Musculoskeletal Therapies: Musculoskeletal Injection Therapy

Injections often are used in the management of common musculoskeletal conditions. Physicians should understand the disease pathophysiology and evidence supporting available injections when determining appropriate therapy. These therapies include corticosteroid injections (CSIs), hyaluronic acid (HA) injections, hypertonic dextrose prolotherapy, platelet-rich plasma (PRP) injections, mesenchymal stem cell (MSC) injections, and trigger point injections (TPIs). CSIs are recommended conditionally by the American College of Rheumatology for osteoarthritis (OA) management. CSIs are associated with short-term improvement in pain and function in patients with OA, although cartilage volume loss can occur with repetitive, frequent use. CSIs show no long-term benefit in the management of lateral epicondyle pain. For knee OA, HA injection shows prolonged improvement of pain and function compared with CSI. Studies of HA injection for other joints show the injection to be no more effective than placebo. Evidence for prolotherapy and PRP injection shows long-term improvement of pain and function in knee OA and tendinopathies. There is low-quality evidence showing MSC injections improve pain and function in OA and tendinopathies. It is unclear whether TPIs are effective because of a lack of high-quality evidence. Ultrasonography guidance has been shown to improve accuracy of delivery and clinical outcomes in injection therapies.