Injection therapies for soft-tissue disorders

Article Outline

• Abstract
• 1. Corticosteroid injections
  • 1.1. Rationale for use and mechanisms of action
  • 1.2. General indications for corticosteroid injections in soft-tissue lesions
  • 1.3. Clinical evidence for the use of corticosteroid injections in soft-tissue lesions
    • 1.3.1. Tendinopathies
      • 1.3.1.1. Trigger finger
      • 1.3.1.2. Tennis elbow
      • 1.3.1.3. Rotator cuff tendinopathy
      • 1.3.1.4. Achilles tendinopathy
    • 1.3.2. Corticosteroid injections for other disorders
      • 1.3.2.1. Plantar fasciitis
      • 1.3.2.2. Adhesive capsulitis
    • 1.3.3. Facet joint injections
  • 1.4. Implications of the existing literature
  • 1.5. Potential adverse effects
  • 1.6. Practical suggestions for use
• 2. Local anaesthetic injections and dry needling
• 3. Other agents
  • 3.1. Botulinum toxins
  • 3.2. Others
• 4. Neural blockade in the management of soft-tissue disorders
  • 4.1. Peripheral somatosensory nerve blockade
    • 4.1.1. Carpal tunnel syndrome
  • 4.2. Neuraxial blockade
• 5. Summary
• References
• Copyright

Abstract 

Local injection therapies are used in the management of a variety of musculoskeletal pain syndromes and include the local infiltration of substances such as corticosteroid and/or anaesthetic, dry needling and neural blockade. Although commonly used, the rationale for their use in many conditions is arguable and evidence of efficacy is often lacking. In this chapter, a number of common injection therapies for soft-tissue-mediated pain are described. The reasoning for their use, potential mechanisms of action and unwanted effects are discussed. The literature relating to their documented effects is critically reviewed. Practical suggestions for their utilization in the management of soft-tissue conditions are given and proposals are made for future research in this important area.

Keywords:  injection, corticosteroid, soft tissue, pain, tendon, botulinum, nerve block

Local injection therapies include the local infiltration of substances such as corticosteroid and/or anaesthetic, dry needling and nerve blockade. Such treatments are used in the management of a spectrum of painful regional musculoskeletal complaints and have been used since several thousand years BC.¹ Routes and injectates for local injection therapies in soft-tissue complaints are listed below:

Routes

Injectates

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1. Corticosteroid injections 

Steroid hormones were initially recognized as potent anti-inflammatory substances in the 1930s and a flurry of activity during that decade resulted in the isolation of a number of steroids, most importantly ‘Compound E’, later known as cortisone.² This was administered in 1948 to a patient with rheumatoid arthritis with dramatic results, and the evolution of steroid therapies for a spectrum of disorders swiftly followed.^2., ^3. Administration of local corticosteroid injections for musculoskeletal complaints began in the 1950s. They rapidly became an essential component of the rheumatologist's therapeutic repertoire and, indeed, the administration of steroid through local, extra-articular infiltration or intra-articular injection is the most commonly used procedure undertaken by rheumatologists.⁴

Most local corticosteroid injections for soft-tissue disorders are extra-articular, where the corticosteroid may be delivered into the lesion itself, such as in the case of an intrabursal injection, or around the lesion, as in peritendinous/tendon sheath infiltration. Steroid injections are also used for back pain and diagnostic blockades: these are described in more detail below.

Intra-articular injections are most commonly used in the presence of joint disease but are also used in the treatment of capsulitis (typically that of the shoulder). In such cases, this may be combined with additional hydrodistension of the joint.⁵

1.1. Rationale for use and mechanisms of action 

Corticosteroids are the most potent anti-inflammatory agents available, exerting their manifold effects on the inflammatory process through a number of mechanisms; these mechanisms include marked effects upon transcription and translation and the inhibition of cytokines, chemokines, adhesion molecules, receptors, enzymes and other mediators.⁶ Corticosteroids may also have some inducing effects on some cytokine receptors. Additional effects upon alternative sources of pain in soft-tissue lesions have yet to be established.

