Use of injection therapies in tendinopathies at the shoulder and elbow
Tendinopathies account for a fraction of all injury-related physician office visits. Hundreds of thousands of the working population, not only sports individuals, are affected by overuse tendinopathies each year, causing significant loss of work time. Understanding the pathophysiology, diagnostic criteria, and treatment of tendinopathies can therefore help reduce pain, hasten return to function, and reduce the economic economic impact of lost productivity in the workforce (2005).
Steroid injections are a popular modality among orthopedists but much less so among sports medicine specialists. These procedures are said to reduce pain and other symptoms of tendon injuries (1999), which is good because it allows highly active patients to return quickly to their sports in a shorter time. Local steroid injection therapy may be considered for many conditions commonly treated by the primary care physician. However, chronic overuse and flawed biomechanics may lead to inflammation in areas easily accessible to injected local corticosteroids, including bursae, tendon sheaths and joints (1995).
Locally injected corticosteroids, of which steroids is a member of, are a topic of debate, and more research in this area is still needed. The optimal drugs, dosages, techniques, intervals, and post-injection care remain unknown. For unclear reasons, injected corticosteroids may be more effective than oral medicines for relief in the acute phase of tendon pain, but they do not tend to alter long-term outcomes (2005).
The rationale for steroid injections is that inflammation causes tendinopathies, or “tendinitis” as the injuries are commonly called. This may be the case immediately after injury, but many experts now question whether chronic, sports-related tendon pain stems from inflammation ( 1999).
Thus is said that the effectiveness of corticosteroids is believed to be related to their ability to reduce and prevent inflammation, as is discussed in the previous paragraph. Clinically, this action results in a decrease in pain, erythema and swelling. Although the clinical efficacy of these medications in managing inflammation is not disputed, the exact biochemical mechanisms are unknown (1995).
Bursitis, inflammation of the fluid-filled sac of the elbow or shoulder, may also respond well to injection of corticosteroid. Some specific areas of bursal inflammation that have been managed successfully in this fashion include the subacromial, anserine and trochanteric bursae (1997). Local injection of a corticosteroid decreases the risk of systemic effects but may carry other problems. Adherence to several general principles should guide the primary care physician in the safe, efficacious use of injection therapy for overuse injuries (1995).
Rotator cuff or shoulder tendinopathy is typically treated with non-steroidal anti-inflammatory drugs and physical therapy, but even compliant patients can experience a worsening of their pain and eventually require surgery. One study has participants free of shoulder pain even without the use of steroid injections (2006).
Injections may predispose patients to tendon rupture. In rabbit models, steroids weakened tendons for up to 4 weeks if injected directly into the tendon tissue. Injection into the paratendinous sheath did not cause this weakness ( 1999).
It is generally preferable to mix the steroid preparation with an anesthetic agent to minimize the injection pain, provide immediate symptom relief and confirm the diagnosis. Local complications of corticosteroid injection include tendon and ligament weakening, bacterial infections of joints and related structures, and cosmetically significant depigmentation and subcutaneous tissue atrophy. Systemic complications are rare but reportedly include hyperglycemia and adrenal axis suppression (1995).
The effects of peritendinous corticosteroid injections are unknown, therefore it is strongly advised that they should be used with some caution. Because the role of inflammation in tendinopathies is unclear, corticosteroids may serve only to inhibit healing and reduce the tensile strength of the tissue, predisposing to spontaneous rupture (2005). There is evidence to support that injected steroids can help relieve pain, but should be used with caution.
Unfortunately, no evidence-based guidelines support the use of local corticosteroid injections in tendinopathy, and there may be deleterious effects on the tendon when they are injected into the tendon substance (2005). Evidence of benefit is therefore largely anecdotal ( 1995). There is however evidence to support that iontophoretic delivery of the steroid can keep patients comfortable and works to relieve pain with fewer side effects than steroid injections (2003).
Other injection therapies that are mentioned to help sports injury tendinopathy in the shoulder and elbow are prolotherapy, traumeel, and botulinum toxin. Prolotherapy is originally called sclerotherapy. It works by strengthening weak, relaxed ligaments that cause joints to loosen. The muscles around weak ligaments contract to help stabilize the joint. This causes pain from tight muscles (2001). This fact alone could be helpful in injuries but there is however no evidence found that directly points out its use in treating sports injury tendinopathy to the shoulder and elbow.
Traumeel, in any form including injected solution, is used to help heal wounds and relieve pain and bruising after physical trauma. One proponent gave shots of Traumeel to osteoarthritis and rheumatoid arthritis patients and was found that they’re particularly beneficial–although the treatment hasn’t been clinically tested. Interestingly, a study in the journal Complementary Therapies in Medicine showed that Traumeel’s anti-inflammatory agents, when injected, reduced swelling in the injured hind paws of rats (2005). Its anti-inflammatory agents could help in tendinopathy yet there is no approved research on this.
Botulinum toxin has also been shown to be highly effective in many cases. It is approved for uses on cervical dystonia, blepharospasm, and strabismus. It has also been shown to help in migraine headaches, achalasia, and spasmodic dysphonia among others, but has not yet been approved (2001). Other uses of it are still under investigation, yet there is no mention of it being a specific treatment for tendinopathies although some of its mentioned properties and action could help.
The use of injection therapies in tendinopathies at the shoulder and elbow are not well understood. Yet this has not deterred many from developing increased interest in these injection therapies. Many still undergo such procedures. Perhaps current health care trends demanding choice in health care treatment are simply social trends and a response to consumer desire in the search for the the cure for our ills.
To summarize, these injection therapies that have been discussed are shown to be beneficial to the tendinopathy or tendinitis condition of the patient solely because of its properties. Therapies that involve anti-inflammatory and analgesic or pain relieving properties usually benefit an individual with tendinopathy. However, these injection therapies mentioned here have not been clinically tested and approved by various medical groups.
Credit:ivythesis.typepad.com
0 comments:
Post a Comment