1) The injection missed the spot: We take a lot of pride in using ultrasound guidance for all of our injections. This tremendously improves accuracy, making an injection much more likely to be effective. However, this is a skill set we have honed for 10 years and is still not considered the standard of care in orthopedics. Therefore, many injections by very good clinicians are still given without ultrasound, and unfortunately, the target is often missed. Even missing by a few millimeters can decrease the effectiveness. Medical studies have demonstrated that some of the most commonly given injections in orthopedics without guidance are inaccurate anywhere from 10% to 70% of the time.
2) Steroids don’t help everything: Steroids are great anti-inflammatories but do not reverse damage. They may help in some cases of arthritis, and if so, often are temporary, providing weeks to months of benefit. In addition, in many cases of tendon problems such as tendonosis (degeneration or tendon tearing), inflammation is not the primary source of pain and thus, the steroid injections are unlikely to help for any significant period of time.
3) The pathology is too great to see benefit from an injection: For example, in some cases of severe arthritis, no injection is going to help to a significant degree. A prime example would be severe hip osteoarthritis where total hip arthroplasty (hip replacement) is usually far more effective than any type of injection. There are some ligament and tendon tears that are full thickness, and no injection will get the job done. Thus once again, surgical treatment would be the top recommendation, with an ACL tear being a prime example.
4) After the injection, you do not treat the injected area the correct way: We are very specific in our “dos” and “don’ts” after an injection. For example, after the majority of our steroid/cortisone injections, we recommend a minimum of 5 to 7 days of rest of the affected area. So, if you have a knee joint injection you are not going for a power walk, playing golf, or doing heavy yardwork for 5 to 7 days after the injection. Those who return to rigorous activity too soon often do not see the expected benefit after certain injections. After more complex injections like platelet-rich plasma (PRP), we generally have very specific restrictions and recommendations in our aftercare protocol. For example, after a lateral elbow PRP injection, we typically hold patients out of golf or tennis for 2 to 3 months to allow for healing of the tendon.
5) Lack of experience by the clinician providing the injection: There are many small nuances when it comes to giving a successful injection, including needle length, the right dosing of the injected solution, whether guidance is used effectively or not, how quickly the material is injected, the correct volume of the injected solution and patient positioning during the injection. Those clinicians who have fine-tuned their skill set over years to decades have developed an ability to make the right choices when it comes to these decisions, thus putting the injection in a position to be successful.
Injections are some of the most effective tools in the treatment of musculoskeletal conditions. They can be used to reduce pain, improve function, improve quality of life, serve as diagnostic tools, and in some cases, can promote healing of damaged tissue and/or decrease the deterioration of certain types of tissue such as cartilage within the joint. Therefore, choose your clinician wisely when it comes to injections and utilize someone who has an expertise in this field of medicine.
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
