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John A. Van Houten, M.D.

Much of an orthopedic practice involves various types of injections, and the right shot in the right place at the right time can be very effective. However, there are a number of myths and misconceptions about injections. This article will provide you a better understanding.

The types of injections that we do in our practice can be categorized as "Intramuscular", "intraarticular", "trigger point" and "epidural". These categories are based on where the shot is placed. Intramuscular injections are more commonly

done by internists. The material is injected into a muscle and allowed to be gradually absorbed by the body. Intraarticular injections are "into a joint" (that is what the word means). These may be large joints, such as the knee or shoulder, small joints,

such as the hand and fingers, or in between. Knee and shoulder joint injections are common. Hip joint injections are rather rare and are often done with an x-ray machine, As this is a very deep joint. Trigger point injections are done into a muscle, ligament,

or tendon area that has been identified as causing pain. The pain is triggered when the area is pressed. Epidural injections are inside the spine next to the membrane (the "Dura") that encloses the spinal fluid and spinal cord or spinal nerves. These may be

in the neck (cervical) or low back (lumbar). In our practice, when we say "epidural" injection, we mean an "epidural steroid" injection, that is, a cortisone derivative. In the lower back, an "epidural" injection using an anesthetic agent is used for surgery

or childbirth and involves similar techniques, but a different medication. Facet blocks in the neck or lower back are injections of the small joints that are part of the spine and are really types of "intraarticular" injection. 

The term "steroids" is a general term. Cortisone is an "adrenal" steroid that is produced in the adrenal gland. It is different from male and female hormones, which are also steroids and very different from anabolic steroids, which get much attention

in the media for their illegal use in sports. "Cortisone" itself is produced in the body. When we use the term, we really mean semi synthetic cortisone, of which there are several types, all having a very similar action. These medications, such as

Methylprednisolone, triamcinolone and betamethasone, have longer durations of action than cortisone itself and give more of the desired effects with less of the side effects.

Reactions, or side effects, to cortisone shots are relatively rare and relatively mild. Diabetics will notice an increase in blood sugar, although rarely a cause for concern. Tenderness at the injection site occurs more in small joints or with "trigger point"

Injections, usually lasts no more than 48 hours, and is improved with ice, but made worse with heat. For some time, injections of cortisone derivatives into joints were Felt to be related to producing arthritis, which has not been shown to be the case.

Recent studies using the local anesthetic Marcaine in a more concentrated form may not be good for cartilage and our practice does not use this medication for those injections. Steroid (cortisone) injections into tendons may lead to tendon weakening,

And these injections are rarely done. Injections near, but outside the tendon, are much more common. 

In addition to the steroid injections, "cartilage gel" injections (technically called visco supplementation) are available. There are five brands of this. The first four are derived from chickens (rooster combs) and the fifth from bacteria. Both of these are purified

hyaluronic acid derivatives, which is the building block of cartilage. Most of these will provide eight out of ten people relief for six months or more. Medicare does have specific rules regarding its use (and most other insurance companies follow Medicare).

These are that the ideal patient is not markedly overweight, that their x-rays show some degenerative change, but not severe, pills for pain or arthritis should have been Tried (or there is a reason why they cannot be used), and possibly a trial of cortisone shots first. Medicare rules allow for a subsequent series of injections (usually three, but with one brand five). This can be repeated after six months. The rules also provide that if one series of any of them is done and does not work, then another series, even of a different one, will not be approved. (That is why we have to provide An "Advancement Beneficiary Notice" to each patient who is a candidate for these injections.) The cartilage gel injections also are only approved for use in the knee. There are indications that they may be useful in the ankle and the shoulder, and perhaps other joints, but since that is an "off label" use, it is legal to do them, but

insurance will not cover it. The final question is how many shots a patient can have? The answer to this is "as

many as continue to work". I have already discussed the cartilage gel limitations. As far as "cortisone" shots are concerned, the rumors of "three in a lifetime", "three in a year” or "three in the same joint" have no basis. Usually, we would like to see three or four months of relief after a "cortisone" shot before considering another although there are exceptions to this rule. The same rule applies to "epidural" Injections. The common practice of scheduling three injections in a row is not encouraged by the Academy of Orthopaedic Surgeons, who recommend that a single injection be done and the results observed to see whether further injections are necessary. (If they are, then they would be done. After an initial series of "epidural" Injections, it is a good to wait three to four months for further injections.) 

I hope this gives you more information on what shots are for and how they work. For specific questions, when you come to the office, please discuss it with us and we will answer any further questions you may have.  

John Van Houten, M.D.


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