High Volume Image Guided Injections

Dylan Morrissey
Co-investigators: Otto Chan
  Hatim Abdulhussein
  Sarah Morton

The first paper on high volume image-guided injections (HVIGI) was published in 2008 by the team at Queen Mary University of London and BMI London Independent Hospital. Chan et al., (2008) showed that a HVIGI was beneficial for both pain and function in Achilles tendinopathy. A pilot study by Crisp et al., (2008) showed a similar benefit for patellar tendinopathy.

Since then the research has continued and grown from there. A prospective study by Morton et al., (RSNA 2012) in patellar tendinopathy has further supported the findings originally shown in the pilot study. Similar work has also been started in both greater trochanter bursitis and shoulder impingement syndrome, initially showing promising results.

The mechanism of action of a high volume image-guided injection remains unclear. It is thought that in tendinopathy the high volumes disrupt the neovascularisation. It is currently unknown whether the injection has a chemical effect due to the presence of steroid and local anaesthetic, or whether the injection works mostly mechanically. Early findings suggest a HVIGI without steroid yields similar effects on pain reduction and functional improvements, in comparison to HVIGI with steroid. These results suggest the effects of the injection may be mechanical, or due to the local anaesthetic, rather than chemical due to the steroid. Further research with imaging outcomes and longer follow ups is necessary in order that steroid, with the associated risks it may carry, can be omitted from the injectates.

All injections are followed by a customised physiotherapy regime for all conditions. The exact mechanism and the long-term effects on the tissues require future research.

One of the main areas for future research is the development of randomised controlled trials in comparison to other recognised treatment modalities. Work is beginning in these areas. Future work also involves publishing a systematic review comparing the effects of HVIGI with other injection treatments, in order to help improve understanding of how the injections are proposed to work, mechanically or chemically, and to guide clinical decisions and inform future research.