A Closer Look At Injection Therapy For Athletes

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An Overview Of The Stages Of Wound Healing

When tissue becomes damaged, it undergoes cellular transformation. Tissue healing starts with the inflammation phase. In this phase, the cellular tissues remove bacteria and/or debris, and the release of growth factors causes migration and division of cells. The tissue subsequently enters the “proliferative phase,” which will overlap and start even before the inflammatory phase is complete. In this phase, angiogenesis occurs along with fibroblastic proliferation, which will peak up to two weeks post-injury.

These cells are the main cells that lay down the extracellular collagen matrix. This matrix is rich with new blood vessels and many cell types. Growth factors like transforming growth factor beta come into play and the production of type III collagen begins. In the remodeling phase, which can last many months and even upward of a year, type I collagen, which is more resilient and stronger, begins to replace type III collagen. The tensile strength approaches 80 percent and upward over the course of time.

There are local and systemic factors that can disrupt the natural process of healing. Local factors include mechanical aggravation, edema, ischemia and decreased oxygen. Systemic factors include decreased perfusion, metabolic diseases, immunosuppression issues, smoking and decreased nutrition.

When chaos occurs during the inflammatory cascade, the tissue can easily bypass the acute phase and jump right into the chronic inflammatory state, especially if or when the above factors are present. Keep in mind that complaints of symptoms like achy, dull, nagging pain that just won’t go away for months, despite many attempts at conservative care, is probably a good clue for all of us.

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Author(s): 
Lisa M. Schoene DPM, ATC, FACFAS

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.

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