We're all the grinders here now, right? This is the very end of it, so hopefully this will be interesting and helpful and useful. We're going to talk about the non-biologic injections. I've been asked to talk about the what, the when, and the why. And I want to thank one of our sports medicine fellows, Megan Morley, for helping to put together these. I don't have any disclosures that affect this talk. I'm going to start with the end, which is the what. There's evidence for the stuff on the left, and pretty good level one evidence for the recommendations that I'm going to give you. Intraarticular if you're going to use local anesthetics, use ropivacaine. Triamcinolone if you're using it intraarticular. High molecular weight visco supplements, Ketorolac. And you can use those in combination. Some or all of those, plus or minus a biologic. There's evidence for the extraarticular use of different injectables, non-biologics. The local, in this case, should be based on the duration of the effect. And I would say, from my personal experience, I would generally use a local without epinephrine if you're using it on game day, because sometimes a player can get kind of that apprehensive response, that sort of fight or flight feeling that they don't really like from the epinephrine. So I've gone to using it without epi. Soluble corticosteroid when you're going into soft tissues, a visco supplement of choice. And you can use these in combination, plus or minus a biologic. Here's my level five evidence. So I've been in the NHL since 1997. I've been in the NFL since 1998. So 50 plus professional sports seasons. And this is, speaking to the elite, sort of paid for doing this athlete. A lot of these things I won't do in the youth athletes, high school athletes, and then to a lesser degree in college, because the players in the NFL, we all know, are quite different in a lot of ways. So my level five evidence is I'll use an extra articular local injection for pain relief and to facilitate return to play, typically on game day, sometimes right after the injury. And it's very much individualized. I think Andrew Willis made a really good point, which is these players are speaking to a lot of people. They're speaking, you've got to talk to their agent. They're speaking to their teammates. They're speaking to a second opinion doctor from someplace. If they're missing any time, you can be totally assured that they're getting a second opinion and consulting with somebody, at least by phone. So get everybody on the same page. And if the player's an injection type guy and wants an injection, I'm okay with that. If they are a no injection guy, I don't push it. So it's there as an option. I'll use an intraarticular corticosteroid for a significant arthritic flare when we need a fast response. And this is typically in season and early in the week. Extraarticular corticosteroids we'll use for core muscle injuries, a stable high ankle sprain, and occasionally with a recalcitrant or recurrent hamstring strain associated with prolonged pain. But I generally don't inject hamstrings. Again, if there's a player request, and Scott spoke to this topic, I think, very well, then an aspiration and a PRP injection if they want it. And then a high molecular weight visco supplement in combination with biologics for lower level degrees or chronic arthritic pain when we can tolerate a slower response, like prior to the beginning of training camp or at the end of the season. The why is going to be the rest of this. And this is the evidence. One of the things that I did in preparation for this talk is I surveyed a bunch of my NFL team physician colleagues, got 15 answers back, and you can see that we're all over the place. So in terms of what we inject and where we inject it, the knee's the most common injection, and everything's injected in the knee. There's also shoulder, ankle, hip. We're a little bit more standard in terms of the AC joint with a local and a steroid, but it's not very standardized. The other common themes that came out with getting responses from my team physician colleagues, the most common intra-articular corticosteroid was triamcinolone followed by methylprednisolone, and I hope in this talk I'll convince people to go to all triamcinolone because there's level one evidence that supports that, and when you use it in a joint, it wins. Corticosteroid injection is the most common injection for core muscle injury. If we're injecting a steroid, it's most commonly for a CMI, and NFL team physicians are much more likely to use PRP in general than steroids. As far as recovery is concerned, Scott spoke to that a little bit. This is again, this is now sort of a consensus of some experienced people. Most team doctors recommend one to two days of rest after an intra-articular injection prior to return to play, but it's not standardized and it's not evidence-based. So some more of the why, what injectables are available. We'll talk about local anesthetics, corticosteroids, non-steroidals, and visco-supplements. We have to understand that there's a placebo effect here, so whenever we're looking at level one evidence or we're doing anything that's not level one evidence and we're saying this works or this has got a demonstrable benefit, we've got to acknowledge the placebo effect because it's there, it's real, and it's affecting our results. Local anesthetics, lidocaine, bupivacaine are very commonly used. I would convince people if they're using intra-articular local anesthetic to go to ropivacaine. It's got a fairly quick onset, five to 15 minutes. It's more expensive, but it's got less chondrotoxicity, so it's something that we should be thinking about. If we're using just isolated local anesthetics, it's most commonly used in a systematic review around the AC joint, the hand, SC joint, you can kind of see. Also iliac