When is injection therapy used?

Injection therapy is used widely in musculoskeletal and sports medicine to assist in the recovery of acute or stubborn injuries. For the vast majority of cases a ‘hands-on’ non-invasive approach of physiotherapy is sufficient to achieve a sustainable recovery but in resistant cases, the use of corticosteroids and local anaesthetic can make a real difference.  As well as practising injection therapy techniques at The Physios, Paul Hattam also co-leads the Society of Orthopaedic Medicine’s training course for physiotherapists in injection therapy.

What does it do?

A small amount of corticosteroid injected into an inflamed joint or soft tissue can reduce pain and inflammation dramatically and makes the area more amenable to conventional physiotherapy modalities.

Which conditions can be treated by injection therapy?

Usually more chronic or inflamed conditions respond well to injection therapy such as shoulder capsulitis, tennis elbow and osteo-arthritis of the knee although there are some more acute disorders such as tenosynovitis that benefit greatly.  

What is Viscosupplementation?

Osteoarthritis (OA) should no longer be considered an inevitable accompaniment of aging but rather a dynamic and largely treatable disease. Viscosupplementation is a procedure that involves the injection of a gel-like substance, hyaluronan, into a joint to supplement the viscous properties of synovial fluid. It has become an increasingly popular treatment option in recent years for people with OA and is most commonly used at the knee joint. The hyaluronan is given as a series of weekly injections directly into the affected joint over three to five weeks.

What does it do?
Hyaluronan provides viscoelastic properties to the synovial fluid and is a fundamental constituent of articular cartilage1. In a normal joint it is highly concentrated at the surface coating of articular cartilage, as well as the superficial layers of the synovial membrane. Its properties enable it to function primarily as a lubricant, shock absorber and semipermeable barrier regulating metabolic exchange between the cartilage and the synovial fluid. In OA, the hyaluronan of the synovial fluid becomes degraded which consequently reduces its viscoelastic properties. This increases biomechanical loading of the joint and contributes to cartilage breakdown and erosion of the synovial lining resulting in pain with loss of range and function3. It is not at all clear how hyaluronan relieves the symptoms of osteoarthritis for such a long period of time since, within a few days of injection into the joint, it can no longer be found there. It may be that it promotes long-lasting changes by stimulating the lining cells of the joint to synthesize more hyaluronan.

What are the benefits?
The beneficial results are relief of pain, improved joint mobility and ambulation – effects that appear to last for anything from several months up to one year. However, as with any treatment, patients need a clear understanding of what to expect - if they think that viscosupplementation will cure their arthritis, they are setting themselves up for disappointment but patients who understand that it is part of a comprehensive program including physiotherapy treatment will be more satisfied with the outcome.

What do our patients' think of this treatment?
Quite severe OA of the knees left Mrs P of Fulwood unable to walk without pain and she was no longer able to enjoy her favourite pastime of hiking. She said about her treatment “I have found that a combination of the injections and physiotherapy has been a tremendous help and have enabled me to walk and hike again”. Another of our patients had been suffering from arthritis in her shoulder for many months. Her movement was extremely restricted and she was unable to lift her arm without pain. Mrs H, came to The Physios and received a range of treatment, including viscosupplementation. Mrs H said ‘The injections were brilliant – I’ve had no trouble with my shoulder since I’ve had the treatment.’

Is there evidence for its use?
The Cochrane Library recently updated its systematic review of the evidence for viscosupplementation for the treatment of OA at the knee. Randomised controlled trials (RCTs) were eligible including single and double-blinded studies, placebo-based and comparative studies. Sixty-three trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and one year. Thirty-seven trials included comparisons of hyaluronan/hylan and placebo, nine trials included comparisons of intra-articular (IA) corticosteroids, and five trials included comparisons of non-steroidal anti-inflammatory drugs (NSAIDs). The pooled analyses of the effects of viscosupplements against ‘placebo’ controls generally supported the efficacy of this class of intervention. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 11% to 54% for pain and 9% to 15% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported. Overall the authors concluded that, based upon analysis of all RCTs, viscosupplementation is an effective treatment for OA of the knee with beneficial effects on pain and function at different post injection periods - especially at 5 to 13 weeks.

Where can I receive this treatment?
A number of doctors and physiotherapists have begun to recommend or use this treatment, mainly for patients with OA of the knee although it is increasingly being used for other conditions too. If you would like to know more speak to your physiotherapist.

The consultation fee for injection therapy is £75.00. If you require more information on injection therapy please contact us by telephone or email.