Injection Treatments

Our doctors perform a wide range of injections including spinal and peripheral joint and soft tissue injections. Delivering corticosteroid injections, hydrodilation, prolotherapy, hyaluronic acid (viscosupplement), autologous blood and platelet rich plasma injections and Arthrosamid. Ultrasound guided techniques are used where clinically appropriate.

All Injection Procedures

All injection procedures carry certain common risks. We discuss these here.

The main risks associated with all injection procedures are as follows:

  • The injection might not work. No medical or surgical procedure carries a 100% chance of success. There will always be a minority of patients for whom either the procedure does not work at all, or who only get minimal or short-lived benefit. Unfortunately this is the nature of biology: take two people with identical conditions and they may still respond very differently from each other.
  • Infection: The skin provides a barrier to infection so any procedure which involves puncturing the skin carries a small risk of infection. Doctors are trained in aseptic procedures using sterile equipment and good technique so this risk is very rare. If you experience any swelling or marked redness in the few days following an injection or if the area starts to feel abnormally hot, please seek prompt medical attention.
  • Allergic reactions: Again, this very rarely happens but people can be allergic to certain components in the injection including local anaesthetic. People can also develop allergies to things that they have previously tolerated well. If this happens, then most serious allergc reactions tend to happen quickly. For that reason, after any injection procedure, you are asked to remain in clinic for around 20 minutes as a precaution. Our doctors have equipment and supplies on site to deal with any serious allergic reaction if it arises but you may be reassured to know that we have never had to use this.
  • Because injections involve a needle which is passing through the skin and soft tissues, you may feel a little sore afterwards (particularly when the local anaesthetic has worn off.
  • Injections don’t provide immediate results. Some take longer to work than others and it is not unusual to experience some short-lived/temporary worsening of symptoms first.
  • There may be some bleeding or bruising at the injection site although this is more common if you are taking medicines which slow your blood clotting time.
  • Although we use only a small amount of local anaesthetic in any injection procedure, rarely (and depending upon the location of the injection), the local anaesthetic can spread and cause a degree of temporary numbness or leg weakness. If this happens, you will need to stay longer in the clinic after your injection until these symptoms subside before you leave.
  • Some individuals are susceptible to fainting during medical procedures. Faints result from a sudden short term fall in blood pressure. If you are prone to fainting, please let us know.

Before the doctor performs an injection, you should tell us:

  • If you have any allergies, including things like allergy to certain medications, elastoplasts or latex.
  • If you have any infection even if this is currently being treated with antibiotics
  • If you have any broken skin or a rash near to the site which is going to be injected
  • If you are taking any medication – in particular any anti-clotting medicines such as rivaroxaban, epixaban or clopidogrel.
  • If you have very recently received or are about to receive a vaccination.

Most of the injections we perform use only low doses of local anaesthetic which are very unlikely to affect your motor nervous system. However, this can very occasionally happen, depending upon the location of the injection and whether the local anaesthetic has spread. If this does happen, you will be advised to remain in clinic and not to drive until after the effects of the local anaesthetic wear off.

However, there are other factors which might affect your ability to drive and we would encourage you to think about:

  • Whether the pain aspect of your condition may distract you whilst driving
  • Whether you feel anxious or apprehensive about having the procedure and whether this might be a distraction
  • Whether your condition has restricted your movement in any way, which may impair your driving skills (e.g. your ability to glance to check your blind spot
  • Whether you are already taking any medication for pain which may cause drowsiness and impair your ability to drive.

Corticosteroid Injection

(Sometimes referred to as steroid or cortisone)

In the treatment of joint and soft tissue disorders, corticosteroid injections can be helpful for easing pain and reducing high levels of inflammation. They can help to make rehab easier by easing pain which can often be a barrier to pursuing rehab exercises. There are several different formulations of both steroid and anaesthetic which may be used.

The risk of a complication arising is low and serious complications are extremely rare. However occasionally the following may occur and may require medical attention.