crest, pretty common. This is athlete satisfaction with local anesthetic injection. One of the things that I've learned over the years is that the athletic trainers love for us to inject iliac crest contusions in AC joints, and I think you can see why here as you look at this. If you're talking about the AC joint, there's very few players that would say that they wouldn't do it again, and iliac crest contusions, players absolutely love it. They have a rapid response. I took care of a professional hockey player a week ago who had an iliac crest contusion. He was nine out of ten pain, could barely move, could barely lay on the examining table. After he got his injection, he stood up, it was holy F, I can't believe this, gave us all a high five and went back into the game. So it works. What are the risks of a local anesthetic injection? First of all, it can worsen the injury, right? We all know that sports, if you're injured, you're running into people, it's contact sports, pain can be protective. So I'm not going to tell you that it's good to have an iliac crest contusion and then get it contused again when it's numb. That's certainly not going to improve your outcome long-term, but it certainly seems to be safe. Unintended loss of sensation, so there's other nerves in the neighborhood of some of these things that we're injecting, and I've heard a story about a player that wanted the injection taken out after he got an ankle injection, had a part of his foot go numb, and he said, I don't want that, take it out. That doesn't work, so talk about that ahead of time. Risks associated with any injection, and this could include a flu shot or anything, infection as soon as you penetrate the skin, damage to surrounding structures by the needle, and then chondrotoxicity we've got to acknowledge because local anesthetics are chondrotoxic both in a time and dose-dependent matter. I lived through the time, I didn't do this in anybody personally, but I lived through the time where people were getting intra-articular local anesthetic pain pumps in the shoulder, rapid chondrolysis, it doesn't work, it's bad for the cartilage. The effect is worse when it's mixed with corticosteroids, and ropivacaine is the least toxic to chondrocytes as well as rotator cuff tendon. So the takeaway as far as local anesthetics are concerned, they're generally effective and well-tolerated for short-term relief of pain in sports. Make sure to counsel the athlete on risks, and if you're going to inject a local anesthetic intra-articularly, if necessary, use ropivacaine. There's references that are all available. Corticosteroids will be the next thing that we'll talk about. Some factors to understand in the case of corticosteroids would be the chemical composition and the solubility. Low solubility compounds remain at the injection site for longer, and for that reason have a longer duration of action. They also, though if they're put into soft tissues, have worse side effects, including tendon atrophy, ligament atrophy, fascia atrophy, and can lead to soft tissue calcification. Here's some common corticosteroids with a different degree of solubility. You can see that things like Celestone, freely soluble, I would prefer those for extra-articular soft tissue structures, and then either of the Triamcinolone preparations for intra-articular or the least soluble, and again, there's very good level one evidence comparing Triamcinolone to other corticosteroids for intra-articular use, and it works better. Here's the efficacy of corticosteroids. One of the things that we do in my group, UBMD Orthopedics and Sports Medicine, is we collect outcomes on all of our patients, and we've started to concentrate on the outcomes in our non-operative patients as well. So this is a group of close to 2,000 people who had intra-articular injection of Triamcinolone for knee osteoarthritis, and we collected KUS scores monthly for six months afterwards, calculated the minimal clinically important difference, and then looked to see what happened to those KUS scores. By the time you get to about two months, and certainly by three months from the injection, it's really not doing anything anymore. And this, by the way, we did this for visco-supplements as well, and the effect is far more profound for Triamcinolone than it is for visco-supplements in this patient population. So this is not professional athletes or anything like that. This is a couple thousand people with knee osteoarthritis, but I don't think that if you do this in professional athletes, you're going to find that the curves are radically different. What are the risks of corticosteroids? Soft tissue damage, so possible increased risk of catastrophic soft tissue rupture. Achilles, rotator cuff tendons, that type of thing. There's a higher risk of failure for subsequent surgery for rotator cuff tears and higher rates of recurrence of lateral epicondylitis in comparison to physical therapy at a year after the injection. They can be chondrotoxic, so in vitro a combination of local anesthetic and corticosteroid is also worse than either alone. The toxicity is also worse in osteoarthritic cartilage in comparison to healthy cartilage. So you have to know this, and it just means limit the use of these things and use it as necessary. Counsel your players about the side effects and the risks. What about in vivo? We've seen some reports of rapidly destructive joint disease after intraarticular injections, particularly around the hip. And the JAMA study we all know, there was a significantly greater cartilage volume loss, albeit very small, after repeated corticosteroid injections in the knee compared with saline. So this was an injection every three months for two years, basically in an injection-type clinic, and they found less than a millimeter difference in terms of cartilage loss, but it was