Being an athlete means bumps, bruises and strain on your body. In sports medicine, it is common practice to use soft-tissue injections to help relieve pain and/or inflammation caused by athletic activity. Soft-tissue injections are typically done into or near a muscle, tendon, bursa and/or fascia. Though this practice is widely accepted, there are potential serious side effects – especially in the pre-game setting. (16)

Typical muscle injuries found in sports include strains and contusions (16).

Contusions can result from blunt trauma (16). For example, a player tackling an opponent.

Muscle strains can result from continuous/vigorous muscle contractions. For example, sprinting or jumping. (7, 11, 16)

These types of muscle injuries lead to a partial disruption of muscle fibers and varying amounts of:

  • muscle necrosis – premature cell death of muscle tissues
  • vascular disruption – damage/interruption of blood vessel (arteries, veins, capillaries) development (21)
  • hematoma formation – injury to the wall of blood vessels causing blood to pool outside into the surrounding tissues – which can result in a mass or lump
  • inflammation – reaction triggered by your immune system in response to injury causing swelling, redness and/or pain

Repairing the muscle can take time. After an injury, the connective tissue scar strengthens by day 10 (11). And then, the remodeling stage begins. This includes maturation of muscle repair and contraction and reorganization of the connective tissue scar. (11) Depending on the severity and treatment of the injury, it can take up to several weeks for an athlete to fully recover (10).

Here is a table of common injuries where soft-tissue injections are used:

soft-tissue injury table

What is the body’s healing response?

Inflammation is due to disruption of musculoskeletal tissues (i.e., muscles, tendons, bone, joints, cartilage, ligaments) by excessive mechanical load or repetitive use (16). Once an area becomes overworked or trauma happens, the body’s inflammatory response is triggered. The resulting response is sent to the site of primary injury. For example, an overworked pitcher’s arm. As the inflammation response continues, it can extend to an area of secondary injury (14). This is where corticosteroids or nonsteroidal anti-inflammatory drugs (NSAID) can come into play. These drugs suppress the continued inflammatory response and can potentially limit secondary injuries, in addition to, quicker healing and earlier rehabilitation (16).

The normal healing process of soft tissue injuries consists of 4 phases (6):

  1. inflammation
  2. regeneration
  3. remodeling
  4. maturation

Corticosteroids and NSAIDs inhibit certain “biological players” who play a role in pathways triggered by our body’s inflammatory response (14, 16). That is to say, soft-tissue injections interfere with the normal healing process in order to get an athlete to return to play sooner.

Are soft-tissue injections safe?

CORTICOSTEROIDS

Though use of corticosteroids is considered controversial (2, 4, 14, 17), there is a long history of use in athletics. Some studies have stated no other treatment has provided consistent local symptomatic relief in numerous cases with so few harmful effects (8, 9). In contrast, other studies documented hypertension, glucose intolerance, Cushing’s syndrome, and other side effects with systemic use of corticosteroids (1).

Corticosteroid injections can help treat secondary inflammation. However, inflammation is part of the normal healing process. Therefore, athletes should use caution when using corticosteroids to treat muscle injuries.

Sports medicine clinicians should be aware of the different corticosteroid agents and their varying pharmacologic characteristics. Agents with low solubility are found to have high risk of changes in soft tissue and skin when used for soft tissue injections (3, 20). Knowing the options and characteristics of an injection, allow clinicians to make the best decision when treating individual athletes.

A 2000 study (15) reported improved return to play with corticosteroid injections used on 58 NFL players with severe hamstring injuries. However, this study had no control group. Therefore, we should consider the results with care. Other studies, similarly, found improved short-term results using corticosteroids, compared to local anesthetic or conservative treatments for tennis elbow (18) and golfer’s elbow (19). However, studies have also noted no benefit of corticosteroid injections (5). A 2007 study suggested use of corticosteroid injections were not effective in treating rotator cuff disease (13). A common issue found in baseball players and other athletes.

Should you use soft-tissue injections?