  • Potential risks are as for all injections (see under “All Injections”). AND IN ADDITION:
  • Some patients experience deterioration in their symptoms for about 48 hours after the injection. Rest and simple pain killers usually help.
  • Facial flushing (warmth and redness) may occur. This will usually resolve after 24-72 hours and predominantly affects women. It is not an allergy and does not preclude future injections.
  • Thinning of the skin and soft tissues injection can occur resulting in a dimple. Occasionally the formation of a small lump or loss of a small area of skin colour may also occur.
  • Tendons may weaken when in contact with steroid resulting in rupture. This effect is thought to be very rare and may primarily affect damaged tendons already predisposed to rupture. Seek prompt medical attention if you experience new weakness in the affected body part.
  • The steroid may occasionally cause irregular vaginal bleeding for a few weeks.
  • Joint and soft tissue steroid injections can cause a rise in blood sugar for a few days in diabetic patients. The effect however is usually negligible and would not normally necessitate a change in treatment. In certain circumstances additional monitoring may be recommended.

Before you consider having a steroid injection you must inform your practitioner if
you have:

  • An allergy to steroid or local anaesthetic
  • Infection close to the site of the proposed injection or a significant infection elsewhere (Injection should be delayed until this clears up)
  • Broken skin or rash at or near to the site of the proposed injection
  • A tendency to bleed more readily as a result of illness or medication
  • Surgical metalwork at the site of the proposed injection, for example a joint replacement, screws, plates etc

  • The doctor will disinfect the skin at the injection site and will numb the area using a small amount of local anaesthetic before administering the injection.Depending upon the site of injection, ultrasound guidance may be used to ensure accurate needle placement, although this is by no means necessary for all injection sites.
  • After the injection you will be asked to remain in the clinic for about 20 minutes.
  • Relative rest is usually advised for a few days afterwards and certainly, strenuous activities should be avoided for a few days, particularly if steroid is injected in the vicinity of a tendon or into a weight bearing joint.
  • Additional advice and precautions relating to particular injections and procedures will be discussed if necessary at your appointment.

Please report any known allergies (drugs, elastoplast etc) to the doctor prior to the
procedure.

  • The benefit usually starts after 36 hours or it may build up gradually over a week to 10 days.
  • In some cases, a one-off steroid injection can provide sufficient relief until the condition resolves on its own. However, particularly in chronic conditions such as osteoarthritis, symptoms tend to return once the effects of injection have worn off (typically afer a few weeks or months).
  • Whilst steroid injections can be repeated, if they are only providing very short-lived relief, we will discuss other treatment options with you. A minority of patients will fail to respond to injection, and again, further treatment options may need to be discussed.
  • Driving after an injection: See general advice at the end of this page
  • All patients will be advised to rest for at least 24 hours following a corticosteroid injection, and this may be longer depending upon the nature of your condition and the activities you normally do.

Hyaluronic Acid Injections

(Sometimes referred to as viscosupplement injections

We use hyaluronic acid injections in synovial joints.. The synovial fluid in the joint helps protect the cartilage from wear and tear by keeping the bones slightly apart and by acting as a shock absorber and lubricant. It also acts as a filter, letting nutrients reach the cartilage, but blocking the passage of harmful cells and substances. The most important component of synovial fluid is a substance called hyaluronic acid. It is this substance that allows the synovial fluid to perform its cartilage saving properties. Hyaluronic acid is continuously broken down and replaced. Normally, there is a balance between the breakdown of old hyaluronic acid and the production of new hyaluronic acid. In osteoarthritis, however, this balance is disturbed and breakdown happens
faster than production. As a result, the synovial fluid becomes watery and stops working
properly and the cartilage in the joint gradually wears away. The thinning of the synovial
fluid and wearing away of the cartilage leads to symptoms of osteoarthritis.

