Faculty Bibliography

Platelet rich plasma (PRP), an autologous sample of blood with a platelet concentration above baseline values, is hypothesized to augment soft tissue healing. Its use in sports medicine has risen dramatically, with common applications including the treatment of refractory tendinopathy and augmenting tendon repair. Many commercial preparation systems are available, but the optimal preparation remains unknown. Increasing numbers of clinical studies evaluating PRP have been reported and have provided both positive and negative evidence for its effectiveness. Well-designed, controlled studies are still lacking, but PRP may have a benefit for patients with tendinopathy that is refractory to other non-surgical treatments. Its use in tendon repair is currently not supported. Randomized, controlled studies with documentation of platelet, white blood cell, and growth factor concentration in the PRP preparation are necessary for future comparative research. Use of PRP should be approached judiciously until further evidence is available.

Platelet-rich plasma is defined as autologous blood with a concentration of platelets above baseline values. Platelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s; its use in sports medicine is growing given its potential to enhance muscle and tendon healing. In vitro studies suggest that growth factors released by platelets recruit reparative cells and may augment soft-tissue repair. Although minimal clinical evidence is currently available, the use of platelet-rich plasma has increased, given its safety as well as the availability of new devices for outpatient preparation and delivery. Its use in surgery to augment rotator cuff and Achilles tendon repair has also been reported. As the marketing of platelet-rich plasma increases, orthopaedic surgeons must be informed regarding the available preparation devices and their differences. Many controlled clinical trials are under way, but clinical use should be approached cautiously until high-level clinical evidence supporting platelet-rich plasma efficacy is available

Joint and soft tissue injection of the ankle and foot region is a useful diagnostic and therapeutic tool for the family physician. This article reviews the injection procedure for the plantar fascia, ankle joint, tarsal tunnel, interdigital space, and first metatarsophalangeal joint. Indications for plantar fascia injection include degeneration secondary to repetitive use and traumatic injuries that are unresponsive to conservative treatment. Diagnostic aspiration or therapeutic injection of the ankle or first metatarsophalangeal joints can be performed for management of advanced osteoarthritis, rheumatoid arthritis, and other inflammatory arthritides such as gout, or synovitis or an arthrosis such as 'turf toe.' Persistent pain and disability resulting from tarsal tunnel syndrome, an analog of carpal tunnel syndrome of the wrist respond to local injection therapy. A painful interdigital space, such as that occurring in patients with Morton's neuroma, is commonly relieved with corticosteroid injection. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes

Joint injection of the hip and knee regions is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedure for the greater trochanteric bursa, the knee joint, the pes anserine bursa, the iliotibial band, and the prepatellar bursa is reviewed. Indications for greater trochanteric bursa injection include acute and chronic inflammation associated with osteoarthritis, rheumatoid arthritis, repetitive use, and other traumatic injuries to the area. For the knee joint, aspiration may be performed to aid in the diagnosis of an unexplained effusion and relieve discomfort caused by an effusion. Injection of the knee can be performed for viscosupplementation or corticosteroid therapy. Indications for corticosteroid injection include advanced osteoarthritis and other inflammatory arthritides, such as gout or calcium pyrophosphate deposition disease. Swelling and tenderness of pes anserine or prepatellar bursae can be relieved with aspiration and corticosteroid injection. Persistent pain and disability from iliotibial band syndrome respond to local injection therapy. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes

The shoulder is the site of multiple injuries and inflammatory conditions that lend themselves to diagnostic and therapeutic injection. Joint injection should be considered after other therapeutic interventions such as nonsteroidal anti-inflammatory drugs, physical therapy, and activity-modification have been tried. Indications for glenohumeral joint injection include osteoarthritis, adhesive capsulitis, and rheumatoid arthritis. For the acromioclavicular joint, injection may be used for diagnosis and treatment of osteoarthritis and distal clavicular osteolysis. Subacromial injections are useful for a range of conditions including adhesive capsulitis, subdeltoid bursitis, impingement syndrome, and rotator cuff tendinosis. Scapulothoracic injections are reserved for inflammation of the involved bursa. Persistent pain related to inflammatory conditions of the long head of the biceps responds well to injection in the region. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes

Joint injection of the wrist and hand region is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures for carpal tunnel syndrome, de Quervain's tenosynovitis, osteoarthritis of the first carpometacarpal joint, wrist ganglion cysts, and digital flexor tenosynovitis (trigger finger) are reviewed. Indications for carpal tunnel syndrome injection include median nerve compression resulting from osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypothyroidism, repetitive use injury, and other traumatic injuries to the area. For the first carpometacarpal joint, injection may be used to treat pain secondary to osteoarthritis and rheumatoid arthritis. Pain associated with de Quervain's tenosynovitis is treated effectively by therapeutic injection. If complicated by pain or paresthesias, wrist ganglion cysts respond to aspiration and injection. Painful limitation of motion occurring in trigger fingers of patients with diabetes or rheumatoid arthritis also improves with injection. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes

Joint injection of the elbow is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures for the elbow joint, medial and lateral epicondylitis, and olecranon bursitis are reviewed. Persistent pain related to inflammatory conditions responds well to injection in the region. Indications for elbow joint injection include osteoarthritis and rheumatoid arthritis. Corticosteroid injection is an accepted treatment option for medial and lateral epicondylitis. Olecranon bursa aspiration and injection are useful when that bursa is inflamed. The proper techniques, choice and quantity of pharmaceuticals, and appropriate follow-up essential for effective outcomes are discussed