Injection Therapy at Spine Plus Bow

Please read this information before your appointment

This leaflet explains what an ultrasound-guided corticosteroid injection involves, why you may be offered one, the possible benefits and risks, and what you should do after your injection.

Our service provides ultrasound-guided injections for joints, bursae and tendon-related problems. We do not perform injections into the spine or around nerves.

Your practitioner will medically assess you to ensure the injection is safe for you. You will have the opportunity to ask questions to your practitioner prior to injection.

WHAT IS AN ULTRASOUND-GUIDED INJECTION?

An ultrasound-guided injection uses an ultrasound scan to see the tissues underneath your skin. This allows the practitioner to guide a small needle accurately to the area being treated.

Depending on your condition, the injection may be given into or around:

• A joint;
• A bursa (a small fluid-filled sac that helps reduce friction around a joint); or
• A tendon-related structure.

The injection contains a mixture of local anaesthetic and corticosteroid.

WHY MIGHT I BE OFFERED A CORTICOSTEROID INJECTION?

Corticosteroid injections may be recommended when inflammation is thought to be contributing to your pain, swelling or stiffness.

The aims of treatment may include:

• Reducing pain and inflammation;
• Making it easier to take part in physiotherapy and return to your usual activities;
• Helping to diagnose whether a particular joint, bursa or tendon-related structure is causing your symptoms.

A steroid injection is part of a wider treatment plan rather than a cure for the underlying problem. For example, reducing your pain may make it easier for you to exercise and strengthen the affected area.

WHAT BENEFIT CAN I EXPECT?

Response to corticosteroid injections varies between patients.

Some people experience a significant improvement in pain and movement. Others experience temporary improvement, while some people experience little or no benefit.

Corticosteroid may take several days (up to 4 weeks) to have its full anti-inflammatory effect. You may experience instant pain relief from the local anaesthetic used this is often temporary.

It is important to understand that:

• An injection does not guarantee improvement;
• Any benefit may be temporary;
• The amount and duration of benefit vary depending on your specific condition

Your practitioner will discuss what benefit you can reasonably expect in your individual circumstances.

WHAT ARE THE POSSIBLE RISKS AND SIDE EFFECTS?

Most people have an ultrasound-guided steroid injections without serious complications. However, any procedure involving a needle carries some risk.

Temporary increase in pain – common

The area may be sore after the injection.

Your usual pain can sometimes temporarily become worse. This is sometimes called a “steroid flare”.

This usually happens within the first 24–48 hours and settles over the following few days. Occasionally, the pain may be more noticeable and last for up to a week.

This does not necessarily mean that anything has gone wrong and does not reduce the effectiveness of the injection. The tissues can become temporarily irritated before the steroid’s anti-inflammatory effect develops.

Infection – very rare

There is a very small risk of infection following an injection into or around a joint, bursa or tendon-related structure.

Published NHS patient information gives figures of approximately 1 in 10,000 for some ultrasound-guided injections, although the exact risk varies depending on the procedure and injection site.

An infection involving a joint or deeper tissue can be serious if it is not treated promptly.

Seek urgent medical attention if you develop increasing pain, swelling, redness or heat around the injection site, particularly if you also develop a fever or feel unwell.

Bleeding or bruising – uncommon

A small amount of bleeding or bruising where the needle enters the skin can occur. This normally settles without treatment.

The risk may be higher if you take blood-thinning medication.

Please tell your practitioner about any anticoagulant or anti-platelet medication you take.

Do not stop blood-thinning medication unless you have been specifically advised to do so by an appropriate healthcare professional.

Changes to the skin or fatty tissue – uncommon

Steroid can occasionally cause:

• The skin around the injection site to become lighter or darker; or
• Loss of some of the fatty tissue underneath the skin, causing a small indentation or “dimple”.

These changes often improve with time but can occasionally be permanent.

Temporary increase in blood sugar

Corticosteroids can temporarily increase blood sugar levels.

This is particularly important if you have diabetes. You may need to monitor your blood glucose more closely for several days after the injection.

If you have diabetes, follow the monitoring or medication advice given to you by your healthcare professional.

Facial flushing or feeling hot

Some people experience temporary:

• Facial flushing;
• A feeling of warmth; or
• Sweating.