Hyaluronic Acid (viscosupplement) Injections can

  • Improve the viscosity of the synovial (lubricating) fluid.
  • Reduce pain and swelling within the joint.
  • Increase the articular cartilage depth on load bearing surfaces.
  • These products can provide symptom relief but do not cure the underlying osteoarthritic disease process.
  • Hyaluronic acid is sometimes administered along with a small amount of corticosteroid

The risk of a complication arising from injection with the hyaluronic acid products we use is low and serious complications are extremely rare. However occasionally the following may occur and may require medical attention:

  • Potential risks as for all injections (see under “All Injections”). AND IN ADDITION:
  • If a small amount of corticosteroid is also used in the injection, please see under CORTICOSTEROID INJECTIONS for further potential side effects.

The area around the joint is prepared with anti-septic solution, and the injection is performed under aseptic conditions. An area of skin and the tissues underneath are numbed with some local anaesthetic – this may sting a little. A needle is inserted into the joint space, to inject the hyaluronic acid and then the needle is withdrawn. Ultrasound guidance will be used where appropriate.

The products we tend to use are Ostenil Mini (small joints) and Ostenil Plus or Durolane for large joints.


Please report any known allergies (drugs, elastoplast etc) to the doctor prior to the
procedure.

  • These injections can take anywhere up to ten days to work.
  • Although a minority of patients do not respond to treatment, patients with mild to moderate osteoarthritis often see improvements in symptoms lasting around 6 to 12 months. However, this can vary from individual to individual. It should be noted however that patients with severed destructive osteoarthritis are far less likely to respond to treatment with these products, and for these patients, surgical joint replacement may offer the best solution.

You will usually be advised to rest for at least 24 hours after injection. You can carry on with your normal everyday activities, but strenuous use of the joint should be avoided for 1 week.

Autologous Blood and Platelet Rich Plasma Injections

A regenerative medicine technique

In recent years there have been rapid developments in the use of growth factors to accelerate healing. Blood contains many nutrients and substances which are thought to
promote this. Platelets are tiny cells in blood which stick to each other when we cut
ourselves to result in the formation of a clot to stop any further bleeding. Platelets contain many powerful growth factors, in particular PDGF (Platelet Derived Growth Factor) which has been shown to promote healing of many types of tissues, including bone and soft tissue.

In both procedures, a small amount of blood is withdrawn from a vein.

Autologous Blood Injections involve injecting the blood that has been withdrawn into the site of the injury.

PRP injections involve a slightly larger amount of blood being taken from the arm using either the Arthrex ACP or ACP Max double barrelled syringe. This is then placed into a centrifuge which spins at many thousands of times a minute and causes the blood to separate to produce a quantity of platelet rich plasma. It is this platelet rich plasma which is then injected into the site of injury.

Platelet rich plasma contains more concentrated growth factors than whole autologous blood.

  • It is not uncommon for patients to experience a flare in their symptoms following the injection. This can involve increased pain and stiffness. A flare up of symptoms typically starts to build up a few hours following injection and typically lasts for 48 hours. Rest and simple pain killers usually help. Very occasionally, this reaction can be more prolonged and you are advised to contact your doctor if you have suffered a flare up which is not resolving after 48 hours.
  • Other than this, the risk of complications is extremely low. Potential risks are as for all injections (see under “All Injections”). AND IN ADDITION:
  • Theoretically, tendon rupture is possible with any procedure which involves injecting a diseased tendon although this is extremely rare. Seek prompt medical attention if you experience new weakness in the affected body part.
  • Blood is normally taken from an arm for this procedure. First the skin over a vein is cleansed and prepared and a small amount of blood is withdrawn from it.
  • In the case of a PRP injection, the special double-barrelled syringe containing the blood will be placed into the centrifuge to extract the platelet rich plasma component. In the case of an autologous blood injection, the blood will not be centrifuged and will be used whole.
  • For PRP injections, because the procedure involves concentrating the growth factors, the usual amount of blood taken to produce 6ml of platelet rich plasma is around 15ml with the standard ACP procedure and around 60ml with ACP Max.
  • For both procedures: Local anaesthetic is then injected into the skin overlying the area and the Autologous blood or the PRP is then directed into the affected area, using ultrasound guidance when appropriate.

Because the procedure aims to encourage healing (involving the growth and
organisation of new tissue cells), it can take four to six weeks before benefits start to
become apparent.

