This page provides all the information you need if you are considering injection therapy here at The Physios. Please read this carefully as it contains important information you need to be fully aware of before your injection appointment.  Please also ensure you have also completed the necessary consent forms contained within your appointment reminder email. This must be completed PRIOR to your appointment.


What injection am I having?

Steroid Injections

Steroid injections can be a rapid and effective treatment for joint pain and inflammation, with the majority of improvement occurring in the first 3 weeks or so. Steroids are used to harness their anti-inflammatory effects but cannot be used too frequently as repeated injections (more than 3 a year) can cause harm to the joint.

What are steroids and how are steroid injections used?

Cortisol is a naturally occurring hormone which helps to control the body’s systems as well as providing anti-inflammatory properties. Man-made ‘synthetic’ steroids act like natural steroids to reduce inflammation and can be targeted effectively with injection therapy.

When might a steroid injection NOT be right for you?

If you have any of the following you must advise your physiotherapist at the consultation:

  • If you are feeling unwell or have any form of infection
  • If you have a known allergy or have experienced an anaphylaxis episode in the past
  • If you are pregnant or breastfeeding
  • If you are on medication or suffer from a disease that suppresses your immune system
  • If you are on medication to thin your blood
  • If previous steroid injections have not helped
  • If you have problems with your liver or kidneys

Hyaluronic acid injections

We are able to offer hyaluronic acid (HA) injections for a range of conditions. This treatment is generally used to treat degenerative conditions like knee osteoarthritis but it can also used in other joints like the thumb, shoulder and big toe. HA is also popular among the sporting population, with many high profile professional athletes utilising it for joint problems.

What will a hyaluronic acid injection do?

Hyaluronic acid is based upon a naturally occurring substance within all joints of the body which helps to provide nourishment to the joint and viscoelastic properties which assist with motion and shock absorption. It has also been shown to dampen down pain and inflammation.

How do I know if hyaluronic acid injection is appropriate for me?

This will be discussed in your consultation with your physio but should you have any further queries please feel free to contact [email protected] Our team is very experienced in the use of hyaluronic injections (along with the full range of assessment and treatments for osteoarthritis) and therefore will be able to guide you as to whether or not this treatment is appropriate.

Why have hyaluronic acid injection rather than a steroid injection?

Hyaluronic acid may be favoured for a number of reasons. Some people are unable to have steroid injections for medical reasons or previously have only experienced short term relief from a previous injections. Furthermore, it is recommended that the number of steroid injections that a patient can have is limited to no more than 3 per year although this limit is rarely reached. Any more than this can have a detrimental effect on the joint.

Hyaluronic acid provides a significantly different option and may be a viable solution for maintaining comfort in the joint especially for patients who are active. HA works in a very different way to steroid injections (which are potent anti-inflammatories) as it helps to replenish and nourish the normal conditions within joint. There is some evidence it may be able to slow down the progression of ‘wear and tear’ (osteoarthritis) as part of an overall maintenance program including strengthening, weight management and activity modification.

When might a HA injection NOT be right for you?

If you have any of the following you must advise us at or before the injection consultation

  • If you are feeling unwell or have any form of infection
  • If you are on medication to suppress your immune system
  • If you are on medication to thin your blood
  • If previous injections have not helped

What precautions do I need to take if I am taking blood thinning medication?

It depends on the type of medication you are on and the area that is being injected. Most people are now on anti-platelet drugs such as Apixaban and Rivaroxiban. Because these drugs don’t stay in your system for longer than a few hours, it is usually safe to miss the dose immediately before the injection and resume the dose afterwards. For example, if you take Apixaban once daily in the morning and your injection appointment is during the day, you would miss the dose on the day of the injection and resume your medication the following morning. You should discuss this with your doctor or physiotherapist prior to your injection appointment.

If you are taking anti-coagulant drugs such as Warfarin, you will need to know your INR value which needs to be 2.5 or lower before injection treatment can be considered. In some cases discontinuing your Warfarin for a short period of time may be necessary but this MUST ONLY be done in consultation with your doctor.


What are the possible side effects to injection treatment?

Side effects from a steroid injection are very rare. Your safety is of paramount importance and great care is taken to ensure any risks are minimised.

