{"name":"Back Pain Doctor evidence atlas","url":"https://www.backpaindoctor.com.au/evidence/atlas","description":"Evidence rating for each non-surgical treatment against each musculoskeletal condition guide. A rating describes the published evidence for that pairing. It is not a prediction of outcome for an individual and not medical advice.","lastReviewed":"2026-11-11","levels":{"core":"Core care","supported":"Good support","discuss":"Worth discussing","mixed":"Evidence mixed","untested":"Plausible: no studies","situational":"Only if relevant","notOffered":"Not offered for this"},"counts":{"conditions":111,"treatments":12,"pairings":1332,"reviewed":1224,"underReview":108,"byStatus":{"core":103,"supported":39,"untested":325,"situational":297,"notOffered":243,"discuss":161,"mixed":56}},"treatments":[{"id":"rehab","name":"Diagnosis, education and progressive rehabilitation","url":null},{"id":"wetNeedling","name":"Wet needling and trigger point injection","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/wet-needling-trigger-point-injection"},{"id":"guidedInjection","name":"Ultrasound-guided injections","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/ultrasound-guided-injections"},{"id":"vactor","name":"V-ACTOR vibration therapy","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/vactor-vibration-therapy"},{"id":"radialShockwave","name":"Radial shockwave","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/radial-shockwave-therapy"},{"id":"focusedShockwave","name":"Focused shockwave (ESWT)","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/shockwave-therapy-eswt"},{"id":"emtt","name":"EMTT","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/emtt-magnetotransduction"},{"id":"prp","name":"Platelet-rich plasma (PRP)","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/platelet-rich-plasma-treatment"},{"id":"prolotherapy","name":"Prolotherapy","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/prolotherapy-treatment"},{"id":"viscosupplementation","name":"Viscosupplementation","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/viscosupplementation"},{"id":"perineural","name":"Lyftogt perineural therapy","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/nerve-therapy-treatment"},{"id":"hydrodissection","name":"Ultrasound-guided nerve hydrodissection","url":"https://www.backpaindoctor.com.au/non-surgical-treatments/nerve-hydrodissection"}],"conditions":[{"slug":"ac-joint-injury","title":"AC Joint Injury","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/ac-joint-injury","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Ultrasound raised accuracy of acromioclavicular joint injection from 68.2% to 93.6% (Aly, Br J Sports Med 2014). The joint is small and the landmarks are unreliable.","fit":"Where an injection is indicated for a painful AC joint, guidance is worth the extra step.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave, radial or focused, in an acromioclavicular (AC) joint injury. A PubMed search for shockwave with acromioclavicular and other ligament terms (15 records, all read) returned only reviews of shoulder pain that mention the AC joint, and a second search pairing acromioclavicular with shockwave or extracorporeal (11 records) found no treatment study.","fit":"Not part of early management. Considered only once pain persists well beyond the expected healing time, and then for the tender muscle and fascia around the shoulder rather than the injured joint.","reviewedOn":"2026-10-23"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in an acromioclavicular (AC) joint injury. A PubMed search for shockwave with acromioclavicular and other ligament terms (15 records, all read) returned only reviews of shoulder pain that mention the AC joint, and a second search pairing acromioclavicular with shockwave or extracorporeal (11 records) found no treatment study. A trial and systematic-review pass over shockwave in ligament injuries (17 records) found none at this joint.","fit":"Not part of early management, which is a sling for comfort, then movement and strengthening. It may become a question only for persistent pain in the surrounding muscle, and then without evidence in this injury.","reviewedOn":"2026-10-23"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for platelet-rich plasma in the acromioclavicular joint returns eight records and no controlled trial in AC joint injury. The nearest published human report is a single case of refractory distal clavicular osteolysis settled with an ultrasound-guided PRP injection, whose authors note that no efficacy studies exist for that indication either (Kim, Clin J Sport Med 2024). Where AC joint arthrosis has been measured as a variable rather than a target, it predicted a worse response to PRP elsewhere in the shoulder (Berna-Mestre, AJR Am J Roentgenol 2020).","fit":"Rarely relevant. Most AC joint sprains settle with load management and a graded return, and the position on PRP here is that nobody has tested it.","reviewedOn":"2026-09-02"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested prolotherapy in an acute AC joint sprain or separation. The one prospective study injected 15% dextrose around the acromial enthesis and AC joint capsule in 31 people with chronic AC joint arthropathy and acromial enthesopathy, and reported substantial pain reduction in 20 of them with no adverse effects, but it had no control group and a mean follow-up of only 62 days (Hsieh, J Ultrasound Med 2018).","fit":"Not used for the acute injury, where the joint needs time and graded loading. Considered only for AC joint pain that is still there months later, and offered as an option with weak uncontrolled evidence behind it.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for hyaluronic acid trials in the acromioclavicular joint returned no randomised trial in either acute injury or arthritis of that joint, only reviews listing the injection as a technique. The one prospective study that reported on it, 80 shoulders given five weekly subacromial injections, found the subgroup with acromioclavicular arthritis got worse on every scale measured while other diagnoses improved (Jimenez, Acta Ortop Mex 2018).","fit":"Not offered for this problem. An acute AC joint injury is managed with a sling and relative rest, then a return to loading.","reviewedOn":"2026-09-07"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Dextrose tested into the joint, not the nerve","evidence":"No study of perineural injection after an acromioclavicular joint injury. The dextrose evidence at this joint is an injection into the joint capsule and the acromial attachment of deltoid rather than around a nerve: 31 people with chronic moderate-to-severe shoulder pain had two sessions of ultrasound-guided 15% dextrose, average pain fell from 6.8 to 2.5 out of 10 and 20 of the 31 were substantially better with no adverse effects, in a single-arm study with no control group (Hsieh, J Ultrasound Med 2018). The supraclavicular nerves that supply the skin over this joint appear in the literature only as a target for anaesthetic blocks during surgery (Jiang, BMC Anesthesiol 2025).","fit":"Not an acute-injury treatment. Occasionally relevant much later, if tender, hypersensitive skin persists over the joint after the injury itself has settled.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of hydrodissection at the acromioclavicular joint was found. Hydrodissection, hydrorelease, hydrodilatation and perineural injection searched against acromioclavicular and AC joint terms returned only general shoulder injection reviews (Mezian, Acta Chir Orthop Traumatol Cech 2025; Vargas-Figueroa, Cureus 2025), the second of which recommends brief sling use for acute low-grade AC joint injuries.","fit":"Not a treatment for the injured joint. Considered only if a nerve becomes involved as the injury heals.","reviewedOn":"2026-09-29"}}},{"slug":"achilles-tendinopathy","title":"Achilles Tendinopathy","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/achilles-tendinopathy","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Dry needling added nothing to rehab","evidence":"Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection, myofascial or intramuscular stimulation with Achilles or calcaneal tendon, 74 records, most of them animal, healthy-volunteer or other-condition studies; and a randomised-trial and systematic-review pass across the tendon conditions). No study has injected a calf-muscle trigger point in Achilles tendinopathy, with glucose or anything else. The nearest evidence is dry needling, the same needle with nothing injected, which is not offered here, and it is negative: in a 52-person trial of persistent midportion Achilles tendinopathy, adding calf needling to a 12-week loading program was no better than sham needling or the program alone (VISA-A 76 with needling, 76 with sham and 82 with rehab alone at 12 weeks; no difference at 6 or 12 months) (Solomons, PLoS One 2020). A 22-person feasibility trial of dry needling of calf and tibialis posterior trigger points added to manual therapy and exercise found no between-group difference at four weeks or three months, with 68% lost to follow-up (Koszalinski, J Man Manip Ther 2020). In a 60-person single-blind trial, dry needling of gastrocnemius trigger points did less well than percutaneous electrolysis of the tendon (Delgado Álvarez, Cureus 2026; between-group figures not given in the abstract).","fit":"The loading program treats the tendon. A trigger point injection would be considered only where examination finds a tender calf-muscle band adding to the pain, and you would be told that the closest trials found no added benefit.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not into the tendon","evidence":"Corticosteroid is not injected into or around the Achilles tendon here. A systematic review of 41 randomised trials and 2,672 participants found the short-term pain benefit of corticosteroid in tendinopathy reversed at intermediate and long term, and recorded one serious adverse event among the 991 participants who received corticosteroid, a tendon rupture (Coombes, Lancet 2010). Reviewing the two recent trials that added corticosteroid to exercise in Achilles tendinopathy and plantar fasciopathy, a 2024 appraisal weighed the higher recurrence and rupture risk and recommended against corticosteroid injection for tendinopathy (Visser, J Orthop Sports Phys Ther 2024). Ultrasound guidance improves needle accuracy but only improves outcomes where the target is small or deep (Aly, Br J Sports Med 2014; Fan, Arthroscopy 2021), and it does not make the tendon a safe target. The largest trial of a steroid-containing injection beside this tendon, 192 people given 50 mL of fluid with 25 mg of hydrocortisone, a steroid-free version or a sham alongside exercise, found the steroid injection ahead of the sham at six weeks, no different at 12 months, and behind the steroid-free injection at 26 weeks; the authors advise against routine use (Malliaras, BMJ 2026).","fit":"Not offered for the tendon itself. A separate inflammatory target, such as a retrocalcaneal bursa or a tendon sheath, is a different question and is assessed on its own merits, with the number of injections kept low and the loading programme continuing alongside it.","reviewedOn":"2026-11-06"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Mid-portion only; trials unblinded","evidence":"Radial shockwave is the form most Achilles trials used, and the answer depends on where the tendon hurts. For MID-PORTION pain, three low-energy sessions did better than waiting, 52% against 24% recovered or much improved at four months, and about as well as eccentric loading in 75 people (Rompe, Am J Sports Med 2007). Added to loading in 68 people, 82% against 56% were recovered or much improved at four months, with no difference left at a year (Rompe, Am J Sports Med 2009). In 46 runners, three sessions added to exercise gave a larger gain in the Achilles score at three months, 33 points against 18 (Tenforde, BMJ Open Sport Exerc Med 2025). A review pooling three mid-portion trials put the benefit over a loading program alone at about 9 points out of 100, at moderate certainty, and classes the early trials as radial (Paantjens, Sports Med Open 2022). The three trials named above were not blinded. One double-blind trial of 50 people did favour shockwave over a sham, but reviews disagree about whether its device was radial or focused (Abdelkader, Foot Ankle Int 2021), and the blinded trial with a clearly radial device found the recommended dose no better than a minimal dose in 57 people (Wheeler, Foot Ankle Int 2025). For INSERTIONAL pain, where the tendon meets the heel bone, three trials against a sham found no benefit, the largest in 119 people with scores of 63.2 and 62.3 out of 100 at 24 weeks (Mansur, J Bone Joint Surg Am 2021; Alsulaimani, Clin Rehabil 2024; Pinitkwamdee, Foot Ankle Int 2020). An earlier unblinded trial of 50 had favoured it over eccentric loading (Rompe, J Bone Joint Surg Am 2008). The most recent pooled analysis, of nine trials against sham or no treatment, found no clinically meaningful benefit at either site and advises against routine use, while noting very low-certainty evidence of a meaningful effect for the radial form (Korakakis, J Orthop Sports Phys Ther 2026).","fit":"An adjunct that can be discussed for mid-portion Achilles pain alongside a loading program, not instead of one, with the position that the supportive trials were mostly unblinded and the blinded trial of a clearly radial device was not supportive. For insertional pain the sham-controlled trials found no benefit, so patients are told so and the effort goes into loading.","reviewedOn":"2026-10-09"},"focusedShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Focused sham trials null","evidence":"The Achilles shockwave evidence has to be split by device, because most of the positive trials used the radial form on the row below. For the FOCUSED form, the two trials with a clearly focused device and a sham comparison found no benefit: 49 people with chronic Achilles pain had no more pain relief than with sham, and two people aged 62 and 65 had tendon ruptures after treatment (Costa, Clin Orthop Relat Res 2005); and in 66 people doing the same physiotherapy, point- and line-focused treatment improved the Achilles score by 23 and 18 points against 15 with sham, a difference that was not significant at 24 weeks (Gatz, Sports Health 2021). A 43-person sham trial using focused and radial pulses together found small differences at 16 weeks but no difference in the change over time (Vahdatpour, J Res Med Sci 2018), and a 2026 trial of 41 people adding focused treatment to twelve weeks of resistance training reported tendon changes on imaging but no clinical difference from training alone (Katolický, J Sci Med Sport 2026). Two positive double-blind trials are classed as focused by some reviews and as radial by others: 50 people with mid-portion pain had large gains over sham that lasted to 16 months (Abdelkader, Foot Ankle Int 2021), and 48 people had a better ankle score than sham at 8 and 12 weeks (Rasmussen, Acta Orthop 2008). For INSERTIONAL pain, the one focused trial did worse than a laser treatment (Notarnicola, Lasers Med Sci 2014), and the studies that favoured high-energy treatment were not randomised (Furia, Am J Sports Med 2006 and 2008). The most recent pooled analysis, of nine trials against sham or no treatment, found no clear advantage for either device, no clinically meaningful benefit at the insertion, and reported the two ruptures after focused treatment (Korakakis, J Orthop Sports Phys Ther 2026). The earlier review this row rested on placed its mid-portion trials in the radial group by its own account (Paantjens, Sports Med Open 2022).","fit":"Can be discussed as an adjunct for mid-portion Achilles pain that has not settled with a good loading program, with the position that the trials of a clearly focused device were no better than sham. For insertional pain the evidence does not support it, and the effort goes into loading. Used with care over the age of 60 because of the rupture reports.","reviewedOn":"2026-10-24"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"No better than sham in largest trial","evidence":"Tested against a dummy injection in four randomised trials, and three found no benefit. The largest, across 24 UK hospitals, gave 240 people with mid-portion Achilles tendinopathy one PRP injection into the tendon or a sham needle. At six months the Achilles scores were 54.4 and 53.4 out of 100, a difference that was not significant (adjusted difference -2.7, 95% CI -8.8 to 3.3), and its authors concluded the findings do not support the treatment (Kearney, JAMA 2021). Two earlier double-blind trials against saline found the same in 54 and in 24 people (de Vos, JAMA 2010; Krogh, Am J Sports Med 2016). The exception used a course of four injections a fortnight apart with eccentric training in 60 men, and found a larger gain than a sham at 24 weeks, 20 points against 9, while a high-volume cortisone injection did better still in the first twelve weeks (Boesen, Am J Sports Med 2017). Pooling six randomised trials and 422 people, PRP did not improve the Achilles score over placebo at three months, six months or a year (0.5 points at six months, 95% CI -8.5 to 9.3), and the authors advise against its use until better trials show a benefit (Barreto, Clin Orthop Relat Res 2024). Soreness at the injection site was more common than after the sham, 97 against 73 people in the largest trial. None of these trials studied the insertional form, where the tendon meets the heel bone.","fit":"Not a routine treatment for Achilles tendon pain. A progressive loading program is the core, and the best trial of a single PRP injection found it no better than a sham. It can still be discussed for stubborn mid-portion pain that has not responded to months of properly dosed loading, with that evidence, the cost and the fact that the one positive trial used a course of four injections all stated beforehand.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Only one randomised trial of prolotherapy in Achilles tendinosis was identified in a systematic review of 20 trials, and it found combined prolotherapy plus eccentric loading improved symptoms more rapidly than prolotherapy alone (Capotosto, Orthop J Sports Med 2024).","fit":"Considered only alongside a loading programme, never instead of one. The evidence base here is a single trial.","reviewedOn":"2026-08-30"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here. A meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems, 1,629 patients in all, reported less pain than the comparison treatments overall, but it contained only one Achilles tendinopathy trial, so that result has not been repeated (Khan, Sports Health 2022). These are injections around a tendon, which is a different procedure from the joint injection in this row.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested perineural injection for Achilles tendinopathy itself, and the treatment targets nerves rather than tendon. Its relevance here is diagnostic: one detailed case report describes sural nerve dysfunction that mimicked Achilles tendinopathy, with the nerve two-and-a-half times its normal size on ultrasound and pain settling from 8 to 2 out of 10 after dextrose hydrodissection, sustained at two years (Yoon, Diagnostics 2025).","fit":"Not part of treating a tendinopathy. It becomes relevant only if the pain turns out not to be tendon pain at all. Burning, numbness or a nerve that is tender and enlarged on ultrasound point to a different diagnosis, which is then treated on its own terms.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Tested — no benefit over sham","evidence":"Searched 6 November 2026 (PubMed: Achilles with high-volume injection, hydrodissection, hydrorelease, brisement, paratenon or Kager's fat pad, 47 records, plus randomised-trial and systematic-review passes; every abstract read). At this tendon the nearest procedure to this row is the high-volume injection, in which a large volume of fluid is injected under ultrasound between the tendon and the fat pad in front of it to strip the tissues apart. It has been tested against a sham injection, and the result is evidence of absence rather than absence of evidence. Without corticosteroid it did no better than a sham in three randomised trials: 80 people at 24 weeks, an adjusted difference of 0.5 points on the 100-point VISA-A score (van der Vlist, BMJ 2020); 62 servicemen with Achilles or patellar tendinopathy at six months (Barker-Davies, Orthop J Sports Med 2022); and 192 people at 12 months (Malliaras, BMJ 2026). With 25 mg of hydrocortisone added it helped more than the sham at six weeks (by 9.2 points), was no different at 12 months, and did worse than the same injection without corticosteroid at 26 weeks (Malliaras 2026). An earlier trial of 60 men found a steroid-containing high-volume injection ahead of a placebo to 24 weeks (Boesen, Am J Sports Med 2017); the larger, later trial did not confirm a lasting benefit. No serious adverse events were recorded in the 2026 trial. Every trial added the injection to an exercise program, and every group, sham included, improved.","fit":"Not offered as a treatment for the tendon itself: the loading program does the work, and adding fluid around the tendon has not added to it in trials. Where burning, numbness or an enlarged, tender sural nerve on ultrasound suggests the pain is coming from the nerve beside the tendon rather than the tendon, nerve hydrodissection is a separate question, and that rests on one case report (Yoon, Diagnostics 2025).","reviewedOn":"2026-11-06"}}},{"slug":"achilles-tendon-rupture","title":"Achilles Tendon Rupture","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/achilles-tendon-rupture","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the tear; rupture reported after","evidence":"No controlled study of radial shockwave for an acute or surgically repaired Achilles rupture was found. A search on 11 November 2026 of shockwave terms with Achilles rupture or repair returned 33 records, and a randomised-trial and systematic-review pass returned four, none of them in rupture. The radial reports run the other way. A 61-year-old man with ten years of mid-tendon pain had six radial sessions, became pain-free and returned to sport, then ruptured the tendon six months later stepping off a pavement; the authors note that feeling better may not mean the tendon has regained its strength (Briffa, Cureus 2026). An earlier case report also describes rupture after radial treatment (Argyropoulou, J Surg Case Rep 2025; read for the focused row on 22 October 2026). Case reports cannot show that the treatment caused the rupture.","fit":"Not used on a ruptured or repaired tendon. Considered only for a separate tendon or muscle problem, once the rupture is being managed and a graded rehabilitation programme is under way.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No rupture trials; rupture reports","evidence":"No controlled study of shockwave for an acute or surgically repaired Achilles rupture was found. Search: PubMed, shockwave terms with Achilles or calcaneal tendon and rupture, repair or tear, animal work excluded (21 records), with a trial and systematic-review pass. The only rupture data are three cases, one a complete rupture repaired and re-ruptured twice, reported as recovered on MRI with no numbers and no device type (Ringeisen, Orthopadie 2026), and one partial tear treated with a focused device (Hsu, J Pain Res 2017). The harm signal runs the other way: two tendon ruptures in the treated group of a placebo-controlled trial in chronic Achilles pain (Costa, Clin Orthop Relat Res 2005), counted by a 2026 meta-analysis as ruptures after focused treatment (Korakakis, J Orthop Sports Phys Ther 2026), and case reports of rupture after radial treatment (Argyropoulou, J Surg Case Rep 2025; Briffa, Cureus 2026, whose authors could not infer a cause).","fit":"Considered only for a coexisting tendinopathy, not for the tear.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.","fit":"Not part of the plan here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"PATH-2 settled this. 230 adults with acute Achilles rupture managed non-surgically were randomised to platelet-rich plasma or a placebo injection, and at 24 weeks there was no difference in tendon function, patient-reported function, quality of life or adverse events (Keene, BMJ 2019). The two-year follow-up found the same (Keene, Bone Joint J 2022). This is not an absence of evidence. It is good evidence of absence.","fit":"Not offered for a ruptured Achilles. The plan is the rehabilitation protocol and, where indicated, surgical review: an injection adds cost and a needle without adding recovery.","reviewedOn":"2026-08-30"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in a ruptured tendon","evidence":"No study has tested prolotherapy for a ruptured Achilles tendon. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose or hypertonic glucose with Achilles rupture or tendon rupture, then randomised-trial and systematic-review passes) found no clinical study in rupture. The human prolotherapy studies at the Achilles are all in tendinopathy, a different condition, and the largest of them excluded anyone with a past rupture (Pham, J Am Podiatr Med Assoc 2025, 132 people, retrospective). The only rupture-related work is in rats: 12.5% dextrose injected into healthy rat Achilles tendons did not weaken them (Martins, Knee Surg Sports Traumatol Arthrosc 2012). That is animal work on an intact tendon and says nothing about healing a tear.","fit":"A ruptured tendon is not something an injection can repair. The plan is the functional rehabilitation protocol, with surgical review where indicated. Prolotherapy is considered only for a separate ligament or tendon problem later in recovery, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with tendon rupture, Achilles, patellar tendon, quadriceps tendon, tendon repair or sural nerve, 23 records; Achilles rupture with sural nerve, nerve entrapment or neuroma and injection or ultrasound guidance, 8 records; a randomised-trial and systematic-review pass returned none). No study has tested hydrodissection for a torn Achilles tendon, and it cannot repair one. The rupture records are about surgical technique: in one comparison, 3 of 19 people repaired through an open incision had a sural nerve injury against none of 22 with a small-incision ultrasound-assisted repair, with no treatment of the nerve described (Wang, J Orthop Surg Res 2025). The nearest hydrodissection reports concern the same nerve after other surgery near the heel: a sural nerve caught in scar after a heel-bone fracture operation, with over 90% relief after two ultrasound-guided sessions of 5% dextrose (Yoon, Cureus 2025), and another where hydrodissection helped but the pain fully settled only after the plate was removed and the nerve freed surgically (Omodani, Cureus 2023). Both are single cases with no comparison.","fit":"Not a treatment for the ruptured tendon, which is managed with a functional boot or surgery and a staged rehabilitation program. Considered only if burning, numbness or nerve pain along the outer heel and foot persists after healing, which points to the sural nerve rather than the tendon.","reviewedOn":"2026-11-10"}}},{"slug":"acl-injury","title":"ACL Injury","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/acl-injury","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Tested after surgery only","evidence":"The one randomised trial at this ligament tested needling after surgery rather than as a treatment for the injury, and it used a dry needle. Forty-four people in rehabilitation after reconstruction of a complete anterior cruciate ligament rupture were randomised to the rehabilitation programme alone or with trigger point dry needling of vastus medialis: knee flexion range improved in the short term and function in the short to medium term, but pain was higher immediately after the first treatment and knee stability was unchanged (Velázquez-Saornil, Medicine 2017). A second trial of needling for quadriceps inhibition after reconstruction has been registered and published only as a protocol (Zarrin, J Acupunct Meridian Stud 2023). In the Cochrane review of platelet-rich therapies, needling at this ligament appears only as the comparison arm (Moraes, Cochrane Database Syst Rev 2014). The injected form has not been tested here at all.","fit":"Not a treatment for the torn ligament. Considered only where a tender band in the quadriceps is reproducing part of your pain during rehabilitation.