As with all medical and surgical treatments, the treatment will not work for everyone. NICE (The National Institute of Clinical Excellence) cite two studies, involving 250 patients with tennis elbow, which looked at how well the autologous blood injection procedure worked. In one of the studies, 150 patients had either the whole-blood injection or the platelet rich plasma injection. When asked 6 months after the procedure, these injections had worked well for 89 out of 130 patients followed up. In the other study, 100 patients had either the platelet-rich plasma injection or corticosteroid injection. After 2 years, the procedure had worked well in 39 of the 51 patients who had the platelet-rich plasma injection and 21 of the 49 patients who had the corticosteroid injection. However, 6 patients who had the procedure and 14 patients who had the corticosteroid injection needed more treatment within 2–14 months.

Further research articles are available on the Arthrrex website.

  • You should avoid taking anti-inflammatory medication such as ibuprofen for at least
    24 hours prior to your injection and at least 72 hours following injection.
  • Advice on activity modification and rehabilitation following injection will depend upon what activities you normally do, although all patients will be advised to take it easy for at least a few days.

Dextrose Prolotherapy Injections

(A regenerative medicine technique for the treatment of ligament laxity)

Ligaments help to provide passive stability in the joints. In other words, they prevent the joint from moving more than it should. When ligaments become lax, they become inefficient at providing stability for the joint and we refer to the joint as being unstable. Some people are simply born with lax ligaments whereas in other cases, ligaments can be overstretched, or even torn (as in a sprained ankle). Stretched/lax ligaments can lead to joint movements which are beyond the normal range and this can cause pain. Instability can occur in any joint but the most common cases involve:

Spinal instability
In the spine there is a complex arrangement of ligaments which allows flexibility of the spine in some directions whilst producing restraint in other directions. When ligaments become inefficient in the spine, this may put abnormal stresses on the joints and on the intervertebral discs in the spine.

Pelvic Instability
In women, the pelvic joints need to be supple for child bearing, and so the ligaments soften and stretch more readily. Occasionally they do not tighten up after childbirth which can lead to pain problems.

How does Prolotherapy work?
The treatment works by encouraging the body to make new fibres which are laid down in the substance of the ligaments to strengthen them. The treatment involves injecting a slightly irritant substance such as a 25% dextrose solution. The solution is mixed with local anaesthetic and a small amount is injected into each end of the ligament, close to the attachment to the bone.

This initially causes inflammation which attracts the cells that make collagen to the area. Over the following weeks, the new fibres are organised into the existing ligament.
Each ligament has to be stimulated 3 to 4 times (and occasionally up to 6 times) at intervals of 1 to 2 weeks in order to produce a good clinical effect, so the injections are given as a course of treatment.

The solution used for the injection is used in other treatments so it is known to be safe.
However the compounds in the solution are rapidly disposed of by the body, it is safe to have a repeat course of treatment – should it be necessary.

Prolotherapy does NOT create scar tissue but healthy collagen fibres in the lax ligaments.

  • Complications are very rare since even with spinal ligament prolotherapy since the injection is not placed into the spinal canal or near spinal nerves.
  • Potential risks are as for all injections (see under “All Injections”). AND IN ADDITION:
  • Because the procedure is designed to stimulate healing and needs to produce a small amount of inflammation to do this, you may be sore for a few days following the procedure.

First the skin is cleansed with an antiseptic solution and the prolotherapy solution will be injected into the ligaments under an aseptic technique.

Please report any known allergies (drugs, elastoplast etc) to the doctor prior to the
procedure.

The effects of prolotherapy are not instant but build up gradually, with full clinical benefit
taking approximately three months to achieve following a course of treatment.

As with any medical or surgical procedure, there is a risk that the treatment might not work. However, many patients obtain long lasting relief from prolotherapy.

In some cases, e.g. with spinal instability, prolotherapy is often used in conjunction with
exercises such as core stabilising exercises, particularly when core stabilising exercises alone have not been effective at stabilising the back.

