It is possible that podiatrists just may utilize injection therapy more than any other physicians as we perform injections on numerous patients on a daily basis. Our unique knowledge of foot and ankle anatomy allows us to have complete precision when we do surgery or inject into or around anatomical structures. When athletes do not desire surgical care or it is not an option, injection therapy gives us another route to heal the patient.
Injections have such a profound ability to change the direction of tissue response. We can use injections to control, reduce or eradicate inflammation, or reduce the bulk of damaged tissues. We have injections to cause neurolysis and we can now utilize injections to revive the inflammatory cascade to allow the immune system to come to the rescue to repair torn, thickened or scarred tissue. The armamentarium of injection products and protocols we have in our toolbox is great.
Although there are certainly conditions that will benefit from our traditional corticosteroid injections, a steroid will work to its fullest capability on specific conditions. Therefore, one needs to use injections properly and judiciously at that tissue site. When physicians overutilize injections or use them for the wrong diagnosis, injections have their downsides.
Since corticosteroids work best to reduce inflammation, they work best in fluid filled structures, like ganglions or other cysts. They also can reduce tissue bulk in neuromas, fibromas or even keloid scars. In these circumstances, the downside of the potential atrophy of the tissue is actually the desired effect.
As clinicians, we use the “-itis” term too regularly and forget that probably most of our patients are not in the acute phase but rather more of a semi-chronic or chronically injured state. This will commonly be evident when a typical corticosteroid injection does not relieve the pain. If clinicians repeatedly continue down the same pathway and there is little or no response, one needs to direct the protocol immediately toward a “chronic” treatment regimen. When a corticosteroid injection is the only type of injection the doctor offers, then continuity of care changes because there are no more conservative options to offer and often, physicians then suggest a surgical route to the athlete.
Keys To Proper Diagnosis And Effective Treatment
Obtaining the proper diagnosis is imperative. I generally prefer diagnostic ultrasound. This test determines the true echotexture, which describes collagen alignment and thickness, and will often detect if any linear tearing or deficits are present, even if they are very small. Since this test can look at the structures in multiple planes, there are no limits of slicing parameters or limited planes of imaging as determined by magnetic resonance imaging (MRI) protocols.
Functional testing can determine the presence of joint laxity and whether capsular or ligamentous tissues have true, complete tears. When the results show the tissue is in a chronic state, it is very reasonable to understand why the steroid did not work as there are no acute inflammatory cells present. This understanding is why it is important to have more than one injection option, which will benefit the patient and the doctor, and allow quicker resolution.
I believe the future of soft tissue repair is really biologically based. If we can manipulate and accelerate the biology of healing and augment the mechanical strength of the tissue by inducing growth factors and inciting the inflammatory cascade, we are truly making a difference in the future structure of the tissue that is injured. Encouraging the tissue to remodel and lay down type I collagen is the goal here as long-term chronic “inflammation” results in a loss of function, production of other non-desirable collagen types and sometimes complete fibrosis. Here the physician should consider the use of different injection therapies that induce growth factors and resurge the inflammatory cascade to redirect tissue repair back into the proper direction (see “An Overview Of The Stages Of Wound Healing” at right)