Rehab for Post Steroid Injection for Biceps Tendon

[JanineRoss]

Hello!

My Sunday morning is usually spent indulging in all the great info FourLegRehab has to offer!

This Sunday morning I have a question for Laurie!

I have a 13 year old JRT being referred for rehab following a steroid injection for treatment of bicipital tenosynovitis. This patient has been dealing with ongoing biceps tenosynovitis for the past 2-3 months. The specialist and owner have decided to go ahead with a steroid injection despite my suggestion of perusing rehab first. Up until now periods of rest and NSAID use is all that has been done.

For biceps tendons I'm typically successful with a conservative rehab protocol including U/S therapy, cryotherapy, deep friction massage, eccentric exercise and gradual increase in activity thereafter. That being said, I'm looking into different suggestions/options for post steroid injection rehab as I've yet to treat one.

Would you suggest using your Post PRP Injection rehab protocol for post steroid injection rehab also? Do you know of any further studies or evidence of ultrasound or shockwave therapy being successful when utilized following PRP/steroid injections?

Sorry for the novel and THANK YOU for your help

Janine

[lehughes]

Hi Janine!

Well, it's a catch 22.

They inject the steroid to reduce inflammation. However a tendinopathy isn't usually inflammatory, it usually degenerative. And in being that way, it requires stimulation of the lesion to create a mild inflammatory reaction and stimulate healing. In true tendinopathy cases, cortisone is not the answer!

The tendon sheath however could be inflamed. Or the shoulder joint could be inflamed (which can make the biceps inflamed). In these instances, cortisone could help calm down the area. The main reason for the shoulder to become inflamed is a medial shoulder instability. (Check out the Shoulder Issue going back a bit in FourLeg News.)

As a physiotherapist, I was taught to avoid ultrasound for 2 weeks after a cortisone injection. This rule was just because you didn't want to dissipate the cortisone. However, it's a questionable suggestion, as it has been shown that a localized cortisone injection will become systemic within 24 hours. So really, would a therapeutic modality 'ruin' an injection. I don't believe so!

So... your plan will still work - U/S, frictions, Ice (but just for pain), eccentrics, and gradual exercise increases. All Perfect. I'd do shockwave or laser if available as well.

Caution: IF the injection was directly into the tendon, then you need to be aware that the tendon is likely to be weakened for quite some time after the injection. So caution would be needed with jumping, landing, and pouncing-type activities. However, often vets will inject into the shoulder joint in an attempt to treat a biceps tendon. So, a cortisone injection might actually help the likely root of the cause (i.e. the medial shoulder compartment syndrome / medial shoulder instability). And for treatment, add shoulder joint mobilizations, and aim some of your therapeutic modalities towards the medial side the glenohumeral joint.

I hope this helps you to think about the condition a little differently!

Best of luck!

Laurie

[David Lane]

I am aware of no research about concurrent PRP or ESWT with IA steroids… for precisely the reasons LEH suggested above. Patients can choose 1 path or the other, but from what we do know, you are working against yourself to do both.
Do you know what was injected? Triamcinolone? Depo-medrol? Hopefully the former. Was any sort of soft tissue imaging used in making the diagnosis?

David Lane DVM
ACVSMR

[JanineRoss]

Thank you to both of you for your very helpful input!

Depo-medrol was the steroid of choice as per specialist and leading up to the procedure radiographs and palpation has been performed as per the specialist's summary.

I did my best to suggest pursuing rehabilitation first and then proceeding with the procedure if the pain/lameness persisted. It sounds like the owner is frustrated and looking for a "quick fix". Regardless, my game plan is set and I look forward to seeing the patient and proceeding with the road to recovery!

Thanks again!

Janine

[David Lane]

At the very least, if the owner is receptive, plant the seed of not repeating the steroid injection if it didn't work the 1st time. Depo-medrol is chondrotoxic and to use it IA in a non-arthritic joint is "unwise". I have heard others use the term "malpractice"... and I don't have an immediate argument to refute that. Triamcinolone is chondroprotective in-vitro, but there is still a question mark about what it does in-vivo. If the depo injection doesn't work, then that increases my suspicion of biceps tendinopathy, at which point steroids are contra-indicated. Alternatively, SST and BT issues can be hard to distinguish based on palpation alone, and if this is SST, then an IA injection isn't going to get you far either...

I recognize that little of the above information helps you in your situation (all you can do is treat the patient in front of you), but I thought it was worth stating it aloud in case it dissuades someone else from taking the same therapeutic approach that your referring vet did.

David Lane DVM
ACVSMR