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

   Needling. This is my choice as needling is a general injection therapy that one can use for most tissues: ligaments, tendons, fascia or muscle, and with various solutions. Some physicians or physical therapists even do needling “dry.” The benefits to this technique are that costly solutions or products are not necessary, the office visits are quick, and insurance typically covers the traditional injection CPT codes.

   I utilize a homeopathic medication that induces growth factors. Although it has some mild anti-inflammatory effects unlike corticosteroids, the medication will not dampen the immune system but rather incite the properly mediated cells to do their job. Depending on location/injury size, it is helpful to fan the injection throughout the damaged tissue. These injections can occur weekly or bimonthly in combination with other office treatments. In over 10 years of performing these injections, I have found that the optimal timing of tissue repair, which has had a nice correlation with patients’ decreasing symptoms, has typically been approximately 10 to 16 weeks with continual repair/strengthening of the tissues occurring even after the last injection.

   “Biopuncture” is another simple needling injection technique. With this technique, the physician raises small wheals in a pattern all around the injured tissue. It is similar to “ringing the dragon,” an acupuncture technique that some physicians use. Raising small wheals or just depositing the medication in individual or specific acupressure or acupuncture points will also work well.

   Percutaneous alcohol nerve sclerosing injection. Also known as alcohol sclerosing injection, this is another injection therapy that podiatric physicians may be under-using. It is an excellent injection therapy that one can use in lieu of surgical intervention, especially for athletes.

   Physicians typically use percutaneous alcohol nerve sclerosing injection for web space neuromas. Hughes and colleagues in 2007 followed 101 patients in a study on alcohol injections for Morton’s neuromas.2 The author related that alcohol injections had a very high success rate in eradicating interdigital web space neurtic pain. Some other studies have shown upwards of 90 percent success rate.3 In the podiatric world, the nerve injection technique can be credited to Marvin D. Steinberg, DPM, and later Max Weisfeld, DPM, and G. Dock Dockery, DPM.4-6

   In theory, the 4% Dehydrated Alcohol Injection (Akorn Pharmaceuticals) produces injury to tissue cells by Wallerian degeneration, dehydration and precipitation of protoplasm, thus casing nerve degeneration. Clinicians would typically perform the injections weekly and approximately three to seven injections may be needed. With each injection, the symptoms diminish.

   Akorn Pharmaceuticals notes that “the injection of alcohol used for therapeutic neurolysis involves amounts too small to produce significant systemic effects of ethyl alcohol.”7 Furthermore, the company states that “Ninety to 98 percent of the product that enters the body is completely oxidized.” The complications are minimal or even rare, but some post-injection neuritis or lymphatic reactions can occur. I have only observed the post-injection neuritis a few times.

In Conclusion

Having a variety of injection techniques in our toolbox is essential for the podiatric physician as we traditionally use many conservative treatments even in the busiest surgical practices. Improving conservative options for any practice improves patient satisfaction, especially when surgery is not an option. This can even be helpful for improving practice revenue when reduced surgical reimbursements are the norm. Most injections have rare or minimal complications, and almost any patient population can benefit.

   When treating chronic conditions, it is imperative for physicians to control any abnormal edema with formal compression products, offload the tissues when appropriate, evaluate for any shoe gear issues and help realign any abnormal foot mechanics with custom orthoses. Any and all of the aforementioned injection protocols will work to their fullest when clinicians address all of these other aspects of patient care as well.

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