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Tendon & soft tissue injections

The use of cortisone for treating injuries of the musculoskeletal system has been widespread for many years. Common conditions like arthritis (inflammation of the joint) and tendinitis (inflammation of the tendon) were shown to respond dramatically to a cortisone ‘shot’ which propelled its use in sports medicine, orthopaedics and general practice. Over the past 20 years or so, the clinical and scientific community have begun to observe and investigate less desirable outcomes with tendon and soft tissue injections.

Why are tendons so ‘special’?

Tendons are composed of densely arranged collagen tissue which forms the building blocks of the connective tissues in our body 1 2 . In younger people, tendons have tremendous tensile strength which allow them to tolerate a high level of loading. Think about the amount of force the shoulder tendons of a climber, gymnast, throwing athlete or a professional tennis player have to withstand. With age 3 (and I’m sorry to tell you this – but tendon health starts diminishing over the age of around 30) tendons start to show signs of ‘wear and tear’. They become less elastic, less adaptable, de-conditioned and their loading capacity reduces. Usually the demand we put on tendons in our 30s and 40s is erratic too (think of someone who has a sedentary job in front of a screen but chooses an hour of explosive exercise on the 5-a-side pitch once a week!) and this can lead to small (but often persistent) injuries of the tendon which in turn causes pain and disability. Tennis elbow, Golfer’s elbow, rotator cuff injury, patella tendinopathy, Achilles tendinopathy tendinopathy and plantar fasciitis are all really common injuries in this age group and are conditions that previously could have been treated with a tendon & soft tissue cortisone injection. When these structures are injured there is an initial inflammatory stage where the repair process starts and this is closely followed by a repair and regeneration phase and finally the remodelling and maturation phase at which point the process is complete 4. The trouble is, we need our tendons and the healing process is often interrupted by necessity (“I can’t afford to stop working to let this injury repair properly”) or life choices (“I love climbing too much to let this injury stop me”). Instead of the recovery being completed in one process, the healing tissue is repeatedly injured causing a ‘re-start’ of the inflammatory process. This leads to a chaotic situation in the tissues where the healing process gets stuck in a chronic cycle of inflammation, repair and breakdown. At this point the tendon has a complex mix of pathology and is labelled a tendinopathy 5 – which just means ‘pathology of the tendon’.

Why do we have to be careful with tendon & soft tissue injections?

Cortisone is a powerful anti-inflammatory and so is very good at ‘putting the fire of inflammation out’! The problem is that an injured tendon has to go through the normal healing process. If cortisone is introduced at the wrong time it can interfere with the healing process and prevent the tendon recovering properly. To make matters worse, the immediate and dramatic improvement in pain that can be achieved with cortisone makes it a tempting treatment option for both therapist and patient. What we now know with certainty is that cortisone has very limited utility for most tendon injuries and can only be used in rare circumstances. Furthermore there is evidence to show that when cortisone is used for tendon and soft tissue injections, it can harm the biomolecular make-up of tendons 6, stunt their healing potential 7 and has been associated with tendon rupture, particularly in sport 8. For all these reasons, a cortisone injection for a tendon injury is very low down the list of possible treatment options but the good news is that there are much better options for treating these conditions (see below ‘What is the best treatment for tendon injury then?’). For the more recalcitrant tendinopathies we now have an effective injection option in the form of platelet rich plasma (PRP) which is enjoying increasingly strong support from scientific studies demonstrating its effectiveness in the treatment for all tendons (e.g. tennis elbow, rotator cuff, Achilles and patellar. All the conditions where cortisone is problematic – PRP provides an effective alternative.

What is the best treatment for tendon injury then?

The good news is that there is a great deal of evidence supporting non-invasive treatment techniques for tendon injury. These injuries need to be managed carefully from the beginning – reducing the load it has to deal with and gradually increasing this with specific exercises over many weeks. “Boring” I hear you say! Well maybe, but if you’re looking for evidence-based practice, you don’t get any better than this and your physio will love guiding you through this with creative and innovative exercises to help you achieve a full recovery.  The other ‘gold-standard’ treatment modality for tendinopathies is shockwave therapy (SWT) which also produces excellent clinical outcomes. 

We are here to help with tendon & soft tissue injuries

Leave the thinking up to us. As with any painful condition or injury, the treatment process starts with a comprehensive examination by one of our expert team. From here we will present your diagnosis and discuss a plan for your recovery. If a tendon and soft tissue injection would be a helpful part of this – we’ll let you know.