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Injections

Types and Locations

Joint injections are common orthopaedic procedures. Your surgeon may provide you with a joint injection for various reasons including diagnosis, pain, and therapeutic treatment.  There are various types of injections offered in different locations. Injections are often lower risk compared to surgical intervention. It is an excellent intervention for hip and knee arthritis.

Injections

Contents

Types of Injections

Injection Sites

Injection Delivery

Frequently Asked Questions

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Types of Injections

Corticosteroid injections

Steroid injections are typically composed of an anesthetic such as lidocaine and/or marcaine as well as the selected steroid. The lidocaine and marcaine take effect almost immediately and can provide relief for several hours.  Typically if pain is relieved during this time, then we are addressing the appropriate pain generator. The steroid portion of the injection often takes 2-3 days to begin to take effect

Adverse Reactions:

  • Infection - This is an extremely rare, but sometimes severe complications. If you have redness and severe pain following an injection - please seek emergency care.
  • Steroid flare - Sometimes patients experience an elevation in pain the day after a steroid injection. This often resolves over the course of 24 hours.
  • Elevation in blood glucose - Patients who undergo a steroid injection with a history of diabetes are encouraged to monitor their blood sugar levels and expect an increase over the next three days.

Gel Injections

Hyaluronic acid or gel injections are provided by many manufacturers. The original hyaluronic acid injections were derived from rooster comb. Gel injections theoretically act like a lubricant and shock absorber. The gel decreases swelling and friction, ultimately reducing pain There are now synthetic alternatives that exist to avoid allergic reactions to animal products.  There is conflicting evidence regarding the efficacy of these types of injections. It is approved for knee arthritis injections.

Adverse Reactions:

  • Infection - This is an extremely rare, but sometimes severe complications. If you have redness and severe pain following an injection - please seek emergency care.
  • Gel Reaction - The increase in the amount of fluid in the knee can cause severe pain.

Toradol

An alternative to steroid injections1. This medication works along a similar pathway to reduce pain.  This is a less common injection modality. Research has investigated its use in knee osteoarthritis and subacromial bursitis. It is a good alternative to steroid injections as it will not provide an elevation in blood glucose and is a good option in patients with diabetes.

Adverse Reactions:

  • Infection - This is an extremely rare, but sometimes severe complications. If you have redness and severe pain following an injection - please seek emergency care.
  • Allergic reaction may occur.
  • Tests have not been performed in patients who have had poor tolerance to oral NSAIDs or have renal abnormalities.

  1. SM MCGowan, WE Rodriguez, T Visser, V Yellapu, PN Morton, GF Carolan, “A randomized Double-blind Study Comparing Intra-articular Corticosteroid to Intra-articular Ketorolac Knee Injections.” St Luke’s University and Health Network. AAOS, Mar 2019

Platelet-rich Plasma

Platelet-Rich Plasma, or PRP is a newer injection that has recently become more available.  Several studies have shown that it is not helpful in the treatment of arthritis. However, PRP may be an alternative for patients who are experiencing certain types of tendinopathy. PRP is often expensive and insurance may not cover this procedure. Please seek medical advice before attempting to have this done.

Stem Cell Injections

There are many advertisements for stem cell injections for orthopedic problems. This is no longer considered an experimental process for osteoarthritis, as the studies have already been done. No studies have demonstrated successful treatment of orthopedic issues with stem cells. These are often expensive. It is advised that you do not seek stem cell treatment for osteoarthritis.

Injection Sites

Knee:  There are many locations around the knee that can be injected, including the knee joint, Illiotibial band, and pes-anserine bursa.  Types of injections include corticosteroids, hyaluronic acid, and Toradol. The knee joint is commonly injected four times per year every three months without issue for as long as a patient desires with minimal risk.

Hip: Often the hip can be injected either into the hip joint, greater trochanteric bursa, or iliopsoas tendon.  Hip joint or iliopsoas injections require visualization with either fluoroscopy or ultrasound in order to determine accuracy.  Typical injections include corticosteroid injections. Similar to a knee injection, the joint may injected every three months without issue for as long as a patient desires with minimal risk.

