Do Not Inject The Bursa

R subacromial bursa

I was very surprised when I came across the following findings from a research paper. Whether an accurate placement of corticosteroid injection into the subacromial bursa for subacromial pain (or shoulder impingement) resulted in decreasing shoulder pain and disability (Chung et al, 2022)

A bursa is small sac (or bag) filled with fluid. They act like thin shock absorbers between the bones and other moving parts of the body like muscles and tendons to reduce friction. When a bursa gets irritated (or inflamed) it fills up with more fluid resulting in a condition called bursitis. We have many bursae (plura for bursa) in our hip, elbow and knee joints.

Researchers reviewed video images of ultrasound guided corticosteroid injections to rate the accuracy of injection into 3 groups. Group 1: Definitely/ probably not in the subacromial bursa. Group 2: Probably in the subacromial bursa and Group 3: Definitely in the subacromial bursa. 

There were a total of 114 subjects. 22 were categorised in Group 1, 21 into Group 2 and 71 in Group 3. I definitely expected the subjects in Group 3 to have the best result, but I was wrong. 

Results showed that there were no significant differences between the 3 groups at 6 weeks. So, no clear evidence that accurately injecting the subacromial bursa under ultrasound guidance is better than missing it. Even if the injections were done *blind versus guidance by ultrasound! 

*Blind means the injection is done at the point where the patient says the pain is versus using ultrasound to guide the injection into the correct inflamed area.

The authors concluded that the accuracy of injection placement in shoulder impingement did not influence pain and function suggesting that improvements in patients' outcome did not require ultrasound guidance.

Perhaps there is no difference in outcomes possibly because neither 'blind' nor ultrasound guided corticosteroid injections work in the medium to long term. The sample size is small and follow-up period is too short. Plus y'all know how I feel about steroid injections.

Another systematic review also investigated ultrasound guided versus landmark injections for rotator cuff related pain (Adamson et al, 2022) and came to the same conclusions.

Will these findings affect the doctors/ surgeons who charge more using ultrasound guided injections compared to doing the injections 'blind'?

And another paper (Marshall et al (2023) showed that the subacromial bursa promoted an early inflammatory response in an injured tendon to help healing. Using a rat to model rotator cuff injury and repair, the bursa protected the tendon adjacent to the injured tendon and maintained the structure of the underlying bone. 

I do not normally consider results from obtained from animal studies usually (rats in this case), but am persuaded in this case as every time a 'diseased' or damaged body part is deemed worthy of removal or function suppressed, we find out later it is a bad idea. Like our tonsils and meniscus.

Inflammation and healing are definitely misunderstood. Our busae release essential inflammatory fluid/ cells for help our injured tendons recover. Injecting them with cortisone/ steroids means hindering the body's own healing process and harming your own tendons. Think of it as the human body is being programmed to sort out its own injuries.

References

Adamson N, Tsuro M and Adams N (2022). Ultrasound-Guided Versus Landmark-Guided Subacromial Corticosteroid Injections For Rotator Cuff Related Shoulder Pain: A Systematic Review Of Randomised Controlled Trials. Musc Care. 20(4): 784-795. DOI: 10.1002/msc.1643

Chean CS, Raval P, Ogollah RO et al (2022). Accuracy Of Placement Of Ultrasound-Guided Corticosteroid Injection For Subacromial Pain (Impingement) Syndrome Does Not Influence Pain And Function: Secondary Analysis Of A Randomised Controlled Trial. Musc Care. 20(4): 831-838. DOI: 10.1002/msc.1634

Marshall BP, Ferrer XE, Kunes JA et al (2023). The Subacromial Bursa Is A Key Regulator Of The Rotator Cuff And A New Therapeutic Target For Improving Repair. bioRxiv (Preprint). July 2. DOI: 10.1101/2023.07.01.547347

Steroid Injections Accelerate Damage To Joint Surfaces

Picture from Ortho Arizona

Many patients with knee osteoarthritis (OA) who come to see us in our clinics often tell us that they were given intra articular (inside the joint) corticosteroid injections (IACS). ICAS is a common treatment choice that is considered minimally invasive to delay knee replacements for patients with severe OA. 

Other than providing brief pain relief, the pain often comes back. I wrote earlier this year that steroid/ cortisone injections significantly increases the risk of tendon tears.