Corticosteroids are used in most soft-tissue lesions to provide an anti-inflammatory effect. However, the origin of pain in soft-tissue disorders is highly complex and the existence of inflammatory changes in soft-tissue complaints—and their relative contribution to pain—appears to be variable. Although inflammation is clearly evident in cases of bursitis and in early capsulitis^7., ^8., its role in tendinopathies is less clear. With the exception of some cases of tenosynovitis, most histological studies of a range of chronic tendon lesions (such as Achilles, patellar, lateral elbow, wrist and rotator cuff tendinopathies) have demonstrated an absence of cellular evidence for inflammation.^9., ^10. Degenerative features predominate, characterized by alteration in cellular and extracellular components of the tendon and paratenon or sheath.^9., ^10., ^11. It is for this reason that the term ‘tendinosis’ (degeneration) is preferred to ‘tendinitis’, which suggests inflammation.

The histopathological studies of tendon performed to date, however, are not without limitations. Notably, the presence or absence of biochemical features of inflammation has been largely ignored, although normal levels of prostaglandin have been shown in painful Achilles tendon lesions.¹² In addition, most studies have involved end-stage, non-healing lesions; it is not clear whether the degenerative features are primary or whether they are preceded by an inflammatory phase. Other mechanisms of tendon pain have been proposed, including irritation of mechanoreceptors by vibration, traction or shear forces. Triggering of nociceptive receptors by neurotransmitters such as Substance P and biochemical irritants such as chondroitin sulphate extravasated by damaged tendon may also play roles.^13., ^14. The influences of corticosteroid on such processes are undefined. Hence, the theoretical basis for the use of local corticosteroids in soft-tissue conditions is arguable.

1.2. General indications for corticosteroid injections in soft-tissue lesions 

Corticosteroid injections are rarely used in isolation in soft-tissue complaints. Other issues must be addressed, including correction of causative and provocative factors and appropriate rehabilitation.¹⁵ Ideally, local corticosteroid injections should be considered when there is an excessive or chronic inflammatory response, and where rehabilitation is inhibited. They have little or no role to play in most acute injuries, where inflammation is present as a vital component of the healing response, and inhibiting this process may potentially result in a suboptimal outcome. They are also not indicated in the management of ligament and muscle injuries and do not appear to offer any advantage over dry needling in myofascial pain.Box 1

1.3. Clinical evidence for the use of corticosteroid injections in soft-tissue lesions 

Studies and reports relating to the use of corticosteroid injections in soft-tissue disorders span the last five decades of medical literature. Unfortunately the quality of many studies is disproportionate to their quantity and good evidence for benefit in many soft-tissue disorders is scant. The literature relating to some of the most common soft-tissue conditions can be used to illustrate this point.

1.3.1.1. Trigger finger 

Trigger finger is one of the few conditions where evidence supports the use of corticosteroids in its management. In a double-blind placebo-controlled trial of 20mg (0.5ml) methylprednisolone acetate with lignocaine versus 0.5ml 1% lignocaine in 41 subjects with trigger finger, Lambert et al found a significant improvement in 60% of the treatment group compared with 16% in the control group at 1 month follow-up.¹⁷ Similar findings have been noted by others.¹⁸ Corticosteroid injections in trigger finger appear to be less effective in diabetic patients, in whom soft-tissue lesions are frequently more resistant to most therapies, for reasons that are not fully understood.

1.3.1.2. Tennis elbow 

A systematic overview of corticosteroid injections for lateral epicondylitis identified 12 randomized controlled trials (RCTs) with an adequate methodological score for consideration, although the median score of 40/100 indicated overall poor to moderate quality of trials on this subject. Pooled analysis indicated short-term (2–6 weeks) effectiveness only, with pooled odds ratio of 0.15 (95% CI 0.1–0.23), chi-squared=13.3 (degrees of freedom=5), indicating statistical heterogeneity. Studies of better methodological quality had more favourable results. No conclusions could be made with respect to the most suitable corticosteroid, dose, injection interval and injection volume.¹⁹

1.3.1.3. Rotator cuff tendinopathy 

Injection of corticosteroids by the subacromial approach is considered to be the most suitable route when treating rotator cuff lesions. A Cochrane Review of interventions for shoulder complaints concluded that there is some evidence for short-term (4 weeks) benefit of subacromial corticosteroid injections in rotator cuff tendinosis with respect to range of motion, but not pain.^21., ^22. Effectiveness over the longer term and in other shoulder complaints is unknown as there are insufficient data of adequate quality upon which to base a recommendation for practice.

