Are All Injections the Same??

You can see the needle starting on the top left, pointing down and to the right towards the target of the injection

Over the years we have seen drastic differences develop in the ways that injections are provided. I will review the differences in the common types of injections, from simplest to most skilled. This should help you find a provider who can take the best care of you, your friends and your family.

INTO THE MUSCLE:

The simplest injection provided at a doctor's office is into your muscle. This is an injection often done into an area around your shoulder or buttocks. The injection is usually a type of anti-inflammatory medication ranging from a weaker drug like toradol to potent high dose steroids. The idea is that these drugs will be absorbed by the high number of blood vessels that are in your muscles, and then distributed around your body. This form of drug delivery is quicker and usually stronger than having a person take medication by mouth.

There are a number of problems with this form of treatment:

1. Patient's often get the injection into a muscle near where they hurt (for example, in a muscle around the shoulder joint if they have pain from shoulder arthritis). They leave the appointment thinking they got a "shoulder injection" into the joint for painful arthritis, but they actually just got a dose of intramuscular steroids. Injections into the muscle will get into the blood and be distributed all over the body, it does not go directly to your aching joint.

2. We now know that steroids destroy local tissue. Ultimately, every dose of steroids injected destroys all the healing cells, including stem cells, in the local environment. Without these local stem cells to promote healing, local tissue degenerates. Over time this causes major problems. In a muscle, the muscle cells will turn to fat instead of muscle causing atrophy and weakness. This also increases the likelihood of tears in muscles and tendons. At this time there is almost no scenario when providers should be injecting the usual high doses of steroids that are given into muscles to help with pain.

PALPATION GUIDED INJECTIONS:

Next up is an injection that targets the joint instead of a muscle. The aim here is to actually get into the joint causing pain due to arthritis. In the past, the best a provider could do was know their anatomy, use their hands to feel for landmarks, and place a needle into a patient in the direction of a joint. Now that we have ultrasound and x-ray machines to help us visualize needles as they go into the body, there is no scenario where patients should be getting joint injections done blindly without these machines.

Here are the main problems with these injections:

1. Numerous studies have been done showing that even physicians who have done tens of thousands of blind injections, MISS THE JOINT HALF THE TIME. This is a terrible risk to take. Imagine if you had knee pain and your doctor said, "You need an injection into your knee and based on your response we can decide to schedule surgery." If there is a 50% chance they are going to MISS their target, are you going to feel comfortable agreeing to surgery? I hope not!

2. Again, steroids are harmful. If they are luckily injected into the joint in this scenario it is well known at this time that they cause cartilage to break down quicker than usual, leading to worse arthritis and more orthopedic surgeries. If the injection is one of the 50% that misses the joint, that means the steroid is injected into some soft tissue that will be destroyed, degenerate, atrophy, tear, etc.

IMAGE GUIDED INJECTIONS:

These injections SHOULD be the standard of care. Depending on the target, and depending on the skill of the person doing the injection, an ultrasound and/or an x-ray machine in the office can help them see where the needle is so they can be as close to 100% accurate as possible. The picture above is an example of an ultrasound guided injection. There is no doubt where that needle tip is.

The physicians who have been trained to do injections with these machines at the highest skill levels are Interventional Pain and Interventional Rehab physicians.

Some orthopedic surgeons take the time to learn these skills, but most do not. Most orthopedic injections done by primary care doctors and orthopedic doctors are done into muscles and blindly into joints, without confirming on ultrasound or x-ray.

So, when it comes time for you, your friends or your family members to have an injection - do your best to find an Interventional Physician with training and with equipment in their office to guide them. Otherwise, there's around a 50% chance your injection will end up in the wrong spot and worst case scenario this could be leading to a surgery you don't need!

At my practice I have state of the art ultrasound and x-ray fluoro to guide all treatments. I have extensive training using both machines, and often will use them together for the safest and most effective treatments.