Injection (Therapy)
in Sports Medicine
Nadhaporn Saengpetch
Division of Sports Medicine
Department of Orthopaedics
Steroid Injection
Corticosteroid Injection
• Lack of good quality research data to support
the wide space use
• Reduce tendon strength (not universal)
• Tennis elbow: effective in short term (2-6 wks)
(Hey EM BMJ 1999;319:964-8)
• Report some higher recurrence rate than “wait
and see”
(Smidt N Lancet 2002;359:657-662)
• 123 male Sprague-Dawley rats
• Control, tendon injury, steroid injection and
tendon injury with steroid injection
• Single corticosteroid dose has significant
short-term (transient) effects on the
biomechanic properties of both injured and
uninjured RCT
(Mikolzyk DK J Bone Joint Surg Am 2009;91:1172-80)
ISP Tendon
• Single strands rat tail collagen fascicle
• 1 mL methylprednisolone acetate 40 mg +
9% saline 0.5 mL VS 1 mL
methylprednisolone acetate 40 mg + 9%
saline 2 mL
• Tensile strength markedly reduced after 3and 7-day incubation in both high and low
concentration
(Haraldsson BT Am J Sports Med 2006;34(12):1992-7)
Ultimate stress in High/Low Conc.
High(40) vs Low(10) Dose
Improve pain 6 wks
Improve sleep disturbance 6 wks
Improve functional impairment 6 wks
• Subacromial corticosteroid injection
• To analyse type III to type I collagen
expression ratio
(Wei AS J Bone Joint Surg Am 2006;88(6):1331-8)
Gene Expression on
Collagen Type I/III
Supraspinatus Tendinopathy
• 2 studies show a small benefit at 4 weeks
• Small numbers of subject
(Buchbinder R Cochrane Database Syst Rev.
2003;1:CD004016)
Shoulder Pain
• No absolute distinction between acute and
chronic pain
• May reflect by ineffectiveness of initial
intervention
Causes of Shoulder Pain
Pathology of Shoulder Pain
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•
•
•
•
•
Osteoarthritis
Rotator cuff tear
Primary adhesive capsulitis
Tendinitis (SSP, Biceps)
Bursitis (SA-SD)
Impingement syndrome
Overlapping diagnosis or shoulder pain is the
secondary cause of diseases
Chronic Shoulder Pain
Non-surgical Treatment Algorithm
(Andrews JR Arthroscopy 2005;21(3):333-47)
Intra-articular Steroid Injection
• Better relief than oral NSAIDs
• No enough evidence to refuse or support
the benefit of steroid (Cochrane 2002)
• Good for polymyalgia rheumatica
• Adverse effects: dermal atrophy, bacterial
arthritis, hemarthrosis and
thrombophleblitis
Bicipital Tendinitis
• Local and steroid (1%Xylocaine and
Triamcinolone 10 mg)
• Bony landmark: bicipital groove
• Target tissue: biceps sheath
How to prove the RIGHT location?
External rotate to show the
better groove exposure
Palpate the groove , then point the
tip more superficial to the tendon
Rotator Cuff Tendinitis
• Partial cuff torn: pain and loss of the power
• Tendinitis may be the presenting symptom
• Stiff shoulder with loss of AER and
concomittant with impingement signs
• Should we prove the tendon integrity? If
yes….how?
ultrasound, CT scan and MRI
• 58 pts
• 5 mL of 2% xylocaine VS or 4 mL of 2%
xylocaine and 1 mL (6 mg) of betamethasone
• no more effective in improving the quality of life,
range of motion, or impingement sign than
xylocaine alone
(Alvarez CM Am J Sports Med 2005;33(2): 225-62)
WORCI
• AIR, AER, AFE
• Neer impingement tests
• WORCI, ASES, DASH
Effects of Steroid on Cuffs
• Collagen fascicles
• Biomechanic strength
• Can mimic a rotator
cuff tear
(Borick JM Arthroscopy
2008;24(7): 846-9)
• Methylprednisolone
0.6mg/kg subacromial
injection
• Type I and III
Collagen expression
60 SpragueDawley rats
Control
Tendon
injury
Steroid
Tendon
Injury
+
Steroid
Subacromial Methylprednisolone
• A single dose corticosteroid does not alter
the acute phase response of an injured
rotator cuff tendon in the rat
• same steroid dose in uninjured tendons
initiates a short-term response equivalent
to that of structural injury
(Wei AS J Bone Joint Surg Am 2006;88(6): 1331-6)
Hyaluronic Acid Injection
What is hyaluronic acid?
• A polysaccharide secreted into the joint
space by type B synoviocytes or
fibroblasts
• Viscoelasticity for lubrication and
chondroprotective effects
• Anti-inflammatory properties, stimulate
synovial fibroblasts to produce
endogenous HA and decrease pain
What is hyaluronic acid?