1.3.1.4. Achilles tendinopathy 

The sole prospective, double-blind randomized controlled trial in the literature addressing the effectiveness of corticosteroid injections in Achilles paratenonitis involved 28 active patients with three lesions and showed no benefit of peritendinous methylprednisolone and marcaine over marcaine injections alone.²³

1.3.2.1. Plantar fasciitis 

Corticosteroid injections, with or without additional local anaesthetic, are commonly utilized in the management of pain in plantar fasciitis. However, systematic reviews have found no significant long-term benefit of corticosteroid injection versus placebo, and there is evidence that symptoms resolve spontaneously in most cases.²⁴ In a systematic review of treatments for heel pain, Atkins et al identified only one small RCT of 19 people with recalcitrant heel pain, comparing local injection of hydrocortisone acetate 25mg with saline; no significant difference in pain relief (RR 0.52, 95% CI 0.15–1.79) was noted.²⁵ The same systematic review and a subsequent RCT²⁶ found no evidence of significant long-term benefit from corticosteroid plus local anaesthetic injections versus alternative treatments, and only limited evidence of a short-term (1 month) benefit.

Local corticosteroid injections for plantar heel pain can be painful and this does not appear to be reduced by local anaesthesia or tibial nerve blockade.²⁶ Plantar fascial rupture after injection has also been reported to occur in up to 33% of patients, although these reports relate to clinical observations unconfirmed by imaging.²⁷ Infection, subcutaneous fat atrophy, skin pigmentation changes, fascial rupture, peripheral nerve injury and muscle damage are all reported unwanted effects.²⁸

1.3.2.2. Adhesive capsulitis 

Histological and histochemical studies indicate that adhesive capsulitis (frozen shoulder) is a cytokine-driven inflammatory process resulting in synovitis, where chemotactic and cellular responses and synovitis occur, followed by fibroplasia and capsular contracture.^7., ^29. Hence, an anti-inflammatory approach may be indicated in the early stages—although there is little basis for this approach in the latter restrictive phases of the condition.

Two systematic reviews (involving the same two RCTs)^21., ^30., ^31., ^32. of the use of local injections in frozen shoulder, plus one subsequent RCT³³, have found no clear evidence of benefit from intra-articular corticosteroid injection versus control treatment. In the reviews, no reduction in pain nor improved range of movement with intra-articular corticosteroid were noted in either the first RCT (24 people with shoulder pain, 4 weeks of follow-up³¹) nor in the second RCT (30 people with frozen shoulder, 24 weeks of follow-up³²). The subsequent RCT compared three intra-articular injections of triamcinolone versus three intra-articular injections of saline and also found no significant difference in pain score, change in mobility or function.³³

Combined intra-articular and subacromial corticosteroid injections have not been demonstrated to be superior to placebo.^21., ^22., ^33., ^34. Hydrodistension may be useful, at least in the short term. In a study of 22 subjects with adhesive capsulitis recruited from a rheumatology clinic, Gam et al⁵ demonstrated that distension of the glenohumeral joint with 19ml 0.5% lignocaine, in addition to intra-articular steroid injection, given weekly for 6 weeks is superior to weekly intra-articular corticosteroid injection alone in increasing the range of movement and reducing analgesic use at 12 weeks, although no significant reduction in subject-rated function nor pain at rest was noted. Both groups received intra-articular steroid, so it is not clear whether any effect of hydrodistension versus no hydrodistension depends on the intra-articular steroid injection. Hydrodistension is more painful than injection alone.

Facet joint injections with steroid and anaesthetic into the joint itself are performed under fluoroscopic control and are commonly used in the management of chronic back pain considered to be arising from this source. Reported success rates for lumbar and cervical facet joint injections vary from 16 to 86%.³⁵ Overall, there is little sound evidence to indicate that they have long-term benefit. Two systematic reviews of the use of facet joint injections in people with chronic back pain found no significant difference in pain relief with facet joint injections (intra-articular corticosteroid) versus placebo (intra-articular saline) or versus facet joint nerve blocks.^36., ^37. Adverse effects included pain at the injection site, infection, haemorrhage, neurological damage and chemical meningitis.

There are no randomized controlled trials of facet joint injections in the management of chronic neck pain.

1.4. Implications of the existing literature 

The limited evidence to support the use of local corticosteroid injections in many chronic soft-tissue conditions may be related to methodological issues relating to the research to date or to a true lack of effect. Trigger finger is notably one of the few tendon lesions where there is evidence of chronic inflammation¹¹; this may explain the improvement demonstrated with local corticosteroids.

