Foot and Ankle Injections

Mr Andy Roche

The Fortius Clinic Lecture Series - November 2015 Issue

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Pills and Potions

Professor Cathy Speed

Cervical Injections

Mr Jason Harvey

In this issue:

MSK Cocktail

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Sophie Whitby, Marketing Assistant

e: Sophie.Whitby@fortiusclinic.com t: 0203 195 3043.

November TOPIC:

MSK Cocktail

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You will also find us on Facebook and LinkedIn.

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> news-events > lecture-series

This month’s lecture evening was popular as ever, with over 60 attendees and many new faces. The topic of ‘MSK Cocktail’ was an interesting mix of non-operative treatments which made room for stimulating discussion. This November lecture was the last one for 2015 as we take a break during the festive period.

The evening’s speakers were physician Professor Speed, Mr Harvey on of our spinal surgeons and Mr Roche one of our foot and ankle surgeons. A line up which proved a well-rounded insight into diagnosis of musculoskeletal injury and their treatments. Professor Speed discussed the ‘pills and potions’ typically used in sports injury clinics, whilst to Mr Harvey and Mr Roche who focused on injection therapies.

Professor Speed kicked off the evening explaining the range of non-surgical interventions and their effectiveness. She emphasised the importance of considering risk factors, such as, not using NSAIDs when the patient has GI toxicity, renal impairment, hypertension, cardiovascular problems, allergies, asthma or bleeding diathesis.

Secondly we had Mr Harvey whose talk was on ‘Cervical Injections’. He highlighted that cervical injections can help diagnose, alleviate and avoid surgery for neck pain, radicular symptoms or myelopathy, recalling upon his personal experiences and leading studies.

To conclude the lecture evening Mr Roche spoke about foot and ankle injections. He believes that PRP may have a big role to play in acute Achilles rupture if animal models are backed up by human trials, touching on evidence from a recent study in The Lancet.

Please send any enquiries through to me, you will find my details above. Feedback is always beneficial for us to ensure that we are covering popular topics and catering to everyone’s needs. We look forward to seeing you all in January 2016.

The Fortius Lecture EveningEvery month the Fortius Clinic hosts a lecture evening for Physiotherapists and Sports & Exercise Medicine professionals, led by a different team of specialists. The evening event is held in central London. If you would like to be added to our invitation list, please email marketing@fortiusclinic.com.

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“Coming across Fortius Clinic was one of the best decisions my team and I have ever made for my career. I was unsure if I would be returning to skiing at a competitive level and now my knee feels stronger than

it was before”Natalie Harte, British Skiier

Ski Injury Service The Fortius Clinic Ski Injuries service is built upon proven excellence in diagnosing, managing and treating sports injuries, and we use this knowledge to provide a world-class service for skiers and snowboarders.Snow sports have become extremely popular in recent years. But both skiing and snowboarding place great mechanical stress upon the musculoskeletal system, bringing with them a high number of orthopaedic injuries.

Our multi-disciplinary team of surgeons, physicians and radiologists are all highly experienced specialists in their field of orthopaedics. They are amongst the UK’s finest and their areas of specialism cover:

• Knee• Shoulder• Elbow• Foot and ankle• Hand and wrist• Spine• Hip and groin

Whether you are a professional or leisure skier, you can be confident that you will receive the highest standards of care and treatment, based on the latest medical evidence and using leading edge procedures and techniques.

Patients are welcomed and looked after throughout their visit to our clinic in the centre of London, which sets a new standard of service and comfort for outpatient orthopaedic treatment and care. The clinic has comfortable consulting rooms, treatment rooms where non-surgical procedures are carried out and in-house imaging facilities, including state-of-the-art MRI, ultrasound and X-ray scanning equipment. This means that we are able to assess all snow sports injuries, develop rapid diagnoses and provide unified treatment plans under one roof. Each patient receives the same level of world-class, personalised treatment that defines us.Ski Injuries Team can be contacted by phone or email and will book your appointment and any imagine requirements. We offer a same day and next day appointment service and ensure that there is a member of every sub specialty in clinic each day. If surgery is necessary this will be carried our by a Fortius surgeon at one of our partner private hospitals in London. Non-surgical procedures, such as guided injections, can be carried out at the clinic. The Fortius team manages the entire process from referral, through consultation and diagnosis, outpatient and hospital treatment to a managed hand-over for follow up and rehabilitation. Visit our website www.fortiusclinic.com for education-al material on some of th more common ski and snow-boarding injuries that we treat

To arrange an appointment call us on +44 (0)203 195 2445

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FEATURE | Cervical InjectionsLecture by Mr Jason Harvey Consultant Orthopaedic Spinal Surgeon

Nicole Atmore reports on the talk by Mr Jason Harvey, Consultant Spinal Surgeon, on Cervical Injections.