Perhaps it's time to think more than twice before you allow anyone to inject into you knee joint. Make it any other joint for that matter as latest published research shows that individuals who got IACS were twice as likely to have harmful effects on knee articular cartilage structure than those who received no or placebo treatment.

Different stages of articular cartilage damage

A group of researchers investigated the effect of IACS on articular cartilage structure in patients with knee OA using joint space width on x-ray and articular cartilage thickness with MRI.

They found 6 studies consisting of a total pf 1437 participants. The estimated effect of IACS on articular cartilage structure showed significant odds of it worsening as measured by joint space narrowing and articular cartilage thickness. The authors concluded that their meta- analysis showed that IACS increases the likelihood of knee joint deterioration.

Other than increasing the risk of tendon tears, steroid/ cortisone  injections into knee joints may be doing more harm than good by accelerating joint surfaces degeneration. The short lasting pain relief is definitely not worth the long term consequences of your articular cartilage degenerating. 

Reference

Ibad HA, Kasaeian A, Ghotbi G et al (2023). Longitudinal MRI-defined Cartilage Loss And Radiographic Joint Space Narrowing Following Intra-articular Corticosteroid Injection For Knee Osteoarthritis: A Systematic Review And Meta-analysis. Osteo Imaging. DOI: 10.1016/j.ostima.2023.100157

Steroid/ Cortisone Injections Significantly Increase Risk Of Tendon Tears

Picture from BuzzRx

I was asked to do a home visit for a patient who was having some pain in his hip 2 days ago. The patient hurt his knee last year while playing golf and the doctor he consulted did a steroid/ cortisone injection for him. His knee was better for a while but some of the pain came back a short while later. 

Perhaps my patient was not able to weight bear well on that right knee since then and subsequently that caused his right hip to act up. After assessing him, I found that his sore knee was not the main cause of his hip pain, but definitely a contributing factor. 

I shared an article (referenced below) that I just read just a few days ago with my patient and his family regarding steroid/ cortisone injections. There were 1025 patients with shoulder pain in that hospital study. 205 patients received a steroid/ cortisone while 820 did not (they acted as the control group).

Patients in that study who received a steroid/ cortisone injection (for their shoulder pain) significantly increased the risk of having a shoulder tendon tear by 7.44 times compared to those who did not receive a steroid/ cortisone injection! 

Those who had concurrent chronic liver disease were 3.25 times more likely to have a torn tendon while those who smoked by 2.4 times. Another reason to stop drinking and smoking too.

Since my patient is an avid golfer and still very active, I told him he definitely does not need to have any more steroid/ cortisone injections anywhere else on his body. There are high chances of degenerative changes in the surrounding areas where the steroid/ cortisone is injected.

Remember my true story when I used to work at the Singapore Sports Institute (formerly Singapore Sports Council). Back then, I used to treat the badminton players frequently and traveled with them on most of their training trips and competitions. (Ronald Susilo and I pictured below after he beat world number one Lin Dan at the Athens 2004 Olympics).

I'm more excited than Ronald

In 2006-2007, Ronald Susilo had on and off right elbow pain, in his playing arm. He was subsequently injected with steroids (cortisone) a few times to help with the pain so he could train and compete.

Tragedy struck at the 2007 SEA Games in Thailand. He tore a forearm muscle while playing at the Games. I was tasked with accompanying him back to Singapore for a visit to the surgeon to repair it.

I've accompanied Ronald for all his sporting surgeries. His shoulder in 2004, Achilles in 2005 and right forearm in 2007. These were his words to the operating surgeon, "Gino knows my body better than I, he's been around for all my operations."

As usual I was waiting outside the operating theater for Ronald when they operated on his forearm. The first words the surgeon said to me when he came out of the operating theatre was, "We found cortisone still in his arm." My interpretation was that he meant too much steroid/ cortisone had been injected into Ronald's forearm. That probably caused the muscle to tear. Just like what the study by Lin et al (2022) had found.

Yes, there would definitely be occasions where a steroid/ cortisone injection is needed.  However, speaking from personal experience, if you're an athlete or participating in sports regularly like my patient, please reconsider if your doctor suggests a steroid/ cortisone injection. There are definitely other ways to treat your pain/injury besides getting a steroid/ cortisone injection. You definitely do not want to risk tearing any muscle or tendon after that.