Relevant methodological issues include study design and accuracy of both diagnosis and injection. Inadequacies of study design, such as small sample sizes and heterogeneous study populations, unsuitable outcome measures, short-term follow-up, inadequate blinding, lack of a true placebo. The increasing availability of imaging in the form of MRI and ultrasound should improve diagnostic reliability.

1.5. Potential adverse effects 

The overall incidence of side-effects after local corticosteroid injections for soft-tissue complaints is unknown and the relevance of factors such as the steroid used, the tissue involved, the extent of the injury, the phase of healing at the time of injection and post-injection events—particularly loading of the tissue—has not been established. The vast majority of unwanted effects of local corticosteroid injections are minor, such as short-term local pain after injection, a post-injection flare, facial flushing, local skin lesions, temporary menstrual irregularity and post-menopausal haemorrhage.⁴¹ Complete tendon rupture with loading after steroid injection is recognized, although the literature is limited to case reports^42., ^43. and rigorous studies have not been performed. Sepsis is reported in 1/14 000–1/50 000 intra-articular/soft-tissue injections.⁴ Other commonly reported side-effects include tissue atrophy and hypersensitivity reactions.⁴¹ Resuscitation facilities should be available in the event of a rare severe reaction. Corticosteroid arthropathy and osteonecrosis are rare (<0.8%) and seem to affect mostly weight-bearing joints after intra-articular injections.^4., ^43.Box 2

1.6. Practical suggestions for use 

Many of the recommendations for the use of local corticosteroid injections are based upon anecdote. For both local and intra-articular injections there is no consensus with respect to environment (operating theatre, treatment room, clinic), the skin preparation, the wearing of gloves, use of local anaesthetic, the safe number of injections at one site, or the appropriate interval between injections.^4., ^15.

Agents differ with respect to their potency and solubility, the latter inversely correlating with the duration of action (Table 1).⁴² There are few data on the absorption of corticosteroids from peritendinous injections, but methylprednisolone acetate remains in plasma for a mean of 16 days after peri-articular injection.⁴⁴ Short-or moderate-acting, more soluble preparations (e.g. hydrocortisone, methylprednisolone) are recommended for soft-tissue injections on the theoretical basis of likelihood of fewer side-effects; agents with low solubility should not be used for this purpose.²¹

Table 1. A comparison of injectable corticosteroids

Preparation	Potencya	Concentration (mg/ml)	Solubility (% wt/vol)	Onset of action	Dose
Hydrocortisone acetate (Hydrocortistab)	1	25	0.002	Variable	5–25mg
Prednisolone acetate (Deltastab)	4	25	0.001	Variable	5–25mg
Methyprednisolone acetate (Depomedrone)	5	20, 40, 80	0.001	1–5 days	20–80mg
Tramcinalone acetonide (Adcortyl, Kenalog)	5	10, 40	0.004	Variable	5–40mg
Betamethasone sodium phosphate/acetate	25	6	NA	2–24 hours	0.25–2mg
Dexamethasone phosphate	25	4	0.01	2–24 hours	N/A
Triamcinalone hexacetonideb	5	20	0.0002	Variable	N/Ab

NA, not applicable.

Local anaesthetic mixed with the corticosteroid is usually used in soft-tissue injections with the aim of improving patient comfort and increasing the volume of the injection for wider dispersion.^4., ^15., ^45. Although this is a common practice, some manufacturers advise against mixing agents because of the theoretical risk of clumping and precipitation of steroid crystals. There is no evidence that injection of local anaesthetic in advance of the corticosteroid is beneficial, nor of a difference in outcome between the addition of long-acting versus short-acting anaesthetic.⁴⁵

Local steroid injections in the vicinity of the achilles or patellar tendon, and in the circumstances of a tear, are frequently discouraged owing to the concerns with respect to rupture of heavily loaded tendons and/or impairment of tissue repair where disruption is already present.^46., ^47. Although used by some in trigger-point injections, there appears to be no benefit of infiltration of corticosteroid over local anaesthetic or dry needling, and the potential side-effects are greater. They are reserved for use in the resistant trigger point. The Practice points provide some suggestions for local corticosteroid injections for soft-tissue injuries in the face of a vacuum of evidence.Box 3

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2. Local anaesthetic injections and dry needling 

Injections of local anaesthetic alone are used for both diagnostic and therapeutic purposes in soft-tissue conditions. Local anaesthetics reversibly block sodium channels and hence nociceptive impulses. In some cases, the duration of analgesia obtained can exceed the duration of action of the local anaesthetic, for reasons that are not fully understood.

