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About those joint injections

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  • About those joint injections

    One of my favorite vets here discussed at a recent AAEP conference.

    https://m.youtube.com/watch?v=Oa438e...ature=youtu.be

  • #2
    The video is 5 minutes and the description is:
    Performance Horse Medication: How much is too much?
    Sports medicine veterinarians and AAEP members Drs. Sherry Johnson and Rick Mitchell discuss the impact of medication administration, particularly joint injections, when the evidence-based need is absent.
    If you are allergic to a thing, it is best not to put that thing in your mouth, particularly if the thing is cats. - Lemony Snicket

    Comment


    • #3
      We all really want those joint injections to work and we want it so much that we're willing to keep doing them and paying for them even without a ton of evidence. There's an ethos of "what can it hurt" but in fact in addition to the possible known side effects there is also not a lot of evidence that lets us be certain that they don't hurt.
      If you are allergic to a thing, it is best not to put that thing in your mouth, particularly if the thing is cats. - Lemony Snicket

      Comment

      • Original Poster

        #4
        Rick cared for a OTTB I had back in the late 80’s. Even back then I distinctly remember him heaving a sigh of relief when I told him an increase with NSAIDs might be the best first approach in the hopes of getting comfort and hocks fusing. We injected after 3 months anyway but he was thrilled I was willing to try the other way first.

        meanwhile, my QH is 20 now, and his hocks are trying to fuse. He takes a poor step occasionally but he’s been sound behind without any injections. At this point, I doubt there’s any room in there.
        Last edited by Sansena; Oct. 6, 2019, 08:58 PM. Reason: Hocks. Not Hicks.

        Comment


        • #5
          Dr. David Ramey has shared a similar, dubious opinion for years: On joint injections, Adequan/Legend, as well as supplements.
          Last edited by Lusoluv; Oct. 14, 2019, 07:52 PM.
          Savor those rides where you feel like a million bucks, because there will be those where you feel like a cheap date...

          Comment


          • #6
            Injections are NOT WITHOUT RISK!!!! I've seen ulcers from the steroids, and horse was much unhappier from that than anything else. I always go back to human medicine, if they were the end all be all for arthritis (knowing different species and all... but similar pathology), we just don't see it done with humans to the same extent.

            I just don't think we have the evidence to back up injections as preventative or for early OA.

            Comment


            • #7
              Originally posted by Moogles View Post
              I always go back to human medicine, if they were the end all be all for arthritis (knowing different species and all... but similar pathology), we just don't see it done with humans to the same extent.
              There are a lot of reasons to be hesitant to use steroid joint injections in equines, but lack of use in human medicine sure isn't one of them. Steroid joint injections are a backbone of orthopedic practice, and are often required before proceeding to other injections or surgery. Orthopedists stick steroid in joints all day long, often with a very limited review of risks or possible side effects. They are very often quite effective, at least for a period of time, hence the widespread use.

              Use of hylauronic acid is also picking up more traction on human medicine--it's certainly seeing more use than just knees. PRP and stem cell also have a niche following, but are getting more popular as patients age, research improves, and more are looking for alternatives to surgery.

              Signed, someone who has had too many steroid joint injections to count, along with several PRP injections, and a laundry list of orthopedists.

              Comment


              • #8
                Originally posted by Simkie View Post

                There are a lot of reasons to be hesitant to use steroid joint injections in equines, but lack of use in human medicine sure isn't one of them. Steroid joint injections are a backbone of orthopedic practice, and are often required before proceeding to other injections or surgery. Orthopedists stick steroid in joints all day long, often with a very limited review of risks or possible side effects. They are very often quite effective, at least for a period of time, hence the widespread use.

                Use of hylauronic acid is also picking up more traction on human medicine--it's certainly seeing more use than just knees. PRP and stem cell also have a niche following, but are getting more popular as patients age, research improves, and more are looking for alternatives to surgery.

                Signed, someone who has had too many steroid joint injections to count, along with several PRP injections, and a laundry list of orthopedists.
                Agreed!