This usually settles without treatment.

You may also feel temporarily light-headed or faint around the time of the procedure.

Allergic reaction – very rare

An allergic reaction can occur to the steroid, local anaesthetic or another substance used during the procedure.

A severe allergic reaction (Anaphylaxis) is very rare but can be life-threatening.

Symptoms can include:

• Difficulty breathing;
• Swelling of the lips, tongue or throat;
• A widespread rash;
• Severe dizziness; or
• Collapse.

Call 999 immediately if you develop symptoms of a severe allergic reaction.

Weakening of tissues

If your injection is for a tendon-related problem, your practitioner will explain where the medication will be placed.

Steroid can weaken tendon tissue, and tendon rupture has been reported following steroid injections.

The risk depends on:

• Which tendon is being treated and the condition of that tendon;
• Where the medication is placed

For this reason, steroid injections are not appropriate for every tendon problem.

To reduce risk of tendon injury you will be advised to avoid heavy or repetitive loading of the tendon for a 3 week period after the injection and then gradually return to activity.

Your practitioner will explain any additional risks and activity restrictions that apply to you.

Other less common side effects

Because a small amount of corticosteroid can enter the bloodstream, some people may experience temporary effects elsewhere in the body. These can include:

• Headache or dizziness
• Difficulty sleeping
• Temporary mood changes, such as feeling more anxious, restless or unusually energetic
• Menstrual changes, including an irregular or delayed period or unexpected vaginal bleeding. These are usually temporary.
• Hiccups, which are very uncommon and usually temporary
• Temporary changes in appetite
• Temporary increase in sweating
• Temporary blurred or altered vision - seek medical advice if this occurs
• Temporary stomach upset or indigestion

These effects are very rare after a single local injection, but the likelihood can be higher with larger doses or repeated steroid treatments.

WHAT SHOULD I DO AFTER MY INJECTION?

For the first 24–48 hours

• Take it easy and avoid activities that aggravate your symptoms.
• Avoid strenuous exercise or heavy/repetitive loading of the treated area unless your practitioner has advised otherwise.
• Gentle movement is usually encouraged, unless you have been given different instructions.
• You may use over-the-counter pain killers if required and safe to do so.
• If the area is sore, a cold pack wrapped in a cloth may help.

After 48 hours

Gradually return to your usual activities as your symptoms allow, unless you have been given specific restrictions.

If your injection was for a tendon-related problem, follow the specific advice given by your practitioner, as you may need to avoid heavy loading for longer before gradually increasing activity.

A temporary increase in pain during the first few days can occur. However, severe or rapidly worsening pain is not something you should ignore. Follow the urgent medical advice below if you are concerned.

WHEN SHOULD I SEEK URGENT MEDICAL HELP?

Seek urgent medical attention if, following your injection, you develop:

• Severe or rapidly worsening pain;
• Increasing swelling;
• Redness or heat around the injection site;
• Fever or chills;
• Feeling significantly unwell;
• Persistent or excessive bleeding;
• Difficulty breathing;
• Swelling of your face, lips, tongue or throat; or
• A widespread rash associated with feeling faint or unwell.

Call 999 immediately if you develop difficulty breathing or swelling of your tongue or throat.

Very rarely, a severe inflammatory reaction can occur after an injection and may look like an infection. This is sometimes called a “pseudo-sepsis” reaction.

Because it can be difficult to distinguish this from a genuine infection, severe or rapidly worsening symptoms require urgent medical assessment.

SIDE EFFECTS THAT MAY OCCUR AFTER THE STEROID INJECTION

• A small amount of bleeding and bruising may occur, which will usually settle without any treatment
• Numbness may occur in the region of symptoms, and may extend down a limb or into the hand/foot
• There may be some pain, heat, redness and swelling for 1-2 days in the region of symptoms. It usually settles with a cool pack and regular painkillers
• If you are a diabetic using insulin, your blood glucose levels may increase for a few days. Contact your diabetic nurse if needed
• Facial flushing and/or a hot flush may occur for 1-2 days after the injection
• An irregular menstrual cycle may occur for a few months
• The skin may go white and/or form a dimple around the injection site (resolves after a few months)
• Headaches (1 in 10 patients)
• Increased blood pressure
• Stomach pain or acid reflux (particularly if you have a stomach ulcer)
• Tendons can be more prone to tears/rupture after steroid injections (see below)
• Weakening of the cartilage in a joint (particularly with repeated injections)

WHAT HAPPENS AFTER THE STEROID INJECTION?