Mr Jason Harvey Consultant Orthopaedic Spinal SurgeonConsultant Spinal Surgeon who specialises in neck and back pain,as well as nerve pain related to these conditions.

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Mr Harvey began by emphasising that if a patient presents with neck pain, radicular symptoms or myelopathy, he would always consider cervical spine injections first, in order to avoid surgery, and particularly multiple level surgery, where possible. He highlighted a cervical radiculopathy survey which evidenced the beneficial effect of injection therapy. The survey, which was carried out from 1976 to 1990 of 561 patients, aged between 13 and 91, and treated by injection, showed that over two thirds of the patients did not have a recurrence of the condition after about five years and only just over a quarter needed surgery.He covered the reasons for neck pain, including physical compression of the nerve, pressure, ischemia and the release of biochemical sensitizers such as interleukin 1 or prostaglandins. Clinically it can be extremely difficult to decide which level is responsible for the pain or whether it’s a truly radicular problem with nerve compression or alternatively a referred pain. This is because there are a lot of connections between the various nerve roots. Pain around the scapular region can suggest

radicular issues or it could be facet joint pain referred to the scapular region. It can result from peripheral nerve dysfunction, thoracic outlet syndrome, shoulder pathology and some even rarer conditions. So diagnosis is difficult.While patients with C2 compression may have pain in the neck or occipital pain radiating over the posterior aspect of the skull, those with radicular symptoms at C3-4 may only have neck pain which can be operated on successfully to decompress nerve roots. C5 pain will be over the deltoid area and so it is difficult to differentiate neck from shoulder pain - it might be a rotator cuff problem, an impingement or a frozen shoulder.C6 radicular symptoms can cause periscapular pain, which mimics carpel tunnel compression, or even double crush syndrome where there is compression of the wrist as well as the neck. It’s very similar in the C7 nerve root area where you can get both referred neck pain and median nerve compression pain, which is similar to carpal tunnel compression. C8 goes over the ulnar border and may mimic an ulnar nerve entrapment of either the elbow or the Guyon’s canal of the wrist. Surgeons also regularly see thoracic outlet syndrome – initially the problem sounds radicular but if the Roo’s test is carried out, asking the patient to put their arms above

their heads, and they find it impossible to hold their arms up for more than 30 seconds thoracic outlet syndrome is the most likely cause.So, diagnosis is difficult. History and examination play their part but injection therapy may help to determine whether it’s a neck or cervical problem or a completely different issue, and if it’s a neck problem, whether it’s radicular or a referred pain for degenerative changes in the neck. Although the body of evidence is limited, Mr Harvey uses injections both to identify the cause of the problem, the level within the neck and also as a therapeutic treatment. He uses selective nerve root block, injections into the facet joint, as well as medial branch blocks which can help to determine whether radiofrequency ablation will provide a more long term solution to neck pain.A selective nerve root block is primarily therapeutic, but also diagnostic in locating the particular nerve root which is causing the symptoms. Mr Harvey performs this under local anaesthetic to get the patient’s feedback. Following lateral and oblique X-rays, he aims the needle to the back of the neuroforamen behind

the existing nerve root and the vertebral artery, for safety reasons. Dye flows up the pedicle to check the position and then he injects local anaesthetic and steroid. In a study of 60 patients receiving this treatment, 41 needed no surgery, but of course the vast majority of

people would get better in time anyway. Another study of 30 patients found this technique was useful in determining which level of the neck to operate on, thereby limiting multiple level operations. Mr Harvey also uses cervical facet joint blocks as a diagnostic and therapeutic tool. If a facet joint injection provides relief, this suggests it’s not a radicular symptom. I will operate for radicular symptoms, so this injection helps him to avoid operating unnecessarily.Medial branch blocks exhibit a better result when local anaesthetic is combined with steroid, rather than local anaesthetic alone. Facet joint ablation is not a permanent solution as the nerves eventually grow back, but it does give more long term relief.Infection, hematomas and neural damage (when the steroid and local anaesthetic go intravascularly to the brain) are all possible following injection therapy, but although serious, such complications are rare and there are fewer adverse effects than arise from surgical intervention. Looking ahead, a very recent pilot study focused on autologous conditioned serum, which uses a concentrated version of the patient’s own serum instead of steroid in the injection. Results of this initial trial show this may have a more prolonged effect than steroids.