                I'm pretty conservative about steroid joint injections for my horse based on a number of risks and other individual considerations. But having now had multiple MDs shoot triamcinolone into my joints, and consulting with others who consider this to be a relatively conservative treatment for inflammatory issues associated with joint injuries and degeneration, I'm calling shenanigans on the argument that this treatment is disfavored by human medicine.

                And if we're looking for the end-all-be-all in human arthritis treatment, the orthopedists I've worked with tend to think that is joint replacement. I'm thankful that my vet doesn't have such a black and white view of things (steroids are considered alongside biologics, anti-inflammatories, PT in a far more individualized way by my vet, IME, than my MDs).

                I'm saving my pennies now for some PRP (and am jealous of my horse, who can get it at a fraction of the cost of human treatment).

                Comment


                • #9
                  It's pretty simple, really. If you horse is having an issue and joint injections may help, you can do the injections and see if there is a change. There are multiple medications and combinations you can use, and a good vet will be able to identify which ones will best benefit your horse. It is very much dependent on the individual. I've had racehorses that really come around on Legends and Adequan (not joint injections), and those that do not change at all on the same regime. My vet practices at the track part time and is very good at injections, and there are absolutely situations where draining fluid out of the joint and injecting a medication to help settle things down really benefits the horse.
                  "When a true genius appears in the world, you may know him by this sign, that the dunces are all in a confederacy against him."

                  Comment


                  • #10
                    Originally posted by Simkie View Post

                    There are a lot of reasons to be hesitant to use steroid joint injections in equines, but lack of use in human medicine sure isn't one of them. Steroid joint injections are a backbone of orthopedic practice, and are often required before proceeding to other injections or surgery. Orthopedists stick steroid in joints all day long, often with a very limited review of risks or possible side effects. They are very often quite effective, at least for a period of time, hence the widespread use.

                    Use of hylauronic acid is also picking up more traction on human medicine--it's certainly seeing more use than just knees. PRP and stem cell also have a niche following, but are getting more popular as patients age, research improves, and more are looking for alternatives to surgery.

                    Signed, someone who has had too many steroid joint injections to count, along with several PRP injections, and a laundry list of orthopedists.
                    True, also the recipient of such injections.

                    One to the shoulder was for diagnostic purpose.
                    If it worked, then I didn't need surgery.
                    Didn't work, so off to MRI and surgery I was sent.

                    Two in swollen, sore knees 30 years ago and knees were like new, never again had any trouble with them.

                    Injecting joints works, no matter what species, if used properly, of course.

                    Are vets over-injecting, are clients demanding it?

                    Well, those are a different topic than if joint injections are proper medical practice.

                    Comment


                    • #11
                      Originally posted by Bluey View Post



                      Are vets over-injecting, are clients demanding it?

                      Well, those are a different topic than if joint injections are proper medical practice.
                      I'm seeing vets use it as a diagnostic now. Like my vet injecting my mare's SI in case it needed it because he wasn't confident any problems there would show up well on xrays. Though he was happy that I wasn't wanting to just inject her joints willy-nilly, he says typically he has owners coming in wanting to just inject whatever area is having problems without finding out what the problem actually is so they can get back to work.

                      Comment


                      • #12
                        Originally posted by RainWeasley View Post

                        I'm seeing vets use it as a diagnostic now. Like my vet injecting my mare's SI in case it needed it because he wasn't confident any problems there would show up well on xrays. Though he was happy that I wasn't wanting to just inject her joints willy-nilly, he says typically he has owners coming in wanting to just inject whatever area is having problems without finding out what the problem actually is so they can get back to work.
                        People doctors do this too!

                        My back was troublesome earlier this year, and my orthopedist looked at old radiographs & MRI, did not feel the need to do further imaging, and said we should do an anesthetic block to confirm that was the source of my pain. No big deal.

                        We do that, I feel better, and when I come back for a recheck expecting the conversation to be whether we now do steroid or jump straight to PRP, I found out that no...there was a hefty load of steroid with that block a few weeks ago.

                        I'm savvy with orthopedists, and this isn't my first rodeo. I generally know what questions to ask and am a good listener. But I had NO idea we were doing steroid straight off the bat.