• We advise you not to drive for six hours after an injection
• If you have had local anaesthetic injected, you may not have any pain for the first few hours
• Do the minimum activities necessary for the next 2 days after the injection
• In the first month afterwards, do not put any strain on the area of symptoms while the injection works
• For tendon sheath/bursa injections, you should avoid activity that caused pain (during or after the activity) for at least 1-2 months afterwards
• Physiotherapy follow up is important for advice on when and how to return to activities, and for advice on a rehabilitation/exercise programme (particularly with tendons, which can take 4-6 months to heal).

After 48 hours

Gradually return to your usual activities as your symptoms allow, unless you have been given specific restrictions.

If your injection was for a tendon-related problem, follow the specific advice given by your practitioner, as you may need to avoid heavy loading for longer before gradually increasing activity.

A temporary increase in pain during the first few days can occur. However, severe or rapidly worsening pain is not something you should ignore. Follow the urgent medical advice below if you are concerned.

HOW QUICKLY DOES IT WORK AND HOW LONG DOES IT LAST?

Most people notice an improvement within a few days or a week. However, it may take up to 6 weeks for the steroid to work. The benefit can last for 2-12 months, or for even longer sometimes.

RARE SYMPTOMS THAT REQUIRE AN URGENT GP APPOINTMENT OR VISIT TO THE EMERGENCY DEPARTMENT (A&E)

If you have severe pain, redness and swelling at the site of the injection, or fever persisting for at least 2-3 days after the injection, then this could be infection. Please see your GP urgently or go to A&E.

Allergic reactions are extremely rare, and if they occur soon after the injection at home, look out for redness and swelling of the skin. Please see your GP urgently or go to A&E, particularly if you are having difficulty breathing.

If you feel drowsy, confused, dizzy or euphoric, have tinnitus, blurred or double vision, generalised sensations of heat, cold or numbness, twitching, or tremors at home on the day of the injection, this would also be extremely rare, but could be due to the local anaesthetic injection. You will need to go to A&E.

If any further advice is required then please contact your clinic provider

Please read this information before your appointment

Hyaluronic acid (HA) injections can give some reduction in the pain of Osteoarthritic joints. However, the improvements are usually temporary (lasting a maximum of 6-9 months). HA injections are generally very safe, although occasionally patients may experience some side effects after treatment.

The aim of this patient information leaflet is to provide you with the necessary information regarding your treatment. We ask all patients to provide written consent prior to booking an injection to ensure they have read and understood the information provided.

WHAT ARE HYALURONIC ACID INJECTIONS AND HOW ARE THEY USED?

Hyaluronic acid occurs naturally within the body. The Hyaluronic acid used in injections is a synthesised (man-made) version of this substance. HA injections are sometimes recommended for people with Osteoarthritic conditions (wear and tear of joints), which may cause pain. A range of Hyaluronic acid injections exist. Some patients may require a series of injections and some injections can be delivered as a one-off treatment.

WHAT HAPPENS WHEN I HAVE A HYALURONIC ACID INJECTION?

The clinician, who will be performing your injection, will choose the most appropriate Hyaluronic acid for your condition and symptoms. They will usually inject the HA directly into the area where you have the pain, such as a joint. Most injections are quick and easy to perform.

An ultrasound scan can be used to find out more about where the pain and osteoarthritis is, and also to deliver the injection more precisely.

WHAT HAPPENS AFTER THE INJECTION?

If you have a local anaesthetic your pain may be relieved within minutes, but the effect will usually wear off after an hour or two. It usually takes 4 weeks for the effect of the HA to become apparent.

You might wish to arrange alternative transport home after your injection, especially if you are having a local anaesthetic which may cause some numbness and make it difficult to drive.