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Two small trials after reconstruction","evidence":"Both radial trials are after ACL reconstruction, not for the injury on its own. In a single-blind sham-controlled trial of 72 people (63 analysed), six weekly radial sessions from the second day after surgery (Swiss DolorClast) improved the Lysholm and IKDC knee scores and range of movement at three and six weeks, but by 24 weeks the groups were the same (Lysholm 90.9 against 90.2) (Song, BMC Musculoskelet Disord 2024). In a 30-person trial (26 analysed) without a sham, five weekly sessions over the bone tunnels from three months after surgery gave better Lysholm and Tegner scores at two years, with no difference in knee laxity or the IKDC score (Zhang, Orthop J Sports Med 2023). Neither reported an adverse event. Pooled with the focused trials, the gains in knee scores fall below the minimal clinically important difference and every trial was at high risk of bias (Shin, BMC Musculoskelet Disord 2025). Search: PubMed, shockwave terms with anterior cruciate or ACL, animal work excluded (19 records).","fit":"Discussed only after reconstruction, alongside the staged rehabilitation program. In the sham-controlled trial the early gains did not last to six months, and it has no role in the decision between surgery and rehabilitation for the injury itself.","reviewedOn":"2026-10-22"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"After reconstruction: small trials","evidence":"Every trial is after ACL reconstruction; none tests shockwave for an ACL injury managed without surgery. One randomised trial of 53 people given a single shockwave session straight after hamstring-graft reconstruction found a better Lysholm knee score at one and two years and less bone-tunnel widening, with no difference in the IKDC score (Wang, J Surg Res 2014; described as focused by later papers, not confirmed from its own text). A controlled study of 65 athletes allocated to three focused sessions (Storz Duolith) at four to six weeks after surgery, or none, without a sham, reported return to pivoting sport at 28 against 43 weeks (Weninger, J Clin Med 2023). Pooling five studies (242 people), knee scores were better with shockwave but below the minimal clinically important difference, and every trial was at high risk of bias (Shin, BMC Musculoskelet Disord 2025); a second pooling of six studies found the Lysholm gain uncertain (3.7 points, 95% CI -0.3 to 7.7) (Salimi, World J Orthop 2025). A 2011 Am J Sports Med paper on shockwave after hamstring ACL reconstruction has been retracted and is not relied on here. Search: PubMed, shockwave terms with anterior cruciate or ACL, animal work excluded (19 records).","fit":"Discussed only after reconstruction, as an adjunct to the staged rehabilitation program while the graft incorporates. It has no role in the decision between surgery and rehabilitation for the injury itself.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.","fit":"Not part of the plan here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"This has been tested, and the answer is no. Three recent meta-analyses of randomised trials of platelet-rich plasma added to anterior cruciate ligament reconstruction agree with each other. Fourteen trials and 869 patients: anterior tibial laxity was reduced, but by less than the amount that matters clinically, with no difference in patient-reported scores or revision rates (Migliorini, Orthopadie 2025). Eleven trials and 583 patients: laxity better at 3 and 6 months, gone by 12, and no difference in Lysholm score at any point (Han, Am J Sports Med 2026). Nine trials and 502 patients: an IKDC difference of 2.05 points at 12 months, statistically significant but smaller than the smallest change a patient would notice (Pinho, Arthroscopy 2025). That is evidence of absence, not absence of evidence.","fit":"Not offered. A torn cruciate ligament is a structural problem, and the decision that matters is whether you need a reconstruction, which turns on how unstable the knee is and what you need it to do, not on an injection. Rehabilitation is the treatment either way, before surgery and after it.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled laxity series of 16","evidence":"No randomised trial of prolotherapy for an ACL injury was found. The nearest evidence is in ACL laxity in painful knees, largely older knees with arthritis rather than a recent sports injury. In a prospective series of 16 people with at least six months of knee pain and a lax ACL, repeated injections of 10% dextrose into the joint over a year, then every two to four months, left 10 of 16 knees measuring normal for laxity at three years, with laxity improved by 71% and pain on walking by 43%; there was no comparison group (Reeves, Altern Ther Health Med 2003). In a placebo-controlled trial in knee arthritis, the lax-ACL subgroup showed no significant improvement at six months, and the gains reported at 12 months, when 8 of 13 lax knees were no longer lax, came after all knees had moved to open-label dextrose (Reeves, Altern Ther Health Med 2000). One case report describes a complete ACL tear appearing intact on MRI after seven sessions (Grote, Int Musculoskelet Med 2009), and one case of a serious knee joint infection after prolotherapy for a partial ACL tear has been reported (Bourget-Murray, J Clin Orthop Trauma 2019). PubMed search, 14 October 2026: prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain or ligament injury terms (21 records), and prolotherapy with ligament terms (121 records, all screened), each with randomised-trial and systematic-review passes.","fit":"Not a substitute for reconstruction where a torn ACL leaves the knee giving way in someone returning to pivoting sport. Can be discussed for a partially torn or lax ACL with ongoing symptoms despite a completed rehabilitation program, with the evidence stated: small uncontrolled series in mostly arthritic knees, and a rare risk of joint infection.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 6 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with anterior cruciate ligament, 3 records). No study has tested hydrodissection for the ligament injury. In one non-randomised comparison during reconstruction surgery, 22 people whose patellar tendon sheath was separated with fluid as the graft was taken had pain of 1.3 out of 10 at four weeks against 4.1 in 23 without it, and better knee bend (Luna-Pizarro, Cir Cir 2006); that is a step in the operation, not a clinic treatment. After reconstruction, two single case reports describe ultrasound-guided fluid injection for scarring in the fat pad below the kneecap, with the Kujala knee score rising from 62 to 82 at four weeks (Machida, Cureus 2020), and for a trapped branch of the saphenous nerve below the kneecap, where local anaesthetic around the nerve gave only partial, temporary relief before a needle-knife release (Rao, J Back Musculoskelet Rehabil 2022).","fit":"Not a treatment for a torn ligament. Considered after surgery only where ultrasound shows a scarred fat pad or a trapped skin nerve below the kneecap that is holding back the rehabilitation program.","reviewedOn":"2026-11-06"}}},{"slug":"acute-hamstring-strain","title":"Acute Hamstring Strain","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/acute-hamstring-strain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, trigger point, lignocaine or local anaesthetic injection with hamstring strain or injury, calf or gastrocnemius strain, tennis leg, muscle strain, muscle injury or muscle contusion, 18 records; and a randomised-trial and systematic-review pass, 12 records). No study has injected a trigger point after a hamstring strain. The only injection study after hamstring injury treated the fascia around a skin nerve at the back of the thigh rather than the muscle, months after the injury, and is described in the nerve hydrodissection row (Shiwaku, J Funct Morphol Kinesiol 2025). Needling after a hamstring strain appears only as acupuncture in a descriptive case report (Tang, Med Acupunct 2023).","fit":"Not part of early care for a fresh strain, which is graded loading. Considered later only where a tender muscle band persists and is holding back the return-to-sport program.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Footballer series, no control","evidence":"Searched 8 November 2026 (PubMed: hamstring strain or injury, muscle strain, calf strain, tennis leg or muscle contusion with corticosteroid, steroid, triamcinolone, methylprednisolone, betamethasone or dexamethasone injection, 23 records; and a randomised-trial and systematic-review pass across muscle and ligament injuries, 9 records, none a trial of this injection). No controlled trial exists. In one National Football League team over 13 years, 58 of 431 players with a severe hamstring injury and a palpable defect in the muscle were given an intramuscular injection of corticosteroid and local anaesthetic; 9 of them (16%) missed a game, strength was normal at final examination and there were no complications from the injection, but there was no comparison group and the authors say efficacy cannot be judged (Levine, Am J Sports Med 2000). A second NFL team series of 37 corticosteroid or anaesthetic injections for muscle strains and ligament sprains, given blind or under ultrasound about a week after injury, reported every player returning to play and no complications; proximal hamstring strains cost an average of three games (Drakos, HSS J 2014). In a retrospective comparison of image-guided injections for grade 2 proximal hamstring injuries, 46% of 24 people given corticosteroid reported less pain at one week against 72% of 32 given PRP, and 54% against 72% at four weeks, a difference that was no longer significant (Park, Skeletal Radiol 2019). A systematic review found strong to moderate evidence that local anaesthetic injected into muscle damages muscle fibres, and limited evidence that corticosteroid alone does not but adds to that damage when combined with local anaesthetic (Reurink, Sports Med 2014).","fit":"Not a routine treatment for a hamstring strain, which is graded loading and a return-to-sport rehabilitation program. Where a strain is severe, an injection may be discussed as an adjunct to that program, with the lack of controlled evidence and the concern about local anaesthetic in muscle explained. See the note on cortisone.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small sham-controlled trial","evidence":"This is the one acute muscle injury in which radial shockwave has been tested against a dummy treatment, and it came out ahead, narrowly. Forty semi-professional soccer, hockey and rugby players with an ultrasound-diagnosed grade 3b hamstring tear were randomised, with patients and assessors blinded, to up to nine sessions of real or sham radial shockwave on top of the same eight-week rehabilitation programme. In the 36 analysed, the treated group returned to sport in 25.4 days against 28.3 (p = 0.037), about three days sooner; four players were removed after the trial when their tears were re-graded as smaller, and with all 40 included the difference was 25.8 against 28.2 days and no longer statistically significant (p = 0.069). Re-injury at six months was one player in each group, satisfaction did not differ, and there were no serious side effects. The treated group had no strength deficit in the injured leg afterwards, but strength was not a planned outcome and the overall treatment effect on strength was not significant (Crupnik, Br Med Bull 2025). The authors say a definitive trial would need 62 to 82 players. A 2023 systematic review of shockwave for muscle injuries found eight small studies, mostly case reports and series, and called the results promising but low quality (Mazin, Cureus 2023). No other randomised trial in an acute hamstring injury was found (PubMed, searched 28 October 2026).","fit":"Reasonable to discuss as an addition to the rehabilitation programme, never instead of it; the programme is what determines whether the hamstring holds. A gain of about three days matters to someone with a season to get back to and probably does not to everyone else, and the trial was done in young athletes, so that is who the result belongs to.","reviewedOn":"2026-10-28"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Tested with the radial device only","evidence":"Searched 21 October 2026: shockwave terms with muscle injury, strain, tear, lesion, hamstring injury or contusion in humans (25 records) and a trial and review pass (18). The one sham-controlled trial in an acute hamstring tear used a RADIAL device: in 36 semi-professional athletes it shortened return to sport from 28.3 to 25.4 days (Crupnik, Br Med Bull 2025); that result sits on the radial row. A series of 20 muscle injuries in professional footballers was treated almost entirely with radial shockwave (Morgan, J Orthop Surg Res 2021), and a series of eight long-standing hamstring and adductor tears does not state the device type (Astur, Acta Ortop Bras 2015). No study of a focused device in a hamstring strain was found.","fit":"Not part of early management with this device. Where shockwave is added to rehabilitation for a recent hamstring tear, it is the radial form that has been tested.","reviewedOn":"2026-10-21"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered; trials disagree","evidence":"Trialled in a torn hamstring, with results that disagree, and not offered here. The two newest pooled analyses favour it. Across nine randomised trials and 474 people with an acute muscle injury, return to sport was about a week sooner with PRP, in the hamstring trials and in the double-blind trials taken on their own as well as overall, on evidence the authors grade as limited, with five of the nine trials at high risk of bias (Bensa, Sports Med Open 2026). Across six hamstring trials and 277 people it was 21 days against 30, with results that varied widely between trials and certainty rated low to moderate (Nakagawa, Br J Sports Med 2026). The positive trials compared PRP plus rehabilitation with rehabilitation alone and were not blinded: 26 days against 34 in 60 athletes with a moderate tear (Desouza, Eur J Orthop Surg Traumatol 2025) and 27 against 43 in 28 (A Hamid, Am J Sports Med 2014). The best-designed trials found less. In a multicentre double-blind trial of 80 athletes, PRP was no better than a placebo injection for return to play or for re-injury at two months or one year (Reurink, N Engl J Med 2014; Br J Sports Med 2015). In 90 professional athletes it was 5.7 days faster than an injection of platelet-poor plasma but not significantly faster than no injection, and the authors concluded it added nothing to intensive rehabilitation (Hamilton, Br J Sports Med 2015). Re-injury was no less common in the pooled trials, 15% against 16%. An earlier pooled analysis found no benefit once only the double-blind trials were counted (Grassi, Sports Med 2018), a Danish evidence statement rated the effect on return to play as trivial (Ishøi, Br J Sports Med 2020), and a German-Austrian-Swiss consensus found no clear evidence that any injection into an injured muscle helps (Hotfiel, J Exp Orthop 2018).","fit":"Not offered for a hamstring strain. These tears are monitored and rehabilitated. A torn muscle has already bled into the injury, so an injection of concentrated platelets is unlikely to add to what is there. The best-designed trials agree: against a placebo injection, or against no injection at all, PRP added nothing to a proper rehabilitation program, and it did not reduce re-injury. Progressive loading and a staged return to running and sport are what determine the outcome.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No human trial has tested prolotherapy in acute hamstring strain. Reviews of orthobiologics for muscle injury name prolotherapy but report that high-level clinical evidence is lacking (Droz, Clin Sports Med 2024; Stephens, Phys Med Rehabil Clin N Am 2023). The animal work conflicts: dextrose improved repair in a mouse muscle-injury model (Tsai, Int J Med Sci 2018), while a rat model reported excess connective tissue and necrosis and advised against it (Kunduracioglu, Neurosciences 2006).","fit":"Not used for the acute tear. Graded loading is what rebuilds the muscle and lowers the re-injury risk. Injection is considered only much later, and only for a persistent tendon attachment problem such as chronic proximal hamstring tendinopathy.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Untested in people. A search pairing hyaluronic acid with muscle injury, muscle strain, muscle tear, calf strain, hamstring injury, tennis leg and contusion terms returned 39 records. Twenty-five were animal, hydrogel, scaffold or spinal cord studies, and none of the other 14 was a trial of hyaluronic acid for a muscle injury. The nearest were a single case of a torn adductor muscle given hyaluronic acid together with platelet-rich plasma (Giannini, J Sports Med Phys Fitness 2023) and a review of injections in professional footballers, which gives hyaluronic acid a role only for cartilage injury (Jader, Int Orthop 2024). No study has injected it for a hamstring strain.","fit":"Not offered for an acute muscle injury. Graded loading and a staged return to sport is what changes the outcome.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested small dextrose injections under the skin for a torn hamstring. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against hamstring, muscle strain, muscle tear and muscle injury returns no treatment study of any design, and widening to any dextrose or prolotherapy injection finds no human study of a hamstring strain either. A review of injection treatments for muscle injury, prolotherapy among them, concludes that high-level clinical evidence is lacking (Droz, Clin Sports Med 2024). The nearest dextrose report is in the tendon rather than the muscle, and it was a failure: a three-injection course of 12.5% dextrose gave no lasting relief in a 61-year-old with chronic semimembranosus tendinopathy (Senchyshak, Pain Med Case Rep 2026). The skin nerve that runs down the back of the thigh, the posterior femoral cutaneous nerve, can cause pain in the same area. It has been injected under ultrasound with local anaesthetic, with immediate partial relief and no adverse events reported, but in a technique paper that gives no patient numbers and no follow-up (Vita, J Ultrasound 2025).","fit":"Not part of treating a hamstring tear. Graded loading is what rebuilds the muscle and lowers the re-injury risk. Considered only if tender, hypersensitive skin over the back of the thigh persists once the tear has otherwise healed.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small series, persistent pain only","evidence":"Searched 3 November 2026 (PubMed: hydrodissection or hydrorelease with hamstring, posterior thigh, posterior femoral cutaneous nerve, sciatic nerve, muscle strain or muscle injury, 24 records; a randomised-trial and systematic-review pass returned none). No trial exists, and no study treated a fresh strain. In seven people with pain persisting at least eight weeks after a hamstring injury, and thickened fascia around the posterior femoral cutaneous nerve on ultrasound, an ultrasound-guided injection of 6 mL saline with 0.17% lignocaine into that tissue was followed by pain falling from 10 to under 1 out of 10, with no adverse events or recurrence over a mean of 6.6 months; there was no comparison group, and three people needed two to four sessions (Shiwaku, J Funct Morphol Kinesiol 2025). Fascial hydrodissection for chronic hamstring injury in athletes is also described in case reports that give no figures (Courseault, Curr Sports Med Rep 2019), and freeing a sciatic nerve tethered by scar after an old complete hamstring avulsion in one case report (Bohyn, Skeletal Radiol 2022).","fit":"Not a treatment for a fresh strain, which is graded loading. Where pain persists months later and ultrasound shows a nerve caught in thickened tissue, hydrodissection may be discussed to let the return-to-sport program progress.","reviewedOn":"2026-11-03"}}},{"slug":"adductor-related-groin-pain","title":"Adductor-Related Groin Pain","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/adductor-related-groin-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, dry needling or trigger point with adductor, groin, pubic, hamstring, posterior thigh or ischial, 54 records, all read). No study has injected a muscle trigger point in adductor-related groin pain, with glucose or anything else, and there is no controlled study of any needling. The nearest are two case reports of dry needling (nothing injected, not offered here) combined with adductor strengthening in two footballers with an adductor strain, with no figures after treatment (Kaur, J Bodyw Mov Ther 2023), and an uncontrolled series of 21 men with groin pain from chronic prostatitis given ultrasound-guided trigger point injections into the hip flexor, adductor and lower abdominal muscles, whose pain fell from 6.3 to 2.9 out of 10 after the first treatment (Kim, Arch Phys Med Rehabil 2013). That is a different condition. In Dutch professional football, dry needling was used in 61% of longstanding groin injuries, with no outcomes reported by treatment (Gouttebarge, J Back Musculoskelet Rehabil 2018).","fit":"Considered only where examination finds a tender adductor or hip-flexor muscle band contributing to the pain, as an adjunct to the adductor strengthening program, which is the treatment with trial evidence.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Case series in athletes","evidence":"No randomised trial was found; the evidence is two consecutive case series from one group. In 24 competitive athletes, a single injection of local anaesthetic and steroid into the adductor attachment at the pubic bone relieved pain at once in all of them; at one year none of the 7 with a normal MRI had relapsed, but 16 of the 17 with tendon changes on MRI had, at a mean of five weeks (Schilders, J Bone Joint Surg Am 2007). In 28 recreational athletes, 68% had a good result at one year after one injection and 75% after a repeat, whatever the MRI showed (Schilders, J Bone Joint Surg Am 2009). Neither series had a comparison group, and neither abstract states how the needle was guided. In a retrospective study of athletes with chronic adductor lesions alongside osteitis pubis, return to sport was 80% after corticosteroid and 63% after platelet-rich plasma, a difference that was not statistically significant (Eraslan, J Orthop Traumatol 2025).","fit":"The adductor strengthening programme comes first. Where pain at the adductor attachment is blocking it, a guided injection may be discussed as a short-term aid, with the higher relapse rate when the scan shows tendon changes explained. See the note on cortisone.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No radial-device study","evidence":"Searched 21 October 2026: shockwave, shock wave or ESWT with groin, adductor, pubalgia, osteitis pubis or pubic (21 records, most about kidney stones), and a trial and review pass (4). No study of a radial device in groin pain was found. The groin studies that exist used a focused device or do not say: a single-arm series of 31 footballers given focused shockwave to the adductor or rectus abdominis attachment (Santilli, Life 2026), and a randomised trial in pubic overload whose abstract does not name the device (Schöberl, Knee Surg Sports Traumatol Arthrosc 2017). One harm is reported near this site: a large bleed between the hip adductor muscles six weeks after radial shockwave to both hips, given for bone forming in soft tissue after a brain haemorrhage, which settled over a month (Kim, Ann Rehabil Med 2017). The earlier line saying the trials here used focused devices was not accurate.","fit":"Not a first choice here. The adductor attachment can be reached with either device, but the only published groin results are with the focused form, alongside the strengthening programme that remains the main treatment.","reviewedOn":"2026-10-21"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled series in footballers","evidence":"Searched 21 October 2026: shockwave terms with groin, adductor, pubalgia, osteitis pubis or pubic (21 records) and a trial and review pass (4). No controlled trial has tested shockwave in groin pain defined as adductor-related. The closest is a single-arm series of 31 adult footballers with groin pain of at least three months confirmed on MRI, given three weekly sessions of focused shockwave to the tender adductor or rectus abdominis attachment on the pubic bone within a 16-week rehabilitation programme built around adductor strengthening. Groin function (HAGOS) rose from 47 to 90 and pain fell from 6.8 to 1.9 out of 10 at four months, with brief discomfort during treatment and no other adverse events. Just over half had osteitis pubis, there was no comparison group, and the authors state the change cannot be credited to shockwave rather than the rehabilitation (Santilli, Life 2026). In the neighbouring diagnosis of pubic overload, a randomised trial of 44 footballers found rehabilitation plus shockwave relieved pain and returned players to football sooner than rehabilitation alone (Schöberl, Knee Surg Sports Traumatol Arthrosc 2017), and a 2024 systematic review rated shockwave a possible addition to exercise there (Rhim, Br J Sports Med 2024).","fit":"Reasonable to discuss as an addition where a strengthening and load-management programme has stalled, never in place of it. The evidence is in footballers, and the one series that targeted the adductor attachment had no comparison group.","reviewedOn":"2026-10-21"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Case reports; harm signal reported","evidence":"Not tested in a trial. A search for PRP in adductor-related groin pain, osteitis pubis and athletic pubalgia returned 23 records, and a pass for randomised trials found none at the groin. What exists is small and uncontrolled. There are single case reports of athletes returning to sport after an ultrasound-guided injection with rehabilitation, such as a 17-year-old footballer back at six weeks (Zeppieri, Int J Sports Phys Ther 2024). A series of 408 people with tendon problems at several sites, the adductor among them, improved after one injection, without the groin results being reported separately (Dallaudière, J Vasc Interv Radiol 2014). In 132 athletes with osteitis pubis, 63% of the 19 given PRP for a long-standing adductor problem returned to sport against 80% of the 31 given cortisone, a difference that was not statistically significant (Eraslan, J Orthop Traumatol 2025). A systematic review of conservative treatment rated the evidence for PRP here as conflicting, below exercise-based care and prolotherapy (Bisciotti, Biol Sport 2020). There is also a caution specific to this region. At one surgical centre that saw 3,642 people with groin and lower abdominal muscle injuries, bone forming in the injured tissue was found mostly in those who had already had PRP: 44 of the 68 cases, and 22 of 28 professional American footballers given PRP against none of 28 matched players. Their results at three months after surgery were poorer, and had caught up by six months. That is an observation in people whose PRP had not worked, not proof of cause (Poor, Am J Sports Med 2024).","fit":"Not something to choose ahead of the rehabilitation program, which has the best evidence for this condition. Where an injection is being considered for groin pain that has not settled, prolotherapy has two published case series at this site and PRP does not, and the reported risk of bone forming in the tissue is discussed before PRP would be.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Case series in athletes","evidence":"Tested in athletes, in case series rather than controlled trials. In 24 elite rugby and soccer players with chronic groin pain from osteitis pubis or adductor tendinopathy that had not responded to therapy, monthly injections of 12.5% dextrose into the adductor origins, lower abdominal insertions and pubic symphysis took pain during sport from 6.3 to 1.0 out of 10 after an average of 2.8 treatments. Twenty of the 24 had no pain and 22 were playing without restriction at an average of 17 months (Topol, Arch Phys Med Rehabil 2005). A second series from the same clinic enrolled 75 elite athletes, 72 of whom completed at least two treatments: pain with sport improved by 82%, 66 returned to unrestricted sport in an average of three months and six did not improve, at an average follow-up of 26 months (Topol, Am J Phys Med Rehabil 2008). A systematic review of conservative care for long-standing adductor-related groin pain placed prolotherapy among its three best-supported options, alongside compression garments and manual therapy with strengthening, while rating that evidence only moderate and the recommendation grade D (Bisciotti, Biol Sport 2020). The limits are plain. Neither series had a comparison group, both come from one clinic, every athlete was elite, and there is still no randomised trial (Choi, Br J Sports Med 2011; a search on 6 October 2026 found none since).","fit":"Worth discussing where adductor-related groin pain has not settled with a proper course of strengthening and load management, which remains the first treatment. The injections go into the tender tendon attachments on the pubic bone, usually as a short monthly series alongside continued rehabilitation. The published results are encouraging but come from uncontrolled series, and that is explained before treatment.","reviewedOn":"2026-10-06"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here, and not studied. PubMed searches for hyaluronic acid with adductor and groin terms (17 records after excluding cosmetic filler and graft work) found no trial in adductor-related groin pain. The only human report is a single footballer with an acute adductor tear treated with PRP and hyaluronic acid together, whose outcome is not given in the summary (Giannini, J Sports Med Phys Fitness 2023). A meta-analysis of 19 soft-tissue trials of hyaluronic acid contains no groin trial (Khan, Sports Health 2022).","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon and muscle problem. Adductor strengthening remains the centre of treatment.","reviewedOn":"2026-11-09"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"The technique in this row has a single report at the groin: a 45-year-old man with nine months of left groin pain attributed to the superficial fascia had 5% glucose injected below the inguinal ligament by feel, with complete resolution within four weeks (Lam, Cureus 2024). One case, no comparison, and not described as an adductor tendon problem. The better-known dextrose work in athletic groin pain is a different procedure, prolotherapy into the tendon attachments on the pubic bone. In 24 kicking-sport athletes with chronic groin pain from osteitis pubis or adductor tendinopathy, monthly 12.5% dextrose took pain during sport from 6.3 to 1.0 out of 10, with 22 of 24 back to unrestricted sport (Topol, Arch Phys Med Rehabil 2005), and in a later series 66 of 72 returned to unrestricted sport (Topol, Am J Phys Med Rehabil 2008). Neither had a control group, a systematic review of athletic osteitis pubis found no randomised trial of any treatment (Choi, Br J Sports Med 2011), and a randomised-trial search on 6 October 2026 across the dextrose and perineural terms and the groin, adductor and osteitis pubis terms returned no record. Nerves can also produce groin pain: in 58 people with neuralgia of the ilioinguinal, iliohypogastric or genitofemoral nerves, CT-guided injections around the nerve improved pain after 53 of 63 procedures (Poh, AJR Am J Roentgenol 2019). Those are nerve blocks placed deep under imaging, not small injections under the skin.","fit":"Not a treatment for the adductor tendons or the pubic joint, which are managed with the options higher up this page. Considered only where examination finds tender, hypersensitive skin over the groin or inner thigh rather than pain on resisted squeezing alone.