Prolotherapy is designed to strengthen the ligaments to increase the stability of the joint, whereas stabilising exercises are used to strengthen the muscles surrounding the joint to provide additional support to the joint.

  • These injections do cause some aching and stiffness for two to three days following their administration. If this occurs, paracetamol can normally be taken for pain relief, but you should avoid taking anti-inflammatory medications such as ibuprofen or aspirin since this will work against the intended effect of treatment. We normally recommend that you do not take anti-inflammatory medications for at least 24 hours prior to your injection and for at least 72 hours following injection.
  • Whilst some activity modification may be suggested following prolotherapy injection, you should not aim to rest as such because a certain level of activity is actually helpful. Your doctor will be able to advise on this.

Caudal Epidural Steroid Injections

A type of spinal corticosteroid injection

  • Epidural steroid injections can be beneficial for conditions where nerves which emerge from the spine become irritated due to spinal disc problems or narrowing of the spinal canals. The purpose of the injection is to carry the anti-inflammatory medication to the inner part of the back where there is pressure or chemical irritation being caused to the nerves. There, the solution which contains a mixture of saline and corticosteroid can bathe the structures to reduce swelling and irritation.
  • An epidural given by the caudal route is administered just above the tail-bone.
  • Caudal epidural injections can be performed safely and effectively as an outpatient procedure without the need for overnight stay, general anaesthetic or x-ray guidance. The procedure is performed under ultrasound guidance.

Complications following a caudal epidural are very rare although you may experience:

  • Some temporary light headedness after the procedure.
  • Potential risks are as for all injections (see under “All Injections”) and for Corticosteroid Injections (see under “Corticosteroid Injections” AND IN ADDITION:
  • Very rarely the epidural needle may penetrate the dural membrane. This is usually recognised immediately and if it occurs your doctor will discontinue the procedure and ask you to lie down for 24 hours to avoid a “spinal headache”, The small hole in the dura normally seals itself very quickly without causing any further problems.
  • It is extremely unlikely that you will experience any other significant side effects and there is no satisfactory evidence of any long term complication from epidural steroids. However, in the rare event you do experience any untoward reaction in the following 24 hours, such as shortness of breath, dizziness or severe headache, please seek prompt medical attention

If you are taking medication to reduce blood clotting (e.g. rivaroxaban or epixaban) this medication will need to be stopped for a short period prior to having a caudal epidural injection to reduce the risk of a bleed. The decision to stop your anti-clotting medication may need to be discussed with other members of the healthcare team who are responsible for your care to make sure that they are in agreement that it is safe to stop your medication for a few days.

  • This procedure is carried out under ultrasound guidance and the doctor will identify the base of the sacrum before administering the injection.
  • First, some local anaesthetic will be used to numb the skin. The steroid/saline solution is then injected slowly.
  • The needle enters the spinal canal through the base of the sacrum, and the saline mixedwith steroid penetrates up the canal to reach the level of the third lumbar vertebra.
  • In the majority of cases this is not a painful procedure, although you may experience some
    feeling of pressure as the volume of fluid is injected, or reproduction of your sciatic pain
    temporarily.
  • After the procedure, you will be expected to rest for a while (20 minutes or longer)
    before going home.


Please report any known allergies (drugs, elastoplast etc) to the doctor prior to the
procedure

  • The benefit usually starts after 36 hours but may build up gradually over a week or 10 days.
  • A minority of patients will fail to respond to caudal epidural injection, and some further patients may obtain only short-lived but significant relief of symptoms. If the latter scenario happens, the epidural injection may be repeated to give a longer-lasting effect.
  • Please note that your pain may be the same, or worse in some cases than before the
    procedure. This will usually last for 24 – 48 hours and is part of the normal process.
  • After the procedure, you should remain in clinic for at least 20 minutes. You are then advised to go home and rest for the remainder of the day and preferably the next day too.
  • Prolonged sitting and long car journeys should be avoided if possible.

