Pills, Injections

Last updated May 2017

Early degenerative changes are common in the joints of sportsmen, particularly after injury. Short of surgery, there are quite a number of non-surgical options. Sometimes temporary moderation of activities, perhaps with a short course of non-steroidal anti inflammatory drugs (“NSAIDs” are drugs like voltarol, brufen and nurofen) will help, especially combined with optimising the muscle control around the weak joint. Splintage & bracing has a very limited role

Medicines

Beyond NSAIDs & simple analgaesia, there are a very wide variety of dietary supplements & alternative treatments which are often pushed quite hard. Some undoubtedly help, but the evidence for many is just not there one way or the other. There evidence for a high benefit / risk (and benefit / cost) ratio is strong for Glucosamine Sulphate in early degenerative change when taken at a dose of 1500mg per day regularly for 3 months. I am not persuaded that we should all be on it to prevent trouble in the future. It is often combined with chondroitin which may be beneficial. I think that the evidence for other potions is a bit thin, but there is a bit of support for cod liver oil, “fish oils” & msm.

For tendinopathies, we have recently had good results in avoiding surgery by using GTN (angina) patches. Work has been published primarily from Sydney supporting the use of a quarter of an angina patch daily directly on the painful spot for up to 24 weeks. It is thought to work through a nitric oxide (NO) related pathway.

Alternative Therapies

Undoubtedly, some so-called alternative treatments and remedies are effective, but there is often very little evidence of this. In fact, once there is evidence, they cease to be “alternative” and become main stream (for example acupuncture for certain conditions). It is easy to waste a lot of time and money pursuing cures which “have been used for thousands of years”, but for which there is neither any sensible reason why they might work, nor any practical evidence that they do. Before recommending an intervention, I need to see either one or other of these, and preferably both. This particularly applies to the mumbo jumbo of homeopathy.

Injections

Steroid (“cortisone”) injections are widely used, but I tend to avoid them unless there is a clear diagnosis and logical rationale for their use. They tend to calm everything down for a few weeks which may often break a vicious cycle of swelling, pain & muscle inhibition. They slow up the healing cells as well as the injury cells, but if the “bad guys” predominate, then they get hit harder by the steroids. The injection is a mixture of local anaesthetic with a steroid & often has a short term effect through the local anaesthetic for a few hours. The area is then sometime a bit worse the next day before settling again over the next few days.
In my opinion, there is absolutely no logic in giving a steroid injection unless it can be followed by a week or so of relative rest to allow it to have the maximal calming effect. If you feel good after a few days and then go out and train hard, you aren’t giving it a fair chance to work.

Viscosupplementation - hyaluronic acid preparations are also pushed quite hard by the manufacturers. Hyaluronic acid is a natural substance which probably acts as a shock absorber, lubricant & space-filler. It is made either by purifying an extract of roosters’ combs or bioengineered. Depending on the preparation, they will require either one or more often 3 to 5 weekly injections. They certainly have some effect, probably working by coating the unstable joint lining to “seal it off”. Interestingly, all but one of the preparations on the market have been licensed as “devices” rather than “drugs” implying that they are mechanical lubricants. The exact role is yet to be defined & they are quite expensive to buy (sometimes over £200 per injection), which explains why I am unable to use them in my NHS practice at present. They are available privately & it is usually possible to persuade the major insurers to cover the cost.

A very wide variety of other substances are used, usually with very little scientific support. Usually for poorly defined diagnoses, or musculotendinous problems. They are particularly popular on the European mainland. These include:
Prolotherapy - most commonly used in back ache, but also used in sports injuries especially partial ligament tears. This is an injection of sclerosant, which it is suggested may strengthen / tighten ligaments by inciting a fibrous response. In fact it may well work by killing the nerves which transmit the pain.
There is better evidence for localised sclerosing injections (polidocanol) into the new vessels which form adjacent to a tendinopathic area. This may also work by devervation allowing painless rehabilitation.
Whole blood / ACP / PRP (platelet rich plasma) etc - some good science is coming through now to support the uise of this in tendinopathies. Usually under ultrasound guidance after dry-needling the area. NICE has produced some
patient information.
Mesotherapy - this is very popular in France and has numerous devotees, but no evidence of efficacy. In my opinion, it may well primarily work through acupuncture with smoke and mirrors.
Actovegin - protein free ultrafiltrate of calf’s blood - may have an effect in encouraging granulation tissue and new blood vessel formation.
Traumeel - homepathic “herb garden” mixture of over a dozen ingredients. May have anti inflammatory properties.

Other therapies:
Cryotherapy - whole body cooling to minus 120 degrees C for a few minutes stimulates the skin, and may release mediators which appear to cure most ailments!
Hyperthermia - if cold doesn’t work........
Hyperbaric oxygen therapy - in a diving decompression chamber. This is thought to work not just by delivering more oxygen to the tissues (since the vast majority of oxygen in transported bound to haemoglobin which is fully saturated at sea level), but by effects on blood vessel constriction and agin on the release of chemical mediators. This is falling out of favour for sports injuries in the absence of any good evidence of efficacy.
Extracoporeal shock wave therapy - originally introduced to break up kidney stones, there is now quite good evidence for an effect in calcific tendinitis & especially in plantar fasciitis. Less good evidence if there isn’t any calcification. NICE has produced some
patient information.
Pulsed ultrasound and pulsed electromagnetic treatment - usually sold for acceleration of fracture healing (especially non-unions and stress fractures). Quite expensive and while they almost certainly do no harm, the evidence for a big effect is rather thin.

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