“Cervical spine injections can help diagnose, alleviate and avoid surgery for neck pain,

radicular symptoms or myelopathy ”

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Lecture by Professor Cathy SpeedConsultant in Rheumatology, Sport and Exercise Medicine

Nicole Atmore reports on the ‘Pills and Potions’ talk from Professor Cathy Speed, Consultant in Rheumatology, Sport and Exercise Medicine

Professor Speed started by explaining that there is no straightforward process from injury to treatment when dealing with musculoskeletal conditions. Unlike other disciplines, cardiology for example, rheumatology does not have a substantial body of evidence available from large randomised trials and systematic reviews. An intervention for one condition cannot be easily transferred to another MSK issue, as there is such a variety of tendon injuries. Professor Speed advised that the particular characteristics of each individual patient’s injury needs to be explored, taking into account the location of the problem, the grade of tendinopathy and the presence or absence of neovascularization. The practitioner can then consult the best evidence around; consider the range of interventions available, and their own experiences, before finally combining all of that to decide on a strategy.

She explained that non-surgical intervention has several aims: to manage pain, which in turn will facilitate rehabilitation; to modify the disease process, and to optimise function. The natural process of tissue inflammation should be left alone, unless excessive inflammation is preventing early rehabilitation, or acute inflammation persists after at least a week, or the area is so inflamed that the condition cannot be accurately assessed.

Treatment typically starts with topical agents, moves onto oral nonsteroidal treatments and then injections. In terms of risk-benefit this isn’t necessarily the right way around, but it is the most usual and probably the most practical approach.

Nonsteroidal agents, both topical and oral, are generally effective in managing acute and chronic MSK pain. Topical nonsteroidal agents can access cartilage and meniscus, getting right to the tissue. Oral agents work centrally, so are more suitable for some patients, but if the problem is a local inflammation, localised treatment with a topical nonsteroidal medication is the starting point.

We were reminded that risk factors must always be foremost in our minds. Never use NSAIDs when the patient has GI toxicity, renal impairment, hypertension, cardiovascular problems, allergies, asthma or bleeding diathesis. In these cases, such treatments can be fatal. Also, we should

remember that nonsteroidal agents can inhibit soft tissue repair, particularly muscle regeneration, and can weaken the enthesis with prolonged use. NSAIDs should only be used topically, or in case of acute inflammation, orally, when the patient is in severe pain. They should not be used in muscle injuries or bone stress injuries as they inhibit bone repair.

Professor Speed highlighted topical Traumeel gel as an effective alternative treatment which is popular globally, based on fourteen natural ingredients. A small number of studies have shown it to be as effective, with fewer adverse effects, as oral and topical diclofenac.

Corticosteroid injections have been used for seventy years. They are effective at reducing inflammation, which we can explain but they also appear to aid pain control, even if we still can’t support this scientifically! They provide short-term pain relief for three to six weeks and perhaps that is better than six weeks of oral nonsteroidal agents. Corticosteroid injections are beneficial in acute conditions such as calcific tendonitis and bursitis, as well as tenosynovitis, the inflammation of the fluid-filled sheath around a tendon. However, Professor Speed cautioned against using steroid injections when there is evidence of significant underlying tendinopathy. Again, the risk-benefit ratio must be measured, so if the patient has none of the risk factors judicious use of steroid injections is a good idea.

In comparing steroids with nonsteroidal agents in osteoarthritis, the evidence reveals that the risk-benefit ratio comes out in favour of steroids. There is a similar ratio with physical supplement injections, though these are not quite as effective as steroids. creasingly the period of relief to months rather than weeks. Again it’s necessary to consider potential side effects such as infection and tissue atrophy.

Often Professor Speed combines steroids with viscosupplements because the latter don’t start to work for about five weeks, which is when steroid injection effects are wearing off, thereby in increasingly the period of relief to months rather than weeks. Again it’s necessary to consider potential side effects such as infection and tissue atrophy.