                        Thankfully (unsurprisingly) those injections did the trick and I've had no further problems. But yep, it sure is easy to wind up with steroid injections!

                        ​​​​​

                        Comment


                        • #13
                          Originally posted by Simkie View Post

                          There are a lot of reasons to be hesitant to use steroid joint injections in equines, but lack of use in human medicine sure isn't one of them. Steroid joint injections are a backbone of orthopedic practice, and are often required before proceeding to other injections or surgery. Orthopedists stick steroid in joints all day long, often with a very limited review of risks or possible side effects. They are very often quite effective, at least for a period of time, hence the widespread use.

                          Use of hylauronic acid is also picking up more traction on human medicine--it's certainly seeing more use than just knees. PRP and stem cell also have a niche following, but are getting more popular as patients age, research improves, and more are looking for alternatives to surgery.

                          Signed, someone who has had too many steroid joint injections to count, along with several PRP injections, and a laundry list of orthopedists.
                          Absolutely not seen in human medicine is joint injections for preventative or early arthritis (I am assuming you are past early with your history). NSAIDs are often used as is PT/OT. Rheumatoid arthritis different story. Cosigned someone in medicine looking at the research. My personal physio said the Stem Cell studies have been canned recently...take that for what it is worth.
                          Last edited by Moogles; Oct. 16, 2019, 07:42 PM.

                          Comment


                          • #14
                            Originally posted by x-halt-salute View Post

                            Agreed!

                            I'm pretty conservative about steroid joint injections for my horse based on a number of risks and other individual considerations. But having now had multiple MDs shoot triamcinolone into my joints, and consulting with others who consider this to be a relatively conservative treatment for inflammatory issues associated with joint injuries and degeneration, I'm calling shenanigans on the argument that this treatment is disfavored by human medicine.

                            And if we're looking for the end-all-be-all in human arthritis treatment, the orthopedists I've worked with tend to think that is joint replacement. I'm thankful that my vet doesn't have such a black and white view of things (steroids are considered alongside biologics, anti-inflammatories, PT in a far more individualized way by my vet, IME, than my MDs).

                            I'm saving my pennies now for some PRP (and am jealous of my horse, who can get it at a fraction of the cost of human treatment).
                            Is is not favored in human medicine for preventive or early arthritis (again not Rheumatoid arthritis, different pathology)! Every time you enter the joint space there is a risk. I am sorry but if you are at the stage where steroids are ok, then there is disease pathology going on. My hesitance is the widespread use in the horse word for preventative, or where arthritis isn't even at the stage of detectable changes.

                            Was there a documented problem or are you injecting your joints preventatively? I would be shocked if a MD injected you with a history of pain, dysfunction, or changes on imaging.

                            To clarify I am not trying to be argumentative, just that I see vets promote injection for "preventative" or supposed joint disorders that show no pathology on imaging. It frustrates me.
                            Last edited by Moogles; Oct. 16, 2019, 07:43 PM. Reason: taking out some abbreviations..sorry bad habit

                            Comment


                            • #15
                              Originally posted by Moogles View Post

                              Absolutely not seen in human medicine is joint injections for preventative or early OA (I am assuming you are past early with your history). NSAIDs are often used as is PT/OT. Rheumatoid arthritis different story. Cosigned someone in medicine looking at the research. My personal physio said the Stem Cell studies have been canned recently...take that for what it is worth.
                              I have ZERO evidence of OA. Multiple steroid injections. Multiple orthopedists. Multiple hospitals, including the one that's #1 in the country.

                              Your physio is behind on the research 👍

                              Originally posted by Moogles View Post
                              I would be shocked if a MD injected you with a history of pain, dysfunction, or changes on imaging.
                              And why would that shock you? History of pain, dysfunction and changes on imaging are pretty much a checklist FOR injections.

                              If you don't think doctors are injecting people preventatively for relatively minor joint pain, you must not keep up with any professional sports or athletes?

