Orthopedic Medicine Injection Treatments

by Dr. Fenton

PROLOTHERAPY

Aka: Regenerative injection treatment (RIT), Stimulated Ligament Reconstruction, Trigger Injection of Ligament and Tendon (TILT),Sclerotherapy

DEFINITION

Use of hypertonic/chemotactic irritant solution (mixed equally with local anesthetic) or biologicals injected into joints or into bone-ligament or bone-tendinous junctions to stimulate the body’s regenerative capacity for healing of joints, ligaments and tendons.

MECHANISMS OF ACTION

  • Injection of a proliferant stimulates a regenerative and/or inflammatory response. The inflammatory mechanism is to stimulate neutrophil, macrophage, lymphocyte, and fibroblastic infiltration, collagen deposition (proliferation), and finally maturation / tissue healing. Studies on animals have demonstrated proliferation of ligament (type II collagen) with this approach, not scar type collagen.
  • Stimulation and release of multiple growth factors
  • Attraction of local and circulating stem cells
  • Local anesthetic effects also occur, “turning-off” the trigger response, resetting alpha- gamma loop/golgi tendon organs.
  • Neurolytic effects also occur but are rarely mentioned in the literature. Dextrose, glycerin, phenol (1%), and Sarapin all act as mild neurolytics for C fiber and unmyelinated fiber pain. The neurolytic effects (when they occur) typically lasts ~3-4 weeks, which helps patients “make it” to the next injection.

INDICATIONS

  • Ligament Laxity
    • palpable
    • via orthopedic testing
  • In the presence of persistent joint dysfunctions
    • often those patients receiving osteopathic manipulative treatment (OMT) who need more frequent treatment to maintain their function than is “reasonable,” or if OMT begins to become ineffective
  • Ligament generated pain
  • Osteoarthritis

LOCATIONS

Cardinal Rule: ONLY inject at the bone/ligament or bone/tendon junction
Obeying this rule makes the risk of serious complications exceedingly small. Only exception is when injection into the intra-articular (joint) space.

Prolotherapy/RIT is most often used in:

  • S.I. ligaments/joint pain syndromes -Lumbar spine pain
  • Cervical and cervico-occipital pain -Peripheral joint pain, laxity, and arthritis -Tendinopathies

CONTRAINDICATIONS

  • ~Acute ligament injuries
  • In the presence of wounds/skin infection
  • During infectious disease/fever
  • In poorly controlled diabetics
  • With anti-inflammatory medicines in the system: NSAIDS, steroids, arnica, nutrients, botanicals etc.
  • In individuals with poor hormonal / nutritional status

OUTCOMES

Efficacy is approximately 85% when a positive diagnostic block is obtained: classically reproduction of typical pain upon needling and elimination of typical pain in the anesthetic period. Outcomes when a diagnostic block isn’t possible are based on presence of ligament laxity, tendinopathy, and arthritis.

Efficacy is greatly reduced in the presence of:

  • Hormonal imbalance (usually deficiency): Vitamin D, testosterone, thyroid, estrogen, etc.
  • “Bad” vegetarians (poor protein nutritional status)
  • Diabetics
  • Smokers and alcoholics

TREATMENT SOLUTIONS

Anesthetics

  • procaine 0.2-0.5% final strength
  • lidocaine 0.1-0.5% final strength
  • Ropivacaine 0.125-0.25% final strength

Preservative free preparations are recommended. Preserved preparations are probably chondrotoxic at any concentration.

*Bupivacaine is severely chondro-myo-cardio toxic at any concentration and should not be used in any applications!
Lidocaine above 0.125% is also chondrotoxic.

Proliferants

Dextrose 10-25%

  • only slightly hyperosmotic
  • most mild
  • best to start with as a beginner

DPG / P2G (Dextrose 25%, Glycerin 25%, Phenol 2%)

  • diluted 1:1 with local
  • quite hyperosmotic
  • most widely used proliferant
  • 1-2% phenol safe (body is 0.6% phenol)

Sodium Morhuate 5% (in ligaments only)

  • diluted to 0.5 or 1:10
  • salt of cod liver oil extract
  • generally is 80-85% arachidonic acid which jump-starts the inflammatory cascade
  • concentrations higher than 1% can cause chronic neuritis
  • intra-articular injection used in animal models to cause joint inflammation/OA, so avoid in joints!! Do not use in spinal midline.