Natural alternatives include Traumeel and Zeel injections.

FEATURE | Pills and Potions

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Professor Cathy Speed Consultant in Rheumatology, Sport and Exercise MedicineProfessor Speed specialises in the management of elite athletes and patients of all ages with arthritis and complex pain, bone and soft tissue conditions.

Although few studies have been done into their benefits, those that have appear to show a combination of good results with few adverse reactions.

Overall Professor Speed found that injection therapies may be more beneficial to some patients than prolonged nonsteroidal treatment.

Finally, for problems with patella or Achilles tendons, other options include high volume injections between the fat pad and the tendon to eliminate new vessels. These show promise but there is no body of evidence to support their use.

As a rheumatologist, Professor Speed said she would also consider biologic agents which are very effective in patients with insertional enthesitis. GTN (topical glyceryl trinitrate) patches are an option, shown in randomised control trials to reduce pain in tendinopathies. Bone agents are suitable for recalcitrant bone injuries such as stress fractures as they reduce inflammation and act on the bone itself.

Cell therapies such as PRP (platelet-rich plasma) are the latest buzz word in tendon treatments but we heard that most of the best trials show a negative effect. In Professor Speeds view, we are a long way from commonplace cell therapies in human tendon pathologies, although animal models of mesenchymal stem cell therapy show great results in tendon healing, when treatment takes place very soon after the injury. There are human trials taking place and there may be some form of cell therapy in the next few decades, but in the meantime, the important thing is to focus on the simple procedures that we have just heard outlined.

In ending her talk, Professor Speed concluded that non-surgical intervention in an MSK injury is often effective if it is the right treatment, at the right time, for the right patient. And all decisions must take full account of the risks involved.

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FEATURE | Foot and Ankle Injections

Lecture by Mr Andy RocheConsultant Orthopaedic Foot and Ankle Surgeon

Nicole Atmore reports on the talk given by Mr Andy Roche, Consultant Orthopaedic Foot and Ankle Surgeon, on Foot and Ankle Injections

Mr Andy Roche rounded up the evening lectures, speak-ing on foot and ankle injections. He began by explaining when injection therapy might be used. Foot and ankle injections are often therapeutic, and short term, perhaps to help a patient awaiting a surgical procedure or an athlete desperate to get to the end of the football sea-son. Sometimes it’s a series of injections for longer term pain control. Occasionally injections are an attempt to try something different when other interventions haven’t worked.

The other reason for doing injections is diagnostic. The foot and ankle is a complicated area. Take posterolateral ankle pain - this can be caused by ankle impingement or an injury to the peroneal tendon. An MRI won’t neces-sarily identify the origin, so if an injection of the peroneal tendon sheath gets rid of the pain, the root of the problem is located. Similarly, the anatomy of the hind foot where the Chopart and subtalar joints are very close, means it’s difficult to identify the pain source. But it is safer to inject first one joint and then another, than it is to do an ankle fusion.

You can inject an arthritic ankle, an arthritic big toe or even a Morton’s neuroma, as well as the retrocalcaneal bursa, but generally you should avoid injecting the Achil-les area.

For intra-articular injections Mr Roche uses a lower concentration of Marcaine than the 0.5% standard, mixed with equal volumes of Depo-Medrol. Kenalog is useful in larger joints where its lower solubility doesn’t matter so much.

What about complications from steroids? Those that he has experienced are: a hot, red, painful steroid flare,

which usually settles down quite quickly; infection, when healing is slow because the skin is thin and there isn’t much blood supply to the area, or a build-up of steroid deposition, necessitating removal and therefore further damage to the tendon.Injections for plantar fasciopathy and Achilles tendonitis are more contentious areas. Mr Roche only uses injec-tions for plantar fasciopathy when other therapies, such as physiotherapy, shock-wave therapy and gel pads have failed. If you catch it in the early acute inflammatory stage with lots of swelling in the heel pad, then it’s worth inject-ing. Whatever the stage, an ultrasound is a good idea as it informs the patient about their condition and the steps which are necessary to improve it.