Reference

Lin CY, Huang SC, Tzou SJ et al (2022). A Positive Correlation Between Steroid Injections And Cuff Tendon Tears: A Cohort Study Using A Clinical Database. Int J Environ Res Pub Health. 19(8): 4520. DOI: 10.3390/ijerph19084520.

Iliotibial Band Pain In Runners

The ITB originates from the TFL

I had a patient this week that was suffering from Iliotibial band (ITB) pain and he was so fed up with the pain that he was considering getting a steroid/ cortisone injection to get rid of the pain. He sent me an article he'd found for me to ask for my opinion.

Having previously suffered from Iliotibial band or ITB syndrome myself before, I'll naturally read any article I'd come across about the ITB.

The ITB over the Vastus Lateralis muscle

The article itself wasn't so interesting even though the authors got a good result after their intervention. The authors concluded that a steroid/ cortisone injection was effective in reducing ITB pain in runners in the first two weeks of treatment.

I'm not a fan at all when it comes to injecting steroid (or cortisone) to treat any sporting injuries. I written previously that often the cause of the problem is from the hip. For best results, you treat the cause of the problem.

As I've written previously, if you're an athlete or exercising regularly, you definitely do not want a steroid/ cortisone injection since there is a very high chance of degenerative changes in the surrounding area of the steroid injection. You can read about how my patient tore his forearm flexor tendon after repeated steroid injections.

Anyway, what intrigued me about this article was the small sample size and how long it took to recruit the runners (it took two whole years). The authors managed to recruit 45 runners but only 18 fulfilled the criteria and finished the study.

There was an attempt to have a longer follow up period, but there was too much variability in the second phase treatment of the condition. Their return to running, distance ran, rehabilitation program, change in footwear and use of orthotics etc.

Most of the eligible runners did not want to stop running during the 2-week intervention period. Exactly what I said about athletes (not wanting to rest) in my interview which you can see here. This shows the challenge of recruiting runners for research.

How about you? If you were recruited for a running research and asked to stop running for 2 weeks for the sake of research, would you comply? I'd like to hear your views.

Reference

Gunther P and Schwellung MP (2004). Local Corticosteroid Injection In Iliotibial Band Friction Syndrome In Runners: A Randomised Controlled Trial. BJSM. 38(3): 269-272. DOI: 10.1136/bjsm.2003.000283.

What? $3000 For A Steroid Jab!

Straits Times 030819, page B5, home section

Wow, that's very expensive for a steroid/ cortisone injection! What shocked me was that some doctors actually charged more as a result of the court case against an orthopaedic surgeon whose patient complained to the Singapore Medical Council after she developed side effects. 

On the flip side, some doctors stopped giving the steroid/ cortisone injections after that case.

As an athlete or as someone who is actively exercising, you definitely do not want to have a steroid/ cortisone injection. There are high chances of degenerative changes in the surrounding area where the  steroid is injected.

Here's a true story when I was working at the Singapore Sports Institute (formerly Singapore Sports Council). I've never written about this before and I guess it's time to put it on record. Back then, I used to treat the badminton players frequently and followed them on training trips and competitions.

In 2006-2007, Ronald Susilo was having right elbow pain, his playing arm. He was subsequently injected with steroids (cortisone) to help with the pain so he could train and compete.

Tragedy struck at the 2007 SEA Games in Thailand. He tore a forearm muscle while playing at the Games. I was tasked with accompanying him back to Singapore for a visit to the surgeon to repair it.

I've accompanied Ronald for all his sporting surgeries. His shoulder in 2004, Achilles in 2005 and right forearm in 2007. These were his words to the surgeon, "Gino knows my body better than I, he's been around for all my operations."

As usual I was waiting outside the operating theater for Ronald when they operated on his forearm. The first words the surgeon said to me when he came out of the operating theatre was, "We found cortisone still in his arm." My interpretation was that he meant too much steroid/ cortisone had been injected into Ronald's forearm. That probably caused the muscle to tear.

Granted, there would definitely be occasions where a steroid/ cortisone injection is needed.  However, speaking from experience, if you're an athlete or participating in sports regularly, please reconsider if your doctor suggests a steroid/ cortisone injection. There are definitely other ways to treat your pain/injury besides getting a steroid/ cortisone injection.

Here's a picture of Ronald after his left Achilles tendon rupture in 2005 at the World Badminton Championships. Kudos to him for coming back to play after each and every badminton career threatening surgery.

