When it comes to infiltrations and pain control, the Saint-Georges Medical Clinic offers a rapid and ongoing medical care/management that is difficult to find in the public sector. When referred to a specialist for an infiltration in the public sector, the latter often does not have the mandate to evaluate and follow up on your condition. His mandate is to provide the infiltration indicated on the request form trusting the evaluation was performed by a doctor with sufficient expertise in musculoskeletal conditions to not simply determine the site of infiltration based on imagery.

Also, too often, patients are referred to orthopedic surgeon or neuro-surgeon for non-surgical conditions that will simply chronicize and complicate as you wait to see them.

In order to prevent a painful condition from becoming chronic, it is better to consult within 4-8 weeks.

Most forms of arthrosis or other degenerative conditions are painless unless inflamed.

Some individuals have severe osteo-degenerative conditions on imagery, yet have little pain because not “inflammatory inclined”.

Others have little degenerative conditions on imagery and have significant pain syndromes. It is not because one has a huge radiological pathology that his pain doesn’t come from an inflamed non radiological tendon or ligament in that same region.

Only a good expert physical exam can determine this.

It is acceptable to start with any of the mainstream manual therapies such as physo, chiro, osteo and kinesiology.

However if after a month of therapy, no improvement is found, it is wise to include an infiltration to this therapy. The combination of infiltration and a manual therapy is better than either one alone.

PRP is the acronym for “platelet rich plasma”.

It is used in esthetics, dermatology, sport medicine, orthopedic medicine, urology, veterinary medicine and dental medicine to potentiate healing/regeneration of damaged/degenerative tissue.

PRP is obtained by centrifuging 25+cc of a patient’s blood to separate and concentrate by 3-4 times “3-4” that person’s platelet and growth factors.

This increases by “3-4 times” the person’s natural healing potential.

What the body could not succeed with its natural concentration of “1” in healing factors, PRP concentrated by “x3-4” can. 

Another reason for its great potential is that it is often placed where blood flow is poor. To be noted, what grows older faster on our body are tendons and joints because they are poorly vascularized compared to other structures.

FYI, old skin biopsies show they have much less capillary vessels than younger skin.

Diabetics grow older faster because the disease makes blood vessels degenerate faster.

Cardio exercises keeps, not only the heart young but also the blood vessels by stimulating the demand for blood flow.

The greater the demand for oxygen, the more the body increases its blood vessels.

The more blood vessels, the more healing factors available.

I give it two reasons:

• Very often chronic pain which starts with a primary lesion will develop secondary and tertiary local and regional lesions…
• Secondly, just as you may need 10 days of antibiotics, if you stop on 5th day and treatment fails, it won’t make it the wrong treatment…Experience teaches how long a treatment is required. My experience shows 50% of patients require 2 infiltrations of cortisone or PRP while 20% require three infiltrations

Cortisone is an anti-inflammatory medication. It reduces pain simply by reducing the inflammatory response to degenerative or damaged tissue. It is not the degenerative or damaged tissue that hurts, it’s the inflammatory response to it.

All healing processes of the body involves an inflammatory process involving the blood and its platelets/growth factors/immune factors…

Chronic inflammation is the perpetual unsuccessful attempt of the body to heal.

It is unfortunately painful and can become destructive to the structure involved if left uncontrolled/unrepressed.

Cortisone remains my first line treatment.

It can often control pain for 3-6+ months. 

Sometimes, it permits a tissue to scar just enough to stop producing inflammation permanently

Cortisone infiltrations are not to be confused with oral cortisone treatments involving prolonged daily use and all the related side effects. That is what is at the origin of such social phobia.

Cortisone infiltrations provoke no damageable side effects unless repeated too often.

It is safe to do a maximum of 2-3 initial infiltrations to maximize success and then repeat as necessary at least 3 month apart.

Statistically, I find 40% of patients respond sufficiently to the first infiltration, 40% require a second infiltration. Of the 20% that have not responded, only 15-20% of them will respond to the third. I rarely encourage the third infiltration unless there is a slow but encouraging improvement after the 2nd infiltration.

Repetitive quarterly infitlrations become unreasonable if started below age of perhaps 60. One should then consider PRP.

In truth, the tendons and ligaments are the structures that can be truly damaged from repetitive infiltrations of cortisone. The most vulnerable tendons to cortisone is the Achilles tendon which should never be infiltrated with cortisone but can be with PRP.

In truth, a joint can rarely be damaged by cortisone. It can even theoretically be protected by it. The reasoning is the following: 

Chronic inflammation accelerates cartilage degeneration, therefore cortisone can slow down cartilage degeneration by slowing down a chronic inflammatory condition.

My favorite protocol is to start with 1-2 cortisone infiltrations before doing 2-3 PRP infiltrations. It permits me to better understand the pathology of primary and secondary lesions before doing PRP. In average PRP infiltrations will be efficient for 1-3 years.

Trigger point infiltrations have two aims:

• They provoke a reflex relaxation in muscle spasms and by their multiple minor traumas, stimulate a healing process by liberating the same healing factors we exploit with PRP but at much lower concentrations.
• They are usually done with Xylocaïne as volume substraste and muscle relaxant.

HA is a molecule made up of long intertwined chains of sugars found naturally in the skin and joint fluid (synovia).

It serve as a thickener and lubricant by having strong water retention properties. It explains why kids have beautiful skin turgor and why women put HA in their lips.

Some claim it has a discrete regenerative effect.

We use it in joints for visco-supplementation.

Botulinic agents are added to xylocaine to perform trigger points when spasms resist to standard trigger points. Botulinic agents are muscle paralytics. They will paralyze some of the muscle fibers involved in the muscle spasm.

Neuropathic pain originates from a inflamed or degenerated nerve.

It can also have a central (cerebral) origin.

Fibromyalgia is considered by many as a central neuropathy with strong psychosocial modulators.

Neuropathic pain is the most difficult to manage.

They respond poorly to infiltrations and medication.

Fortunately they are fairly rarely seen in their primary form compared to orthopedic conditions which are endemic.

However, they are often seen as tertiary lesions in many orthopedic conditions.

Tendinosis

Degenerated/worn out tendon

Arthrosis

Degenerated/worn out joint

Tendinitis

Inflamed tendon

Osteoarthritis

Inflamed joint caused by arthrosis

Arthrite

Inflamed joint from an inflammatory disease as Rhumatoid arthritis

Tendinopathy

Unspecified tendon pathology

Enthisis

Point of insertion of a tendon or ligament on bone

Enthesopathy

Unspecified pathology of a enthesis

Infiltration

injection

Epidural infiltration

Infiltration in the epidural space

Caudal epidural

Epidural performed through the sacral caudal hole