolane or Monovisc) is low and serious complications are extremely rare. Infection may be introduced into the joint or soft tissues as a result of an injection. If you experience progressive warmth, swelling or worsening symptoms at the injection site particularly in association with fever, seek urgent medical attention. Allergic reaction is rare. Bruising can occur – please advise the doctor if you are taking aspirin, warfarin or other antiplatelet drugs. For more information see the patient information leaflet.