• A long-chain biopolymer with repeated
sequences of N-acetyl-glucosamine and
glucuronic acid
• Avian / bacterial origin
• Hylan: cross-link molecules modified
from HAs (to increase viscosity and
clearance from the joint)
Intra-articular Hyaluronans Injection
• Safety profile, no adverse effect
• Enhance endogenous hyaluronan
synthesis, enhance biosynthesis and
degradation of cartilage, inhibit
inflammation, inhibit secondary pain
mediators and direct coat nociceptors
• Hyalgan (Sodium Hyaluronate) clarified its
true usefulness
(Andrews JR Arthroscopy 2005;21(3):333-47)
How to choose the
‘right one’
for each patients
• Who is fit to have the IA-HA injection?
• The cost-effectiveness for the equivocal
type of patients
• How last long does it work in the joint?
• The rheological properties and
molecular weight of the hyaluronan
preparations??
• Which joints that I should inject it?
Who is proper to have
IA-HA?
• Old age < 65 yrs.
• Early arthritis (Albach grade 1,2) without
mechanical symptoms
(Wang CT J Bone Joint Surg Am 2004;86A-3:538-45
Toh EM Knee 2002;9(4):321-30)
• Inactive with household ambulation
• Good expectation
(Turajane T J Med Assoc Thai 2007;90(9):1845-52)
Cost-effectiveness: Police
General hospital
• 183 pts.(208 knees) from 2001-2004
• A minimum of 2-year period follow up
• drugs cost, hospitalization, resources
• Non-response = proceed for TKA
• Success group: 47,044.18 THB (12,240.41
THB) 63.26%
• Failure group: 144,884 THB (9,324 THB)
(Turajane T J Med Assoc Thai 2007;90(9):1839-44)
How does it last long?
• 1 day intra-articular sustaining
• Variable onset of their efficacy
• Hyalgan 26 wks, Hylan G-F20 52 wks
(labeled)
(Raman R The Knee (2008), doi:10.1016/j.knee.2008.02.012)
• Inconclusive and controversial for the therapeutic
efficacy
(Adams ME Drug Safety 2000;23(2):115-30
Wobig M Clin Ther 1999;21:1549-62, Allard S Clin Ther 2000;22:792-5)
• Need a well designed prospective RCT to resolve the
uncertainty about magnitude of efficacy of various
products
• Hylan G-F 20 (Synvisc) (MW 6 x 106
Da.) vs
Orthovisc (MW 1.55 x 106 Da.)
• HMW HA produce an analgesic effect
• The higher MW, the better the effect on
the cartilage production
• WOMAC physical function, stiffness
scores and pain scores (patient &
physician)
• Improvement in physical function begin
at the end of the 1st month lasted until 6
months.
• No difference for stiffness scores, pain
scores
(Kotevoglu N Rheumatol Int 2006;26:325-30)
Efficacy and safety of
AI-HA or Hylan: RCT
• 3 preparations in Switzerland (SVISCOT-1)
a cross linked HMW hylan
a non-cross-linked MMW HA of avian origin
a non-cross-linked low LMW HA of bacterial origin
•
•
•
•
3 shots/cycle, N=660 pts
WOMAC pain score at 6 months
Local adverse events (flare/effusion), costs
No difference in efficacy between hylan and
HAs
• Hylan had more local adverse events and
higher cost ($1,459>$1,238>$1,017)
(Jüni P Arthritis Rheumatism 2007;56(11):3610-19)
Crosslink vs
non-crosslink
• Efficacy up to 1 yr in favor of cross-link
HA
(Torrence GW Osteoarthritis Cartilage 2002;10(7):518-27
Raynauld JP Osteoarthritis Cartilage 2002;10(7):506-17)
Other support evidence
• Higher viscosity and longer half-life
increase long-term efficacy for duration
and intensity of pain relief
• Mechanism of pain relieve: directly
inhibit nociceptors or binding
substance P
(Moreland LW Arthritis Res Ther 2003;5:285-9)
• But mechanism to relief pain in OA knee
remains under investigation
Shoulder
Adhesive capsulitis
• Compared with intra-articular steroid injection
• Should separate 1° frozen shoulder from
post-traumatic
• Hyaluronan show exponentially increasing
osmotic pressure with increasing
concentration
(Laurent TC Ann Rheum Dis 1995;54:429)
• HAs may restore a normal capsular
hydrataction.
• Absorb and desorb water molecules capacity
of HA can inhibit in some way the fibrotic
process
(Rovetta G Tissue Reactions 1998;4:125-30)
Glenohumeral OA
Rheumatoid Arthritis both shoulder
OA shoulder
• The same idea for symptomatic OA
knee
• Outcome measures: VAS score, UCLA
score, SST
• Improved ADL and ability to sleep
• Significantly improve mobility
• Adverse events: local pain, swelling,
flare
• Main problem: correct space of injection
• Shoulder OA, impingement, bursitis,
tendinopathy and frozen shoulder
• N=660, Hyalgan (3&5 shots and saline)
• VAS score, shoulder motion
• Presence of shoulder OA may be
underappreciated in the setting of rotator cuff
pathology
• Shoulder OA demonstrated significantly
better VAS after treatment than others.