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Hydrodissection has not been studied in adductor-related groin pain. Searching the technique against groin pain, adductor tendinopathy and osteitis pubis (setting aside the many surgical papers that use the word for a step in hernia repair) leaves two case reports, and both are nerve problems presenting as groin pain rather than tendon problems: groin pain referred from an overlooked lumbar transverse process fracture that settled after three ultrasound-guided dextrose hydrodissections at the fracture site (Yoon, Cureus 2025), and a femoral nerve injury after groin flap surgery relieved by hydrodissection with the gain holding at six months (Hasnain, Pain Med Case Rep 2026).","fit":"Only where the assessment suggests a nerve is contributing (an obturator, ilioinguinal or genitofemoral pattern, or pain referred from the lower back) rather than the adductor tendons themselves. The tendon problem is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"ankle-osteoarthritis","title":"Ankle Osteoarthritis (Ankle Arthritis)","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/ankle-osteoarthritis","pairings":{"rehab":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Knee and hip evidence only","evidence":"Exercise, education and weight management are the standard first-line care for osteoarthritis, but the trial evidence is in the knee and hip, not the ankle. In knee and hip osteoarthritis a network meta-analysis of 152 randomised trials found exercise gave similar pain relief and function to oral anti-inflammatories and paracetamol (Weng, Br J Sports Med 2023), and EULAR also names footwear, walking aids and weight management in its core recommendations (Moseng, Ann Rheum Dis 2024). At the ankle, a 2015 Cochrane review found no randomised trial of any non-surgical treatment other than hyaluronic acid and warned that hip and knee guidance may not transfer, because ankle arthritis usually follows injury (Cochrane Database Syst Rev 2015). The only ankle exercise study located is a 30-person feasibility trial of education plus exercise against general advice, which showed the trial can be run and did not test whether the programme works (Musculoskelet Sci Pract 2024). A small crossover study of 10 people found no significant difference in pain or function between ordinary shoes, rocker-bottom shoes and an ankle-foot orthosis, with preferences varying by age (Muir, J Prosthet Orthot 2026).","fit":"Still where care starts, because it is safe and the alternatives have thin evidence at this joint, but it is borrowed evidence, and patients are told so. Expect to try footwear, a brace or stick, strengthening and weight management and see what helps your ankle, rather than a programme with a proven ankle result.","reviewedOn":"2026-10-04"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested needling in ankle osteoarthritis. A PubMed search pairing ankle, tibiotalar and talocrural with arthritis or osteoarthritis and dry needling, trigger point, wet needling, acupuncture and electroacupuncture returned 59 records. On screening the titles, nearly all were animal or acupoint laboratory studies, rheumatoid arthritis, acute injury or other joints, and the only human ankle osteoarthritis item was a 2026 randomised trial protocol of electroacupuncture combined with diclofenac gel, which reports no results (J Pain Res 2026).","fit":"Only where a separate tender band in the calf or foot muscles is reproducing part of the pain. It does not treat the worn joint.","reviewedOn":"2026-10-04"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Weak evidence for any injectate","evidence":"Guidance and injectate answer different questions here. Ultrasound reliably places a needle inside the ankle joint, with 100 per cent accuracy in cadaver work (Reach, Foot Ankle Int 2009). One cadaver study found blind injection into the ankle joint was also 100 per cent accurate, and that guidance mattered for the midfoot joints rather than the ankle (Khosla, Foot Ankle Int 2009). A 2026 systematic review of five tibiotalar studies concluded ultrasound was more accurate than landmark injection, and one randomised trial in inflamed joints found better pain control at six weeks, but it found no high-quality trials of outcomes (Gharib, Arch ISPRM 2026). What goes in the joint has weak support. A 2025 systematic review found only two small randomised trials of corticosteroid in foot and ankle osteoarthritis and none against placebo at the ankle (Rheumatol Adv Pract 2025). One trial of 135 people found corticosteroid plus hyaluronic acid beat corticosteroid alone on ankle scores at 6 and 12 weeks, but pain was lower with corticosteroid alone at 6 weeks and the same at 12 (Woo, BMC Musculoskelet Disord 2025). Trials of hyaluronic acid and platelet-rich plasma against saline are mostly negative (see their rows).","fit":"An option to settle a flare enough to get walking, footwear and exercise started, not a treatment of the arthritis and not something to repeat on a schedule. Ultrasound is used for accuracy, but the ankle joint can usually be entered without it.","reviewedOn":"2026-10-04"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No clinical study of vibration or percussive devices in ankle osteoarthritis. A PubMed search pairing ankle, tibiotalar and talocrural with arthritis or osteoarthritis and vibration or percussion returned nine records; none studied the ankle joint, and they covered whole-body vibration in knee osteoarthritis, elderly balance and occupational risk.","fit":"A comfort measure within a session, only where tight calf or foot muscles are limiting movement. Not a treatment for the arthritic joint.","reviewedOn":"2026-10-04"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No randomised trial of shockwave in ankle osteoarthritis. A PubMed search pairing ankle, tibiotalar and talocrural with arthritis or osteoarthritis and shockwave terms returned one record, a technique video on the big toe joint, and a second search for radial or focused shockwave in ankle osteoarthritis returned only unrelated items. The osteoarthritis evidence is in the knee, where a meta-analysis of 12 randomised trials favoured shockwave over sham for pain and function in the short term, with high heterogeneity (Silva, Clin Rehabil 2023).","fit":"Reasonable to discuss on the same mechanism, with the gap stated. It is not a substitute for footwear, walking aids, exercise and weight management.","reviewedOn":"2026-10-04"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No randomised trial has tested shockwave for ankle osteoarthritis: searching ankle osteoarthritis and ankle arthritis against shockwave, shock wave and ESWT returns no study of either device. The nearest evidence at this joint is in cartilage injury of the talus rather than arthritis. Fifteen people with persisting pain after keyhole surgery for an osteochondral lesion improved in pain and ankle scores twelve weeks after shockwave, with smaller lesions on MRI at follow-up (Zhang, J Foot Ankle Surg 2020), and in a retrospective comparison, shockwave after microfracture gave better ankle scores at two years than platelet-rich plasma after microfracture (Li, J Clin Med 2023). The osteoarthritis trials themselves are at the knee and hip (Tang, Int J Surg 2024; Şah, J Pers Med 2022).","fit":"A reasonable option to try for arthritic ankle pain on the strength of the knee and hip trials, with the gap at this joint explained. Used alongside footwear, bracing where it helps, exercise and weight management.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial of electromagnetic transduction therapy in ankle osteoarthritis. The nearest human evidence is an uncontrolled pilot of eight people with midfoot osteoarthritis, in which pain scores fell over time overall but the comparisons with baseline at three and six months did not reach statistical significance, function scores improved, and there was no sham group (J Am Podiatr Med Assoc 2026). For the related pulsed electromagnetic field therapy, the evidence is in knee osteoarthritis. A PubMed search of ankle and tibiotalar osteoarthritis with electromagnetic terms returned seven records, none a human ankle osteoarthritis trial.","fit":"Offered only as an adjunct alongside care that has evidence, never as the plan itself, and only after the gap is explained. Much of the published work is manufacturer-linked, which is part of why that is stated.","reviewedOn":"2026-10-04"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One trial, no benefit over saline","evidence":"The only placebo-controlled trial found no benefit. In 100 people with ankle osteoarthritis given two PRP or two saline injections six weeks apart, the adjusted difference in AOFAS score over 52 weeks was 2 points in favour of saline (95% CI -5 to 2) and no secondary outcome differed (Paget, Am J Sports Med 2023). A systematic review of the ankle injection trials found no clinically relevant difference from placebo at 3, 6 or 12 months, with the PRP evidence graded moderate certainty and resting on that single trial (Paget, Clin Orthop Relat Res 2023). Evidence outside controlled trials is more favourable but weaker. A meta-analysis of four studies in 127 people (three cohorts and one randomised trial) found AOFAS and pain improvements at six months or longer that reached the minimal clinically important difference, though short-term gains did not and heterogeneity was high (Int Orthop 2023). Another pooled before-and-after data and noted the improvement was about the size of the placebo response in the trial (J Orthop Surg Res 2023). A single-centre retrospective series of 178 people reported pain falling from 6.6 to 2.4 out of 10 at six months, held to 36 months, with the best results in milder disease and in athletes, and no control group (BMC Musculoskelet Disord 2026). Across foot and ankle conditions, PRP was followed by more treatment-site pain than comparison injections (odds ratio 2.23, number needed to harm 13), with serious complications rare (Arthroscopy 2025).","fit":"Offered as an option for people who want to try an injection after footwear, bracing, strengthening and weight management, and particularly considered for younger or athletic people with milder joint wear, where the uncontrolled results were best. The expectation set up front is a possible benefit rather than a likely one, because the one saline-controlled trial found no advantage; it can leave the ankle more sore for a few days, and it is not expected to restore worn cartilage. Response is reviewed at six to twelve weeks and it is not repeated if there has been no benefit.","reviewedOn":"2026-10-04"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial of dextrose prolotherapy in ankle osteoarthritis. A PubMed search pairing ankle, tibiotalar and talocrural with arthritis or osteoarthritis and prolotherapy or dextrose returned seven records. They were a trial protocol and a randomised trial in chronic ankle instability, a retrospective comparison with PRP in talar cartilage lesions, a case series of seven people with hip, knee or ankle osteoarthritis who received bone marrow plus dextrose, and two systematic reviews of injections. In chronic ankle instability, a 114-person placebo-controlled trial found dextrose improved balance and re-sprains but not its primary instability score (Arch Phys Med Rehabil 2026), and a smaller trial in chronic ligament sprain found no pain benefit over saline (Arch Phys Med Rehabil 2026). The osteoarthritis evidence is in the knee, where a meta-analysis of 14 trials favoured dextrose, with caution about heterogeneity and bias (Chen, Clin Rehabil 2022).","fit":"Reasonable to discuss on the same rationale, with the gap in evidence stated. It would not replace footwear, walking aids and exercise, and it does not treat an arthritic joint that has lost its cartilage.","reviewedOn":"2026-10-04"},"viscosupplementation":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Low certainty, mostly negative","evidence":"Ankle trials exist and they disagree. A 2015 Cochrane review pooled two of three small placebo-controlled hyaluronic acid trials and found a possible benefit at six months on the Ankle Osteoarthritis Scale (12 points on a 100-point scale, 45 people), graded low quality, and concluded hyaluronic acid could be conditionally recommended if simple analgesics fail (Cochrane Database Syst Rev 2015). A 2020 meta-analysis favoured hyaluronic acid over saline at six months at very low certainty (Int Orthop 2020). Later work is more negative. A systematic review of seven trials found no clinically relevant difference from placebo at 3, 6 or 12 months and advised against using these injections in practice until better trials exist (Paget, Clin Orthop Relat Res 2023). A 2025 meta-analysis of six trials in 274 people found no significant difference in pain, AOFAS or ankle scores, with limited benefit (Tham, Foot Ankle Spec 2025). A placebo-controlled trial of a diclofenac-hyaluronate product in 60 people found no ankle benefit although it helped the hip (Kubo, BMC Musculoskelet Disord 2022).","fit":"A low-certainty option that may be discussed for a person who wants an injection and has not responded to simpler measures, with the mostly negative recent evidence stated. It would not be expected to change the arthritis.","reviewedOn":"2026-10-04"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has injected dextrose or other solution around skin nerves for ankle osteoarthritis. A PubMed search pairing ankle, tibiotalar and talocrural with arthritis or osteoarthritis and perineural, hydrodissection, nerve block, neurolysis or radiofrequency returned 20 records, mostly operative anaesthesia and nerve complications of ankle replacement, none a perineural injection for the arthritic joint.","fit":"Only if a separate tender, hypersensitive nerve territory is found around the ankle, for example after an old fracture or scar. Pain from inside the joint is not what this treats.","reviewedOn":"2026-10-04"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested hydrodissection for ankle osteoarthritis. The same 20-record search for ankle osteoarthritis with hydrodissection or perineural terms found none for the arthritic joint. Where the technique does appear in this region it is for a different problem, a case report of freeing the sural nerve from scar after a heel bone fracture (Cureus 2025).","fit":"Only where examination suggests a nerve trapped in scar after an old injury. It does not treat the worn joint surface.","reviewedOn":"2026-10-04"}}},{"slug":"ankle-sprain","title":"Ankle Sprain","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/ankle-sprain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Dry needling studied, not injection","evidence":"Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection or intramuscular stimulation with ankle sprain, ankle instability, lateral ankle, inversion injury or syndesmosis, 17 records). No study has injected a muscle trigger point after an ankle sprain, and none has treated a fresh sprain. The nearest evidence is dry needling, the same needle with nothing injected and not offered here, in chronic ankle instability long after the sprain: a 2024 review of seven small studies (169 people), mostly of needling the peroneus longus, found short-term gains in pain, balance and function against baseline but judged the evidence premature, with underpowered trials and inconsistent controls (Salemi, J Chiropr Med 2024). In a 24-person randomised trial, adding dry needling to 12 sessions of perturbation training gave no extra benefit for pain or function (Abbasi, J Bodyw Mov Ther 2023). A network meta-analysis of 44 trials ranked balance and strengthening exercise, with manual therapy or dry needling added, highest for function (Yang, J Orthop Sports Phys Ther 2025).","fit":"No role in a fresh sprain, where protected loading and balance training are the treatment. Considered only for ongoing pain months later where examination finds a tender lower-leg muscle band, alongside the balance and strengthening program.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Series for pain after a sprain","evidence":"Searched 8 November 2026 (PubMed: ankle sprain, syndesmosis, MCL, wrist or finger sprain with corticosteroid, steroid, triamcinolone, methylprednisolone, betamethasone, anaesthetic or lidocaine injection or infiltration, 51 records; ankle sprain with procaine, hyaluronidase or local anaesthetic, 11; and a randomised-trial pass, 3, none a trial of this injection). For a fresh sprain, a 2026 systematic review counted five studies of local anaesthetic injection that favoured faster recovery, without giving their designs in the abstract, and called for higher-quality research before any recommendation (Frey, Musculoskelet Surg 2026). The one placebo-controlled trial of a guided injection in acute sprains tested PRP mixed with local anaesthetic against saline and found no difference (Rowden, J Emerg Med 2015). For pain persisting after a sprain, 88 people with sinus tarsi syndrome given a betamethasone and lignocaine injection into the sinus tarsi had low pain scores at one month (1.2 out of 10) rising by twelve months (2.8), and symptoms returned in 65% within a year; there was no comparison group (Xu, Zhongguo Gu Shang 2024). In professional rugby league, ankle injections given so players could keep playing were judged less safe than injections elsewhere at long-term follow-up (Orchard, Am J Sports Med 2010).","fit":"Not a treatment for a fresh sprain, which is early movement, bracing where needed, and balance and strength work. Where pain persists months later from a specific source such as the sinus tarsi, a guided injection may be discussed alongside the rehabilitation program, with the high chance of the pain returning explained. See the note on cortisone.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial, no sham","evidence":"There is no shockwave trial in a fresh ankle sprain. In a persistent (chronic) ankle sprain, one randomised trial of 30 people added shockwave to joint mobilisation and compared it with mobilisation alone over six weeks: both groups improved, and the shockwave group gained more on the Karlsson ankle function score (about 20 points against 14) and on ankle movement. The abstract does not say whether the device was radial or focused, gives no between-group statistical test, reports no follow-up after treatment ended, and there was no sham (Aslam, Insights J Health Rehabil 2025; found through Consensus, not indexed in PubMed). A second small study of 18 people with chronic ankle instability gave shockwave to both groups, so it cannot show what shockwave itself adds (Lee, J Korean Phys Ther 2022). A PubMed search for shockwave with ankle sprain, ankle instability, the lateral ankle ligaments or the syndesmosis (9 records, all read) found one case report and no trial; a trial and systematic-review pass returned none in ankle sprain.","fit":"Not part of early sprain care. Discussed only for an ankle that is still sore and stiff months after a sprain, as an add-on to the balance and strength program, mainly for the tender ligament and the surrounding muscle. The one trial is small and unblinded, and the device type was not reported.","reviewedOn":"2026-10-23"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial, no sham","evidence":"There is no shockwave trial in a fresh ankle sprain. In a persistent (chronic) ankle sprain, one randomised trial of 30 people added shockwave to joint mobilisation and compared it with mobilisation alone over six weeks: both groups improved, and the shockwave group gained more on the Karlsson ankle function score (about 20 points against 14) and on ankle movement. The abstract does not name the device type, gives no between-group statistical test, reports no follow-up after treatment ended, and there was no sham (Aslam, Insights J Health Rehabil 2025; found through Consensus, not indexed in PubMed). A second small study of 18 people with chronic ankle instability gave shockwave to both groups, so it cannot show what shockwave itself adds (Lee, J Korean Phys Ther 2022). A PubMed search for shockwave with ankle sprain, ankle instability, the lateral ankle ligaments or the syndesmosis (9 records, all read) found one case report of shockwave with stretching for scarred ankle ligaments (Parchimowicz, Pomeranian J Life Sci 2016) and no trial; a trial and systematic-review pass returned none in ankle sprain.","fit":"Not part of early sprain care. Discussed only for an ankle that is still sore and stiff months after a sprain, as an add-on that may help the ankle move and load better while the balance and strength program does the main work. The one trial is small and unblinded, and the device type was not reported.","reviewedOn":"2026-10-23"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Tested, and it does not change the outcome that matters. In a double-blind, placebo-controlled trial of 37 people with severe ankle sprains, PRP produced no difference in pain or Lower Extremity Functional Scale scores against a saline injection (Rowden, J Emerg Med 2015). Two further randomised trials in grade II sprains found an early advantage that did not last: PRP over the anterior talofibular ligament was better at eight weeks but identical to rigid immobilisation alone by 24 weeks (Blanco-Rivera, Foot Ankle Surg 2019), and in 83 patients the same eight-week advantage had gone by six and twelve months (Zhang, Front Bioeng Biotechnol 2022). That is evidence of absence, not absence of evidence.","fit":"Not offered for an ankle sprain. Ligament healing and a graded return to load do the work, and an injection buys at most a few weeks of head start that the control groups caught up with anyway.","reviewedOn":"2026-09-02"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat saline on balance, not pain","evidence":"Two randomised trials have tested dextrose prolotherapy against saline injections in a long-standing ankle sprain, both in people whose ankle had stayed painful or unstable for months rather than in a fresh sprain. In the larger, 114 people with chronic ankle instability had four injections of 15% dextrose or saline into the anterior talofibular ligament over 16 weeks. At one year the main instability score (the Cumberland Ankle Instability Tool) was no different between the groups, but the dextrose group did better on a balance test (about 4.3 points on the Star Excursion Balance Test at 52 weeks) and had fewer repeat sprains; no procedure-related adverse events were reported (Sit, Arch Phys Med Rehabil 2025). In the smaller, 27 people with a chronic anterior talofibular ligament sprain had ultrasound-guided 15% dextrose or saline alongside a home physiotherapy program; pain scores were no different between the groups at 12 weeks, both groups improved, and only tenderness to pressure was better with dextrose (Wu, Arch Phys Med Rehabil 2025). An uncontrolled study of 25 people with chronic ankle ligament injury reported large gains after two injections of 12.5% dextrose around the nerves and fascia, a different technique with no comparison group (Kazempour Mofrad, Anesth Pain Med 2022). One case of a painful nerve injury (complex regional pain syndrome) after prolotherapy for a lateral ankle sprain has been reported (Kim, Medicine 2021). No trial in a recent sprain was found. PubMed search, 14 October 2026: prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain, ankle instability, collateral ligament or syndesmosis terms (21 records), and prolotherapy with ligament, ankle, wrist, finger, thumb or soft-tissue injury terms (121 records, all screened), each with randomised-trial and systematic-review passes.","fit":"Not for a fresh sprain, which settles with a graded rehabilitation program. Can be discussed for an ankle that keeps giving way or stays sore months later despite a completed balance and strengthening program, with the trial results stated as they are: steadier balance and fewer repeat sprains, but no clear difference in pain or in the main instability score. The rehabilitation program remains the treatment.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Not a treatment for a sprained ankle. Viscosupplementation is an injection into a joint for a problem inside that joint, and a sprain is an injury to the ligaments outside it. One research group has trialled hyaluronic acid injected around the sprained ligaments, not into the joint: in 158 athletes it gave less pain at day eight and a return to sport at 11 days against 17 with a placebo injection (Petrella, Clin J Sport Med 2007; Phys Sportsmed 2009). That is a different procedure from the one in this row, nobody else has repeated it, and a meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems found no second sprain trial (Khan, Sports Health 2022).","fit":"Not offered for an ankle sprain. Hyaluronic acid is considered only for a problem inside a joint, such as arthritis.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Chronic instability only","evidence":"Tested, but in the long-standing sprain rather than the fresh one, and without a control group. Twenty-five people with chronic ankle instability after ligament injury had two sessions of extra-articular neurofascial 12.5% dextrose a month apart: Cumberland Ankle Instability Tool scores rose from 1.9 to 21.8 and pain fell from 6.1 to 1.2 out of 10 by six months (Kazempour Mofrad, Anesth Pain Med 2022). There was no comparison group, so time and rehabilitation are not separated from the injection. Where the same injectate was put into the ligament instead and compared against saline it did not help pain: in 27 people with a chronic anterior talofibular ligament sprain, 15% dextrose was no better than normal saline on pain or ankle function over 12 weeks, with only pressure pain threshold favouring it at 12 weeks (Wu, Arch Phys Med Rehabil 2025). A randomised trial of 114 people is under way (Sit, Trials 2022; ChiCTR2000040213). There is also a harm report at exactly this site: a woman developed complex regional pain syndrome after injury to a small skin nerve on the outer ankle following prolotherapy for a lateral sprain, still allodynic a month into treatment (Kim, Medicine 2021).","fit":"Not part of treating a new sprain. Occasionally worth discussing much later, where the ankle keeps giving way and the skin over the outer ankle is tender and hypersensitive, and only once a proper balance and strength programme has had a fair trial.