Orthopedic Medicine Injection Treatments
by Dr. Fenton
Aka: Regenerative injection treatment (RIT), Stimulated Ligament Reconstruction, Trigger Injection of Ligament and Tendon (TILT),Sclerotherapy
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.
- Ligament Laxity
- 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
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
- ~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
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)
- Smokers and alcoholics
- 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.
- 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.
- 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%
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
- 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
- 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
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.
3-4 injections, generally done monthly.
Not recommended, in my opinion, due to $$$ and fragility of the molecule
- 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
- post traumatic stress syndrome
- fear/avoidance behaviors
- secondary gain (unconscious>conscious)
- occult psychiatric or personality disorder
- -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
- 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)