By: Dr. Phillip To
There are a lot of misconceptions published on the Internet today about various types of injections. One of the most common injections, corticosteroid or cortisone injections, receives a lot of criticism and flak while other, newer therapies like PRP and stem cell therapy get a lot of praise. In this interview, Dr. Philip To of Arizona Bone and Joint Specialists takes a moment to debunk some of the common myths and misconceptions about injection therapy.
Interviewer: Please provide a brief overview of corticosteroid injections.
Dr. To: All patients should undergo non-op treatment first. Part of non-operative care includes the possibility of getting an injection. The most common injection is something called a corticosteroid injection. It’s very common, and it’s very safe. We've been doing it for many, many years. The purpose of a steroid is to change the inflammation patterns in that area.
For the upper extremity and shoulders, you’ll do a steroid injection around the tendon and inside the joints. All medicines have some side effects, including steroids. Common side effects are a loss of skin fat, white discoloration of the skin, and increased blood sugars. Uncommon side effects are tendon ruptures. Some steroids can leak deposits on tendons. Still, many studies have shown that steroid injections work.
I always compare them to this analogy: when you have a headache you take a Tylenol. This pill didn’t cure your headache, right? But it did help it go away and not be there. That's how I look at an injection. It's temporary, but it may just be the trick that helps.
Interviewer: How are steroid injections used in the hand and upper extremity? I.e. what conditions and surgeries benefit from injections most?
Dr. To: The most common body part I inject are trigger fingers. These injections work about 50-70% of the time. It's a good injection, and when done right, it's not that painful.
Another common area I inject is the thumb for arthritis. However, it is not as effective trigger finger injections. Carpal tunnel injections are a little less effective than trigger finger injections and arthritis injections, but I'm in the camp that, if you're not ready for surgery, I'll do whatever is best for the patient to relieve their pain and reduce their inflammation.
So, these injections can be beneficial. I've had patients who’ve received one injection and they never come back.
Interviewer: Patients often hear or read on the Internet that corticosteroid injections generally cause more harm than good. Can you comment on that?
Dr. To: To me, that's bad. If you get a cortisone shot every month, yeah, that's going to do more damage than good. That's with any treatment, though. It’s important patients understand steroid injections are okay in moderation. Most steroid injections are okay within a three-month interval. For me, I go by the “two-strike” rule. Meaning, I only administer two shots to a patient before suggesting a different therapy or procedure.
Those fears have led to Dogma that patients shouldn’t have any injections because they’re going to do more harm than good. I agree that the relief is usually temporary, but it's one of those things that if you don’t want to have surgery, and an injection only gives you three months of pain relief, then technically it served its purpose.
In a nutshell, corticosteroids are not harmful when used appropriately and they have more than one purpose. If I inject an area and the patient improves their pain, then I feel like I have the correct diagnosis. Corticosteroid injections can be therapeutic and diagnostic.
Interviewer: Do you know how long a corticosteroid injection will last in a patient with a mild condition versus a severe condition?
Dr. To: The problem is, everyone is so different. Researchers still don't know what causes arthritis, trigger finger, or carpal tunnel syndrome. We just have associations and correlations, but not causation. I tell patients, “You can get two weeks to two months of relief. Occasionally, your condition can be cured.”
Part of medicine is shaping expectations. Patients may be disappointed when they hear it might be only two weeks, but I try to say, "Let's not focus on that. Let's focus on the chance that it could make you better and could cure you." Then just go with that as the main focus versus trying to give the patient a timeline.
Interviewer: What are your thoughts on PRP injections and other newer injections?
Dr. To: These other injections like PRP, stem cell, and amniotic have gotten a lot more press lately. I have even heard of people injecting there own fat into their joints. The thing with those injections is, a lot of advertising is focused on the message, "avoid surgery today,” and “stem cell injections cure everything.”
The problem with that is, there's not a ton of research to back up these claims. I think it's misleading the customer and making them think, "If I pay $1,500 out of pocket, I can avoid surgery.”
That's why it’s important for patients to be informed. With PRP injections, the jury's still out on whether or not it works or doesn't work. I think there are some good, basic science and studies that support this therapy, but there are also studies that show it doesn't do anything.
I just try to be honest with the patient about it because PRP injections and stem cell therapy are not covered by insurance. I think it's important that a patient understands this. That's where the trust comes in. The other injections, the stem cell and amniotic, are currently not offered by us.
There's very little literature to support them right now. If a patient does want an alternative injection, they should have an honest conversation with the provider and say, "can you show me the study?"
If the provider can’t show you the study and explain why it works, they should not be injecting you.
I just want people to be educated. There needs to be more studies about these injections because they really could be the future of medicine. Until there are more studies, I'm going to be a little more skeptical for the sake of my patients. I don't like to try things on my patients without something to back it up with.
Interviewer: I read that the pain worsens before it gets better with steroid injections. Is that true?
Dr. To: Well, I always tell my patients that they’ll be sore the next day. Steroid injections are pretty similar to flu shots. If you think about it, your arm's pretty sore the day after a flu shot, right? It's a similar thing with steroid injections. It's not a myth because there is some truth to that statement, but it’s a different kind of pain for sure. It’s soreness that usually lasts two days. Although, not so much with trigger finger injections or carpal tunnel injections, but other injections that go directly into joints like the shoulder or elbow. I think that's going to leave a little more pain than not.
Interviewer: What makes you decide injections over surgery for a patient’s condition?
Dr. To: We know surgery will work better than injections for almost every single condition of the hand, but the reason why I may suggest an injection first is, it might work. If I can avoid my patient having to undergo surgery, I think that's huge. I think they're appreciative of it too.
The other thing is, injections are both therapeutic and diagnostic. You can't ever be a 100% sure that a patient has a condition without administering certain tests like an injection first.
Additionally, not all patients need surgery. I had a really famous spine surgeon tell me that he never operates on a patient until he has had two visits. Hand surgery is vastly different than the spine, but in the end, I think it is pretty reasonable. It's something I keep at heart. I really want to build that relationship with my patient. I like to see them more than once before we decide on surgery.
Interviewer: Is physical therapy helpful for any of this? Would you recommend physical therapy before an injection?
Dr. To: Typically, physical therapy is successful for people with pain in the shoulders or other extremities. For these patients, physical therapy can be just as good as an injection.
For the hands, however, like trigger fingers and stuff like that, physical therapy doesn't really work. It's not necessarily a waste of their time, but I don't think it's a good idea. I do think therapy is very good. I think there are a lot of beneficial aspects to it. If a patient wants therapy before they try surgery, I will totally do it. I tell them, however, that I think the success would be less than 50%.
Interviewer: On the flip side, would you recommend therapy after hand surgery?
Dr. To: Absolutely. If needed, I would definitely do that, no question. Therapy's very good. It makes a big difference. You have to individualize their care to what they need.
Interviewer: Is there anything else you’d like readers to know that we may not have asked?
Dr. To: I think the biggest thing that drives me insane is the stem cell and "avoid surgery now." Really, you should be talking to your surgeon and having an honest conversation with them. Get a second opinion when you do anything that's expensive and experimental. Bottom line: Do your homework.