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Case reports, nerve after a sprain","evidence":"Searched 6 November 2026 (PubMed: hydrodissection, hydrorelease, perineural injection or 5% dextrose with sprain, ligament injury, syndesmosis, collateral ligament, calf or muscle strain, contusion or gastrocnemius, 12 records; a randomised-trial and systematic-review pass on hydrodissection at the ankle, calf or lower leg returned one narrative review). No study has tested hydrodissection for the sprain itself. Three single case reports describe a nerve trapped after an ankle sprain and freed with an ultrasound-guided fluid injection: the sural nerve on the outer ankle, with more than 80% pain relief after two sessions (Zhu, Clin Case Rep 2026); the medial plantar nerve in the sole six months after a sprain, with pain falling from 8 to 2 out of 10 after two sessions of 5% dextrose with local anaesthetic (Wu, Diagnostics 2024); and the superficial peroneal nerve, where hydrodissection gave three weeks of relief before pulsed radiofrequency was used (Martins da Silva, Cureus 2023). None had a comparison group.","fit":"Not a treatment for a sprained ligament, which recovers with early movement and a balance and strength program. Considered only where burning, tingling or numbness persists after the sprain and ultrasound shows a nerve caught in the healing tissue.","reviewedOn":"2026-11-06"}}},{"slug":"ankylosing-spondylitis","title":"Ankylosing Spondylitis (Axial Spondyloarthritis)","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/ankylosing-spondylitis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise and education sit alongside medical disease control, not instead of it. Both the ASAS-EULAR recommendations and the American College of Rheumatology guideline place education, regular exercise and physical therapy as core non-pharmacological management in axial spondyloarthritis, escalating to a biologic where disease activity stays high (Ramiro, Ann Rheum Dis 2023; Ward, Arthritis Rheumatol 2019).","fit":"The critical point is sequencing: this does not replace rheumatological treatment, and a delay in getting disease control is the thing that causes lasting damage. Assessment here is aimed at recognising the pattern early and getting you to the right treatment, with exercise supporting it throughout.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial evidence in axial spondyloarthritis. Secondary muscular pain around a stiff spine is common, and is treated as muscular pain rather than as the disease.","fit":"Occasionally helpful for a specific tender band that is limiting the exercise programme. The exercise programme is the treatment.","reviewedOn":"2026-08-30"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Injection has no role in controlling the spinal disease. Where a separate peripheral joint, bursa or tendon sheath is symptomatic, ultrasound guidance improves needle placement at those targets, and corticosteroid is used sparingly in inflammatory disease because repeated doses can undermine tendon and bone.","fit":"Occasionally useful for a specific peripheral problem, in discussion with the treating rheumatologist. Never a substitute for disease-modifying treatment.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Same position as focused shockwave. The one randomised trial in axial spondyloarthritis treated co-existing plantar fasciitis, not the spondyloarthritis (Caner, Rheumatol Int 2022, n=22). Nothing addresses the axial disease.","fit":"Only for a co-existing peripheral enthesopathy, and only alongside proper disease control.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Shockwave is not a treatment for the spinal disease itself. Disease control in axial spondyloarthritis is exercise, education and anti-inflammatories first, then a biologic where disease activity stays high (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019): no guideline lists shockwave. The only randomised evidence in this population treats a co-existing problem: 22 patients with axial spondyloarthritis and chronic plantar fasciitis, shockwave against sham, with better pain and foot function in the shockwave group (Caner, Rheumatol Int 2022). The trial is small, and an earlier conference report of the same cohort described no difference between groups, so it is held loosely.","fit":"Considered only where a separate peripheral enthesopathy (a plantar fascia or Achilles) is the thing actually hurting, and treated on its own merits. It does nothing for the sacroiliac or spinal disease, and it is not a reason to delay rheumatology review.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Not part of managing inflammatory spinal disease. Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study of platelet-rich plasma in ankylosing spondylitis or axial spondyloarthritis was found. A PubMed search on 11 October 2026 pairing platelet-rich plasma terms with ankylosing spondylitis, spondyloarthritis, sacroiliitis, enthesitis, psoriatic arthritis and inflammatory back pain returned six records, and none tested PRP in people with this disease. The nearest is a look back through the records of 60 people with sacroiliitis on MRI, whose cause is not stated, given cortisone, PRP or hyaluronic acid into the joint: cortisone eased pain fastest, and at six months pain averaged 3.8 out of 10 after PRP, 4.3 after hyaluronic acid and 5.1 after cortisone, without randomisation (Yadav, Cureus 2026). This is an immune-driven inflammatory disease, and the treatments with evidence for it are exercise and medication that acts on the immune system.","fit":"Not a treatment for the disease itself, which is managed with a rheumatologist. Considered only for a separate, clearly identified mechanical problem alongside it, in discussion with the treating rheumatologist and judged on the evidence for that problem.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"No study of prolotherapy in ankylosing spondylitis or axial spondyloarthritis. A PubMed search on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with ankylosing spondylitis, spondyloarthritis or axial spondyloarthritis, searched together with spondylolysis, spondylolisthesis and scoliosis; 10 records) found no trial, series or case report treating the spondyloarthritis. The only record of prolotherapy in a person with the disease treated shoulder pain, which improved with physiotherapy and prolotherapy at a site the abstract does not state (Clark, J Orthop Case Rep 2022); the other records used dextrose as an intravenous fluid or for a nerve procedure, and one could not be retrieved.","fit":"Not part of managing this diagnosis. If a separate mechanical problem is present it is assessed on its own terms, not as treatment for the spondyloarthritis.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Hyaluronic acid is a treatment for an arthritic peripheral joint, not for inflammatory spinal disease.","fit":"Not used for this condition.","reviewedOn":"2026-08-30"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study of perineural injection in ankylosing spondylitis or axial spondyloarthritis was found. A search of perineural injection, neural prolotherapy, subcutaneous and perineural dextrose, glucopuncture, Lyftogt and neurofascial terms against spondylitis, spondyloarthritis and sacroiliitis, with separate passes for randomised trials and systematic reviews, returned one related record: a systematic review of jaw-joint arthritis in rheumatic diseases that included a study of subcutaneous perineural dextrose at the jaw joint. One of its five studies included people with ankylosing spondylitis, the abstract does not say whether that was the dextrose study, and the reviewers judged the evidence too sparse and low in quality to draw conclusions (Aiello, BMC Musculoskelet Disord 2025). Nothing has tested the treatment at the spine or the sacroiliac joints.","fit":"Not part of managing this condition.","reviewedOn":"2026-11-04"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"No trial of nerve hydrodissection in ankylosing spondylitis or axial spondyloarthritis was found. Searching hydrodissection and hydrorelease against spondylitis, spondyloarthritis, sacroiliitis and Bechterew, with separate passes for randomised trials and systematic reviews, found one case report: a 52-year-old man with ankylosing spondylitis and stiff shoulders who developed a brachial plexus injury from his arm position during chest surgery. He was treated with physiotherapy and several ultrasound-guided injections, including 5% dextrose hydrodissection of the brachial plexus and suprascapular nerve, and his pain and weakness had resolved by about six months (Go, World J Clin Cases 2022). The nerve injury came from the operation rather than the spondylitis, and with several treatments given together the effect of the hydrodissection cannot be separated out.","fit":"Not a treatment for the spinal inflammation. Considered only where a specific nerve entrapment is found alongside it.","reviewedOn":"2026-11-04"}}},{"slug":"wrist-arthritis","title":"Arthritis of the Wrist","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/wrist-arthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested any needling technique in wrist arthritis. A search pairing dry needling, trigger point needling and trigger point injection with arthritis of the shoulder, elbow, wrist, thumb base and big toe returned 19 records, and none tested needling in an arthritic wrist; a second pass restricted to clinical trials returned nothing at this joint. The nearest work is a cadaveric study showing that the pronator quadratus, a deep forearm muscle just above the wrist whose referred pain can mimic nerve symptoms, can be needled accurately without piercing the nearby nerves and vessels (Perez-Bellmunt, Physiother Theory Pract 2022).","fit":"Only where the assessment finds a separate tender forearm muscle band reproducing part of the wrist pain. It does not treat the arthritic joint.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No trial in wrist OA","evidence":"A search of sixteen records on intra-articular injection at the radiocarpal and scaphotrapeziotrapezoid joints found no randomised trial in wrist osteoarthritis. The only report specific to the condition is three people with end-stage radiocarpal osteoarthritis given platelet-rich plasma mixed with microfat, all of whom had pain fall by more than half at 12 months (Mayoly, Int J Mol Sci 2019): three people, no control group. The nearest randomised evidence is in a different population: 40 people given dexamethasone or saline into the radiocarpal joint within two weeks of an intra-articular distal radius fracture showed no difference in joint space or in any patient-reported outcome at two years (Logli, J Hand Surg Am 2024). The randomised wrist injection trials that do exist are in rheumatoid arthritis, which is a different problem.","fit":"Considered where a single wrist compartment is the clear pain source and rehabilitation has stalled, on mechanism rather than on trial evidence. A wrist splint and load modification come first.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies at this joint","evidence":"Searching shockwave, shock wave, ESWT and radial shockwave against wrist and radiocarpal arthritis and hand osteoarthritis returns no trial of either device as a treatment for arthritis at the wrist. The only wrist records are about something else: radial shockwave applied to the forearm muscles to reduce muscle tone after stroke, where 62 patients improved in tone, wrist movement and hand function (Marek, J Clin Med 2026). That tells you the treatment can change how a muscle behaves, not that it helps an arthritic wrist.","fit":"Offered for tender forearm muscle where examination finds it contributing. Splinting, load management and an ultrasound-guided injection where one specific compartment or joint is inflamed are the options with evidence behind them here.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested shockwave for arthritis of the wrist: searching shockwave, shock wave and ESWT against wrist osteoarthritis, wrist arthritis and hand osteoarthritis returns no study of either device at this joint. The case for it rests on other arthritic joints. Pooled trials at the knee favour shockwave over sham for pain and function (Tang, Int J Surg 2024), and at the hip a 148-person trial found focused shockwave better than sham (Şah, J Pers Med 2022).","fit":"A reasonable option to try for arthritic wrist pain on the strength of the knee and hip trials, with the gap at this joint explained. Used alongside splinting and load management, and where you would like to avoid or defer an injection.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Tiny uncontrolled series only","evidence":"No trial of PRP in wrist osteoarthritis. A search on 8 October 2026 returned 12 records with no trial among them, and a randomised-trial pass returned 13, every one of them about carpal tunnel syndrome, tennis elbow, de Quervain's, tendon pain or a wrist fracture rather than arthritis. What exists is three small uncontrolled reports. Two, from one French unit, injected PRP mixed with the patient's own micro-fragmented fat rather than PRP alone. Three people with end-stage radiocarpal osteoarthritis all had pain fall by more than half, with meaningful gains in function, at twelve months (Mayoly, Int J Mol Sci 2019), and a follow-on pilot reported lower pain and disability scores at each follow-up with no serious adverse event, though measured wrist strength also fell (Mayoly, J Clin Med 2022); the side effect noted was pain where the fat was harvested. The one report of PRP on its own included eight people with arthritis of the scaphotrapeziotrapezoid joint among 29 treated with two image-guided injections, and found no effect on pain, function or grip at three months, although 16 of 28 said it had helped (Swärd, PLoS One 2022).","fit":"Can be discussed for a painful arthritic wrist only on the knee-based rationale, making clear that the wrist evidence is a handful of uncontrolled cases, most of them using a fat-and-PRP mixture rather than PRP alone. A splint, load changes and hand therapy come first.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy in wrist arthritis. A search on 12 October 2026 for dextrose or prolotherapy in arthritis of the elbow, wrist or big toe returned four records and none at the wrist. The hand-arthritis trials, including a pooled analysis of 14 trials in which dextrose improved pain and hand function at six months or more (Chen, Am J Phys Med Rehabil 2024), studied the finger and thumb-base joints rather than the wrist.","fit":"Prolotherapy is offered here and can be discussed for wrist arthritis pain that persists despite splinting, activity changes and hand therapy, with the absence of studies at the wrist stated. Hand therapy remains the core of care.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched PubMed for the same hyaluronic acid terms with wrist, radiocarpal or scapholunate advanced collapse and osteoarthritis, arthritis or arthrosis: 13 records, none a human study of hyaluronic acid injected into an arthritic wrist (three were horse studies; the human records were a rheumatoid study that combined it with cortisone and a cartilage-surgery case). The randomised-trial and systematic-review passes returned none. The thumb-base joint, which is a different joint, has trials pointing to little benefit over placebo.","fit":"Rarely relevant here. Discussed only with that gap explained, after splinting, hand therapy and a guided cortisone injection have been considered.","reviewedOn":"2026-10-26"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"arthritis-overview","title":"Arthritis: An Overview","region":"General","url":"https://www.backpaindoctor.com.au/conditions/arthritis-overview","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Short-term relief","evidence":"How well a corticosteroid injection works depends on which joint and which kind of arthritis. In knee osteoarthritis, 27 trials in 1,767 people show a modest benefit that peaks in the first weeks and has gone by six months (Jüni, Cochrane Database Syst Rev 2015), and in hip osteoarthritis an ultrasound-guided injection added to advice and education improved pain over six months in a trial of 199 people (Paskins, BMJ 2022). The American College of Rheumatology strongly recommends corticosteroid injection for knee osteoarthritis and only conditionally for the hand (Kolasinski, Arthritis Rheumatol 2020). It does not carry over to every joint: at the base of the thumb, triamcinolone injected under imaging guidance was no better than saline in a double-blind trial of 40 people (Meenagh, Ann Rheum Dis 2004). In rheumatoid arthritis, injecting an inflamed knee worked better than giving the same dose into muscle in a double-blind trial of 60 people (Konai, Clin Exp Rheumatol 2009). In gout it is recommended by guidelines, but a Cochrane review found it has never been tested in a randomised trial (Wechalekar, Cochrane Database Syst Rev 2013).","fit":"Most useful when one painful, swollen joint is stopping you from exercising. The page for each joint sets out what the evidence shows at that site. Used sparingly: see the note on cortisone.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Knee trials; focused did better","evidence":"The radial form of shockwave has been tested against a sham or placebo device in osteoarthritis at the knee, with mixed results. In 104 people all doing the same physiotherapy and home exercise, adding three weekly radial sessions gave better pain, function and walking scores than a sham device up to three months (Uysal, Int Orthop 2020), and in 89 people every treated dose reduced pain more than placebo at four weeks, the higher energy doing more (Zhang, J Rehabil Med 2021). Against that, in 105 women with severe, long-standing knee arthritis, three low-energy radial sessions were no better than placebo for the main outcome, pain on movement at three months (Imamura, J Rehabil Med 2017). Where the two devices have been compared directly the focused form did better, at the knee in 42 people (Ko, Int J Environ Res Public Health 2022) and at the hip in 148 (Şah, J Pers Med 2022). A search on 11 November 2026 for randomised trials and meta-analyses of radial shockwave in osteoarthritis returned seven records: five knee trials and two animal studies. It did not retrieve the hip trial above, so it is not a complete count, and no trial of a radial device at any other joint is known to this review.","fit":"Worth discussing for knee arthritis pain, and for the tender muscle around an arthritic joint, alongside exercise and weight management. Where a deeper joint is itself the target, the focused form has the better head-to-head results. It does not rebuild cartilage, and the trials stop at three months.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Strongest in the knee","evidence":"Shockwave has real trial evidence in osteoarthritis, concentrated at the knee. There, an umbrella review of eight meta-analyses found it better than sham treatment for pain, by 2.0 points out of 10, and for function and range of movement (Tang, Int J Surg 2024). At the hip, a 148-person trial found focused shockwave better than both radial and sham treatment at eight weeks (Şah, J Pers Med 2022), and in cervical spondylosis a 320-person sham-controlled trial found less pain and disability after focused treatment (Li, Medicine 2024). At the smaller joints, the shoulder, elbow, wrist, thumb, ankle and big toe, no randomised trial has been done.","fit":"A non-invasive option for arthritis pain where the joint itself is the target, with the evidence strongest at the knee and thinner elsewhere. It reduces pain and improves function alongside exercise and weight management; it does not rebuild cartilage.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Strongest in the knee","evidence":"How well PRP is supported depends on which joint. The knee has by far the most evidence: pooling 18 placebo-controlled trials in 1,995 people, PRP improved function more than a dummy injection by a clinically meaningful margin from one to twelve months, and pain at three and six months (Bensa, Am J Sports Med 2025), although the largest Australian trial, in 288 people, found no difference from saline in pain or cartilage volume at twelve months (Bennell, JAMA 2021). At the hip, PRP has a small edge over hyaluronic acid in pooled trials (Zhang, Pain Res Manag 2026) but was no better than saline in the one placebo-controlled trial (Topaloglu, Turk J Phys Med Rehabil 2024). At the ankle and at the base of the thumb it did no better than saline (Paget, JAMA 2021; Evans, JB JS Open Access 2025). At the shoulder one trial found it equal to hyaluronic acid (Kirschner, Clin J Sport Med 2022), and at the elbow, wrist and big toe it has not been trialled. Expert bodies are split: the authors of the Australian trial noted that most clinical guidelines do not recommend PRP for knee osteoarthritis, while a European sports-orthopaedic consensus regards it as a valid option for mild to moderate knee arthritis (Laver, Knee Surg Sports Traumatol Arthrosc 2024). In knee trials, complications - nearly all mild to moderate and self-limiting - were about twice as common after PRP as after comparison injections (Fucaloro, Arthroscopy 2025).","fit":"Worth discussing mainly for knee osteoarthritis that has not responded to exercise, weight management and simple pain relief. At other joints the evidence is weaker or negative, and the page for each joint says what has been found there. It is not expected to regrow cartilage.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Strongest in the knee","evidence":"How well prolotherapy is supported depends on the joint. The knee has the most evidence: pooling 14 randomised trials in 978 people, dextrose prolotherapy did better than placebo injection and non-injection care for pain, function and quality of life, with marked differences between trials and a risk of bias that the authors say calls for caution (Chen, Clin Rehabil 2022). In the hand, a double-blind trial in finger and thumb-base arthritis reduced pain on movement more than a dummy injection (Reeves, J Altern Complement Med 2000), and pooled hand trials favour dextrose at six months or more (Chen, Am J Phys Med Rehabil 2024). At the hip there is one small trial against exercise, in arthritis from hip dysplasia (Gül, Med Sci Monit 2020), and at the shoulder, elbow, wrist and big toe there are no studies. A systematic review across joints found the trials to date at high risk of bias (Waluyo, J Rehabil Med 2023), and a 2025 orthopaedic review judged the evidence insufficient for routine use at the hip and knee (Seah, J Bone Joint Surg Am 2025).","fit":"Prolotherapy is offered here. It is most worth discussing for knee and hand arthritis that has not settled with exercise, weight management and simple pain relief; at other joints the evidence is thinner or absent, and each joint's page says what has been found there. It is a way to make the exercise program possible, not a substitute for it, and it does not regrow cartilage.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Little or no benefit over placebo","evidence":"Hyaluronic acid has been tested against a dummy injection at several joints, and the results range from a very small effect to none. In the knee, the 24 large placebo-controlled trials (8,997 people) show pain reduced by 2 mm on a 100 mm scale more than placebo - less than patients can feel - with more serious adverse events than placebo (Pereira, BMJ 2022). In the hip, five placebo-controlled trials in 591 people show no benefit on pain or function (Liao, Med Sci Monit 2019), including the largest, in 357 people (Brander, Osteoarthritis Cartilage 2018). At the big toe, a Cochrane review found at moderate certainty that a single injection gives no clinically important benefit over placebo (Munteanu, Cochrane Database Syst Rev 2024), and at the shoulder a 300-person trial found a difference from saline that was not statistically significant (Kwon, J Shoulder Elbow Surg 2013). Guideline bodies disagree at the knee - the American College of Rheumatology and Arthritis Foundation do not recommend it, while OARSI and the United States Veterans Affairs guideline do (Sabha, Osteoarthr Cartil Open 2021) - and the higher-quality guidelines consistently recommend against it at the hip (Gibbs, Osteoarthritis Cartilage 2023).","fit":"Considered only for arthritis inside a joint, mainly the knee, as a non-steroid option when corticosteroid is unsuitable or has already been used repeatedly. The small average effect is stated beforehand, and the page for each joint sets out what has been found there.","reviewedOn":"2026-10-08"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"bakers-cyst","title":"Baker's Cyst (Popliteal Cyst)","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/bakers-cyst","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line, aimed at the knee","evidence":"Standard references list rest, anti-inflammatory medicines, physiotherapy and steroid injection as the non-operative options, and treat the cyst as a marker of underlying knee disease such as osteoarthritis or a meniscal tear (StatPearls, Baker Cyst 2023; Zmerly, Cureus 2026). No randomised trial of an exercise programme for Baker's cyst itself was found, so this rests on treating the knee condition behind it. In an observational study of 130 people with knee osteoarthritis, 33 of them with a cyst, those with a cyst did worse at the start and had lost their three-month gain by six months, while those without a cyst held theirs (Abate, Med Princ Pract 2021).","fit":"The starting point: a proper knee examination and weight-bearing x-ray to find out why the knee is making fluid, then progressive strengthening, load pacing and weight advice. A knee with a cyst is followed up more closely, because the early gain can fade.","reviewedOn":"2026-10-04"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searches pairing popliteal or Baker's cyst with dry needling, trigger point treatment and needling returned no study treating the cyst or the knee problem with needling; the hits were case reports and MRI studies that matched only on other words.","fit":"Only where a separate tender band in the hamstring or calf is adding to the pain. A needle does not shrink the cyst or treat the knee behind it.","reviewedOn":"2026-10-04"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Short-term relief, cysts can return","evidence":"In a randomised trial of 60 people with knee osteoarthritis and a Baker's cyst, groups given ultrasound-guided aspiration and steroid held lower pain at four weeks than before treatment, with the combination of injection and a physical therapy device doing best, but the maximum axial area of the cyst on the scan did not change in any group, although its sagittal area changed over time (Di Sante, Eur J Phys Rehabil Med 2012). Of 47 people followed after ultrasound-guided aspiration, fenestration and steroid, the average WOMAC score improved from 48.6 to 17.2 and 12.7 per cent needed re-aspiration (Smith, Sports Health 2015); in 32 people followed for six months, all six cysts that returned were the complex type (Koroglu, Eur J Radiol 2012). A systematic review of 30 studies calls intracystic steroid with fenestration effective but rests on low-level evidence (Van Nest, JBJS Rev 2020). No sham-controlled trial, and no trial of ultrasound versus landmark guidance for this cyst, was found.","fit":"Considered for a large or painful cyst that is limiting bending, always under ultrasound because the cyst sits beside the main nerve and vessels of the knee. Relief is often short-lived if the knee behind it stays irritated, so it is paired with treatment of the knee.","reviewedOn":"2026-10-04"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A combined search for vibration therapy with popliteal and Baker's cyst terms returned no study treating this condition.","fit":"A comfort adjunct at most for tight hamstring or calf muscle guarding around a sore knee. It does nothing for the cyst or the joint fluid behind it.","reviewedOn":"2026-10-04"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not established","evidence":"A search pairing popliteal and Baker's cyst with shockwave and extracorporeal terms returned no study of shockwave for this condition. This is untested rather than tested and negative, and there is no recognised mechanism by which shockwave would empty a fluid-filled cyst.","fit":"Not offered for this condition.","reviewedOn":"2026-10-04"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not established","evidence":"The same search returned no study of focused shockwave for Baker's cyst. It is untested, and a fluid collection fed by the knee joint is not a tendon or bony target.","fit":"Not offered for the cyst. A coexisting tendon problem would be assessed and treated on its own merits.