  • Infection is the most serious side effect although its incidence has been estimated to be in the region of 1:40,000. Whilst extremely rare, everyone is warned that increasing pain, redness, heat, swelling around the injection site and feeling unwell could be signs of an infection and immediate medical assistance is warranted.
  • Allergic reaction (including anaphylaxis) is another rarity but with increasing incidents reported in the media every care is taken to avoid this. Local anaesthetic has been known to trigger an allergic response and we tend to avoid using this where possible.
  • Local skin changes can occur where the skin gets lighter (depigmentation) and the skin contours diminish slightly (sub-cutaneous atrophy) but these are usually temporary and recover over several months.
  • Tendon damage has been reported where tendons are repeatedly exposed to steroid injections and this practice is avoided.
  • Pain ‘flares’ are occasional reported in the first 24 hours after injection although this again is unusual. Simple paracetamol will settle any discomfort

CV-19 – Why are extra precautions regarding corticosteroid injections needed?

As well as having useful anti-inflammatory properties, corticosteroids can also suppress your immune system. Although there is very little research or data to guide policy, it is possible that a steroid injection could increase the likelihood of contracting COVID-19 and inhibit the body’s ability to fight the virus. Because of this, health professionals are on high alert and have tried to avoid using corticosteroid medication unless absolutely necessary. There are people however who are experiencing extreme difficulties with pain and disability which in turn impacts their physical and mental well-being during these challenging times and the benefit of injection treatment needs to be balanced with the possible additional risk.


CV-19 – What extra precautions are we taking?

We are following the guidelines to ensure every patient meets the following criteria

  • Does not currently have symptoms of COVID-19 or have recently been in contact with a person with symptoms
  • Not in a high risk group for COVID-19 and/or live with a person in a high risk group (e.g. patients over the age of 70, and those with diabetes, ischaemic heart disease, chronic respiratory disease or hypertension)
  • Has high levels of pain and disability (e.g. disturbing sleep, unable to do normal daily activities, restricting work etc)
  • Has failed first-line treatment measures (e.g. analgesia, rest, splints, activity modification or exercise) and continuation of pain symptoms will have a significant negative effect on their health and wellbeing.
  • Is willing to integrate corticosteroid injection treatment with holistic rehabilitation e.g. activity modification and exercise therapy.
  • Has considered/trialled alternative treatment options
  • Patient’s GP has referred patient for injection or has been made aware that injection is being considered
  • Confirms that they have been counselled about the possible COVID-19 risk and understand and accept the additional associated risk
  • Has concerns that deferral of injection treatment could lead to a deterioration in their health

We are also taking the following steps to minimise risks to our patients:

  • Additional screening including direct call to patients prior to any bookings
  • Use of PPE for clincians
  • Additional time between each patient booking to clean room and equipment and facilitate social distancing in waiting area
  • Monitoring staff and patient temperatures on arrival
  • Use of lowest dose of steroid that is clinically appropriate
  • Additional COVID-19 specific consent form


References

NHS England

Faculty of Pain Medicine

British Journal of Sports Medicine

British Society of Skeletal Radiologists

The Chartered Society of Physiotherapy


Other considerations following injection therapy

Can I drive after the injection?

That largely depends on you! There are no medical reasons why you shouldn’t drive after the injection (we usually monitor you for 30 mins after the injection) but some people prefer to arrange to come with someone so they don’t have to drive home.

Should I rest after the injection?

If you have an injection into a joint, you should rest it, or at least avoid strenuous exercise, for the first 1–2 days. It’s also important, however, not to rest for too long. We recommend that you return to your physiotherapist within 5-7 days of the injection to check the outcome of the injection, ensure there are no complications and to resume your rehabilitation.

Will I need more than one injection?

Not usually, although if you have a long-standing condition you may well benefit from repeated injections, provided there is an interval of several months between each one. In specific cases, it may be necessary to inject more frequently (e.g. Frozen shoulder).


Clinician profile

Paul Hattam was one of the first physiotherapists in the UK to incorporate injection therapy as part of his clinical practice in 1994. In 2000 he developed an educational programme for physiotherapists and doctors to gain competency in injection therapy and has since trained over 2000 clinicians across the UK, Ireland and Norway. The course forms part of a MSc in Musculoskeletal Medicine based in Edinburgh and Paul enjoys combining his clinical practice with his teaching commitments. In 2015, he embarked on additional training in using ultrasound guidance and now teaches these skills on another Masters programme in London. Paul is also a qualified Independent Physiotherapy Prescriber.


Should you have any further questions please discuss this with your physiotherapist. Now please complete the injection consent form which you can find in your appointment confirmation and reminder emails.

Alternatively you can find your can complete the consent form here.