a significant difference. So what is the takeaway in terms of corticosteroids? Intraarticular corticosteroid injection can be harmful to chondrocytes, particularly those affected by osteoarthritis. If you're doing soft tissue injections, consider the highly soluble corticosteroids, dexamethasone, betamethasone. Intraarticular injections consider triamcinolone. And there isn't any evidence that there is sustained pain relief with corticosteroids. They'll work anywhere from two weeks to three months, depending on the level one study that you choose to pay attention to. And repeated administration can be damaging to tissues. Nonsteroidal anti-inflammatory medications. These can be used intraarticularly as well. This is another thing that we can combine in our injection pathway. As far as Catorhalac is concerned, a single intraarticular NSAID injection compared to a week of oral NSAID, there is higher local concentrations and lower plasma concentrations. If we compare it to PONSAIDs, it's improved in comparison over the first month and similar at about months two to six. If it's compared to an intraarticular steroid, there's no real difference, although combining these is effective. And again, we've got to be aware of the placebo effect. Physco supplements. Hyaluronic acid is present in synovial fluid. It's high molecular weight, 6,000 to 7,000 kilodaltons. In osteoarthritis, one of the problems is that it gets smaller. The joint fluid becomes sort of waterier. And the supplements that we have available range in molecular weight from 500 to 6,000 kilodaltons and can be linear chain or cross-length. There's different available formulations. There's low molecular weight, medium, and high molecular weight. And when you compare them head-to-head, the high molecular weight tends to outperform the low molecular weight preparations. There's mixed results of trials comparing hyaluronic acid to intraarticular saline, as well as comparing hyaluronic acid to the standard of care, which is basically activity modification and physical therapy. If you're using something and you want the biggest effect that you can get, intraarticular steroids generally work faster and greater than hyaluronic acid. Combination injections. Meta-analysis have showed that hyaluronic acid plus corticosteroid injection provides better pain relief, short-term and long-term. Hyaluronic acid plus corticosteroids can be effective in non-surgical management of rotator cuff pathology. And there's some evidence that combining either corticosteroid or hyaluronic acid with PRP can be superior to PRP alone. We'll mention a couple things about the placebo effect. It's an afferent physiologic response to patient expectations. This is a study here where you've got non-responders at the top and placebo responders at the bottom. They know that they're getting a placebo, but they still have a decrease in their pain. If they were then secretly given either saline or an endogenous opiate blocker, naloxone, at a point into the trial, then their response went away. So it would lead you to conclude that maybe there's some endogenous opiates that are acting to potentiate or to be responsible for the placebo effect. It's not entirely reliant on deception, so you can tell people that they're getting a placebo and they can still get a response. It's modulated by the invasiveness of treatment, the cost of treatment, as well as the patient's prior experience. The more aggressive the intervention that you're doing, going from a topical placebo, which has a certain degree of effect, oral is more effective, injectable is more effective, and then sham surgery is the most effective placebo. It has the biggest placebo effect. We have to acknowledge, we have to work with that. Just understand that the mechanism's not fully understood. It's not mutually exclusive with the effectiveness of the drug. It can actually be thought of as augmenting the physiologic effect of the treatment. You get the drug effect plus the placebo effect. They're not necessarily competing with one another. So take home points. Consider solubility when selecting a corticosteroid for injection. Avoid repeated exposure of cartilage to corticosteroids and local anesthetics. Ropivacaine is the safest local anesthetic if you're going to do an intraarticular injection. Consider the placebo effect as an adjunct to pharmacologic efficacy of the medication. The bottom line is that nonbiologic injections can provide temporary relief of musculoskeletal pain in athletes. There is no demonstrable long-term health benefit, and there is possible long-term health risk. We'll go back to the beginning. Here's our conclusion. Intraarticular, you should use ropivacaine, triamcinolone, high molecular weight visco supplement, and catorolac, either combined or individually. Extraarticular, you can choose a local based on the duration of desired effect. A soluble corticosteroid and a visco supplement, and you can combine those as well. When to use them? I'll use an extraarticular local for pain relief and to facilitate return to play. Game day, and it's individualized with communication between all of the different parties that have interests. I'll use an intraarticular corticosteroid for a significant arthritic flare when I need a fast response in season and early in the week. I'll do an extraarticular corticosteroid for core muscle injuries, stable high ankle sprains, and occasionally for hamstrings. And high molecular weight visco supplement in combination with biologics for lower level or chronic arthritic pain when we can tolerate a slower response like prior to camp or the end of the season. Those are the references. They're all available to you. There's a lot of them there. They're worthwhile. Thank you.

non-biologic injections

pain relief

athletes

types of injections

individualized approaches