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not established","evidence":"Searches for electromagnetic and magnetic therapy with popliteal and Baker's cyst terms returned no study treating this condition; the hits were MRI papers matching on the word magnetic.","fit":"Not part of managing this condition.","reviewedOn":"2026-10-04"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial","evidence":"A randomised trial of 36 people with grade 1 to 3 knee osteoarthritis and a Baker's cyst found that aspiration followed by PRP injected into the cyst gave more pain relief and better WOMAC scores at 12 weeks than aspiration alone, with a similar change in cyst size (Akarsu, Am J Phys Med Rehabil 2026). It is a single small trial with 12 weeks of follow-up and no sham injection. Other reports are individual cases, including a PRP injection into the knee that was followed by resolution of the cyst (Song, Regen Med 2020).","fit":"Can be discussed where the cyst keeps returning in a knee with osteoarthritis, as an option with a thin evidence base and real limits rather than an expected result. Effect sizes you should expect are those of the trial, not of case reports.","reviewedOn":"2026-10-04"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested prolotherapy for a Baker's cyst. The published reports are single cases of dextrose, with or without a sclerosing agent, injected into the knee joint after drainage, in which the cyst resolved (Yavuz, J Clin Diagn Res 2016; Centeno, Pain Physician 2008), and a large calf cyst that recurred after two 25 per cent dextrose injections and after doxycycline (Hassid, Am J Phys Med Rehabil 2023).","fit":"Not offered for the cyst on current evidence. Dextrose injection aimed at an arthritic knee or a lax knee ligament is a separate question about the knee.","reviewedOn":"2026-10-04"},"viscosupplementation":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"For the knee arthritis, not the cyst","evidence":"No trial has tested hyaluronic acid for the cyst. In an observational study of 130 people with knee osteoarthritis, 33 of them with a Baker's cyst, fluid withdrawal and injections of hyaluronic acid and/or steroid improved scores at three months, but the gain had declined by six months in the people with a cyst (Abate, Med Princ Pract 2021). Any benefit belongs to the knee osteoarthritis evidence, which is assessed on its own page.","fit":"Discussed only where the knee has established osteoarthritis that would justify it anyway, not as a treatment for the cyst.","reviewedOn":"2026-10-04"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searches combining popliteal and Baker's cyst with nerve block, tibial nerve and perineural terms found no study treating this condition. The cyst lies next to the tibial nerve and popliteal vessels, and large cysts can occasionally compress them (Radiopaedia, Baker cyst).","fit":"Considered only if examination finds a separate skin or nerve pain pattern around the knee. It is not treatment of the cyst.","reviewedOn":"2026-10-04"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of hydrodissection for Baker's cyst was found in searches pairing the technique with popliteal and Baker's cyst terms. The space behind the knee holds the tibial nerve and popliteal artery and vein, and the cyst is a fluid collection rather than a nerve entrapment.","fit":"Not used for the cyst. Considered only where a nerve behind the knee is separately irritated, and then only under ultrasound.","reviewedOn":"2026-10-04"}}},{"slug":"biceps-tendinopathy","title":"Biceps Tendinopathy (Shoulder)","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/biceps-tendinopathy","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No controlled trial of needling or trigger point injection in long head of biceps tendinopathy. A scoping review screened 4,059 records and found only 14 studies on non-surgical management of this tendon in total, describing a dearth of evidence; dry needling appears among the interventions used but without a trial behind it (McDevitt, Braz J Phys Ther 2023). The only needling-specific report is an uncontrolled case series of ten people treated with dry needling alongside eccentric-concentric loading and stretching, whose pain scores improved by 3.9 points and disability by 19 per cent (McDevitt, Physiother Theory Pract 2018). No study has used an injectate.","fit":"Considered only where examination finds a tender muscle band reproducing part of your pain, as an adjunct to the loading programme rather than a treatment for the tendon.","reviewedOn":"2026-09-11"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Guidance matters most at this target. Ultrasound raised accuracy of biceps tendon sheath injection from 26.7% to 86.7% and produced significantly greater pain reduction and functional improvement than landmark injection (Aly, Br J Sports Med 2014). A meta-analysis of 15 trials found guidance NOT superior at the subacromial bursa or glenohumeral joint, but clearly superior at the bicipital groove (Fan, Arthroscopy 2021).","fit":"One of the few sites where ultrasound guidance changes the outcome and not just the accuracy.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat sham in a 79-person trial","evidence":"Searched 17 October 2026: shockwave, shock wave or ESWT with biceps tendinopathy or tendinitis, bicipital tendinitis, the long head of the biceps or the biceps tendon (16 records, all read; four were in dogs). The old line here said the trials used focused devices; the first trial used this one. In 79 people with long-head biceps tenosynovitis, four weekly sessions of radial shockwave beat sham, with pain falling from 5.7 to 1.4 out of 10 at twelve months against 6.0 to 5.6 with sham (Liu, Ultrasound Med Biol 2012). A larger sham-controlled trial of 144 people, with rehabilitation in every group, found a 16-point gain on the Constant-Murley shoulder score from shockwave at four and six weeks, but does not say which device it used (Liu, Arch Phys Med Rehabil 2026). Against an ultrasound-guided steroid injection, radial shockwave did worse over four weeks in 93 people (overall response 80% against 94%) (Xiao, Am J Transl Res 2021). Neither sham-controlled trial reports harms in its abstract.","fit":"Worth discussing alongside a shoulder loading program when pain from the biceps tendon at the front of the shoulder has not settled with exercise alone. A guided steroid injection did better over the first month in the one head-to-head trial.","reviewedOn":"2026-10-17"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One sham trial; device not stated","evidence":"Searched 17 October 2026: shockwave, shock wave or ESWT with biceps tendinopathy or tendinitis, bicipital tendinitis, the long head of the biceps or the biceps tendon (16 records, all read; four were in dogs). No trial states that it used a focused device. The largest is sham-controlled: 144 people with long-head biceps tendinopathy, all given four weeks of rehabilitation, in whom shockwave added 16 points on the Constant-Murley shoulder score (95% CI 12.7 to 19.1) at four weeks and 16 at six, with less pain at rest, on activity and at night; it gives the energy (0.12 to 0.25 mJ/mm2) but not the device type, and followed people for six weeks only (Liu, Arch Phys Med Rehabil 2026). The other sham-controlled trial used a radial device (Liu, Ultrasound Med Biol 2012). A meta-analysis of 18 trials across upper-limb tendinopathies, including this one, found shockwave relieved pain better than placebo, especially the radial device, without a separate biceps estimate (Xiong, Front Med 2024).","fit":"The long head of the biceps runs in a groove at the front of the shoulder, within reach of a focused device. Worth discussing alongside a shoulder loading program when pain has not settled with exercise alone, with the caveat that the trial that may have used this device followed people for six weeks.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched specifically for the long head of biceps tendon at the shoulder. Thirteen records for PRP or autologous blood at the biceps tendon, and a second pass for randomised trials and reviews, contained no clinical study with results at this tendon. The nearest are a pilot in people with spinal cord injury whose abstract gives no numbers (Ibrahim, Top Spinal Cord Inj Rehabil 2012), and six people treated at the other end of the muscle, the distal biceps tendon at the elbow, whose pain on movement fell from 7.3 to 1.3 out of 10 after an ultrasound-guided injection (Barker, Shoulder Elbow 2015). A review of regenerative treatment for shoulder tendons describes the benefits as supported by little or no evidence so far (Gleich, Unfallchirurg 2020). The PRP trials at the shoulder are in the rotator cuff, not the biceps tendon.","fit":"Can be discussed where a painful biceps tendon has not settled with load management and rehabilitation, on the understanding that it has not been tested in this tendon. If used, it is placed under ultrasound guidance, and the cost and the absence of trials are stated beforehand.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy in biceps tendinopathy was found. A PubMed search on 13 October 2026 (prolotherapy, dextrose, hypertonic glucose or hyperosmolar with biceps or bicipital) returned two records, neither about treating the tendon, and passes restricted to randomised trials and to systematic reviews or meta-analyses found nothing in this condition. The shoulder trials of prolotherapy are in the rotator cuff, and they are mixed: a 2026 pooled analysis of 13 trials found little or no benefit over saline, at low to very low certainty (Zerzan, PM R 2026), while one trial of dextrose onto painful tendon attachments alongside physiotherapy kept more people improved at nine months than saline over the tendon (59% against 27%; Bertrand, Arch Phys Med Rehabil 2016).","fit":"Can be discussed for persistent pain at the long head of biceps despite a shoulder loading program, on the rationale from the rotator cuff trials, with the absence of biceps studies stated.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here. A PubMed search for hyaluronic acid injection in biceps tendon problems (12 records) found no clinical trial in people with biceps tendinopathy. The only human treatment data sit inside a laboratory study: patients with long-head biceps tendinopathy had less pain one month after hyaluronic acid was injected around the tendon, with no comparison group and the number of patients not given in the summary (Wu, Sci Rep 2017). A small trial in stroke patients injected the bursa above the shoulder, not the biceps (Huang, Medicine 2018). An injection around a tendon is a different procedure from the joint injection in this row.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem. Rehabilitation that loads the tendon progressively remains the centre of treatment.","reviewedOn":"2026-11-09"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies found","evidence":"No study of perineural injection in biceps tendinopathy. Searching dextrose, D5W, perineural injection, neural prolotherapy, glucopuncture and prolotherapy terms against biceps tendinopathy, biceps tendinitis, bicipital pain and the long head of the biceps returns two records, and neither concerns this tendon: one describes ultrasound-guided injection of the posterior femoral cutaneous nerve, matched only because that nerve runs over the biceps femoris muscle in the thigh (Vita, J Ultrasound 2025). The nearest shoulder evidence is a sham-controlled trial of 5% dextrose around the axillary nerve in rotator cuff tendinopathy, which found a short-lived pain benefit at one of two injection sites and no change in function (Vitoonpong, Asian Biomedicine 2026).","fit":"Considered where examination finds tender, hypersensitive skin rather than pain along the tendon in the bicipital groove.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of hydrodissection for long head of biceps tendinopathy was found. A search pairing hydrodissection, hydrorelease, hydrodilatation and perineural injection with biceps tendon, long head of biceps and bicipital terms returned no treatment study in this condition, only rotator interval technique papers, one of which warns that injecting into the biceps tendon itself risks rupturing it (Sharma, J Ultrason 2021). The nearest nerve-directed report is a gymnast whose front-of-shoulder pain with a labral (SLAP) lesion settled after hydrodissection of the axillary and thoracodorsal nerves (Omodani, Cureus 2024): one case, and not a biceps diagnosis.","fit":"Only where examination finds a separate nerve pain source around the front of the shoulder. It is not a treatment for the tendon.","reviewedOn":"2026-09-29"}}},{"slug":"distal-biceps-tendon-tear","title":"Biceps Tendon Tear at the Elbow","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/distal-biceps-tendon-tear","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Radial shockwave has not been tested in a torn distal biceps tendon or after a repair (PubMed, 25 October 2026: biceps with shockwave terms, 28 records; tendon tears, ruptures and repairs, 30 records). The one controlled study at this tendon is in chronic distal biceps tendinopathy without a tear: 48 people given a single radial session of 2,000 pulses had mean pain of 3.4 against 5.6 out of 10 with other non-surgical care at three months, and 2.7 against 4.7 at twelve months, with no significant complications. It compared groups after the fact rather than randomising them (Furia, Clin J Sport Med 2017).","fit":"Worth discussing for a painful distal biceps tendon that is intact and slow to settle with loading. Not used for a complete tear, which needs an early surgical opinion.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a torn distal biceps tendon or after its repair. A PubMed search on 25 October 2026 for shockwave, shock wave, ESWT or pressure wave with biceps (28 records, all read) and with tendon tears, ruptures and repairs (30 records) found two reports at the elbow, both in tendinopathy rather than a tear: a comparison of 48 people with chronic distal biceps tendinopathy in which a single session of RADIAL shockwave left less pain than other non-surgical care at three and twelve months (Furia, Clin J Sport Med 2017; not randomised), and one case report (Shaw, J Bodyw Mov Ther 2023). No study with a focused device exists at this tendon.","fit":"Not a treatment for a tear, which is a surgical question when it is complete. Considered only for a painful but intact distal biceps tendon, alongside a loading program.","reviewedOn":"2026-10-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A PubMed search for platelet-rich plasma in distal biceps and biceps tendon rupture returned 18 records and no comparative trial in a torn distal biceps. The only directly relevant report is a single case of platelet-rich plasma given at the time of button repair after a water-skiing injury (O'Leary, Cureus 2025): one patient, no control group, nothing to compare against.","fit":"Not offered. A complete distal biceps rupture is a surgical decision and a time-critical one, because repair is considerably easier in the first few weeks; if that is what has happened you are referred, not injected. A partial tear is a different problem and is assessed on its own terms.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A PubMed search for prolotherapy combined with biceps or bicipital returns no records at all. There is no published prolotherapy literature in this tendon, positive or negative. The comparison that has been done is surgical against non-operative: pooling 62 studies and 2,481 cases, repair gave about 26% more flexion strength, 28% more supination strength and better DASH and Mayo Elbow Performance scores than non-operative management (Looney, J Shoulder Elbow Surg 2022).","fit":"Not offered. A distal biceps rupture is time-critical. The useful thing done here is recognising it and referring you the same week, because the repair becomes harder the longer it is left.","reviewedOn":"2026-09-02"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested hydrodissection for a distal biceps tear. What the search did return is a mimic: a 19-year-old baseball player diagnosed with biceps tendonitis at the front of the elbow, whose pain came from the median nerve where it passes under the lacertus fibrosus (the fibrous band running from the biceps tendon) settled quickly and lastingly after ultrasound-guided hydrodissection of the nerve at that level (Nakagawa, Am J Phys Med Rehabil 2024). That is one case report.","fit":"Not a treatment for the tear itself. Considered where examination points to the median nerve under the lacertus fibrosus rather than to the tendon.","reviewedOn":"2026-09-29"}}},{"slug":"biceps-tendon-tear-shoulder","title":"Biceps Tendon Tear at the Shoulder","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/biceps-tendon-tear-shoulder","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested radial shockwave in a torn long head of biceps. PubMed searches on 25 October 2026 for shockwave or pressure wave with biceps (28 records) and for radial device terms with shoulder or elbow tears, ruptures and repairs (12 records) found trials only in an intact, painful tendon. There, four weekly radial sessions beat sham in 79 people with long-head biceps tenosynovitis, with pain falling from 5.7 to 1.4 out of 10 at twelve months against 6.0 to 5.6 (Liu, Ultrasound Med Biol 2012), and radial shockwave did worse than an ultrasound-guided steroid injection over four weeks in 93 people (Xiao, Am J Transl Res 2021).","fit":"May help the tender muscle around the shoulder, or a biceps tendon that is painful but intact. It does nothing to reattach a torn tendon; the rehabilitation program does the work.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a torn long head of biceps tendon. A PubMed search on 25 October 2026 for shockwave, shock wave, ESWT or pressure wave with biceps (28 records, all read) found trials only in biceps tendinopathy, none in a tear or after a repair; a second search over tendon tears, ruptures and repairs (30 records) and a trial and systematic-review pass found none either. The nearest evidence is for a painful tendon that is still intact: in 144 people with long-head biceps tendinopathy who all did four weeks of rehabilitation, shockwave added 16 points on the Constant-Murley shoulder score against sham at four and six weeks, though the trial does not say which device it used and followed people for six weeks only (Liu, Arch Phys Med Rehabil 2026).","fit":"Not a treatment for the tear. Considered only where the biceps tendon is painful but still intact, or for a coexisting rotator cuff tendinopathy, alongside the rehabilitation program.","reviewedOn":"2026-10-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A PubMed search for platelet-rich plasma in proximal biceps, bicipital and long head of biceps problems returned nine records, none of them a trial in a torn biceps tendon. The nearest are single case reports in tendinopathy of neighbouring structures (Ribeiro Da Silva, Pain Manag 2025) and a 2025 review of non-operative shoulder care that still describes platelet-rich plasma as investigational (Vargas-Figueroa, Cureus 2025). Where it has been given at the time of shoulder tendon surgery, a matched analysis of 646 patients against 3,800 controls found no reduction in revision surgery (Schoch, Orthop J Sports Med 2022).","fit":"Not offered for the tear itself. A ruptured long head of biceps does not reattach, and most people keep their strength and settle over a few months with rehabilitation. The bulge in the arm is cosmetic. If the shoulder stays painful, the useful question is what else in the rotator cuff is involved, not what to inject into the biceps.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A PubMed search for prolotherapy combined with biceps or bicipital returns no records. The technique has never been studied in this tendon. Prolotherapy's evidence base sits in tendon and ligament attachments that are still intact, principally lateral epicondylosis, rotator cuff tendinopathy, plantar fasciitis, sacroiliac pain and osteoarthritis (Hsu, Phys Med Rehabil Clin N Am 2023), and the largest recent randomised trial excluded complete tendon rupture at entry (Lhee, Am J Sports Med 2025).","fit":"Not offered for a ruptured long head of biceps. Once the tendon has retracted most people lose little function and the Popeye bulge is cosmetic; where pain persists it usually comes from the rotator cuff, and that is what gets assessed rather than the biceps injected.","reviewedOn":"2026-09-02"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested hydrodissection for a torn long head of biceps. Hydrodissection, hydrorelease, hydrodilatation and perineural injection searched against biceps tendon, long head of biceps and bicipital terms returned no treatment study of the tear. What the search did return is a caution: an injection through the rotator interval can enter the long head of biceps, and injection into that tendon can rupture it (Sharma, J Ultrason 2021).","fit":"Not a treatment for the tear. Considered only where a separate nerve pain source is found.","reviewedOn":"2026-09-29"}}},{"slug":"bone-stress-injury","title":"Bone Stress Injury (Stress Reaction & Stress Fracture)","region":"General","url":"https://www.backpaindoctor.com.au/conditions/bone-stress-injury","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"The priority","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. The consensus panel recommended structured physical therapy and a stepwise return to sport guided by pain-free activity, bone-loading tests and palpation over the injury, taking account of site, severity and level of sport; it also agreed on load management, adequate energy intake and, for some lower-limb injuries, standard fracture care with immobilisation and partial weight-bearing. It noted that formal return-to-sport guidelines are lacking (Hoenig 2025). Mean return times in a 16-study meta-analysis were 41.7, 70.1, 84.3 and 98.5 days for MRI grades 1 to 4, with more than 90 per cent returning (Hoenig 2021).","fit":"The starting point: confirm the grade and site, reduce load to what the bone tolerates, correct contributors such as energy intake and vitamin D, then progress loading in steps. Time frames are averages, not promises.","reviewedOn":"2026-10-24"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Needling is not among the treatments in the consensus and does not address bone.","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Injection into soft tissue is not among the consensus treatments, and corticosteroid in an unhealed bone injury is not supported by the sources reviewed.","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Vibration-based devices do not reach bone and are not part of the consensus.","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not reach bone","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Radial pressure waves are absorbed in superficial tissue. The consensus panel did not reach agreement on extracorporeal shockwave as a bone stimulation method (Hoenig 2025).","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No consensus","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. The consensus panel did not reach agreement on extracorporeal shockwave, low-intensity pulsed ultrasound or electromagnetic stimulation as treatment for bone stress injury (Hoenig 2025). Case-series evidence in resistant stress fractures is described on the foot and ankle stress fracture page and was not re-reviewed here.","fit":"Not part of the standard care of a bone stress injury. Discussed only for an injury that has not healed on a proper offloading programme, on the understanding that the evidence is limited.","reviewedOn":"2026-10-24"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No consensus","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Electromagnetic stimulation did not reach consensus as a bone stress injury treatment (Hoenig 2025), and no trial in bone stress injury was identified in the sources reviewed.","fit":"Not offered as treatment for the injury itself. At most an adjunct alongside offloading and bone health, after the evidence gap is explained.","reviewedOn":"2026-10-24"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No consensus","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Platelet-rich and bone marrow aspirate injections did not reach consensus as bone stress injury treatment (Hoenig 2025). Higher-risk sites that fail to heal go to orthopaedic assessment.","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No consensus","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Prolotherapy is not mentioned in the consensus, and biological adjuncts did not reach consensus (Hoenig 2025).","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong problem","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Hyaluronic acid is used in arthritic joints, not in bone.","fit":"Not used for bone pain.","reviewedOn":"2026-10-24"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Perineural injection does not treat bone injury and is not part of the consensus.","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the 2025 international Delphi consensus on bone stress injuries (Hoenig, Br J Sports Med; article text without the full statement tables), the 2021 meta-analysis of MRI grade and return to sport (Hoenig, Am J Sports Med) and a 2023 classification commentary (Warden). Australian guidance was not retrieved. Hydrodissection addresses nerve entrapment, not bone injury.","fit":"Not offered for bone stress injury. Healing depends on load management and the factors that caused the injury, and higher-risk sites need orthopaedic input.","reviewedOn":"2026-10-24"}}},{"slug":"bunions","title":"Bunions (Hallux Valgus)","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/bunions","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies in bunions","evidence":"A tested absence. A search on 11 November 2026 (shockwave, shock wave and ESWT with hallux valgus, bunion, ganglion cyst and wrist ganglion: three records) found no study of either form of shockwave as a treatment for a bunion. The only mention is in a surgical series of big-toe joint fusion, where one bone that failed to unite after surgery was treated with shockwave (Waldecker, Z Orthop Unfall 2013). A bunion is a change in the alignment of the bones, which a pressure wave cannot alter.","fit":"Not a treatment for the bunion. Considered only for a separate soft-tissue problem in the foot, such as heel pain.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A tear or structural problem where the decision is a loading or surgical one. No trial evidence for shockwave in the structural lesion itself.","fit":"Considered only for a coexisting tendinopathy, not for the tear.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study of platelet-rich plasma for a bunion was found, and there is no reason to expect an injection to change the alignment of a bone. A PubMed search in October 2026 pairing platelet-rich plasma, platelet concentrate and platelet lysate with hallux valgus, bunion and bunion surgery returned no records. A wider pass on the bare terms PRP, platelet and orthobiologic returned four, none of them a study of PRP for a bunion or for bunion surgery.","fit":"Not offered for the bunion itself. Footwear, load management and, where the deformity is the problem, surgical review are what change it. Considered only for a separate problem in the same foot, such as arthritis of the big toe joint, on that problem's own evidence.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for prolotherapy or dextrose injection in hallux valgus or bunions returns no study of the treatment for this condition. The only hallux valgus result is an anaesthetic nerve-block trial in which dextrose was a diluent.","fit":"Does not correct a bunion: that is a change in bone alignment, and footwear, orthoses and, where the deformity warrants it, surgery are what address the cause. Prolotherapy is offered here and can be discussed for pain around the joint, on the understanding that no study has tested it for this condition.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"bursitis","title":"Bursitis","region":"General","url":"https://www.backpaindoctor.com.au/conditions/bursitis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"The strongest evidence here is what does not work. In a placebo-surgery controlled trial, arthroscopic subacromial decompression gave no benefit over a sham operation or over exercise therapy, at two years, at five, and at ten (Paavola, BMJ 2018; Paavola, Br J Sports Med 2020; Kanto, BMJ 2025). A network meta-analysis of 54 trials and 3,893 patients found shoulder-specific exercise reduced pain out to 52 weeks, and that adding injections, manual therapy or electrotherapy to it added little (Silveira, PLoS One 2024).","fit":"Loading the shoulder properly is the treatment. An injection is occasionally used to settle pain enough to start, which is a different claim from treating the problem.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Bursal and sheath targets are small, often deep, and poorly identified by surface landmarks; ultrasound guidance improved accuracy across shoulder girdle targets and improved efficacy where the target was a sheath rather than a large space (Aly, Br J Sports Med 2014).","fit":"Where an inflamed bursa is the identified target, this is a reasonable step, with the number of injections kept low. See the note on cortisone.