Corticosteroids down-regulate immune function and reduce the number of inflammatory cells and mediators, such as lymphocytes, macrophages, and mast cells. (1)
Essentially, corticosteroid injections minimize pain.
- Down-regulate immune function through the reduction of inflammatory cells and mediators. (lymphocytes, macrophages and mast cells) (1)
- Reduce pain caused by inflammation
- Increase protein catabolism, decrease type I collagen and glycosaminoglycan syntheses, and therefore slow the healing process (1)
- Inhibition of collagen repair leading to accelerated joint degeneration (1,9)
- Bone loss, breakdown, and potential fracture (9)
- Traditionally overutilized in cases of tendinosis
- Intra-articular injections for conditions such as osteoarthritis
- Extraarticular injections for short-term pain relief associated with tendinitis (2)
The vast majority of current and past research supports the use of steroids for short-term pain relief and reduction of inflammation. These medications provide patients with exactly what they are looking for—quick symptom reduction. Unfortunately, pain relief and the anti-inflammatory properties are short-lived, and symptoms often return. Steroids also delay tissue healing, which can lead to an extended period of disability.
Conclusion: steroids may be used sparingly for these non-spinal purposes; however, long-term use is discouraged.
Autologous blood injections involve performing a peripheral blood draw to extract blood from a distal site then injecting it directly into the affected tendon.
Platelet-rich plasma (PRP) is a biological blood product derived from centrifuged whole blood to extract concentrated platelets. They are injected directly into the site of injury to promote tissue healing. (3)
- Introduce blood and platelet products to initiate maturation and proliferation. (4)
- “Stimulate cellular activity to initiate a healing response by increasing growth factors by increasing platelets or aseptic inflammation to trigger the reparative process of tendons.”(5)
- Most insurers do not cover PRP injections. Cash prices range from $800–1200 per dose with typically 1–2 injections providing significant relief of pain and improvement in physiologic tissue recovery. (6)
- There are few condition-specific standardized protocols. (7)
- Treat musculoskeletal injuries by facilitating tissue regeneration and healing. (8)
- Often included in a multimodal approach to treatment, including rehabilitation exercises and possibly instrument-assisted soft tissue manipulation.
Regenerative injection therapy is a conservation treatment designed to stimulate healing. Barnett et al. (2019) found that: “Individuals receiving these injections had long-term pain relief and increased self-perceived upper limb use. The results also suggest that doses of whole autologous blood, as well as platelet-rich plasma, are useful to decrease pain and increase self-rated upper limb use in individuals with lateral epicondylitis. An additionally important consideration is that the regenerative injections were helpful in the acute as well as chronic stages of lateral epicondylitis.” (5)
Conclusion: PRP and autologous blood injections may be used to promote a healing response in both the acute and chronic phases of disease; however, they do come at a higher out-of-pocket cost to patients.
When a chiropractic trial of care results in failure, you and your patients are left to consider other options. When assessing injections, first ask yourself the intent of the medication. Injections are designed to either suppress or catalyze an inflammatory reaction, so choose the diagnosis-specific desired cellular response. While most chiropractic physicians do not perform injections in office, developing relationships with local physical medicine providers may benefit your patients.
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- MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology. 2009;252:647–61. 11.
- Cole BJ, Schumacher RH Jr. Injectable corticosteroids in modern practice. JAAOS-J Am Acad Orthop Surg. 2005;13:37–46.
- Saucedo JM, Yaffe MA, Berschback JC, Hsu WK, Kalainov DM. Platelet-rich plasma. J Hand Surg. 2012;37:587–9.
- Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014;:CD010071. https://doi.org/10.1002/14651858.CD010071.pub3.
- Barnett J, Bernacki MN, Kainer JL, Smith HN, Zaharoff AM, Subramanian SK. The effects of regenerative injection therapy compared to corticosteroids for the treatment of lateral Epicondylitis: a systematic review and meta-analysis. Archives of Physiotherapy. 2019 Dec 1;9(1):12.
- Mlynarek R, Kuhn A, Bedi A. Platelet-rich plasma (PRP) in orthopedic sports medicine. Am J Orthop. 2016;45:290–326.
- Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med. 2009; 37:2259–72.
- Reeves KD, Fullerton BD, Topol G. Evidence-based regenerative injection therapy (prolotherapy) in sports medicine. In: The sports medicine resource manual. Philadelphia: Saunders (Elsevier); 2008. p. 611–9.
- Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?. Radiology. 2019 Oct 15:190341.
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Dr. Brandon Steele
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