What happens when you are diligent in your rehabilitation program, seeing your physiotherapist, chiropractor, and massage therapist and you still have PAIN?! There are many factors to consider here, such as your general health, diet, sleep status, underlying disease process, mechanism of injury and co-morbidities. However, many of our patients inquire about injections for pain relief. They have a friend that it worked wonders for, they read about it in the news or their dog or horse recently had an injection that seemed to help!
The most common injections for joint pain are corticosteriods, hyaluronic acid (HLA), and platelet-rich plasma (PRP). Let’s explore what these are and how and when they may be appropriate for you.
First of all, the healthy joints in our body are normally well lubricated with synovial fluid. Synovial fluid acts as a shock absorber and provides lubrication for the bones to glide against one another. In people with osteoarthritis, a critical part of this synovial fluid, the hyaluronic acid, breaks down. This loss of hyaluronic acid appears to contribute to joint pain and stiffness.
Corticosteriods (ie. Cortisone), which have been around for decades, are the most commonly used injections for osteoarthritis and tenosynovitis (tendon inflammation) in the shoulders, knees and hips. This can offer pain relief within a few days and may last for 2-3 months. The main aim is to reduce inflammatory cell activity in the joint. With repeated use however, corticosteriods have been shown to cause cartilage breakdown and weakening of the soft tissue structures such as ligaments and tendons. As such, doctors often recommend no more than 3 injections. Cortisone costs are typically covered by the Alberta Health Care Plan (AHC).
Hyaluronic acid injections (ie. Synvisc, Orthovisc), also known as viscosupplements, are used for the treatment of knee, hip, shoulder, elbow and ankle osteoarthritis. Hyaluronic acid is a naturally occurring molecule that is normally present in healthy cartilage. The levels of hyaluronic acid have been shown to be lower in arthritic joints.
HA injections may be a better option if corticosteroids or NSAIDS (non-steroidal anti-inflammatory drugs) have been unhelpful or if you have diabetes, as corticosteroids can raise blood sugar. This injection has properties chemically similar to your natural joint fluid. To this regard, studies have shown that injecting supplemental hyaluronic acid has been shown to stimulate the joint to increase its own production of this important substance. This may in turn help preserve the cartilage. HA forms a viscous coating over the cartilage lining, acting as a mechanical barrier over pain receptors and inflammatory cells. It may last longer than cortisone, some studies showing pain relief for up to 6 months. It also has not shown the detrimental effects on surrounding soft tissue structures, such as tendons and ligaments, compared to cortisone. The costs vary, but these injections are typically an uninsured service (not covered by AHC). Private insurance companies vary on their coverage.
As an aside, an interesting article I came across touted the benefits of the “poor man’s joint supplement”, in the form of bone broth! Dr. David Williams discusses how many HA oral supplements and injections are made from rooster combs, which contain the same compounds found in bovine (cattle). He recommends preparing broths from the bones from cattle, chickens and fish and incorporating them into your daily diet. This supplies an increased intake of hyaluronic acid, minerals, proteins and other compounds necessary for proper joint health. A good little tidbit if you’re into making your own soup broth!
Platelet-rich plasma injections (PRP) are an emerging therapeutic procedure used for the treatment of both acute and chronic soft tissue injuries. It involves collecting a blood sample from the patient, separating the platelets via centrifuge and injecting it back into the patient’s injured tissue area. The U of A Sports Medicine Centre describes how “platelets are cells that clot blood and contain over 300 active growth factors to help improve healing by stimulating normal tissue repair instead of scar tissue.” PRP has been shown to enhance the growth of stem cells and fibroblasts, which stimulate the body’s normal healing process. PRP encourages cartilage cells to produce more type 2 collagen, the building blocks of normal cartilage. Furthermore, the joint lining cells are stimulated to produce more hyaluronic acid, which we now know is a great joint lubricant. It has commonly been used to reduce pain levels in patients with osteoarthritis, tennis elbow, rotator cuff injuries and tendinopathies. Currently PRP injections are an uninsured service, typically costing $450+ per injection.
Results of any injections will vary from weeks to months depending on the joint or body part involved, the severity of the disease and the cause of the pain. Some patients get complete relief that is permanent, while others have no significant effect. Large studies like the Cochrane review, reflect on how the average individual responds to therapy. About 30% of people who undergo HA injections became virtually pain free and had symptom relief up to 2 years. Yet another 20% of patients experienced no benefit at all. All treatments require a referral from your family physician. Some general practitioners will do cortisone injections in office, depending on if they require guided ultrasound or not. HA and PRP injections are performed at certain clinics and hospitals and use guided ultrasound to direct the injection into the proper site.
Injections may be your first line of defense for an injury or at the end of a long journey of rehabilitation. Wherever you are in your healing process, it is important to identify and restore joint mechanics, muscle imbalances and possible movement compensations that may have got you in trouble in the first place! Proper joint motion and exercise are integral to stimulating joint health and joint lubrication. An individualized assessment, treatment and exercise plan will help you to maintain and prevent future issues. We are here to answer your questions and help get you on the road to recovery.
Jennifer Gordon (BSc.PT, AFCI, GunnIMS)
Physiotherapist