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study at these bursae","evidence":"Searched 21 October 2026: shockwave, shock wave or ESWT with bursitis, bursa or bursopathy (42 records), a second pass naming the elbow, kneecap, heel, ischial, shoulder and trochanteric bursae (30), and a trial and review pass (7); 49 records read. None tests shockwave of either device for bursitis at the tip of the elbow or the front of the kneecap. The bursitis trials that exist are at other sites and used a focused device or do not name one: pes anserine bursitis at the inner knee (Khosrawi, Adv Biomed Res 2017) and bursitis under the shoulder blade (Acar, J Orthop Surg 2017, device not stated). The outer hip and the pes anserine have their own pages. The earlier line saying the trials here used focused devices was not accurate for this page.","fit":"Not part of managing a swollen elbow or kneecap bursa, where infection and gout are excluded first and padding, drainage or an injection are the usual steps. Could be considered for a bursa that stays painful after those, with the lack of studies explained.","reviewedOn":"2026-10-21"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Studied at other bursae only","evidence":"Searched 21 October 2026: shockwave, shock wave or ESWT with bursitis, bursa or bursopathy (42 records), a second pass naming the elbow, kneecap, heel, ischial, shoulder and trochanteric bursae (30), and a trial and review pass (7); 49 records read. No study tests focused shockwave for bursitis at the tip of the elbow or the front of the kneecap. At other bursae the results are mixed: in 40 people with pes anserine bursitis at the inner knee, focused shockwave beat sham at three and eight weeks (Khosrawi, Adv Biomed Res 2017), but in 180 people it did worse than a cortisone injection at eight weeks (Gouda, Adv Orthop 2023); in 43 people with bursitis under the shoulder blade, three sessions did better than a cortisone injection at three and six months (Acar, J Orthop Surg 2017; device not stated). Those results belong to those bursae and are not evidence for the ones this page is mainly about.","fit":"Not a first step. For a non-infected bursa that stays painful after padding, rest from pressure and, where appropriate, drainage or an injection, it can be discussed, with the caveat that the trials were done at other bursae.","reviewedOn":"2026-10-21"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"No better than placebo at the hip","evidence":"Trialled at three bursae, with mostly disappointing results. At the outer hip, the one double-blind placebo-controlled trial injected PRP into the trochanteric bursa and gluteal tendon in 79 people whose pain had not settled: both groups improved, there was no difference between PRP and placebo at any point to twelve months, and the authors do not support its routine use (Atchia, J Bone Joint Surg Am 2025). An earlier pilot in 18 people found no difference from cortisone, with only the cortisone group improving over 60 days (Ribeiro, Acta Ortop Bras 2016). At the inner knee, in 180 people with pes anserine bursitis a cortisone injection gave better pain and function scores than PRP at one and eight weeks, with no later follow-up (Gouda, Adv Orthop 2023). At the shoulder, in 60 people with impingement given one ultrasound-guided injection into the subacromial bursa, cortisone gave better pain relief at one week and PRP better shoulder movement over the longer term, with follow-up to a year (Hewavithana, Skeletal Radiol 2024). A search of 76 records found no clinical study of PRP injected for bursitis at the point of the elbow, the front of the knee, the heel, the front of the hip or the sitting bone.","fit":"Not a first choice for an inflamed bursa. Most settle with load management and a rehabilitation program, and where an injection is needed to calm things enough to rehabilitate, cortisone has the better short-term evidence. Where the real problem is the tendon beside the bursa, as it often is at the outer hip, the tendon page is the relevant one. PRP is discussed only with these results stated.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Trials disagree; shoulder and knee only","evidence":"Tested only at the shoulder and the inner knee, with conflicting results. At the shoulder (subacromial-subdeltoid) bursa, three ultrasound-guided injections of 15% dextrose did no better than saline at three months (Chang, Arch Phys Med Rehabil 2021, 50 people); one injection of 20% dextrose added to a 12-week exercise program did better than saline plus exercise on shoulder pain and disability, though the 6.4-point SPADI difference at 13 weeks was below the 8 points the authors set as clinically important (Hsieh, Arch Phys Med Rehabil 2026, a pilot of 46 people with pain of under three months); and cortisone beat dextrose on pain at two and six weeks and on disability to twelve weeks in chronic subacromial bursitis (Lin, Am J Phys Med Rehabil 2023, 54 people). A pooled analysis of the shoulder trials found dextrose may have little to no benefit over saline, at very low certainty (Zerzan, PM R 2026). At the pes anserine bursa of the inner knee, 20% dextrose outlasted cortisone at eight weeks in a three-arm trial of 72 people with no placebo group (Babaei-Ghazani, Am J Phys Med Rehabil 2024). A PubMed search on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with bursitis, bursa or bursal, and with the trochanteric, olecranon, prepatellar, retrocalcaneal and pes anserine sites) found no trial or case series at the elbow, the front of the kneecap, the outer hip or the heel.","fit":"Not a first-line option for a bursal problem, and never used for an infected bursa. Where it is considered, it is after load management, padding and a guided cortisone injection have been discussed, with the conflicting trial results stated, and it sits alongside the rehabilitation program.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Trialled at the shoulder, but not offered here. In a double-blind trial of 186 people with long-standing subacromial bursitis, three hyaluronic acid injections into the bursa lowered pain on activity at eight weeks a little more than saline (3.65 against 4.71 out of 10) without improving disability scores, and cortisone did better than both (Hsieh, Clin Rehabil 2021). A pilot of 22 people given cortisone plus hyaluronic acid into the bursa under the shoulder blade improved from 7.8 to 2.2 on pain at three months, with no comparison group and cortisone in every injection (Chang, Arch Phys Med Rehabil 2009). PubMed searches found no human study at the elbow or kneecap bursae, and at the outer hip a network meta-analysis found hyaluronic acid no better than no treatment (Gazendam, Clin J Sport Med 2021). An injection into a bursa is a different procedure from the joint injection in this row.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and a bursa sits outside the joint. Load modification and rehabilitation remain the centre of treatment.","reviewedOn":"2026-11-09"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Named only as a direction for future research. A narrative review of injection treatments for subacromial bursitis covers corticosteroid, hyaluronic acid, anti-inflammatories, hypertonic glucose and platelet-rich plasma, and lists integrating advanced ultrasound techniques including hydrodissection among the things future research should do, not among the treatments with evidence behind them now (Ding, Ann Med 2026). No trial of hydrodissection for bursitis was found.","fit":"Only where a nerve is separately implicated. The bursa itself is treated by the options higher up this page.","reviewedOn":"2026-09-08"}}},{"slug":"calf-strain","title":"Calf Strain","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/calf-strain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, trigger point, lignocaine or local anaesthetic injection with calf or gastrocnemius strain, tennis leg, muscle strain or muscle injury, 18 records; and a randomised-trial and systematic-review pass, 12 records). No study of trigger point injection or wet needling after a calf strain was found. The only calf record was acupuncture for cramp on the sideline in a descriptive case report, which is a different problem (Tang, Med Acupunct 2023); the remaining records were animal studies or other body regions.","fit":"Not part of early care for a fresh strain, which is graded loading. Considered later only where a tender muscle band persists and is holding back the return to running.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"Searched 8 November 2026 (PubMed: calf muscle, tennis leg, gastrocnemius or soleus, muscle haematoma or contusion with ultrasound-guided injection, aspiration or drainage, 16 records, most of them botulinum toxin for spasticity; the muscle-strain corticosteroid search, 23 records; and a randomised-trial and systematic-review pass, which found no trial). No study has tested a corticosteroid or anaesthetic injection in a calf strain. The only treatment record is a single case of a giant clotted haematoma after a medial gastrocnemius tear, drained by repeated ultrasound-guided punctures with urokinase injected into the cavity (Bernabéu García, Rehabilitacion 2023). Injection series in professional footballers report hamstring and quadriceps strains but not the calf (Levine, Am J Sports Med 2000; Drakos, HSS J 2014), and local anaesthetic injected into muscle damages muscle fibres (Reurink, Sports Med 2014).","fit":"Not a treatment for the strain itself, which is graded calf loading. A guided procedure is considered only for a complication found on ultrasound, such as a large collection of blood that is holding back the rehabilitation program.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Tested in the hamstring, not here","evidence":"Searching shockwave, shock wave, ESWT and radial shockwave against calf strain, gastrocnemius strain, tennis leg and soleus injury returns three records, and not one is a treatment study of a torn calf muscle: two are about reducing calf muscle tone after stroke (Lee, PM R 2019; Sohn, Ann Rehabil Med 2011) and the third is a surgical technique paper. The nearest real evidence is in a different muscle: a sham-controlled trial of 36 athletes with an acute hamstring tear, where radial shockwave added to rehabilitation shortened return to sport by about three days (Crupnik, Br Med Bull 2025). Whether that carries across to the calf has not been tested.","fit":"Not part of early management of a torn calf muscle. The graded loading programme and the return-to-running progression are what protect against this happening again. Considered later, if pain persists well past the expected healing time and tender muscle and fascia are what is left.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Case reports only","evidence":"Searched 21 October 2026: shockwave terms with muscle injury, strain, tear, calf strain or tennis leg in humans (25 records) and a trial and review pass (18). No trial has tested focused shockwave in a torn calf muscle. One case report describes focused electromagnetic shockwave over three weeks for a ruptured plantaris muscle with a large haematoma, which resolved without complications (Fuentes, Rehabilitacion 2019). A second treated a firm haematoma in the gastrocnemius two weeks after a slip in a 65-year-old with one session: pain fell from 7 to 3 out of 10 straight away and the swelling had settled by three months; the paper does not state the device type (Jung, World J Clin Cases 2020). The only controlled trial in an acute muscle injury used a radial device, in the hamstring (Crupnik, Br Med Bull 2025).","fit":"Not part of early management of a torn calf; the graded loading programme and return-to-running progression come first. May be considered later for a painful haematoma that has not settled, on the strength of case reports.","reviewedOn":"2026-10-21"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not tested in a torn calf. A search for PRP in calf strain, tennis leg and gastrocnemius or soleus injury returned six records, and none is a clinical study of a calf tear. The one review of calf strain in athletes lists PRP among the treatments that still need to be studied (Meek, JBJS Rev 2022). In the laboratory, PRP injected into a bruised rat calf muscle made no difference to strength or healing (Delos, Am J Sports Med 2014). The muscle-injury trials in people are in the hamstring and thigh, and they disagree: pooled, return to sport was about a week sooner across nine randomised trials and 474 people, on limited-quality evidence (Bensa, Sports Med Open 2026), while the largest double-blind trial found no benefit over a placebo injection in 80 athletes (Reurink, N Engl J Med 2014; Br J Sports Med 2015). In a double-blind trial of 71 people with a leg muscle tear and a collection of blood that was drained, recovery took 32 days with PRP and 38 with a dummy procedure, a difference that could have been chance (Martinez-Zapata, Blood Transfus 2016). None of that is a result in the calf.","fit":"Not offered for a calf strain. These tears are monitored and rehabilitated. A torn muscle has already bled into the injury, so an injection of concentrated platelets is unlikely to add to what is there. Graded loading and a staged return to running and sport are what change the outcome, and no study has tested an injection in a torn calf.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No human trial has tested prolotherapy in acute calf strain. Reviews of orthobiologics for muscle injury name prolotherapy but find no high-level clinical evidence behind it (Droz, Clin Sports Med 2024; Stephens, Phys Med Rehabil Clin N Am 2023), and the animal work disagrees: improved repair in a mouse model (Tsai, Int J Med Sci 2018) against excess connective tissue and necrosis in a rat model (Kunduracioglu, Neurosciences 2006). The published calf reports are single cases of tendon rather than muscle injury (Chang, Med Ultrason 2020).","fit":"Not used for the acute tear. Progressive calf loading is the treatment. Injection is considered only for a persistent tendon attachment problem well after the strain has healed.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Untested in people. A search pairing hyaluronic acid with muscle injury, muscle strain, muscle tear, calf strain, hamstring injury, tennis leg and contusion terms returned 39 records. Twenty-five were animal, hydrogel, scaffold or spinal cord studies, and none of the other 14 was a trial of hyaluronic acid for a muscle injury. The nearest were a single case of a torn adductor muscle given hyaluronic acid together with platelet-rich plasma (Giannini, J Sports Med Phys Fitness 2023) and a review of injections in professional footballers, which gives hyaluronic acid a role only for cartilage injury (Jader, Int Orthop 2024). No study has injected it for a calf strain.","fit":"Not offered for an acute muscle injury. Graded loading and a staged return to sport is what changes the outcome.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested small dextrose injections under the skin for a calf strain. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against calf, gastrocnemius, muscle strain and muscle tear returns no treatment study of a torn calf muscle. Two reports sit nearby and both are different procedures. One is a single case of an ultrasound-guided dextrose injection for a sprain of the outer gastrocnemius tendon behind the knee, after which the pain was completely relieved (Chang, Med Ultrason 2020): a tendon rather than the muscle belly, with no comparison. The other is the reason this row is listed at all. A 34-year-old triathlete with recurrent calf strains and three months of numbness over the outer foot and ankle turned out to have the sural nerve trapped in scar, with nothing wrong in the calf muscles on ultrasound, and had complete relief and a full return to competition after the nerve was freed with an ultrasound-guided fluid injection (Fader, Orthopedics 2015). That is hydrodissection, which has its own row on this page, and it is one case.","fit":"Not part of treating a calf strain. Progressive calf loading is the treatment. Considered only if numbness, burning or tender, hypersensitive skin over the outer calf or ankle persists after the strain has healed, which points to a skin nerve rather than the muscle.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"Searched 6 November 2026 (PubMed: the same 12-record search as for ankle sprain, which included calf strain, muscle strain and gastrocnemius; the randomised-trial and systematic-review pass found nothing at the calf). No study has tested hydrodissection for a calf strain. One case report describes a 34-year-old triathlete with recurrent calf strains and three months of numbness over the outer foot and ankle, whose ultrasound showed the sural nerve swollen and caught in scar with nothing wrong in the calf muscles; ultrasound-guided hydrodissection of the nerve gave complete relief and a full return to competition (Fader, Orthopedics 2015). That is one case, with no comparison.","fit":"Not part of treating a calf strain; progressive calf loading is the treatment. Considered only if numbness, burning or nerve pain over the outer calf or ankle persists after the strain has healed.","reviewedOn":"2026-11-06"}}},{"slug":"carpal-tunnel-syndrome","title":"Carpal Tunnel Syndrome","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/carpal-tunnel-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Conservative care comes first, and it holds up well. A network meta-analysis of 49 randomised trials and 3,323 patients with carpal tunnel syndrome ranked manual therapy first for both short- and medium-term pain relief, ahead of every injection option including corticosteroid (Chen, Arch Phys Med Rehabil 2025).","fit":"Load management, splinting where it fits, and addressing what is irritating the nerve come before any injection. Where the nerve is being compressed structurally and function is being lost, surgical review is the right conversation rather than more conservative care.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Dry needling trials, no sham","evidence":"Three randomised trials have tested needling of the forearm and thumb muscles in carpal tunnel syndrome, all with a needle and no injectate, and none against a true sham. In 30 manual workers, two sessions of dry needling to the thenar muscles improved symptom scores and grip and pinch strength at two weeks compared with a waiting list, with motor nerve conduction unchanged (Rezazadeh, Physiother Theory Pract 2022). In 86 wrists already recommended for surgery, six weekly sessions of dry needling reduced the proportion still recommended for surgery at 12 weeks by 62% (relative risk 0.38, 95% CI 0.20 to 0.72) against staying on the waiting list, without changing nerve conduction or ultrasound findings (Gascon-Garcia, J Bodyw Mov Ther 2025). In 75 people, seven weekly sessions of deep needling into the pronator teres muscle improved pain, grip and the clinical nerve tests more than a shallow needle at an acupuncture point, though the size of the median nerve fell similarly in both groups; the trial was registered after it began (Kvist, J Bodyw Mov Ther 2021). A 2025 review judged the needling evidence in carpal tunnel syndrome insufficient and at high risk of bias (Zhu, J Pain Res 2025). The injected form of this row has one case report, in a woman with median and ulnar nerve entrapment and coexisting muscle pain whose symptoms settled over eight sessions of trigger point injection (Medina, Pain Med Case Rep 2026); a November 2026 search found no trial of it.","fit":"Directed at tender bands in the thumb and forearm muscles that can mimic or add to the nerve symptoms, and used to make hand and forearm loading more comfortable, not to replace it. It does not release the nerve, and the trials behind it used a needle without an injectate.","reviewedOn":"2026-11-05"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"At the carpal tunnel, ultrasound guidance itself has been tested, not just assumed. A meta-analysis of nine randomised trials in 469 people (596 hands) found guided corticosteroid injection better than a landmark-guided one for symptom severity (SMD -0.69, 95% CI -1.08 to -0.31) and function (-0.23, -0.39 to -0.07), with roughly a third the rate of adverse events (RR 0.34, 0.22 to 0.52) (Wang, Clin Rehabil 2021). What goes in the needle is a separate question: in a double-blind randomised trial of 36 people, a single ultrasound-guided injection of 5% dextrose and one of methylprednisolone both improved pain, symptom scores and median nerve cross-sectional area over three months, with no difference between them (Nasiri, Neurol Res 2023).","fit":"Useful for short-term relief, and to confirm the diagnosis when the picture is not clear-cut. It does not decompress the nerve, so where strength is being lost or symptoms keep returning, surgical review is the right conversation. Guidance is the part with the clearest evidence here.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Short-term evidence","evidence":"Radial shockwave has beaten a sham treatment in carpal tunnel syndrome in two independent double-blind trials. In Taiwan, 34 people (40 wrists) had three sessions of radial shockwave or sham, all with a night splint, and the shockwave group had less pain, better Boston questionnaire scores and a smaller swollen median nerve on ultrasound from one to twelve weeks (Wu, J Orthop Res 2016); the same group found three sessions beat sham to at least 14 weeks in 90 wrists, but a single session did no better than sham (Ke, Sci Rep 2016). In Turkey, 45 people (66 wrists) with mild to moderate disease had radial shockwave or sham alongside splints and nerve-gliding exercises; at one month pain on a 10-point scale was 3.5 against 6.6, with better nerve conduction (Menekseoglu, Rev Assoc Med Bras 2023). A meta-analysis of ten trials (433 people, 501 wrists) found shockwave improved pain (mean difference -0.60 points, 95% CI -1.16 to -0.05), symptoms and hand function, and on subgroup analysis the radial device was effective and the focused device was not (Xie, Disabil Rehabil 2022). Not every trial agrees, and the benefit is mostly short term. A meta-analysis of seven trials (376 people) that compared shockwave plus a night splint with the splint alone found an advantage at four weeks that was no longer significant at 8 to 14 weeks (Chen, Medicina 2022). Radial shockwave added nothing to a splint in a 40-person trial (Raissi, Ultrasound Med Biol 2017), a single session added nothing to a PRP injection against sham (Chang, Pain Med 2020), and in a 72-person trial a steroid injection did better than radial shockwave, which showed no clear advantage over a splint alone (Öztürk Durmaz, Am J Phys Med Rehabil 2022). The overall certainty is rated low (Zhang, J Clin Med 2023). Side effects reported are minor: brief tingling or soreness.","fit":"A reasonable option in mild to moderate carpal tunnel syndrome, usually three weekly sessions alongside a night splint and nerve-gliding exercises, particularly if you would rather avoid an injection. Expect a modest improvement over weeks to about three months; one session is not enough, and what happens beyond six months is not well studied. Progressive weakness or wasting of the thumb muscles needs a surgical opinion rather than more conservative treatment.","reviewedOn":"2026-10-28"},"focusedShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Focused shockwave has been tested in carpal tunnel syndrome, and the trials disagree. The only sham-controlled trial of a clearly focused device, a 30-person pilot in Vienna with 20 people analysed, found pain improved within the shockwave group, but the full report shows no significant difference from sham on pain or on any outcome once multiple testing was allowed for (Gesslbauer, Wien Klin Wochenschr 2021). Against conservative care alone (splint, exercises) without a sham, focused shockwave did better in 60 people with moderate disease at three and six months (Vahdatpour, Adv Biomed Res 2016) and in 24 people with moderate to severe disease at three and six weeks (Vongvachvasin, J Rehabil Med 2024). Against active treatments the results are split: no better than a steroid injection on symptoms, with nerve conduction favouring the injection (Seok, Am J Phys Med Rehabil 2013), better than therapeutic ultrasound for pain at 12 weeks (Paoloni, Eur J Phys Rehabil Med 2015), and no better than a nutritional supplement (Notarnicola, Int J Immunopathol Pharmacol 2015). On meta-analysis the focused device was not significantly effective in one review (Xie, Disabil Rehabil 2022) and effective in another rated low certainty (Zhang, J Clin Med 2023). Searched 28 October 2026: PubMed, shockwave terms with carpal tunnel, randomised-trial and systematic-review passes.","fit":"Not the shockwave device of first choice here: the radial device has the stronger controlled evidence in this condition. Focused treatment may be considered in mild to moderate cases where someone wants to avoid or delay an injection or surgery, alongside a night splint and nerve-gliding exercises.","reviewedOn":"2026-10-28"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Carpal tunnel is the one place platelet-rich plasma separates from placebo in a systematic review. Across 33 randomised trials in six conditions it made no difference in lateral epicondylitis, plantar fasciitis, Achilles, rotator cuff or patellar tendinopathy, but in carpal tunnel, pain scores at 3 and 6 months and symptom severity at 1, 3 and 6 months were better than controls (Masiello, Blood Transfus 2022), with the certainty graded low. A network meta-analysis of 49 trials and 3,323 patients ranked manual therapy first, with 5% glucose and platelet-rich plasma close behind (Chen, Arch Phys Med Rehabil 2025).","fit":"A reasonable option, but not the first one. In that same network analysis 5% glucose perineural injection ranked above it, costs less and is the treatment this practice has the most evidence for, so it is offered first, and platelet-rich plasma is discussed if that has not worked.","reviewedOn":"2026-09-06"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"The dextrose evidence in carpal tunnel is for a different injection. In a network meta-analysis of 49 randomised trials and 3,323 patients, 5% glucose in water ranked just behind manual therapy for pain relief (Chen, Arch Phys Med Rehabil 2025), and in a network meta-analysis of nine hydrodissection studies in 458 patients it ranked top for function at 4, 12 and 24 weeks (Lee, Yonsei Med J 2025). That is dilute glucose placed around the nerve: the perineural and hydrodissection rows on this page. No trial of prolotherapy in its usual sense, stronger dextrose at ligament and tendon attachments, was found in carpal tunnel syndrome.","fit":"Not offered for this. The problem at the wrist is a compressed nerve rather than a lax ligament, and the dextrose treatment that does help here is the dilute perineural one described elsewhere on this page.","reviewedOn":"2026-09-03"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"There is no joint here to viscosupplement, but hyaluronic acid itself has been tested at the carpal tunnel, as the fluid used to hydrodissect around the median nerve rather than as a joint injection. In a double-blind randomised trial of 35 people with mild to moderate carpal tunnel syndrome (32 completing) it beat salt water on symptom and pain scores only at two weeks, with no advantage at one, three or six months (Su, Pain Med 2021), and in a comparison of four injection fluids in 61 severe cases it trailed dextrose and platelet-rich plasma on Boston questionnaire scores at one and six months (Wu, Biomed Res Int 2022). A hyaluronic acid anti-adhesion gel used at carpal tunnel release surgery gave no symptomatic or functional advantage in 200 patients at one year (Bilge, Acta Chir Orthop Traumatol Cech 2017). That evidence belongs with hydrodissection, not with joint viscosupplementation.","fit":"Not offered as a joint injection for this problem. Where the aim is fluid placed around the nerve, that is discussed under hydrodissection.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"The strongest evidence for any injection offered here. In mild to moderate carpal tunnel syndrome, ultrasound-guided perineural 5% dextrose beat saline for pain, disability, nerve conduction and median nerve cross-sectional area at 1, 3 and 6 months (Wu, Mayo Clin Proc 2017), and beat corticosteroid from month 4 to month 6 (Wu, Ann Neurol 2018). A meta-analysis of 5 studies and 212 patients found dextrose better than corticosteroid for functional status within 3 months with far fewer adverse events (risk ratio 0.13) (Oh, Arch Phys Med Rehabil 2024). A follow-up of 185 patients reported 88.6% still reporting an effective outcome 1 to 3 years later, after an average of 2.2 injections (Li, Rheumatology 2020).","fit":"A genuine alternative to corticosteroid or surgery in mild to moderate disease. Severe compression, wasting or weakness still needs a surgical opinion.","reviewedOn":"2026-08-30"},"hydrodissection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"The strongest evidence for any injection offered here. In mild to moderate carpal tunnel syndrome, ultrasound-guided perineural 5% dextrose beat saline for pain, disability, nerve conduction and median nerve cross-sectional area at 1, 3 and 6 months (Wu, Mayo Clin Proc 2017), and beat corticosteroid from month 4 to month 6 (Wu, Ann Neurol 2018). A meta-analysis of 5 studies and 212 patients found dextrose better than corticosteroid for functional status within 3 months with far fewer adverse events (risk ratio 0.13) (Oh, Arch Phys Med Rehabil 2024). A follow-up of 185 patients reported 88.6% still reporting an effective outcome 1 to 3 years later, after an average of 2.2 injections (Li, Rheumatology 2020).","fit":"A genuine alternative to corticosteroid or surgery in mild to moderate disease. Severe compression, wasting or weakness still needs a surgical opinion.","reviewedOn":"2026-08-30"}}},{"slug":"cauda-equina-syndrome","title":"Cauda Equina Syndrome","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/cauda-equina-syndrome","pairings":{"rehab":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Emergency, not a clinic pathway","evidence":"Cauda equina syndrome is treated by urgent surgical decompression, and the outcome depends on how quickly that happens. No rehabilitation programme, however good, changes that, and time spent arranging one is time lost.","fit":"Same-day emergency assessment, not an appointment here. Rehabilitation has a place only after decompression, directed by the treating surgical team.