Shoulder: The shoulder is a complex joint that is comprised of different components.  You may receive an injection to the subacromial bursa, glenohumeral joint, and biceps tendon. Typical injection components may be either steroid or Toradol injections.

Nerve Compression or Tendinopathies: Occasionally a one-time steroid injection may be provided to tendinopathies such as de Quervain's tenosynovitis or trigger finger.  Multiple injections in these areas lead to concerns of tendon rupture. Similarly a steroid injection can be provided to nerve compression problems such as carpal tunnel. Some tendinopathies may be amenable to PRP injections.  Surgical treatment is often recommended when steroid injections fail.

Small-to-Medium sized joints: Small doses of steroids are typically used to inject areas such as the thumb, foot, or ankle.

Injection Delivery

There are different methods of getting an injection. Essentially, higher levels of technology are utilized to get better accuracy. Most commonly, patients receive an injection in the clinic. These injections are called "landmark injections". Sometimes in the clinic, you may receive an injection with ultrasound guidance. These are called "ultrasound-guided injections". X-ray technology can be used to help guide an injection. These injections are known as "fluoroscopic-guided" injection. Some injections require a 3-dimensional CT scan to make sure that injections are in the right place.

Bandages

Landmark-based injections are injections that require the lowest level of accuracy. This is because the landmarks used are thought to provide a reliable way to access the joint. Using the knee joint as an example, the kneecap, thigh-bone (femur), and shin-bone (tibia) are used to determine where to place the injection. Stesteroidroid injections are reliable in this setting because the knee joint has a large capsule and steroid medications will be able to diffuse throughout the knee.

Ultra-sound guided injections - Sometimes image-guided injections are required in order to provide a more accurate injection. Even in the knee joint, sometimes a more accurate injection is required. Hyaluronic acid injections (gel shots), PRP, and stem-cell injections require 100% accuracy to ensure that the injections are within the capsule. Unlike steroid injections, these medications are unable to diffuse through the capsule of the joint.

X-ray Injection (fluoroscopic--guided) - Soft-tissue often gets in the way of seeing the joint. The hip joint is a common area to use an x-ray to inject. In patients who are larger, it can be difficult to see the needle enter into the joint without an x-ray.

If you have any questions regarding your injection, do not hesitate to call Dr. Morton at (808)548-7033. He has the ability to perform in-office ultra-sound injections to ensure the accuracy of your injections.

To read more about hip or knee arthritis, click here.

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Frequently Asked Questions About Injections (FAQ)

How often can you get a steroid injection?

For joints and bursa injections such as those located on knees or hips, I am happy to perform the injection every 3 months. For tendon or nerve injections, I rarely inject more than once. This is because we know that it is safe to inject steroids into joints. There is a concern with tendon rupture with multiple steroid injections.

What is the best injection for arthritis?

The best-studied medication for injections is steroid injections. Orthopedic surgeons have a long history of successful steroid injection use. The studies supporting other types of injections are not as strong and should be approached with more caution.

Are injections painful?

There is a small amount of discomfort associated with orthopedic injections. I do my best to minimize this discomfort by using either a "cold spray" or a lidocaine injection. Most patients say that it was a lot less painful than anticipated.

What should I do after my injection?

You can resume normal activities. I usually advise people to avoid strenuous activity such as jogging or lifting on the day of injection. You can resume all higher levels of activity the following day.

Will stem cell or PRP injections rebuild the cartilage in my knee?

There has been no study to substantiate that injections of PRP or stem cells will rebuild the cartilage in your knee. If you find a study, I am happy to review the science with you.

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Meet Dr. Paul N. Morton, MD

Dr. Paul N. Morton, MD is a fellowship-trained orthopedic surgeon in hip and knee surgery, specializing in robotic joint replacements, complex joint reconstruction, sports injuries, and trauma. Reach out to him to learn more about treatment options for your problem.

Written By: Dr. Paul N. Morton, MD

 

Post Published on August 11, 2019

One Response

  1. Like!! Great article post.Really thank you! Really Cool.

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