Subacromial injection of short-acting local anaesthetic (e.g. 2–5ml 2% lignocaine) was recommended by Neer for the evaluation of the patient with rotator cuff tendinopathy.⁴⁸ Neer proposed that the test allows differentiation between tears of the rotator cuff and impingement syndrome/tendinosis. By injecting an analgesic medication into the subacromial space of the shoulder, the tendons of the rotator cuff will be effectively anaesthetized and weakness due to pain inhibition would be abolished, allowing detection of weakness due to a tear. The test, although popular, has not been validated.

Local injection of trigger points with anaesthetic or saline in the patient with myofascial pain aims to reduce symptoms and allow a stretching and exercise programme to proceed. Dry needling may be equally effective, although the use of local anaesthetic may reduce post-injection soreness.⁴⁹ Where multiple muscle groups are involved, the use of dry needling or acupuncture is preferable.

The mechanism of action of needling and anaesthetic injection appears to be mechanical disruption of the trigger point and, where LA is used, desensitization of the area.⁵⁰ It has been proposed that pain relief, increased range of motion, and improved exercise tolerance are achieved with this therapeutic approach.^50., ^51.

Careful localization of the trigger point is first necessary and several techniques have been described to achieve this—including manual palpation and percussion with a tendon hammer. Stretching the area locally prior to injection/needling is also usually recommended. On inserting the needle parallel to the muscle fibres, the clinician should feel resistance as the needle encounters the taut band and the patient may report a dull ache at the site or a full reproduction of their symptoms, including pain in the zone of referral (Figure 1, Figure 2). A local twitch response is also anticipated during the procedure. After needling or injection of the band, the needle can be redirected to other local bands.^50., ^52.

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• Figure 1. 

  Trigger point injection. After needling the trigger point, the needle is re-directed into other taut muscle bands without being withdrawn from the skin. Reproduced from Travell & Simons DG (Myofascial Pain and Dysfunction: the Trigger Point Manual, pp. 63–158. Baltimore: Williams & Wilkins) with permission.

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• Figure 2. 

  A trigger point and its zone of referral. Reproduced from Speed CA, Daltoon S, & Hazleman BL (Fast Facts: Soft-tissue Rheumatology, p. 87. Oxford: Oxford University Press, 2001) with permission.

There is evidence to suggest that trigger point injection and ligamentous injections are beneficial in the control of back pain. Trigger point injection using methylprednisolone or triamcinolone) plus lignocaine versus lignocaine alone is reported to increase the number of people obtaining pain relief after 3 months (60–80% versus 20%). Similarly, injection of lumbar interspinal ligaments with dextrose–glycerine–phenol is superior to saline in providing pain relief at 1, 3 and 6 months.³⁶

Side-effects of local anaesthetic injection are rare. Injection of large volumes into a highly vascular area may theoretically result in systemic effects due to rapid uptake. Adrenaline is not recommended in local anaesthetics for procedures involving the appendages because of the risk of ischaemic necrosis.⁵³

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3. Other agents 

A number of other substances are used in local injections of soft-tissue complaints.

3.1. Botulinum toxins 

Botulinum toxins are purified proteins, produced by the anaerobic bacterium Clostridium botulinum, which block the pre-synaptic release of the neurotransmitter acetylcholine. There are as many as seven antigenically distinct botulinum neurotoxins, but only types A and, more recently B, are in clinical use. This increasingly popular group of agents are used in the treatment of a number of painful conditions, including myofascial pain, muscular low back pain, spasticity, headache and various other neurological disorders.^54., ^55. Clinical effects are typically seen between 3 and 10 days after injection. Pain relief is usually temporary, lasting weeks to months, and repeat administration is usually necessary. As with other injection therapies for soft-tissue conditions, stretching and exercise therapy are important components for a successful outcome. However, when administered properly, the procedure is usually very safe, although the long-term side effects of regular injections are not known. Reported side effects include injection-site pain, muscle soreness, headache, fever, abdominal symptoms, a flu-like illness, rash and antibody formation. The development of immunoresistance results in inefficacy of the treatment but can be limited by using the smallest possible effective dose and extending the interval between treatments as long as possible. Those who do develop resistance may in the future benefit from the use of other botulinum toxin serotypes. Muscle paralysis can occur with misplaced injections or excessive doses.