The quality of literature on steroids is not conclusive. Mr Roche finds that steroids work for the first six to twelve months but aren’t sustained beyond that, so effective joint mobilization is very important. However about 1.5% of patients receiving steroid injections get painful complica-tions to do with fat pad atrophy. There is some evidence that injecting PRP is more beneficial than steroid. It does seem to have a more sustained effect but not everyone has the technology to do this.Dry needling has no benefit beyond around twelve weeks. Both dry needling and prolotherapy have to be repeated every three or four weeks and as they are painful proce-dures, there is a high drop-out rate. He doesn’t use either for plantar faciitis.

Before deciding on a treatment plan for Achilles tendon injuries, Mr Roche cautions that it is important to estab-lish whether you’re dealing with an insertional, (affecting the insertional calcaneal and retrocalcaneal bursa) or non-insertional (in the paratenon or Kager’s fat pad) injury. There might be a split tendon, a degenerate longitudi-

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FEATURE | Foot and Ankle Injections

Mr Andy RocheConsultant Orthopaedic Foot and Ankle SurgeonMr Roche’s speciality interests include the mechanisms of sports injuries and optimisation of rehabilitation in athletes.

nal tendon defect which shows up on a scan, and is different to a torn tendon. The classic diffuse Achilles tendinopathy shows generalized swelling, there can be acute inflammation of the paratenon, or there can be pain on the medial side. The only insertional condition Mr Roche would inject is an isolated retrocalcaneal bursitis. If there is a problem with the bone, such as a spur or little bodies in the tendon insertion, an injection is not going to work.

Animal models are showing that PRP injections for mid portion Achilles tendinopathy are reducing neovas-cularization, normalizing the tendon structure and improving the disorder. But there is currently no com-parable literature for human studies. Similarly, there have been good animal model studies done for PRP in Achilles ruptures which show that you can accelerate tendon regeneration and improve tendon strength. A recent study in The Lancet showed improved type 1 collagen deposition and better healing response, indi-cating that PRP may well have a role to play in acute inflammatory Achilles rupture.

A trial in 2007 using an injection of PRP onto a matrix of VEGF and FGF resulted in a quicker return to training and sport. This is encouraging for many of our patients but there was no consensus on the concen-tration of PRP. Mr Roche uses it because he thinks it improves strength and accelerates healing. Many of his patients are athletes who want to try anything possible and he believes the limited evidence and his personal experience weigh in its favour.

Mr Roche’s view on steroids, is that he would only ever use them with Achilles tendinopathy if there is

retrocalcaneal bursitis or the rare paratendonitis. Intra-tendinous injections are not recommended in this area. Generally he will use prolotherapy for small localized areas of degeneration, small tendon splits for example. It is uncomfortable but it works. High volume injections into Kager’s fat pad devascularize the tendon by strip-ping off any neovascularization and take away pain re-ceptors in front of the tendon. This benefits post-treat-ment physio work but the literature is inconclusive. However if you can get rid of adhesions the tendon will move more smoothly, so it would be beneficial to see more literature on this.

If there’s a problem with a swollen plantaris tendon which runs medially along the much more elastic Achil-les in the mid portion, the options are either surgery to release or cut away the plantaris tendon, or recently Mr Roche has been using hyalauronic acid to strip the plantaris off the Achilles. This has been working well, though there are no published studies on this treat-ment.

Mr Roche wrapped up his talk with a brief summary. The effect of injections in plantar fasciitis are short-lived but facilitate physiotherapy for long-term benefits. PRP is worth exploring further. In Achilles conditions, first explore the pathology in detail, generally avoid high-volume steroid injections, despite their popularity, and only use PRP if there is an acute rupture, where it can be administered intraoperatively.

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On January 11th, the shoulder team will be

hosting a lecture evening at the Marylebone Hotel.

Further details will be emailed at the start of

January.

Merry Christmas from the Marketing Team, Felicity, Harriet, Sophie and Nicole.

2016

To be added to the invitation list please email: marketing@fortiusclinic.com

In 2016 we will be holding some lectures in the City,

near to our new clinic which will be on King William

Street.

To find out more about this, please feel free to email us

on:marketing@fortiusclinic.com

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For further information or to book an appointment, please contact us:

t: +44 (0) 203 195 2442 f: 0203 070 0106 e: appointments@fortiusclinic.comw: www.fortiusclinic.com

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You will also find us on Facebook and LinkedIn

How to find us:Fortius Clinic is situated in Central London, close to Selfridges, and just off Manchester Square.

17 Fitzhardinge Street London W1H 6EQ