Joint and Soft Tissue Injections

Dr. Lemenchick and Dr. Lougheed have extensive experience with providing joint and soft tissue injections with and without the use of ultrasound guidance. They commonly provide injections of cortisone and hyaluronic acid (HA), and recently added Platelet Rich Plasma (PRP) and Autologous Protein Solution (APS – nStride®) to the clinic offerings.

North Bay Sport Medicine is at the forefront of ultrasound use in sport medicine practice and recognizes the growing evidence that ultrasound guided injections for certain indications improves accuracy and effectiveness. The clinic has access to a Clarius L7 handheld ultrasound for smaller joints and body parts, and a larger and more powerful Mindray TE7 for larger joints or difficult anatomy. NBSM performs injections of all joints and soft tissues excluding the spine.

Cortisone 

Cortisone injections have been used for decades for painful and inflamed joints and soft tissues. It is a powerful antiinflammatory that is generally well tolerated, and is used in a variety of conditions including arthritis and tendonitis.

What to Expect

Our physicians will review the potential role for cortisone, particulary in conditions that have not responded to other conservative treatments like rest, icing, physiotherapy, exercise programs, bracing,  and other medications or treatments where appropriate. 

The joint or area will be examined and an ultrasound may or may not be used to better visualize the space. It will then be cleaned and a small needle will be used to inject the cortisone. While there can be a small pinch or some pain with injection, many patients aren’t even aware that it has been done!

There may be soreness to the area for a day or two, but generally this fades quickly. Maximal effects can take up to six weeks. You will often be offered a quick telephone follow-up in the weeks following injection to see how you are responding.

Other potential risks and side effects:

  • Pain – Post injection pain due to steroid ‘flare’ which can last for 2-3 days.
  • Damage – Risk of cartillage damage in joints or tendon rupture in soft tissues. It has also been shown that repeated injections can lead to thinning of the cartilage.
  • Infection – Rare, but serious. Increasing pain, redness, swelling, fevers.
  • Skin changes – Discolouration or atrophy of the skin. May be more common with repeated injections.
  • Systemic effects – Increased risk of hyperglycemia in those with diabetes. 

Cost

$25 if cortisone supplied by NBSM

$0 if cortisone supplied by patient

Ultrasound is only covered by OHIP for cases where a joint injection failed elsewhere. 

depomedrol

Hylarunic Acid (HA)

Inside every joint is a naturally present fluid that contains HA. There is some evidence that supplementing our natural HA with an injection may provide symptom relief in patients with osteoarthritis (OA) and allow patients to return to their activities more quickly or defer or delay consideration of joint replacement surgery. There is also growing interest in the use of a different HA formulation specific to soft tissue tendon injuries.

 

What to expect:

 Our physicians will review the potential role of HA in your condition, with an open discussion of the evolving evidence as well as potential risks. 

As with the cortisone section above, risks may include pain, damage, infection. Of note is that a HA has not been shown to thin the cartilage or tendons. There can also be some financial risk, as outside of insurance coverage the injections can be costly.

All HA injections are performed under ultrasound guidance.

 

Common HA products used at NBSM for joints: Monovisc®, Durolane®, Orthovisc® (for smaller joints)

Combination HA + Cortisone product: Cingal®

Soft tissue HA: SportVis®

Cost:  (covered by many 3rd party insurance plans)

$500 for Monovisc®, Durolane®, or Cingal® (HA + Cortisone) injections

$250 per SportVis® injection (often offered as a series of two injections)

$200 per Orthovisc® injection (often offered as a series of three injections)

$50 injection fee if HA product is supplied by patient (injection of HA is not covered by OHIP)

 

durolane

Platelet Rich Plasma (PRP) & Autogous Protein Solution (APS)

PRP involves collecting some of your own blood, spinning it in a centrifuge, and then injecting a concentrated mixture of platelets and anti-inflammatory factors into a joint or tendon injury. There is growing interest and evidence that PRP injections may be effective in helping promote healing in certain conditions. 

APS follows a similar process, but uses a double spinning technique to further concentrate specific anti-inflammatory proteins and is predominantly used in large joint osteoarthritis. Some patients refer to APS as “PRP+”.

 

What to expect:

Our physicians will review the potential role of PRP or APS in your condition, with an open discussion of the evolving evidence as well as potential risks. 

The main risks include pain, damage, and infection. There can also be some financial risk, as many insurance companies do not provide coverage at this time.

All PRP and APS injections are performed under ultrasound guidance.

 

Cost: (Covered by Insurance Health Spending Accounts)

$600 for PRP of hip and knee joints

$550 for PRP of all other joints

$1800 for nStride® APS

 

durolane

 Ultrasound Guidance

 

The Clarius L7 handheld ultrasound is very portable and versatile, allowing for convenient assessment of joints and soft tissues. This device is preferentially used by North Bay Sport Medicine physicians when conducting hospital consults or in clinic for ultrasound guided injections of small joints or body parts. It connects to the physician’s phone or tablet to display the image.

 

 

 

 

The Mindray TE7 is a larger and more powerful ultrasound device for clinical use, and is the same model used in the North Bay Emergency Department. It is preferentially used by North Bay Sport Medicine for deeper joints or difficult anatomy. It has been upgraded with software for enhanced needle visualization to help with more accurate injections.

 

 

Did you know?

Dr. Lemenchick and Dr. Lougheed have background experience using ultrasound in the North Bay Emergency Department, within the field of Sport Medicine, and are pursuing additional expert training in joint and soft tissue injections to expand their offerings through 2024 and 2025?