(Blaine T J Bone joint Surg Am 2008;90:970-9)
Hip
OA hip
• No difference between steroid-HAsplacebo (saline) at the endpoint result
• Some clinical improvement for pain and
walking ability
(Qvistgaard E Osteoarthritis Cartilage 2006;14:163-70)
U/S guide
Ankle
OA ankle
• Exposure of subchondral bone at a weightbearing site at which bone will be abraded
and further damage
• HAs: viscosupplement and biosupplement
• 4 Meta-analyses: effect equivalent or greater
than NSAIDs
Listrat V Osteoarthritis Cartilage 1997;3:153-30
Lo GH JAMA 2003;209:3115-21
Arrich J CMAJ 2005;172:1039-43
Wang CT J Bone Joint Surg Am 2004;86:538-45
OA ankle
Possible saline effects
• Break scar apart
• Slightly lubricate
• Dilute the lytic
enzymes and
proinflammatory
cytokines
A double-blind RCT
• Hyalgan 1 mL vs phospate-buffered saline 1 mL
• N=17, 6 mo, ankle OA score pain and disability
assessment, WOMAC, pts’ global assessment
• Only significantly difference within-subject
differences (p<0.0001)
(Salk RS J Bone Joint Surg Am 2006;88(2):295-302)
Injection Techniques
Injection Techniques
(Courtney P Best Practice Res 2005;19:345-69)
Injection Techniques
My practice: shoulder
Shoulder:
anterior approach
My practice: knee
Knee: medial approach
Knee:
superolateral approach
Ankle:
anterior approach
EHL
Tibialis
anterior
Complications
• Acute psuedoseptic arthritis: a case
report (Ostenil), onset = ?
(Roos J Joint Bone Spine 2004;71:352-4)
• Mostly reported with Hylan
• None of cases occurred after the first
injection, suggesting a role of
sensitization to HA
• Ostenil: LMW and contains no
component of animal sources
(Kurosaka N J Rheumatol 1999;26:2186-90)
Complications
• Septic Knee Arthritis: 2 case reports
(Albert C Joint Bone Spine 2006;73:205-7)
• S. aureus and N. Mucosa
• Giving HA injection in a brief intervals is not
recommended, pathogen inoculation
• Previous glucocorticoid injections promotes
the occurrence of infection
• The rare pathogen often associates with an
underlying immunodeficiency.
(Lechowski L Ann Med Interne (Paris) 1995;146:592-3
Vigouroux C Presse Med 1992;21:1434-5)
Extended clinical usage
IA-HA
after knee arthroscopy
• A temporary synovial fluid substitute
containing HA
• Purpose: to remove the products of
cartilage wear, inflammatory cells and
molecules from the joint
• Counter the onset of painful
inflammatory phases
• Have a negative effect on the
metabolism and structure of the joint
cartilage
Intra-operative IA-HA injection for
knee arthroscopic debridement
• High dose of HMW HA (Orthovisc) single shot
6 mL/90 mg
• standard recommendation 2 mL/amp x 3
shots weekly
• N=23, ICRS Grade II or III lesion
• WOMAC and SF-36
• POW 1, 3, 12, 24
(Li X J Orthop Surg Res 2008;43:1-8)
Transected ACL
from hind limbs of
Wistar rats
1.0 mg of HA
800 kDa from
rooster comb
cartilage
synovium
Difference in joint width
saline
HA
saline
HA
sham
sham
(Yen-Hsuan Jean J Orthop Res 2006;6:1052-60)
Management of Tendinopathy
normal
Mild tendinosis
Severe tendinosis
Tendinopathy
• A generic description of the clinical
conditions
• Pain and pathologic changes in and
around the tendons arising from overuse
Tendinopathy
• Show either absent or minimal
inflammation
• Hypercellularity
• A loss of the tight bundled collagen
appearance
• Increase in proteoglycan content
• Neovascularization
• “Failed healing response”
Tendinosis
• The histologic description
• A degenerative pathologic condition with a
lack of inflammatory change
Tendinitis
• An inflammatory process
• It may play a role in the initiation, but not
the propagation and progression of the
disease process
Enthesis
• Tendon insertion or osteotendinous
junction
• Recognized as a site of pathologic
changes in many common athletic injuries
• Tendo achilles, patellar, rotator cuff,
forearm extensor and thigh adductor
Achilles Tendinitis
• 3 distinct regions
• Toe, linear and
partial failure
before it failed
(Rees JD
Rheumatology
2006;45:508-521)
Eccentric exercise of TA
New Trends
Autogenous Red Cells Injection
• Poor quality studies
elbow
(Edward SG J Hand Surg (Am) 2003:28:272-8)
(Suresh SP Br J Sports Med 2006;40:935-9)
Patellar tendinopathy
(James SL Br J Sports Med 2007:41:518-21)
• Medial epicondylopathy: may improve
without any intervention
• Required better study design
Sclerosant Injection
• Ultrasound-guided
• Decrease pain and neovascularization
• TA, tennis elbow and shoulder impingement
(Ohberg L Knee Surg Sports Traumatol Arthrosc
2003;11:339-343)
(Zeisig E Knee Surg Sports Traumatol Arthrosc
2006;13:1218-24)
(Alfredson H Knee Surg Sports Traumatol Arthrosc
2006;14:1321-6)
• Nitric oxide (vasodilator), has an opposite effect
of sclerosant injection
Thank you