Corticosteroid injections should only be used when absolutely necessary and other nonsurgical treatments have failed or are not available (14, 16). Athletes should be aware of how frequently they receive injections. Research recommends spacing injections over several weeks and to use no more than 3 per athlete. Corticosteroid injections given before competition, just after injury, or if there are signs of infection should be avoided (2, 12, 14). It is vital athletes feel informed and use caution when accepting injections.

In short, it is all about awareness. It is important athletes have thorough discussions about the costs and benefits of the injection before competition – this will allow the athlete to make an informed decision and not be influenced by the emotions of an impending game. If you’re an athlete, make sure you ask about what injections or other treatments you are receiving. Be aware of the frequency at which you use a treatment and know the risks.

Perhaps we should reorient our focus from how to quickly fix, to how to prevent soft-tissue injuries. Consequently, reducing the need of soft-tissue injections. With Sportavida testing, you can keep an eye on your soft tissue repair index, inflammation, muscle stress, and other important biological factors. This allows you to know beforehand if you are at greater risk for injury.

If you are still unsure about the use of soft-tissue injections – check back to see costs and benefits of other commonly used soft-tissue injections in the next blog.

Thank you for reading! I hope you feel more informed and if you have any questions or comments, please feel free to give a shout out.

 

 

 

REFERENCES

  1. Baxter JD, Forsham PH. Tissue effects of glucocorticoids. Am J Med. 1972;53(5):573-589.
  2. Buckwalter JA. Current concepts review: pharmacological treatment of softtissue injuries. J Bone Joint Surg Am. 1995;77(12):1902-1914.
  3. Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002;66(2):283-288.
  4. Cole BJ, Schumaker R. Injectable corticosteroids in modern practice. J Am Acad Orthop Surg. 2005;13(1):37-46.
  5. DaCruz DJ, Geeson M, Allen MJ, Phair I. Achilles paratendinitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64-65.
  6. Fadale PD, Wiggins ME. Corticosteroid injections: their use and abuse. J Am Acad Orthop Surg. 1994;2:133-140.
  7. Garrett WE. Muscle strain injuries. Am J Sports Med. 1996;24(6)(suppl): S2-S8.
  8. Hollander JL. Intra-articular hydrocortisone in arthritis and allied conditions: a summary of two years’ clinical experience. J Bone Joint Surg Am. 1953;35:983-990.
  9. Hollander JL, Jessar RA, Brown EM. Intra-synovial corticosteroid therapy: a decade of use. Bull Rheum Dis. 1961;11:23-40.
  10. Järvinen, T. A., Järvinen, M., & Kalimo, H. (2014). Regeneration of injured skeletal muscle after the injury. Muscles, ligaments and tendons journal3(4), 337–345.
  11. Jarvinen TA, Jarvinen TL, Kariainen M, Kalimo H, Jarvinen M. Muscle Injuries: biology and treatment. Am J Sports Med. 2005;33(5):745-764.
  12. Kerlan RK, Glousman RE. Injections and techniques in athletic medicine. Clin Sports Med. 1989;3:541-560.
  13. Koester MC, Dunn WR, Kuhn JE, Spindler KP. The efficacy of subacromial corticosteroid Injection in the treatment of rotator cuff disease: a systematic review. J Am Acad Orthop Surg. 2007;15:3-11.
  14. Leadbetter WB. Anti-inflammatory therapy in sports injury. Clin Sports Med. 1995;14(2):353-410.
  15. Levine WN, Bergfeld JA, Tessendorf W, et al. Intramuscular corticosteroid Injection for hamstring injuries. Am J Sports Med. 2000;28(3):297-300.
  16. Nepple, J. J., & Matava, M. J. (2009). Soft tissue injections in the athlete. Sports Health1(5), 396-404.
  17. Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005;15(5):370-375.
  18. Smidt N, Assendelt WJ, van der Windt DA, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic review. Pain. 2002;96(1-2):23-40.
  19. Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis: a prospective study of sixty elbows. J Bone Joint Surg Am. 1997;79(11):1648-1652.
  20. Stephens MB, Beutler AI, O’Connor FG. Musculoskeletal injections: a review of the evidence. Am Fam Physician. 2008;78(8):971-976.
  21. Van Allen, M. I. (1992). Structural anomalies resulting from vascular disruption. Pediatric clinics of North America39(2), 255-277.