There is an important role for joint or soft tissue injections. However, injections usually do not help in the long term and the costs of the clinic consummables are not medicare rebatable.
Steroid soft tissue injections may be performed:
- Under ultrasound-guidance via a referral to Radiology.
- Or by the doctor in the clinic using anatomical landmarks.
There is controversy regarding the extra benefit of ultrasound guidance versus using anatomical landmarks for some types of injection.
The following injections are commonly performed without ultrasound guidance:
- Shoulder – for rotator cuff problems, bursitis, arthritis or frozen shoulder.
- Tennis and golfer’s elbow
- Carpal Tunnel
- De Quervains Tenosynovitis (where thumb joins the wrist)
- Osteoarthritis of the thumb
- Trigger finger or Trigger thumb
- Trochanteric Bursitis / trochanteric pain syndrome
- Knee Osteoarthritis
- Pes Anserine Bursitis
- Plantar Fasciitis (heel)
Few musculoskeletal doctors are happy to do injections into or around the Neck, Back (cervical, thoracic and lumbar spine), or Head & Face.
The American Family Physician recently summarised the evidence for musculoskeletal steroid injections. There is “fair evidence of success” for short-term relief for the following conditions: Frozen shoulder, carpal tunnel syndrome, De Quervain tenosynovitis, greater trochanteric pain, knee osteoarthritis, tennis elbow, golfer’s elbow, trigger finger.
What are the main downsides to a steroid injection?
- The benefit is only short-term
- In fact, some injections worsen long term outcomes eg. tennis elbow
- Those Radiology clinics that do ‘bulk bill’ will require you go to twice to the Radiology clinic. The first visit is to ‘get’ an ultrasound and the second to ‘get’ the injection.
The culture of ultrasound guided injections
There is no medicare payment for the injection that is performed by a GP unless the injection is performed under ultrasound guidance.
This leads to a perverse situation where:
- Medicare pay for the ultrasound that may not otherwise have been indicated.
- Medicare pay for the ultrasound guided injection.
- It’s much quicker and easier for the GP to refer for ultrasounds and injections
- Patients feel they are getting hi-tech medical intervention.
Ultrasound guided injections were once considered a useful method of treating some types of local pain that is difficult to control. It’s not now unusual to ‘get’ an injection after just a few days of mild discomfort. Many of these pains would have gone fairly quickly on their own particularly when underlying causes are addressed.
The GP sticks to time, the patient goes away with referral forms, the Radiologist gets paid and everyone is happy except for health economists!