If you are having an injection into a joint, you may be advised to avoid strenuous exercise for two or three days afterwards due to potential post-injection discomfort. If you are having an injection around a tendon, you may be asked to avoid heavy impact and loading activities for a few days, again due to potential discomfort after the injection.

WILL I NEED ANOTHER INJECTION?

If you find the Hyaluronic acid injection helpful, and other treatments have been unsuitable or have not helped, the injection may be repeated. There is currently no research evidence to suggest any long term harm to tissues from having repeat injections of Hyaluronic acid.

POTENTIAL RISKS AND SIDE EFFECTS.

Most people have HA injections without any side effects. A full list of potential risks and side effects are listed below:

Post injection flare

Some people (around 20-30%) may have some pain for a day or two after the injection (post injection flare), but this usually resolves quickly and can be managed with relative rest and over-the-counter painkillers. A much smaller proportion may have a more significant level of pain which will last for up to a week.

Very rarely patients experience a much more severe pain and swelling (known as pseudo-sepsis) which requires medical review to ensure there is no infection.

Will it hurt?

It can be a bit uncomfortable at the time of the injection, but many people find that it is not as bad as they initially feared.

Infection

Very rarely (approximately 1:50,000 injections) you may get an infection in the area of the injection. If the joint becomes more painful, hot and swollen, and/or you are feeling hot, nauseous and unwell you must seek medical attention immediately e.g., go to your local accident and emergency department (A&E). You should inform the medical professional examining you that you have recently had a Hyaluronic acid injection into your joint as they may need to give you antibiotics.

To minimise this risk, the treating clinician will sterilise the area prior to injection and cover it with a plaster afterwards. It is important that you keep the injection site clean and dry until it has healed (normally 24 hours post injection). You can shower/wash in the 24 hours post injection but keep the area clean and apply a new plaster afterwards.

Anaphylaxis

It is extremely rare to have an allergic reaction to Hyaluronic acid or local anaesthetic (1:500,000). This would usually happen within the first few minutes of an injection and requires immediate medical attention. Very rarely the allergic reaction can be delayed. The symptoms you might experience are feeling light-headed or faint, breathing difficulties (such as fast, shallow breathing and/or wheezing), a fast heartbeat, clammy skin, confusion and anxiety, collapsing or losing consciousness.

You will be asked to remain in the clinic for 20 minutes following the injection to allow for observation of possible adverse reactions.

Other potential side effects

There are very few other reported side effects that have been linked with the use of Hyaluronic acid.

Can I take other medicines along with the hyaluronic acid?

Yes, you can take other medications alongside the Hyaluronic acid injection. There are no known significant drug interactions that occur with Hyaluronic acid. However, if you are taking a blood- thinning drug, such as Warfarin, you may need a blood test to make sure that your blood is not too thin to have the injection. This is because of the risk of bleeding into the joint at the time of the injection. Therefore, you must tell the clinician giving the injection if you are taking an anticoagulant as they may need to discuss this with your GP before giving you the injection.

Pregnancy and breastfeeding

Unfortunately, we are not able to offer Hyaluronic acid injection to patients who are pregnant without receiving specific consent from their GP. There are currently no known associated risks to having HA injection whilst breastfeeding, although you might still wish to discuss with your GP first.

WHAT ARE THE POSSIBLE RISKS AND SIDE EFFECTS?

Below is a summary of the risks/side effects of having hyaluronic acid injections:

Serious side effects are rare but can include:

• Joint and soft tissue infections – requires urgent medical attention.
• Anaphylaxis (allergic reaction) – requires urgent medical attention.
• Very rarely, severe pain and swelling (known as pseudo-sepsis) - requires medical assessment.

Other potential side effects include:

• Post injection flare – usually mild and settles within a few days, but occasionally can be more severe and last up to a week.

Your clinician is highly trained and will take every appropriate step to avoid injecting or traumatising any soft tissue structures, nerves or vessels when performing the injection, but there is always a very small risk that this could occur, particularly with injections at certain locations.

You will be asked to remain in the clinic for 20 minutes following the injection to allow for observation of possible adverse reactions.

If you have any questions regarding the information contained in this leaflet, please contact us and we will arrange for one of our clinical specialists to speak with you.

If any further advice is required then please contact your clinic provider