Steroid Injection Not Better Than Placebo For Low Back Pain

Picture by Army Medicine from Flickr

It seems like another of my patients has been asked if he wanted a cortisone (or corticosteroid) injection for his low back pain after I wrote about my shoulder pain patient last week who was asked by another doctor to get a steroid injection.

Evidence that they (cortisone or corticosteroid injections) work no better than placebo is mounting though.

The article referenced below is a systematic review. A systematic review is a computer aided search for all randomized and clinical controlled trials, meaning it's top of the line in terms of quality.

Researchers pooled data together from 30 placebo controlled studies of epidural steroid injections for radiculopathy (back pain that radiates to legs) and eight studies for spinal stenosis (back/ neck pain caused by narrowing of the spinal canal).

For radiculopathy, the steroid injections provided only short term relief. Over time, they were not more effective compared to placebo injections. They also did not reduce the need for surgery later for patients with more severe conditions.

The pooled data was similar for spinal stenosis.There was only some moderate temporary pain relief after the corticosteroid injections. There were no differences between steroid injections and placebo injections in pain intensity or functional ability lasting six weeks or longer after the injections.

The authors did note that some studies did not have many subjects while others had shortcomings their methodology.

The researcher in charge also suggested that there was probably some financial motivation to carry on using steroid injections despite the lack of evidence for its effectiveness. There is also a worry among professional societies (for doctors) due to implications for insurance coverage.

Other mentioned less selfish reasons is that doctors see their patients in horrible pain and concede that they do get some pain relief after the injections.

Please come to our clinics if you need help with your low back pain. We definitely do not give steroid injections.


Reference

Chou R, Friedly J et al (2015). Epidural Corticosteroid Injections For Radiculopathy And Spinal Stenosis: A Systematic Review And Meta-analysis. Ann Intern Med. 163(5): 373-381. DOI: 10.7326/M15-0934.

Do You Need That Cortisone (Steroid) Injection?

Have you got any pain in your elbow, patella or Achilles tendon? I've seen many cases of what used be called tennis elbow or lateral epicondylitis and Achilles tendinitis in our clinics recently. What is now known as tendinopathy (or diseased tendon) of the elbow or Achilles as these cases are actually due to degenerative change rather than inflammation as numerous studies have shown.

Most of the time patients with tendon problems were given a cortisone (or corticosteroid) injection to treat the pain (rather than treating what caused the pain). Cortisone, an anti-inflammatory agent used to be one of the preferred treatments for overuse injuries of tendons (like tennis elbow, patella and Achilles tendinitis) which were notoriously resistant to treatment. Cortisone is often used to treat plantar fasciitis too. 

Pain wise the injections were effective, but as soon as the patients returned to the their sporting activity or even their daily activities, the pain returned. In adverse cases the tendons can even rupture. This happened on a few occasions when I was working at my previous job at the Singapore Sports Council with our national athletes after receiving the corticosteroid injections. They subsequently needed surgery to repair their ruptured tendons resulting in more time off. So for all you athletes out there, think three, four or five times and not just twice about taking that cortisone injection.

A major new review article published in the Lancet just last week raised major doubts on the efficacy (or wisdom) of using cortisone on tendon problems. Yes, the authors found plenty of evidence (in over 4 dozen high quality randomized controlled trials) that corticosteroid injections reduced patients' pain in the short term, but the effects were not great in the intermediate and long term. In fact patients receiving the injections had a much lower rate of recovery than those who did nothing or received physiotherapy (at 6 and 12 months). This was especially true for patients with tennis elbow pain, rotator cuff (swimmer's shoulder) pain and Achilles tendon pain.

There are more evidenced-based treatment for tendinopathy other than cortisone injections, ultrasound, massage, interferential currents etc. We at Physio and Sports Solutions practice evidenced-based physiotherapy (neural stretching, Mulligan MWM's, eccentric muscles strengthening exercises and Maitland joint mobilizations etc) to treat you. Come let us help you with your tendon injuries.

Reference


Coombes BK, Bisset L, Vicenzino B (2010). Efficacy And Safety Of Corticosteroid Injections And Other Injections For Management of Tendinopathy: A Systematic Review of Randomised Controlled Trials. The Lancet. Epub on 22 October 2010.


*Picture by Ballyscanion/Getty Images.