ADVANCED PROLIFERANTS

Pumice

  • for severe laxity or slow/minimal response
  • generally reserved for 2nd courses of prolo to the SI ligaments or nuchal ligament -avoid intra-articular injection!
  • mixed with Tween to aid flow
  • must use 20-22g needle
  • solution usually Pumice 5%, glycerin 25%, lidocaine 1%

BIOLOGICS

Platelet Rich Plasma (PRP)

  • concentrated platelets taken from a patient performed in a same day procedure.
  • minimum effective concentration 4-5x (1×106 Pl/uL)
  • types: RBC+/WBC+, RBC-/WBC+, acellular (RBC-/WBC-)
    • higher concentrations improve outcomes, especially in >50 y.o. populations.
    • only acellular PRP is well tolerated above ~8x.
    • presence of RBC very irritating and may prevent stem cell attraction and growth
    • presence of some WBCs may be indicated in tendinosis but not OA
  • Typical treatment course is every 4-8 weeks 1-5 times (more in joints, less in tendons).

Bone Marrow Aspirate and Concentrate (BMAC)

  • Taken from patient’s posterior iliac crest in a same day procedure.
  • Generally mixed with PRP for injection
  • More effective than PRP in OA and in tendon tears.
  • Typical treatment is one session followed in 2 weeks with PRP.

Fat Aspiration and Injection

  • Acts as a scaffolding and has apocrine and paracrine function.
  • Combined with PRP or BMAC and PRP.
  • Most often used for large tendon tears.

POST INJECTION CARE

  • No anti-inflammatory medicines pre or post injection 3-5 days
    • NSAIDS
    • steroids
    • tumeric, devil’s claw, boswellian, bromelain, high dose garlic, etc
    • no/minimal ice!!
  • Encourage motion, not rest.
  • Must do lumbar/cervical stabilization training post injection if those areas treated, later strengthening
  • Nutritional support
    • high protein diet (at least 1mg/kg body weight/day, in divided doses every 3- 4 hours while awake, including at bedtime)
    • trace minerals once daily (chromium, zinc, manganese, copper, etc)
    • MSM 1500mg-2000 mg / day (source of elemental sulfur)
    • Vitamin C (low dose) twice daily

SAFETY

Injection risks

  • pneumothoraxn
  • nerve block/neuritis
  • intra-arterial/venous injection
  • organ injection
  • Sodium Morhuate accidentally placed in the epidural space can be fatal
  • excess local anesthetic, or local placed into intravascular space, can lead to seizure and death

Remember the cardinal rule: only inject once contact is made with the bone/ligament junction

INTRA-ARTICULAR INJECTIONS

GLUCOSAMINE HCL OR SULFATE

Made “fresh” by pharmacist: glucosamine HCl 200mg/cc, $2/dose (vs $175/dose for Synvisc)

Solution: typical solution is 3cc 50% D50, 3cc 1% PF lidocaine, 1-2cc glucosamine, 4- 5cc saline

Injection frequency: biweekly or monthly x 3-6

  • often repeat q 6-12 mo, or one q2mo ongoing (if 1st series successful)
  • can mix glucosamine with hyaluronic acid, eliminating the other ingredients

GROWTH HORMONE INTRA-ARTICULAR

Probably doesn’t work in the presence of a joint effusion due to denaturing of GH by proteolytic enzymes (metaloproteinases) present in effusions.

Use 0.4mg.

3-4 injections, generally done monthly.

Not recommended, in my opinion, due to $$$ and fragility of the molecule

PAIN SOURCES

  • In OA no correlation between x-ray evidence of degeneration & the presence of pain or function (except in the hip and knee when there is complete loss of joint space, and then only a 20% correlation!!!).
  • It’s the ligaments and joint capsules that are the common pain generators, often with referred pain.
  • Tendons can be pain generators, often from long-standing overworking/guarding muscles.
  • Muscles are often a pain source but rarely the primary problem
    • muscles guard joints and ligaments that are damaged, resulting in muscle fatigue,
  • poor lymphatic and venous drainage, and resulting pain.

Maintaining Factors in Subacute and Chronic Pain

Emotional/behavioral/psychosocial

  • post traumatic stress syndrome
  • fear/avoidance behaviors
  • secondary gain (unconscious>conscious)
  • occult psychiatric or personality disorder

Hormonal

  • -Hypothyroid, sick euthyroid, hyperthyroid
  • Estrogen/progesterone imbalance
    • BCP’s (start or cessation), Depo-Provera, natural or surgical menopause
  • Low testosterone (women>men!)
  • Vitamin D deficiency
  • Adrenal imbalance

Nutritional

  • Deficiencies of B6, B12, C, essential fatty acids, calcium, magnesium, trace minerals.
  • Infrequent, poor quality, or low protein diets
  • ? Trans-fat intake
  • Medication use: Statins (Lipitor and others), NSAIDS)

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