                              ​​​​​​​Sweeping statements that joint injections aren't used frequently in human medicine just aren't valid.
                              ​​​​​

                              Comment


                              • #16
                                Originally posted by Moogles View Post

                                Is is not favored in human medicine for preventive or early arthritis (again not Rheumatoid arthritis, different pathology)! Every time you enter the joint space there is a risk. I am sorry but if you are at the stage where steroids are ok, then there is disease pathology going on. My hesitance is the widespread use in the horse word for preventative, or where arthritis isn't even at the stage of detectable changes.

                                Was there a documented problem or are you injecting your joints preventatively? I would be shocked if a MD injected you with a history of pain, dysfunction, or changes on imaging.

                                To clarify I am not trying to be argumentative, just that I see vets promote injection for "preventative" or supposed joint disorders that show no pathology on imaging. It frustrates me.
                                When joint injection was first recommended for me I had not been diagnosed with OA -- the steroid injection was part of a long and complex diagnostic/treatment planning process for a different joint issue. However, I have since been diagnosed with OA and it has been recommended to me since then by multiple MDs for the management of OA joint inflammation (as it is used in horses).

                                I, my MDs, and my vets are all well aware of the risks associated with invading the joint capsule. I've had the misfortune of seeing a hock go septic (not on my horse, thankfully) -- as I said before, it's not something I take lightly. As my prior post suggests, I've only seen vets (and MDs) recommend intra-articular steroid injections when there is evidence of joint inflammation and/or degeneration, so I can't speak to your concern about preventative joint injections.

                                But as I said before, this treatment is most certainly in widespread use in human medicine for the management of inflammatory joint problems that include OA. The argument that intra-articular steroid injection is not commonly used to treat arthritis in human medicine, and therefore its veterinary use should be reconsidered (see your statement quoted in post #7), simply holds no water for me.

                                Comment


                                • #17
                                  Originally posted by Simkie View Post

                                  I have ZERO evidence of OA. Multiple steroid injections. Multiple orthopedists. Multiple hospitals, including the one that's #1 in the country.

                                  Your physio is behind on the research 👍



                                  And why would that shock you? History of pain, dysfunction and changes on imaging are pretty much a checklist FOR injections.

                                  If you don't think doctors are injecting people preventatively for relatively minor joint pain, you must not keep up with any professional sports or athletes?

                                  Sweeping statements that joint injections aren't used frequently in human medicine just aren't valid.
                                  ​​​​​
                                  That was a mis-type my apologies! It should have said you should have pain, dysfunction or changes on x-ray. To not have would be unusual. I had typed up a nice chunk of info from Dyna Med but Coth ate it :/

                                  The short of it was the evidence is considered weak, but people still do it. I’m glad they help you, but I still stand by my statement they are not without risk and are not always the first resort.

                                  Comment


                                  • #18
                                    From Dyna Med on OA:

                                    Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.