Erector Spinae Plane Block

(A type of spinal corticosteroid injection)

This procedure was invented around 2016 to block the nerves around the thoracic spine for pain control during surgery or following fracture. Since then, it has begun to be used for nerve pain emanating from the cervical, thoracic or lumbar regions using corticosteroid, local anaesthetic and saline

The risk of complications is extremely rare. Potential risks are as for all injections (see under “All Injections”) and for Corticosteroid Injections (see under “Corticosteroid Injections” )

The area of skin to be injected is first cleaned with antiseptic solution. The procedure is then perfomed under ultrasound guidance and the needle is placed at the level of the transverse process (a piece of bone which sticks out of the vertebrae) and under the fascia of the erector spinae muscles to lift the fascia off the transverse process.

Most patients who receive this treatment are experiencing episodic pain where the episode has persisted. Most respond within 2- 3 days and it is unusual to have to repeat this, partcularly in acute pain.

Advice is the same as for corticosteroid injections in general. Please see the section on corticosteroid injections.

Hydrodilatation

(Sometimes referred to as hydrodistension)

Hydrodilation or hydrodistension procedures use a volume of solution (usually a mixture of sterile saline, corticosteroid and local anaesthetic) to stretch a joint capsule or tendon sheath. This is because some conditions which affect joints and tendons result in adhesions (where the tissues stick together) and this can cause pain and restricted movement.

Common examples of where these types of procedures are used are in:

  • Frozen shoulder (also known as adhesive capsulitis)
  • Achilles tendoninopathy and Kagar’s fat pad stripping

The risk of complications is extremely rare. Potential risks are as for all injections (see under “All Injections”) and for Corticosteroid Injections (see under “Corticosteroid Injections”

The procedure is performed under ultrasound guidance after first cleaning the skin with an antiseptic solution. This type of procedure uses a much larger volume of fluid which is injected slowly into the affected joint capsule or tendon sheath.

This is usualy a very effective treatment which can provide improvements within 24 hours, particularly in range of movement due to the mechanical action of releasing the adhesions. It is unusual to have to repeat this procedure.

General guidance is the same as for corticosteroid injections. Please see the section on corticosteroid injections.

Arthrosamid Injections

(A relatively new treatment for knee osteoarthritis)

Arthrosamid® is an innovative, injectable gel used to treat knee pain and other symptoms of osteoarthritis without the need for surgery. Whilst this procedure is considerably more expensive than other types of knee joint injections, it tends to give more long lasting benefits, lasting around three years.

More information about this procedue is contained in the Arthrosamid patient information leaflet which can be downloaded HERE

Other than the general risks of any injection (please see the section on all injections for rare but possible side effects). Other than these, clinical trials did not report any other serious potential side effects.

The doctor will discuss your suitability for Arthrosamid® treatment at your initial consultation and any reasons why you might not be able to have this procedure. These include:

  • If you have an infection on or near the injection site
  • If you have haemophilia or take anticoagulants
  • If you have an autoimmune condition, such as Multiple Sclerosis, Addison’s, or Coeliac Disease
  • If you’re had a knee arthroscopy in the past six months
  • If you have a foreign body in your knee
  • If you’re pregnant or breastfeeding
  • If your diabetes is poorly controlled
  • If you’re planning to have major dental work

As a precaution, patients are given preventative antibiotics to take one to two hours before the procedure. Arthrosamid is delivered in a single injection to the knee joint.

The skin will be cleaned with antiseptic first and then a small amount of local anaesthetic will be used to numb the skin around the injection site. Next,the needle will be inserted and the first syringe of Arthrosamid® will be administered into your knee’s synovial cavity, using ultrasound guidance. You may notice that the sensation is different as the gel is thicker than most other injectables.

The needle will stay in place, and a further five syringes of Arthrosamid® ge will be injected. The Arthrosamid® will disperse within the synovial fluid and will start to bind with the synovial tissue.

The needles will then be removed and the injection site will be covered with a plaster.

Arthrosamid® may take between four weeks and three months to work but its effects tend to be long lasting – typically around three years.

We advise you not to drive for 24 hours after your injection. You should try to keep moving after your injection, and we’d recommend that you take it easy to begin with and avoid any high impact activities. You should be able to return to your normal activity within three months.