In a randomized, double-blind study of trigger point injections of botulinum toxin in 33 patients with myofascial pain syndrome, Wheeler et al compared two strengths of botulinum toxin type A with placebo.⁵⁶ There was no stastically significant benefit but a high number of patients were asymptomatic after a second injection of botulinum toxin (100 units).

3.2. Others 

Low-dose heparin has been used in the management of Achilles tendinopathies, with the aim to limit the formation of adhesions. However, there is some evidence that there is no good evidence of benefit⁵⁷ and it has been suggested that heparin may, in itself, cause a degenerative tendinopathy.

A calf-derived deproteinized haemodialysate, Actovegin, has been suggested to be useful in the management of Achilles paratenonitis, but a large, high-quality trial is needed.⁵⁷

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4. Neural blockade in the management of soft-tissue disorders 

Neural blockade is used for the diagnosis and treatment of a variety of chronically painful conditions. Such procedures aim to reduce nociceptive input into the dorsal horn on the hypothesis that, if a nerve is quiescent for some time, peripheral sensitization can be reduced or reversed.⁵⁸ Techniques can divided into peripheral somatosensory nerve blocks and neuraxial blockade.

4.1. Peripheral somatosensory nerve blockade 

Peripheral somatosensory nerve blocks are also used in the management of pain in soft-tissue complaints. Common examples include carpal tunnel injection, suprascapular nerve block in the management of shoulder pain, and ilioinguinal nerve blocks for post-hernia pain.

Local corticosteroid injection into the carpal tunnel significantly improves symptoms in the short term. Two randomized placebo controlled trials (one using methylprednisolone 40mg and one betamethasone 1.5mg) demonstrated significantly more people with symptom improvement at 1 month after corticosteroid injection than with placebo injection.^59., ^60. The magnitude of symptomatic improvement and long-term effects are unclear.⁶¹

The suprascapular nerve supplies sensory nerves to the posterosuperior aspect of the shoulder, including major portions of the rotator cuff. There is some evidence to suggest that suprascapular nerve block using steroid/bupivacaine is temporarily effective in reducing pain in rotator cuff tendinitis and tears, improving movement range in tendinitis and is possible in an outpatient setting with little or no risk of complication.⁶² The benefit of using steroid and lignocaine over anaesthetic alone is questionable.

Differing techniques for suprascapular nerve blockade have been described, including needle tip guided by superficial bony landmarks, and a near-nerve electromyographically guided technique.⁶³

Dahan et al⁶⁴ performed a double-blind randomized clinical trial examining the efficacy of suprascapular nerve blockade in 34 subjects with frozen shoulder, comparing a series of three suprascapular nerve blocks using 10ml bupivacaine 0.5%, versus 10ml saline, delivered over a 7-day period. A 64% reduction in pain in the treatment group versus 13% in the placebo group was observed at 1 month. There was a non-significant 15.8% improvement in shoulder function in the treatment group versus 4% in the placebo group (p=0.24), but no improvement in shoulder mobility was noted. No side-effects other than transient vagal symptoms and local tenderness at the injection site were reported.

4.2. Neuraxial blockade 

The epidural space is easily accessible for performing blockade for musculoskeletal pain. Epidurals are most commonly done in the caudal or lumbar space for sciatica. The evidence suggests that epidural steroids may be of short-term benefit in recent-onset radicular leg pain⁶⁵, but there is no evidence of efficacy in back pain without nerve root irritation.⁶⁶ Prolonged symptomology, previous back surgery and spinal stenosis are associated with lower rates of success.^36., ^37., ^67., ^68., ^69., ^70. Readers are referred to more extensive texts on this subject.

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5. Summary 

A number of local injection therapies are available for the management of soft-tissue mediated pain. They should be reserved for the treatment of chronic soft-tissue lesions and as part of a programme that includes identification and correction of provocative factors. Although an increasing number of techniques and injectates are available, the current evidence for the use of many is scant. Accuracy of diagnosis and injection appears to be important for maximum benefit to be achieved.Box 4

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