                                    Management


                                    • Exercise therapy (including physical therapy) and weight loss (if indicated) are the mainstays of nonsurgical management of symptomatic knee OA.
                                      • Self-management programs are recommended for patients with knee OA (Strong recommendation); primary components of self-management programs include patient education, weight management, exercise, use of assistive/adaptive devices, and appropriate footwear.
                                        • Weight loss is recommended for patients with BMI ≥ 25 kg/m2 (Strong recommendation).
                                        • Patients should participate in a regular (daily) exercise program (matching his or her ability) (Strong recommendation).
                                        • Consider the use of walking aids, assistive technology, and adaptations at home and/or work to reduce pain and increase participation in daily activities (Weak recommendation).
                                        • A walking cane should be used on the contralateral side.
                                      • Primary goals of physical therapy are improved pain, function, and joint stability.
                                        • Patients should receive individualized therapeutic exercise programs, with primary components including (Strong recommendation):
                                          • strengthening exercise
                                          • low-impact aerobic exercise
                                          • neuromuscular reeducation
                                          • adjunctive range of motion and stretching exercises
                                        • Prescribe land-based or aquatic-based therapy according to patient ability level/tolerance, preference, and local facility availability (Strong recommendation).
                                        • Consider adjunctive rehabilitation components, including:
                                          • physical modalities such as ice or heat therapy, therapeutic ultrasound, or electrical stimulation (such as transcutaneous electrical nerve stimulation [TENS] or neuromuscular electrical stimulation [NMES])
                                          • manual therapy (Weak recommendation)
                                          • nonelastic therapeutic knee taping (also called Leukotaping, McConnell taping, and patellar taping) (in patients with patellofemoral OA) (Weak recommendation)
                                          • valgus knee braces (in patients with medial knee OA)
                                        • Do not prescribe lateral wedge insoles for patients with symptomatic medial compartmental knee OA (Strong recommendation).
                                    • Pharmacologic agents
                                      • In patients for whom nonpharmacologic treatments are not effective, consider acetaminophen (up to 4 g/day), a topical nonsteroidal anti-inflammatory drug (NSAID) (such as diclofenac or ketoprofen), or an oral NSAID (Weak recommendation).
                                      • In patients ≥ 75 years old or patients at risk for adverse effects from oral NSAIDs, use a topical NSAID such as diclofenac or ketoprofen (Strong recommendation) or consider acetaminophen (Weak recommendation).
                                      • Consider adding acetaminophen to NSAID treatment for symptom control.
                                      • Consider corticosteroid injections in patients with a knee OA flare (joint inflammation and effusion) (Weak recommendation).
                                      • In patients with inadequate response to first-line pharmacologic agents, consider tramadol or duloxetine (Weak recommendation).
                                      • Consider nontramadol opioids only in patients without any other medical or surgical options, and persistent symptoms (Weak recommendation).
                                      • Consider hyaluronic acid injections (viscosupplementation) only in patients with less advanced OA who do not respond to other treatments (Weak recommendation) and who are < 65 years old.
                                    • Alternative/complementary approaches may be considered in patients with persistent symptoms and dysfunction recalcitrant to traditional pharmacological and nonpharmacological approaches.
                                      • Dietary and herbal therapies that may be considered include curcumin (turmeric extract), or ginger.
                                      • Do not recommend glucosamine and chondroitin for patients with symptomatic knee OA (Strong recommendation).
                                      • Consider enrollment in a Tai Chi program as part of nonpharmacologic management of OA of the knee (Weak recommendation).
                                      • Other alternative therapies to consider include:
                                        • yoga
                                        • massage therapy
                                        • balneotherapy (spa therapy/mineral baths)
                                        • magnet therapy
                                        • whole body vibration
                                        • mud pack therapy
                                        • leech therapy
                                      • Acupuncture
                                        • Acupuncture is not recommended for most patients with symptomatic knee OA (Strong recommendation), but acupuncture may be considered if chronic moderate-to-severe pain is present and the patient is a candidate for total knee arthroplasty (TKA) but is unwilling to have the procedure, has comorbid conditions, or is taking concomitant medication that contraindicates surgery (Weak recommendation).
                                        • Moxibustion, a type of acupuncture with higher-quality evidence of efficacy, may be considered in the management of knee OA.
                                    • Nonarthroscopic surgery (such as partial or total knee replacement) should be reserved for cases where symptoms are persistent, and refractory to both pharmacological and nonpharmacological treatment modalities.
                                      • Base type and timing of surgery on the patient's symptoms and degree of suffering (impact on quality of life and activities of daily living), stage of knee OA, age, physical activity level, and comorbidities.
                                      • Joint-preserving surgery:
                                        • Consider high tibial osteotomy (HTO) only in active patients with symptomatic medial knee OA and varus knee alignment (Weak recommendation).
                                        • Consider distal femoral osteotomy (DFO) only in patients with substantial knee valgus (> 10-15 degrees between anatomic and mechanical axes) and lateral compartment knee OA.
                                        • Arthroscopic surgery (knee debridement and/or lavage) is not recommended for most patients with symptomatic knee OA (Strong recommendation); however, it may be considered for short-term symptom relief in select patients (such as those wanting to delay more invasive procedures such as total knee arthroplasty).
                                      • Joint-replacing surgery:
                                        • Consider unicompartmental knee arthroplasty (UKA) in younger patients with less severe knee OA which is limited to 1 compartment.
                                        • Consider TKA in patients with knee OA not achieving adequate pain relief and functional improvement from both nonpharmacologic and pharmacologic treatment (Weak recommendation).

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