Orthopedic Injections: What Not To Do

Injections are one of the most commonly used interventions in an orthopedic practice. Yet, where, how and what is injected is of vital importance, and certain approaches are just not in the best interest of the patient. Here are injections we prefer you avoid:

1) Injections for musculoskeletal conditions given in a chiropractic or primary care office. Both chiropractors, chiropractic mid-levels (NPs and PAs) along with PCPs all often do a great job in their respective specialties. However, giving injections optimally is just not in their wheelhouse. Therefore, if an injection is needed or suggested, then seek the expertise of an orthopedic specialist.

2) Receive a series of steroid injections for soft tissue conditions, such as plantar fasciitis, tennis/golfer’s elbow or gluteal tendinopathy (often mislabeled as “hip bursitis”). We often use the statement, “better in the short term, worse in the long-term.” This really applies to situations when multiple steroid injections are given in a short period of time, as they ultimately can lead to further breakdown and tearing of these tendons/fascia.

3) Receive a steroid injection for Achilles, patellar or quadriceps tendon problems. These tendons are much higher risk for rupture, especially if exposed to a steroid injection. If anyone suggests a steroid for one of these conditions, then RUN (figuratively)!

4) Pay top dollar for an orthobiologic injection such as platelet-rich plasma (PRP) without ultrasound guidance. It’s your choice to have this injection if it’s non-guided but just realize that accuracy is so important with this type of injection. There is no way to ensure the solution is making it to the intended area without ultrasound.

5) Receive “stem cell” injections that do not come from your own tissue. If a stem cell injection is being suggested, it should be derived from your bone marrow or your adipose (fat) tissue. Most of these products "ordered for you” do not actually contain any live stem cells, and at this point, are not approved by the FDA for usage in musculoskeletal conditions.

As always, let us know if we can help you!

F. Clarke Holmes, M.D.

5 Reasons to Either Have or Avoid a Steroid/Cortisone Injection

Steroid, often called “cortisone,” injections have been used in orthopedics and other specialties for several decades as potent anti-inflammatories. In recent years, they’ve become more controversial, as medical studies have validated that they likely have negative effects on our bodies and actually worsen certain conditions in the long-term. However, steroid injections still have some positive utility, and careful discussion with each patient must be undertaken to determine whether a steroid injection may be more beneficial or more harmful in each unique situation. Let’s explore those situations:

A Steroid Injection Can Be Particularly Beneficial in These Situations:

1)      Adhesive Capsulitis- most commonly seen in middle-age women, this highly-inflammatory condition causing shoulder pain and stiffness often responds beautifully to an ultrasound-guided injection into the glenohumeral joint.

2)      Early Phase of Tendonitis- if we catch tendonitis very early and when it’s primarily in the inflammatory stage (like tennis elbow or calcific rotator cuff tendonitis), a steroid injection can be very helpful in reducing pain and restoring function.

3)      Diagnostic and Therapeutic- many times, we see a patient that has pain in an area, yet we can’t determine the exact source. Thus, we use a precisely-placed injection with ultrasound to see if the pain is relieved. If so, then we feel that we’ve located the source and can then customize a more effective treatment plan. We use this strategy often for hip pain.

4)      A Patient Needs Rapid Relief- your knee is swollen and that bucket-list vacation that will require a lot of walking is fast-approaching. Your arthritic knee is in a flare, and we need to reduce pain and swelling within days, so that you can better enjoy that trip or upcoming event.

5)      Gout and Pseudogout- these are highly-inflammatory conditions due to excessive urate or calcium deposits in a joint, respectively. A steroid injection can provide rapid relief from these conditions.

A Steroid Injection Should be Avoided in These Situations:

1)      Chronic Tendonitis and Partial Tears- if you’ve had tennis or golfer’s elbow, rotator cuff issues or gluteal tendonitis for 3 months or greater, then your tendon likely has more degeneration and tearing than just inflammation. Steroid injections are far less likely to provide a long-term benefit in these situations.

2)      Repetitively- unfortunately, many patients make it to our office after having had 3-5 steroid injections over the past 1-2 years for their chronic condition such as tennis elbow or plantar fasciitis. We know that steroid injections have a catabolic (causing further deterioration) effect on joints and soft tissues if used excessively.

3)      Around Tendons at Risk for Rupture- the patellar tendon and Achilles tendon are two areas where we always avoid steroid injections. These tendons are prone to major tears, especially if exposed to injectable steroids.

4)      Risk of Infection- if there is any suspicion for an infection in a joint or bursa, then steroid injections are a “no-go.” It’s better to aspirate the fluid and send for analysis first before considering a steroid.

5)      Surgery in the Near Future- if a patient is considering having a joint replacement in the next 3 months, then steroid injections should be avoided due to the risk of infection during and shortly after the surgery.

We hope you find this information helpful when it comes to one of the most commonly proposed non-surgical treatment in orthopedics. As always, let us know if we can be of help to you!

-F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics