💡 Where INJECTIONS do play a role…

LIFETIME HIP & KNEE

Read on: danhwilliams.com

Read time: 4 minutes

#031: Where INJECTIONS do play a role...

(name changed to protect the innocent)

Injections are good for 3 things.

Injecting the back to see how much pain is coming from the back
Injecting the hip to see how much pain is coming from the hip
Creating a window of less pain to get moving more.

That’s generally it in my hip + knee clinic.

So, what about Amanda from the last Newsletters #029 + #030?

Remember, Amanda had +ve imaging that fitted with her pain...
Affecting BOTH her hip + back.

Would injections help Amanda?

Yes.

Back first…

Spine Injection

2/3rds of sciatic pain settles down on its own
BUT Amanda’s sciatic pain had lasted more than three months.

So, I asked a friendly spinal surgeon to look at her MRI scan.
And he recommended a nerve root injection.

Steroid and local anaesthetic injected around the trapped nerve in Amanda’s back. The aptly named ‘pain clinic’ did this.

THE RESULT: 50% relief of Amanda's sciatic pain
(down the back of her leg).

The local anaesthetic worked well for the first few hours.
The steroid kicked in, as it should, after about a week.

Amanda felt pain relief on and off.
And importantly, learnt how to recognise the pain.
The pain coming from her trapped nerve.

Amanda and my spine colleague decided together NOT to operate.
The benefit of surgery would not outweigh the risks.
Amanda did not want that nerve decompressed.
She was going to live with the residual pain.
Good decision.

However...

What she called her ‘main pain’
The pain around her hip
Had got a little worse.

So next...

We put a plan in place for her muscle pain.

Muscle pain

A friendly physiotherapy colleague coached specific muscle strengthening.
Strengthening for the chronic muscle inflammation
On the outside of the hip.

And I advised slowly building exercise bike cycling.
Exercise bike cycling for her general strength.
That is conditioning of her hip and lower back.
A similar programme to Newsletter #011.

BUT that message had NOT resonated well.

Hmm, so what next?

Another x-ray film of the hip was NOT worse.
BUT Amanda’s ‘main pain’ was really troubling her.
Having a greater and greater effect on her everyday life.

She, naturally, just wanted her pain to be taken away.
So, the plan was to give her a sense of what hip replacement might be like...

Hip Injection

Similar to the back injection, we talked about:

An injection of steroid and local anaesthetic into the hip joint
How I was nowadays offering fewer and fewer hip injections...

...measuring pain more closely, I had seen little long term effect.

And there are one or two reported downsides here...

And an important downside covered off in Newsletter #017.

But...

Judging how much pain was coming from the hip joint would be useful, and..
Creating a window of less pain might allow Amanda to begin strengthening...

...it is difficult to move more when a joints hurts.

The other details we talked about:

Hip injections are in-and-out day case procedures.
Done in an operating theatre with x-ray guidance.
X-ray guides a long needle into the hip joint.
Under local anaesthetic (that's not too bad).
It hurts as the needle enters the (inflamed) joint.

Patients are awake while the hip is filled local anaesthetic.
Local anaesthetic that numbs the hip for about four hours.

And, therefore, takes away any pain originating from the hip joint.

100% better = ALL pain coming from the hip joint
50% better = 50% pain coming from the hip joint
No better = NO pain coming from the hip joint

I had a steroid injection once...
I did NOT like my surgeon the night after the injection.

With a joint full of fluid the hip hurts!
From soon after the local anaesthetic wears off.

My injection, 15 years ago, was into the tendons around my ankle.
Chronic inflammation. Pain that would not settle.

I remember swearing at my surgeon the night after the injection…
(while feeling very sorry for myself)

Then...

The steroid worked like ‘magic’ (the day after)
=> it turned off my pain.
I could not believe it.

The surgeon went from zero to hero.
I had my window to get conditioning.
Strengthening those ankle tendons.
And the inflammation settled.
And stayed settled.

Steroid injections DO have their time and place.

Any steroid injected into a joint
Rather than a tendon.
Takes a bit longer to kick in.

The pain generally settles over the first 7 to 10 days
Dampening down inflammation throughout the whole joint.

How did Amanda get on?

During that first 4 hours...

THE RESULT: Amanda got a 50% improvement in her pain score.

Specifically, Amanda told me...
Her groin pain was completely taken away.
Her lateral hip and buttock pain were perhaps a bit better.

Good news. However, the steroid started to wear off from about 3 weeks.
Amanda’s pain came back. We hoped for 3 months but got 3 weeks.

The pain relief was ‘really good’ for those 3 weeks and the natural next question…

Could she have another one?

I'll answer that next week...
I'm determined to stick to my 4-minute reading rule!

So injections, in my hands are good for:

Seeing how much pain is coming from the back
Seeing how much pain is coming from the hip joint
Creating a window of less pain to get moving more.

All of which helped to define Amanda's pain
And to begin some strengthening.

Next week I'll wrap up Amanda's story
Giving my best sense of why her hip did NOT look that bad.

Then it's the real world outcomes of excess bodyweight and my controversial take on why operating through a thick fat layer is hard.

--

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Duchy Hospital
Truro
TR1 3UP
United Kingdom