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Cauda equina syndrome is treated by urgent surgical decompression. There is no role for any non-surgical procedural treatment, and delay to decompression worsens the outcome.","fit":"Cauda equina syndrome is a surgical emergency. Nothing on this list is part of its management, and any suspicion of it means same-day emergency assessment, not an appointment here.","reviewedOn":"2026-08-30"}}},{"slug":"cervical-radiculopathy","title":"Cervical Radiculopathy","region":"Neck","url":"https://www.backpaindoctor.com.au/conditions/cervical-radiculopathy","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"A Cochrane review of injection therapies for mechanical neck disorders, with or without radicular findings, found intramuscular lignocaine into myofascial trigger points better than placebo in the short term (SMD -1.36, 95% CI -1.93 to -0.80; NNT 3) and better than dry needling, while botulinum toxin was no better than saline across five trials (Peloso, Cochrane Database Syst Rev 2007). Active trigger points were present in 51% of 244 people with cervical radiculopathy and in none of 122 healthy controls, and halved after two weeks of conservative treatment (Sari, Eur J Phys Rehabil Med 2012). Held here rather than rated higher because the pooled effect rests on two small short-term trials of local anaesthetic, not the dilute glucose used in this clinic.","fit":"Directed at levator scapulae, splenius capitis, the rhomboids or upper trapezius where examination finds a tender band reproducing part of your pain. It does not decompress a nerve root, and the arm symptoms are managed on their own terms.","reviewedOn":"2026-09-07"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Conflicting evidence","evidence":"The syntheses do not agree. The American Academy of Neurology review of 90 randomised trials pooled cervical with lumbar radiculopathy and found epidural corticosteroid probably reduces short-term pain (success rate difference -24.0%, 95% CI -34.9 to -12.6, about one extra person helped for every four treated) and short-term disability (-16.0%, -26.6 to -5), with insufficient evidence on long-term pain (Armon, Neurology 2025). A review of neck disorders describes the evidence for epidural corticosteroid in cervical radiculopathy as conflicting, and notes how few trials exist for any neck treatment at all (Cohen, Mayo Clin Proc 2015). These injections are placed under X-ray or CT. Ultrasound has been shown accurate at the cervical facet joints: 92% to 98% of 60 joints were confirmed intra-articular on contrast arthrography (Bodor, Spine J 2022). But a facet joint is not a nerve root, and that accuracy does not transfer.","fit":"Not performed here. Where arm pain is severe or is not settling, this is a referral conversation about an X-ray or CT-guided cervical injection, weighed against the fact that most cervical radiculopathy settles with time and graded loading. New or progressive weakness, clumsiness of the hands or change in walking needs assessment rather than an injection. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the nerve root","evidence":"A tested absence. On 11 November 2026 shockwave, shock wave and ESWT crossed with cervical radiculopathy, cervical radicular pain and cervical disc herniation returned three records, none of them about the neck: they were case reports of low back and pelvic pain. A second search using radial and pressure-wave wording with radiculopathy, stenosis and sciatica in the neck or low back returned one record, a lumbar study (Rashad, Ann Rehabil Med 2025). Neither search found a trial of radial shockwave in people with a compressed nerve root in the neck.","fit":"Not a treatment for a compressed nerve root. Considered only for a separate tender neck or shoulder muscle, once the arm symptoms are being managed on their own terms; new weakness needs assessment first.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the nerve root","evidence":"A tested absence: shockwave, shock wave, ESWT and pressure wave crossed with cervical radiculopathy returned no clinical record on 19 October 2026, and the wider search of radiculopathy and disc herniation (ten records) contained none in the neck. The neck-muscle trials of focused shockwave (Senlikci, Lasers Med Sci 2025; Vasvit, Complement Ther Med 2025) did not enrol people with nerve-root symptoms.","fit":"Not a treatment for a compressed nerve root. Considered only for a separate tender neck or shoulder muscle, once the arm symptoms are being managed on their own terms; new weakness needs assessment first.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"One small study exists. Ninety patients with cervical radiculopathy were allocated across six treatments; the group given four periradicular platelet-rich plasma injections had the largest falls in pain (70.6%) and neck disability (56.6%) at two-month follow-up, with a 25% reduction in nerve root cross-sectional area (Godek, Ortop Traumatol Rehabil 2020). It was unblinded, had no placebo group, and had roughly fifteen people in each arm.","fit":"Not done in this clinic. An injection at a cervical nerve root should be performed under CT guidance, so where it is warranted you are referred to a radiologist to perform it that way. Most nerve root symptoms in the neck settle over time with rehabilitation, so this is a conversation for pain that has not followed that course, and the single unblinded study behind it is part of that conversation.","reviewedOn":"2026-09-03"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for prolotherapy or dextrose injection in cervical radiculopathy returns no trial. The published material is narrative reviews and single cases. A practitioner survey of spinal prolotherapy recorded 472 adverse events including 54 nerve injuries (Dagenais, Arch Phys Med Rehabil 2006), and one report describes cervical spinal cord injury following upper cervical prolotherapy (Yun, Ann Rehabil Med 2011).","fit":"Not offered for arm pain coming from a nerve root. Reserved for a separately identified neck ligament or attachment problem once the radicular symptoms have settled.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Searching hyaluronic acid, hyaluronate and viscosupplementation against cervical radiculopathy, cervical disc, cervical epidural and brachialgia returns no records at all. The lumbar work does not carry across: the one randomised trial there added hyaluronic acid to a nerve root block rather than injecting a joint, and its only advantage was less pain in the first fortnight after the procedure (Ko, Spine J 2018).","fit":"Not offered for this problem. A pinched nerve root in the neck is not treated by lubricating a joint.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. No study has tested dextrose injected just under the skin in cervical radiculopathy. The only record near it is a case series of subcutaneous dextrose over muscle attachments in which one person had shoulder weakness six years after a cervical radiculopathy, and the outcome measured was strength, not pain (Meyers, Cureus 2025). The cervical dextrose studies inject at the nerve root itself, which is the hydrodissection row on this page (Lin, Sci Rep 2023).","fit":"Not a treatment for a compressed cervical nerve root. Considered only where a separate tender superficial nerve in the neck, shoulder or arm is also part of the picture.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Retrospective studies only","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. Two retrospective studies and two case reports, no randomised trial. In 74 consecutive people with arm pain from a cervical nerve root, ultrasound-guided hydrodissection of the root with 10 mL of 5% dextrose, 0.2% lignocaine and 4 mg betamethasone reduced pain at one week, one month, three months and final follow-up (3 to 20 months), equally in mild and in moderate-to-severe narrowing of the exit canal; four (5.4%) had brief dizziness (Lin, Sci Rep 2023). The mixture contained cortisone, so the result cannot be put down to the fluid alone. In a multicentre retrospective comparison of 199 people with cervical spondylotic radiculopathy, adding ultrasound-guided hydrodissection of the brachial plexus in the scalene space to acupotomy gave lower neck disability and pain scores at 4, 8 and 16 weeks than acupotomy alone, with no nerve injury or infection; patients were not randomised and the injectate is not stated (Shang, Front Aging Neurosci 2026). Two single cases describe dextrose around a cervical root (Wu, Cureus 2024; Pan, Pain Med Case Rep 2025). The nearest randomised evidence is indirect: in 40 people with cervical radiculopathy, a nerve-root injection of saline with local anaesthetic did as well as one with cortisone at three weeks (Anderberg, Eur Spine J 2006).","fit":"Discussed alongside a neck and nerve-mobility rehabilitation program where arm pain from a cervical nerve root has not settled, as an alternative to a cortisone nerve-root injection or a step before a surgical opinion. Progressive weakness or any sign of spinal cord compression needs imaging and a surgical opinion first.","reviewedOn":"2026-10-29"}}},{"slug":"cervical-spondylosis","title":"Cervical Spondylosis (Neck Arthritis)","region":"Neck","url":"https://www.backpaindoctor.com.au/conditions/cervical-spondylosis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Studied in muscular neck pain only","evidence":"Searched 1 November 2026 (PubMed: trigger point, myofascial or wet needling injection with cervical spondylosis, degenerative or arthritic neck, or cervicogenic headache; 16 records, plus a randomised-trial and systematic-review pass). None studied neck spondylosis. The nearest evidence is in muscular (myofascial) neck pain, where a meta-analysis of 15 trials found local anaesthetic injection a little better than placebo, 0.8 points out of 10, on low-quality evidence (Nouged, J Oral Facial Pain Headache 2019), and a systematic review of mechanical neck disorders found the effect of local anaesthetic injected into muscle unconfirmed (Gross, Open Orthop J 2013). That evidence comes from a different condition and does not show benefit in a degenerative neck.","fit":"Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.","reviewedOn":"2026-11-01"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a specific target","evidence":"A corticosteroid injection into the small joints of the neck has been tested against a comparison, and it did not outperform local anaesthetic, although that trial was in neck pain after whiplash rather than in wear-and-tear arthritis. In 41 people with painful cervical facet joints, betamethasone into the joint was no better than bupivacaine alone: pain returned to half its former level after a median of 3 days against 3.5 (Barnsley, N Engl J Med 1994). In 40 people with facet-joint neck pain, corticosteroid and platelet-rich plasma injected into the joint under X-ray guidance had similar effects over six months, with pain lower at one month (Allison, Reg Anesth Pain Med 2026). Blocking the small nerves that supply the joint gave at least 50% pain relief at two years in 85% of those given anaesthetic alone and 93% of those given anaesthetic with corticosteroid among 120 people, but it took an average of 5.7 treatments and there was no placebo group (Manchikanti, Pain Physician 2010). Almost all of this was done under X-ray rather than ultrasound. Ultrasound can reach these targets: across 224 procedures on the nerves to the facet joints, technical success was 90.4% with ultrasound against 90.8% with X-ray and pain and disability to twelve months were no different, though the comparison was retrospective and did not formally establish equivalence (Kucukbingoz, Diagnostics 2026), and among 500 people having 2,308 ultrasound-guided blocks there were three minor complications (Etheridge, Reg Anesth Pain Med 2025).","fit":"Considered only where examination points to one identifiable joint or nerve and pain is blocking rehabilitation, and then mainly to confirm the source. Wear-and-tear changes in the neck on a scan are near universal and often unrelated to the pain, so the scan alone is not a reason to inject. See the note on cortisone.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One trial, device not stated","evidence":"In cervical spondylosis itself, one randomised trial of 60 people with calcification of the ligament at the back of the neck found that adding shockwave (0.27 mJ/mm2) to heat and traction gave more pain relief, better movement and lower neck disability than heat and traction alone, to three months; there was no sham and the abstract does not say whether the device was radial or focused (Lin, Kaohsiung J Med Sci 2015). The sham-controlled spondylosis trial used a focused device (Li, Medicine 2024). For the muscle pain that often comes with spondylosis, radial shockwave beat sham in a 57-person upper trapezius trial (Senlikci, Lasers Med Sci 2025), and a meta-analysis of 10 trials found shockwave better than sham but NO better than dry needling, trigger point injection or laser (Zhang, Arch Phys Med Rehabil 2020).","fit":"Directed at tender neck and shoulder muscle and the ligament at the back of the neck, alongside your movement and strengthening programme; not at the disc, joint or nerve. Arm weakness, numbness or any sign of spinal cord involvement is assessed first.","reviewedOn":"2026-10-19"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One large sham-controlled trial","evidence":"Focused shockwave has been tested in cervical spondylosis against a dummy treatment. In a multicentre randomised trial of 320 people, 160 given focused shockwave and 160 a sham, the treated group had less pain, lower neck disability scores, better neck movement and better quality-of-life scores after the course, with no difference in side effects (Li, Medicine 2024). An earlier randomised trial of 60 people with cervical spondylosis and calcification of the ligament at the back of the neck found that adding shockwave to heat and traction gave more pain relief and better movement than the rehabilitation alone, with gains still present at three months (Lin, Kaohsiung J Med Sci 2015). The larger trial is weighed with some caution: its abstract describes collecting data from five clinical studies, and all its authors list a single hospital, so the multicentre design and the randomisation cannot be checked from the abstract. Neither reports long-term results, and the larger trial has not yet been repeated by another group.","fit":"Worth discussing for persistent neck pain and stiffness from spondylosis, directed at the muscle, ligament and joint structures at the back of the neck and never at the front. Used with the movement and strengthening programme. Arm weakness, numbness or any sign of spinal cord involvement is assessed first and is not a shockwave problem.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"There is now one randomised trial. Forty people with cervical facet-mediated pain received either leucocyte-poor platelet-rich plasma or corticosteroid into the facet joint under fluoroscopy. Over six months the two were similar for pain intensity; both improved at one month; the platelet-rich plasma group had a clinically meaningful fall in pain at that point, a larger gain in pain self-efficacy, and less pain during the procedure itself (Allison, Reg Anesth Pain Med 2026). A prospective series of 42 people with chronic whiplash-associated facet pain reported improvement sustained at twelve months, but had no control group and gave rehabilitation alongside (Smith, Clin Pract 2025). Across nine randomised trials of epidural rather than intra-articular injection, a 2026 review graded the evidence fair, Level III, with a moderate effect (Manchikanti, Curr Pain Headache Rep 2026).","fit":"Not done in this clinic. A cervical facet injection should be performed under CT guidance, with the facet joints confirmed as the source by diagnostic blocks first, so this is a referral and not something provided here. For degenerative neck pain the evidence sits with exercise, load management and understanding the problem, and that is where care starts; this becomes a conversation only for pain that has run for months and points clearly at the facet joints.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested prolotherapy in cervical spondylosis. The closest published work is an uncontrolled series of 14 people with neck pain treated with prolotherapy combined with platelet products, reporting a 2.8-point fall in pain score at two years (Williams, Cureus 2021): too small to draw a conclusion from, and unable to separate the prolotherapy from the platelets.","fit":"Considered only for tender facet and attachment pain that persists after loading and mobility work, and discussed as unproven for this diagnosis rather than offered as a repair.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Hyaluronic acid has never been injected into a cervical facet joint in a published study: a search against the cervical spine, cervical facet joints, neck pain, cervical spondylosis and the atlantoaxial joint returns thirteen records and none is an injection at that level. The guideline arguments about hyaluronic acid come from the knee and hip, and the spinal evidence that does exist is lumbar, where a systematic review of 18 studies and 1,496 people found the injection no different from cortisone and of little or no overall benefit (Ambrosio, Global Spine J 2022) and a case of widespread inflammatory joint pain followed a lumbar facet injection of hylan G-F 20 (Kocak, Am J Phys Med Rehabil 2018). Of 62 branded hyaluronic acid products on one national market, only two had any evidence at spinal facet joints and only one was licensed for that use (Migliore, Clin Med Insights Arthritis Musculoskelet Disord 2016).","fit":"Not offered for the neck. Hyaluronic acid injections are a knee and hip treatment, and neck arthritis is managed with exercise, activity and (where a single joint is confirmed as the source) a block or radiofrequency treatment.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested perineural injection in cervical spondylosis. A search across perineural injection, neural prolotherapy and dextrose terms combined with cervical spondylosis returns nothing of any design. The nearest report describes the opposite situation: 18 months of arm weakness and numbness attributed to presumed cervical spondylosis proved on ultrasound to be neurogenic thoracic outlet syndrome, and resolved over six sessions of 5% dextrose hydrodissection below the clavicle (Yoon, Front Med 2026): a change of diagnosis rather than a treatment for the neck.","fit":"Not offered for the degenerative changes themselves. It becomes relevant only where the assessment points to an irritated superficial nerve rather than to the joints and discs, which usually means the working diagnosis needs revisiting.","reviewedOn":"2026-09-09"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Studied in degenerative neck disease, but never against an inactive control. A randomised trial in 100 people with MRI-confirmed cervical disc degeneration found autologous conditioned serum delivered by the fascial hydrodissection technique matched deeper periarticular injection, with pain falling from 4.7 to 2.1 and neck disability from 16.3 to 8.3 at 12 weeks in both arms (Godek, J Pain Res 2026): a comparison of routes rather than proof of the technique. In 199 people with cervical spondylotic radiculopathy, adding ultrasound-guided brachial plexus hydrodissection to acupotomy release improved pain, neck disability and nerve conduction beyond acupotomy alone (Shang, Front Aging Neurosci 2026), though that study was retrospective.","fit":"Relevant where the neck pain has a myofascial or nerve component that can be seen on ultrasound, rather than as treatment of the disc and facet degeneration itself. Arm symptoms with weakness or wasting still need a specialist opinion.","reviewedOn":"2026-09-06"}}},{"slug":"cervicogenic-headache","title":"Cervicogenic Headache","region":"Neck","url":"https://www.backpaindoctor.com.au/conditions/cervicogenic-headache","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled series only","evidence":"Searched 1 November 2026 (PubMed: trigger point, myofascial or wet needling injection with cervicogenic headache; 16 records, plus a randomised-trial and systematic-review pass). No randomised trial has tested injection into the neck muscles for cervicogenic headache. In an uncontrolled study of 23 people, 10 mL of dilute bupivacaine injected under ultrasound into the plane between the trapezius and levator scapulae reduced pain, disability and headache frequency over four weeks (Arıcı, Agri 2023). A retrospective series of 80 people treated with hydrodissection between two deep upper-neck muscles, combined with a C2 injection of local anaesthetic and corticosteroid, reported lower pain and headache-impact scores to six months, but the two injections cannot be separated (Hao, J Pain Res 2025). A systematic review of injections for neck disorders found the effect of anaesthetic nerve blocks for cervicogenic headache unconfirmed (Gross, Open Orthop J 2013), and botulinum toxin, a different injection, has not shown clear benefit over placebo in this headache (Roland, Scand J Pain 2021). No study used this row's dilute glucose.","fit":"Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.","reviewedOn":"2026-11-01"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Temporary relief","evidence":"Injection around the occipital nerves helps, and then wears off. A systematic review of 22 studies found good pain relief in 87% of people given a corticosteroid injection and 79% given local anaesthetic alone, with relief lasting anywhere from thirty minutes to five months (Hazewinkel, Plast Reconstr Surg Glob Open 2022). In a randomised double-blind comparison of 52 people, an occipital injection of corticosteroid with bupivacaine cut pain by more than half and did no worse than cryoneurolysis, but the effect faded from six to seven weeks and 78% still wanted further treatment at eighteen weeks (Kvarstein, Scand J Pain 2019). The only ultrasound-guided study is small and uncontrolled: an interfascial block between trapezius and levator scapulae in 23 people improved pain, neck disability and analgesic use out to four weeks (Arici, Agri 2023). There is no placebo-controlled trial.","fit":"Worth discussing where the headache clearly arises from the upper neck and is not settling with neck-directed rehabilitation. Most useful as a way to confirm where the pain is coming from and buy a working window for that rehabilitation, rather than as the treatment plan itself. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Sham trials from one group","evidence":"In a double-blind trial of 135 people with cervicogenic headache, all doing neck stretching and strengthening, radial shockwave to upper trapezius trigger points at a low or a medium dose was compared with sham; all three groups improved on headache disability and pain, with the greatest improvement at the medium dose, but the abstract gives no between-group figures (Hammam, Am J Phys Med Rehabil 2026). An earlier 50-person trial from the same group, device type not stated, found shockwave beat sham at four weeks (Hammam, Am J Phys Med Rehabil 2024). Shockwave to the sternocleidomastoid was level with manual therapy in 42 people (Xia, Turk J Phys Med Rehabil 2024). Neither sham-controlled result has been repeated by another group or followed beyond the end of treatment.","fit":"Considered for tender upper trapezius or neck muscle that reproduces your headache, alongside your neck exercise programme, which remains the main treatment. It is not aimed at the joints of the upper neck.","reviewedOn":"2026-10-19"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One sham trial; device not stated","evidence":"Shockwave to trigger points in the upper trapezius, added to physiotherapy, beat sham on headache disability, pain and muscle activity in a double-blind trial of 50 people with cervicogenic headache, measured at the end of four weeks; the abstract gives no figures and does not say whether the device was radial or focused (Hammam, Am J Phys Med Rehabil 2024). A later trial by the same group used radial devices (Hammam, Am J Phys Med Rehabil 2026). Shockwave to the sternocleidomastoid did no better than manual therapy in 42 people (Xia, Turk J Phys Med Rehabil 2024; device not stated). No trial names a focused device in this condition, and none follows people beyond the end of treatment.","fit":"Considered for tender upper trapezius or neck muscle that reproduces your headache, alongside your neck exercise programme. It is not aimed at the joints of the upper neck.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search for platelet-rich plasma in cervicogenic headache found no clinical study of it. The same search returned 19 records for platelet-rich plasma in cervical and neck conditions generally (facet injection in whiplash, periradicular injection in radiculopathy, a single cervical disc case report) and none of them in cervicogenic headache.","fit":"Not something offered for headache. Cervicogenic headache is addressed through the upper cervical segments and the muscles that refer pain into the head, which means rehabilitation and, where examination finds a tender band, needling.","reviewedOn":"2026-09-03"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Two PubMed searches (prolotherapy or dextrose injection combined with cervicogenic headache, and separately with headache or migraine) return no trial in cervicogenic headache. The published material is a single whiplash case report followed for 21 months (Stogicza, Regen Med 2020) and narrative reviews.","fit":"Not offered as a headache treatment. If a neck joint or attachment is clearly the pain source it is assessed on its own terms, and the neck work comes first.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"The upper neck joints that refer pain into the head have never been injected with hyaluronic acid in a published study. A search of hyaluronic acid, hyaluronate and viscosupplementation against the cervical spine, cervical facet joints, cervicogenic headache, whiplash and the atlantoaxial joint returns thirteen records and none is an injection at those joints. Where the injection has been tested in the spine (the lumbar facet joints) a systematic review of 18 studies and 1,496 people found little short-term or no benefit (Ambrosio, Global Spine J 2022).","fit":"Not offered for this problem. Blocks and radiofrequency treatment of the upper cervical joints are the established injection route when one of them is confirmed as the source.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of perineural dextrose in cervicogenic headache. Two searches (perineural injection, neural prolotherapy, subcutaneous dextrose and glucopuncture terms against cervicogenic headache, occipital nerve and occipital neuralgia, and separately dextrose against cervicogenic headache) return a single record, and it tested perineural magnesium sulfate added to pulsed radiofrequency of the greater occipital nerve in occipital neuralgia (Zhang, Front Physiol 2026). Different injectate, different technique and a different diagnosis.","fit":"Not a headache treatment. It would only enter the conversation where the occipital nerve territory is itself tender and hypersensitive, and even then the neck assessment and the neck work come first.","reviewedOn":"2026-09-09"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Direct but uncontrolled evidence. In 80 people with cervicogenic headache, four sessions of ultrasound-guided hydrodissection between obliquus capitis inferior and semispinalis capitis, combined with a C2 transverse process injection, lowered pain, neck disability and headache impact scores out to six months (Hao, J Pain Res 2025), but the study was retrospective, had no control group, and the injectate included corticosteroid, so the hydrodissection cannot be separated from it. Beyond that the literature is case reports: 5% dextrose hydrodissection of the greater occipital nerve for occipital neuralgia (Lam, Diagnostics 2024) and fascial hydrodissection of the suboccipital muscles (Kaga, Am J Case Rep 2022). No randomised trial was found in this condition.","fit":"Worth discussing where examination and ultrasound point to the greater occipital nerve or the suboccipital muscles as the source, particularly once medication and manual therapy have not settled it. The absence of a randomised trial is part of that conversation.","reviewedOn":"2026-09-06"}}},{"slug":"coccydynia","title":"Coccydynia (Tailbone Pain)","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/coccydynia","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Conservative care is first line in every review: cushions that offload the coccyx, sitting posture, anti-inflammatories, pelvic floor physiotherapy and manual therapy (Foye, StatPearls 2025; Mazzoleni, Ann Joint 2025). Small randomised trials support stretching, kinesiotaping with exercise, and intrarectal manipulation (mild effect), and in a retrospective series of 79 people completing pelvic floor physiotherapy average pain fell from about 5 to 2 out of 10 (Scott, PM R 2017). Conservative care is often quoted as successful in about 90 per cent, but in a prospective cohort of 115 adults with chronic coccydynia symptoms persisted at 36 months in more than half (Charriere, Eur Spine J 2021).","fit":"The starting point: a cut-out or wedge cushion, sitting and break habits, simple analgesia, avoiding straining, and referral for pelvic floor physiotherapy. Screening for infection, tumour and referred pelvic causes happens at the same visit.","reviewedOn":"2026-09-28"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No controlled trial of needling in coccydynia was identified. Coccygeus trigger point injections were used as a secondary treatment in 17 per cent of a retrospective pelvic floor physiotherapy cohort, without separate outcomes (Scott, PM R 2017), and dry needling of gluteus maximus trigger points has been proposed in correspondence only (Temel, Med Acupunct 2023).","fit":"Only where a tender band in gluteus maximus or the muscles around the coccyx is reproducing part of the pain. It is not treatment of the coccyx itself.","reviewedOn":"2026-09-28"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small trials","evidence":"Corticosteroid injection around the sacrococcygeal joint is widely used and appears most helpful when pain is under about six months old (Foye, StatPearls 2025). The trial evidence is small: ultrasound guidance was no better than a landmark-guided injection in 30 patients, and in a 34-patient trial shockwave gave more durable relief than steroid over six months (both Ahadi 2022, in Mazzoleni, Ann Joint 2025). A narrative review concluded no high-quality study yet supports any injection-based treatment (White, PM R 2021).","fit":"Considered for pain that persists despite cushioning and physiotherapy. Ganglion impar blocks are a separate specialist procedure and are arranged by referral.","reviewedOn":"2026-09-28"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A combined search for vibration and electromagnetic therapies with coccydynia terms returned no records at all.","fit":"A comfort adjunct at most for gluteal muscle guarding. Not a treatment for the coccyx.","reviewedOn":"2026-09-28"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small positive trials","evidence":"Three small randomised trials report benefit: shockwave beat short-wave diathermy with interferential therapy in 41 patients (Lin, PLoS One 2015), outlasted a steroid injection over six months in 34 (Ahadi, Am J Phys Med Rehabil 2022), and both radial and focused shockwave beat sham in 60, with radial possibly the more effective (Sah, Turk J Phys Med Rehabil 2023). The trials are small, short and mostly single-centre (Mazzoleni, Ann Joint 2025).","fit":"Reasonable to discuss for pain that persists after cushioning, seating changes and physiotherapy, alongside those measures and with the limits of the evidence explained. Not used where infection, fracture or tumour has not been excluded.","reviewedOn":"2026-09-28"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One sham-controlled trial","evidence":"Focused shockwave was one arm of the three-arm trial against sham in 60 patients: both focused and radial beat sham, with radial possibly more effective (Sah, Turk J Phys Med Rehabil 2023). That is the only focused-shockwave trial in this condition.","fit":"Discussed on the same terms as radial shockwave. Radial is usually the first choice here given that trial.","reviewedOn":"2026-09-28"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A combined search for electromagnetic, magnetotransduction and magnetic stimulation therapies with coccydynia terms returned no study treating this condition.","fit":"Not part of managing this condition.","reviewedOn":"2026-09-28"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Case reports and one cohort","evidence":"PRP has been reported in single case reports (Sussman, Regen Med 2020; Vukovic, Front Immunol 2023) and in a retrospective comparison of 40 patients, in which PRP at the ganglion impar improved function more than pulsed radiofrequency, with no difference in pain (Pilco Inga, Rev Esp Anestesiol Reanim 2025). There is no placebo-controlled trial.","fit":"Not offered routinely. May be discussed as experimental for refractory pain after standard care, with the absence of controlled evidence part of consent.","reviewedOn":"2026-09-28"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"No randomised trial","evidence":"In a case series of 37 people with chronic coccydynia, 30 had good relief after hypertonic dextrose injections (Khan, J Orthop Surg 2008), and a retrospective comparison of 56 found greater pain reduction at three months when ultrasound-guided 10 per cent dextrose was added to exercise (Zure, Pain Manag 2026). Neither is randomised.","fit":"May be discussed for persistent sacrococcygeal ligament pain after standard care, framed as early evidence without a randomised trial.","reviewedOn":"2026-09-28"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search pairing viscosupplementation and hyaluronic acid with coccydynia terms returned no study of this treatment in this condition.","fit":"Not offered for this problem.","reviewedOn":"2026-09-28"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial","evidence":"One double-blind randomised trial in 32 women injected 5 per cent dextrose around a small perforating cutaneous nerve at the sacrotuberous ligament, weekly for three sessions: pain fell from about 82 to 37 out of 100 at three months, while the saline group did not change (Alptekin, Ir J Med Sci 2026). It is a single small trial from one group, whose authors include members of a prolotherapy school.","fit":"Considered where examination points to a superficial nerve pain pattern beside the coccyx, as an emerging option and not as established treatment.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A combined search for hydrodissection with coccydynia terms returned no records.","fit":"Not part of managing this condition. The perineural dextrose row covers the nerve-directed injection that has been studied here.","reviewedOn":"2026-09-28"}}},{"slug":"compartment-syndrome","title":"Compartment Syndrome","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/compartment-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Rehabilitation addresses what is treatable without an operation: the running or loading pattern, the strength and capacity of the calf, and the training error that usually precedes it. The broader evidence that graded loading beats rest in exertional leg pain is the same body of work that supports it in bone stress injury and tendinopathy (Doherty, Br J Sports Med 2016; Challoumas, Sports Med Open 2023).","fit":"Rehabilitation does not decompress a fascial compartment. Where symptoms reproduce reliably with exertion and settle with rest, and conservative management has had a fair trial, compartment pressure testing and surgical review are the next step and should not be delayed by more of the same.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A tested absence. On 11 November 2026 shockwave, shock wave and ESWT crossed with compartment syndrome returned eight records, all read: none studied shockwave as a treatment for compartment syndrome. They concerned kidney-stone lithotripsy and its complications, blast injury, vascular and laboratory work, a sleep study and bone marrow oedema in the knee. A second search pairing shockwave with chronic exertional compartment syndrome or exertional leg pain returned one record, a case of Achilles tendon pain in a runner. There is no evidence at this diagnosis, and no mechanism by which a pressure wave at the skin would lower the pressure inside a muscle compartment.","fit":"Not offered for this. Where symptoms come on reliably with exertion and settle with rest, and loading and gait work have had a fair trial, compartment pressure testing and surgical review are the next step.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A tested absence. On 11 November 2026 shockwave, shock wave and ESWT crossed with compartment syndrome returned eight records, all read: none studied shockwave as a treatment for compartment syndrome. A second search pairing shockwave with chronic exertional compartment syndrome or exertional leg pain returned one record, a case of Achilles tendon pain in a runner. There is no evidence at this diagnosis, and no mechanism by which an acoustic pulse would change the pressure inside a fascial compartment.","fit":"Not offered for this. Where symptoms reproduce reliably with exertion and settle with rest, and loading and gait work have had a fair trial, compartment pressure testing and surgical review are the next step.","reviewedOn":"2026-11-11"},"emtt":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.","fit":"Not part of the plan here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study has tested PRP for chronic exertional compartment syndrome, and there is no reason to expect one to help: the problem is pressure inside a closed muscle compartment, not tissue that has failed to heal. A PubMed search in October 2026 pairing platelet-rich plasma and platelet concentrate with compartment syndrome, exertional compartment, fasciotomy and cramp returned 12 records, most of them about the plantar fascia of the foot. The two that involve a compartment syndrome are single case reports of PRP used on the surgical wound after an emergency release, one after a snakebite and one after a chemotherapy leak (Nikolovska, Case Reports Plast Surg Hand Surg 2026; Putra, J Cancer Res Ther 2025). That is wound care after an operation, not treatment of the condition. The search found no report of PRP causing a compartment syndrome either.","fit":"Not offered for compartment syndrome. Changes to gait and load and, where pressure testing confirms the diagnosis, surgical release are what address it. Considered only for a separate tendon or joint problem alongside it.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study has tested prolotherapy for compartment syndrome. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose or hypertonic glucose with compartment syndrome, then randomised-trial and systematic-review passes) returned no clinical record in this condition. The problem is pressure inside a closed muscle compartment, which an injection into a ligament or tendon does not address.","fit":"Chronic exertional compartment syndrome is managed with changes to running technique and load, and surgical review where that fails; acute compartment syndrome is a surgical emergency. Prolotherapy is considered only for a separate ligament or tendon problem, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Acute compartment syndrome is a surgical emergency and no injection has any place in it. In the chronic exertional form, one case report describes a serviceman whose leg pain and numbness persisted after bilateral fasciotomy, in whom ultrasound found the superficial peroneal nerve trapped along the fasciotomy scar; four sessions of perineural dextrose improved pain, weakness and function (Bui, Mil Med 2023).","fit":"No role in the acute emergency, and none in first-line management of the exertional form. Worth considering only for nerve symptoms that persist after surgical release, where scar has caught a cutaneous nerve.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":false}}},{"slug":"complex-regional-pain-syndrome","title":"Complex Regional Pain Syndrome (CRPS)","region":"General","url":"https://www.backpaindoctor.com.au/conditions/complex-regional-pain-syndrome","pairings":{"rehab":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Low-certainty evidence","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). The 2022 Cochrane review of physiotherapy included 34 randomised trials (1,339 participants), mostly small single trials at high risk of bias, and graded the certainty as very low for every comparison (Smart). A 2023 meta-analysis of 33 rehabilitation trials found low-quality evidence that mirror therapy and graded motor imagery may substantially improve pain and disability in post-stroke CRPS, and that pain exposure therapy and aerobic exercise added to physiotherapy may improve pain (Shafiee); an overview of nine reviews found mirror therapy and graded motor imagery the most consistently supported, from a small body of primary evidence.","fit":"A supportive and often central part of care, directed by a rehabilitation physician or therapist with CRPS experience: graded return to use of the limb, mirror therapy or graded motor imagery where suitable, with the evidence gap stated.","reviewedOn":"2026-10-24"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Needling is not among the treatments with supporting evidence in the Cochrane overview or the Harden guideline.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Specialist pain medicine","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). The Cochrane overview found moderate-certainty evidence that lidocaine sympathetic blockade probably does not reduce pain compared with placebo, and only low-certainty evidence for comparisons of nerve blocks with each other (Ferraro).","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Vibration-based devices are not part of the guideline or Cochrane evidence reviewed for CRPS.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Shockwave is not among the CRPS treatments in the guideline or Cochrane evidence reviewed.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Shockwave is not among the CRPS treatments in the guideline or Cochrane evidence reviewed.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Magnetotransduction therapy is not part of the guideline or Cochrane evidence reviewed for CRPS.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Platelet-rich plasma is not part of the guideline or Cochrane evidence reviewed for CRPS.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Prolotherapy is not part of the guideline or Cochrane evidence reviewed for CRPS.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong problem","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Hyaluronic acid is a treatment for osteoarthritic joints and has no role in CRPS.","fit":"Not offered for CRPS.","reviewedOn":"2026-10-24"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Specialist pain medicine","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Sympathetic and regional nerve blocks are used by pain specialists, but the Cochrane overview found moderate-certainty evidence that sympathetic blockade probably does not reduce pain more than placebo (Ferraro).","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Hydrodissection addresses a compressed peripheral nerve and is not part of CRPS management in the sources reviewed. Where a definite nerve lesion exists (CRPS type II), it needs specialist assessment.","fit":"Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.","reviewedOn":"2026-10-24"}}},{"slug":"cubital-tunnel-syndrome","title":"Cubital Tunnel Syndrome","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/cubital-tunnel-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Conservative care comes first, and it holds up well. A network meta-analysis of 49 randomised trials and 3,323 patients with carpal tunnel syndrome ranked manual therapy first for both short- and medium-term pain relief, ahead of every injection option including corticosteroid (Chen, Arch Phys Med Rehabil 2025).","fit":"Load management, splinting where it fits, and addressing what is irritating the nerve come before any injection. Where the nerve is being compressed structurally and function is being lost, surgical review is the right conversation rather than more conservative care.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested any needling technique in cubital tunnel syndrome. What exists is a series of three patients who became pain-free after four sessions of dry needling and stayed so at six months (Anandkumar, Physiother Theory Pract 2018), a case report of trigger point injection in a woman with ulnar and median nerve entrapment and coexisting muscle pain (Medina, Pain Med Case Rep 2026), and two cadaveric studies showing that ultrasound guidance makes needle placement close to the ulnar nerve at the elbow more accurate (Lopez-de-Celis, J Ultrasound 2026); in one of them the nerve's sheath was punctured in one in five attempts guided by touch alone and in none guided by ultrasound (Lopez-de-Celis, Healthcare 2023).","fit":"Considered where a tender forearm or upper-arm muscle band is reproducing part of the pain. It does not release the nerve, and the evidence is case reports only.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Depends on the injectate","evidence":"The carpal tunnel result does not transfer to the elbow. A Cochrane review of 15 randomised trials in 970 people rates it as very low certainty whether corticosteroid injection helps at all here, over one trial of 55 people in which it was no different from placebo at three months, while a separate trial found dextrose injection reduced pain against placebo at four and twelve months, and another found dextrose and corticosteroid no different from each other (Caliandro, Cochrane Database Syst Rev 2025). In a double-blind randomised trial, 33 people with mild to moderate ulnar neuropathy had a single ultrasound-guided perineural injection of either 5% dextrose or corticosteroid; the two were comparable at most time points, with larger falls in symptom severity and in ulnar nerve cross-sectional area in the dextrose group from three months onward (Chen, Arch Phys Med Rehabil 2020).","fit":"Worth a conversation about which injectate rather than whether to inject. If an injection is used here, the evidence points away from corticosteroid. Elbow position and load habits do more of the work, and persistent weakness warrants surgical review.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One trial, after burns; device not stated","evidence":"Searched again 17 October 2026 (5 records, all read). The tested absence recorded here in September no longer holds. One randomised trial, published in October 2026: 75 people with cubital tunnel syndrome after burns to the arm, in whom four weeks of shockwave added to ulnar nerve gliding exercises improved nerve conduction and arm function (DASH) more than the exercises alone, to twelve weeks, with no adverse events; high-intensity laser did better than shockwave on every measure (Mohamed, Arch Phys Med Rehabil 2026). The abstract does not say whether the device was radial or focused, and there was no sham group. A retrospective series of three people with medial epicondylitis and an unstable ulnar nerve given combined focused and radial shockwave found two improving and one unchanged (Ryskalin, Front Rehabil Sci 2026). The search also returned a harm report: a 48-year-old man developed numbness, weakness and severe partial axonotmesis of the ulnar nerve immediately after a second session of shockwave for medial epicondylitis (Shim, PM R 2015). A review of conservative care in ulnar neuropathy at the elbow lists shockwave without endorsing it (Poenaru, Exp Ther Med 2022).","fit":"Worth discussing for mild symptoms alongside nerve-gliding exercises and advice on elbow position, or for a separate tendon or muscle problem at the inner elbow, with the pulse kept off the nerve itself. Patients are told the one trial was in people with burn scarring. Where weakness or wasting is developing, the conversation is a surgical one.","reviewedOn":"2026-10-17"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One trial, after burns; device not stated","evidence":"Searched 17 October 2026: shockwave, shock wave or ESWT with the cubital tunnel, ulnar neuropathy, the ulnar nerve or ulnar nerve entrapment (5 records, all read), plus a systematic-review and randomised-trial pass across nerve entrapments outside the carpal tunnel. One randomised trial, published in October 2026, in a particular group: 75 people with cubital tunnel syndrome after burns to the arm. Four weeks of shockwave added to ulnar nerve gliding exercises improved nerve conduction and arm function (DASH) more than the exercises alone, to twelve weeks, with no adverse events; high-intensity laser did better than shockwave on every measure (Mohamed, Arch Phys Med Rehabil 2026). The abstract does not say whether the device was focused or radial, and there was no sham group. Otherwise there are three people with medial epicondylitis and an unstable ulnar nerve treated with combined focused and radial shockwave, two improving and one unchanged (Ryskalin, Front Rehabil Sci 2026), and one harm report: severe partial axonotmesis of the ulnar nerve immediately after a second session of shockwave given at the medial elbow for epicondylitis (Shim, PM R 2015).","fit":"Worth discussing for mild cubital tunnel symptoms alongside nerve-gliding exercises and advice on elbow position, with the energy kept modest over the nerve. Patients are told the one trial was in people with burn scarring. Where weakness or wasting is developing, the conversation is a surgical one.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Case reports; harm signal reported","evidence":"No trial, and no study with a comparison group. What has been published is thin, and none of it is a standard PRP injection given in a clinic: 15 people with ulnar nerve entrapment had a platelet product placed in and around the nerve during open release surgery and had improved by the end of follow-up, a median of twelve months across the study, with no group operated on without it (Galán, J Clin Med 2022); three people improved by more than 75% after fluid was injected around the nerve at the elbow using platelet lysate and glucose (Hooper, Cureus 2025); and one person improved further after an injection of platelet releasate, having already improved with a plain fluid injection around the nerve (Bejarano, Cureus 2023). There is also a harm report at exactly this site: three baseball players given PRP for a partial tear of the ligament beside the nerve, each with an ulnar nerve already known to slip out of its groove, all developed cubital tunnel syndrome with marked scarring around the nerve (Thompson, JSES Rev Rep Tech 2020). A systematic review of ultrasound-guided injections around trapped nerves found ten studies, nine of them at the carpal tunnel and one at the elbow, and its PRP studies concern the carpal tunnel, a different nerve (Buntragulpoontawee, Front Pharmacol 2021). Search on 11 October 2026: 24 records pairing PRP with cubital tunnel, ulnar neuropathy and ulnar nerve terms, all read.","fit":"Not offered for ulnar nerve entrapment at the elbow. Rehabilitation and changes to how the elbow is loaded and positioned come first, and where an injection is being considered the glucose injections on this page are the ones with trial evidence. PRP near this nerve has only case reports behind it, and one report of scarring around the nerve after PRP was injected close by.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"As at the wrist, the dextrose evidence at the elbow is perineural rather than prolotherapy. A randomised double-blind trial of 33 patients with mild to moderate ulnar neuropathy at the elbow found a single perineural 5% glucose injection as effective as corticosteroid, with greater reductions in symptom severity and in ulnar nerve cross-sectional area from three months onward (Chen, Arch Phys Med Rehabil 2020). The Cochrane review of 15 trials and 970 participants records dextrose injection reducing pain against placebo at four and twelve months, and showing no difference against corticosteroid (Caliandro, Cochrane Database Syst Rev 2025). Neither concerns dextrose at ligament attachments.","fit":"Not offered for this. The dextrose treatment with evidence behind it at the elbow is the perineural one, set out in the nerve rows on this page.","reviewedOn":"2026-09-03"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A tested absence rather than an assumption: searches pairing hyaluronic acid, hyaluronate and viscosupplementation with the cubital tunnel, ulnar neuropathy and the ulnar nerve returned no trial of hyaluronic acid in this condition. The only randomised human work pairing the two is a volunteer study in which hyaluronic acid added to local anaesthetic did not change how long an ulnar nerve block lasted (Johansson, Acta Anaesthesiol Scand 1985), and hyaluronic acid appears in reviews of nerve hydrodissection only as one of several possible injection fluids (Colorado, Muscle Nerve 2025). There is no joint at this site to viscosupplement.","fit":"Not offered for this problem.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"In ulnar neuropathy at the elbow, ultrasound-guided perineural 5% dextrose beat saline for pain, disability, ulnar motor conduction velocity and nerve cross-sectional area at 4 and 12 weeks (Mansız-Kaplan, Arch Phys Med Rehabil 2022), and matched corticosteroid overall while producing greater reductions in symptom severity and nerve cross-sectional area from month 3 onward (Chen, Arch Phys Med Rehabil 2020).","fit":"A reasonable option in mild to moderate cases. Progressive weakness or wasting needs a surgical opinion rather than an injection.","reviewedOn":"2026-08-30"},"hydrodissection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"In ulnar neuropathy at the elbow, ultrasound-guided perineural 5% dextrose beat saline for pain, disability, ulnar motor conduction velocity and nerve cross-sectional area at 4 and 12 weeks (Mansız-Kaplan, Arch Phys Med Rehabil 2022), and matched corticosteroid overall while producing greater reductions in symptom severity and nerve cross-sectional area from month 3 onward (Chen, Arch Phys Med Rehabil 2020).","fit":"A reasonable option in mild to moderate cases. Progressive weakness or wasting needs a surgical opinion rather than an injection.","reviewedOn":"2026-08-30"}}},{"slug":"de-quervain-tenosynovitis","title":"De Quervain Tenosynovitis","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/de-quervain-tenosynovitis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in this condition","evidence":"Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection, myofascial or intramuscular stimulation with de Quervain, first dorsal compartment or radial styloid tenosynovitis, 11 records; and a randomised-trial and systematic-review pass). No trial or series has injected or needled a muscle trigger point in de Quervain tenosynovitis. The only needling reports are single cases: ultrasound-guided dry needling of forearm muscles in a woman whose pain was complex regional pain syndrome presenting as de Quervain's after failed surgery (Vas, Pain Physician 2016), and acupuncture as one part of a multimodal program (Howell, J Can Chiropr Assoc 2012). A review of forearm muscle pain lists de Quervain's among the conditions that brachioradialis trigger points can mimic (Kim, Korean J Pain 2025). The studied injection for this condition is cortisone into the tendon sheath, which sits in the guided injection row.","fit":"The problem is the tendon sheath at the wrist, and a sheath injection (see guided injection) and splinting are the established options. A trigger point injection would be considered only where a tender forearm-muscle band is found to be causing or adding to the pain.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Multiple subcompartments are present in about half of wrists, and a missed subcompartment is a common reason an injection fails; ultrasound-guided injection gave at least partial resolution in 97% at six weeks (McDermott, Clin Orthop Relat Res 2012). Against that, a propensity-matched study of 396 hands found guidance did not reduce reintervention rates (Kim, Plast Reconstr Surg 2026).","fit":"Reasonable where a first injection has failed, since a separate subcompartment is the usual explanation.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial, no sham arm","evidence":"Searched for shockwave in de Quervain's by device type: 14 records, and a randomised-trial pass that returned nothing indexed as a trial. The one study that can be read in full randomised 60 people to five sessions of shockwave or to high-intensity laser, with no sham or untreated group. Pain at rest fell from 8 to 1 out of 10 at three months in both groups and hand function improved equally, with pressure tenderness improving more after laser (Karakuzu Güngör, Turk J Phys Med Rehabil 2024). The paper does not use the word radial; it names a pressure-wave device and gives the dose in bar, which is how radial devices are dosed. A network meta-analysis of 14 randomised trials of non-surgical treatment found shockwave better than placebo for pain in the first six weeks and ranked it first to six months, without stating the device type, and its authors still place it second to a cortisone injection with a short period of splinting (Chong, J Hand Surg Am 2024). A review of shockwave in hand conditions found two de Quervain's studies, better than sham and no different from a cortisone injection, and graded the evidence C (Al-Mousllie, GMS Interdiscip Plast Reconstr Surg DGPW 2025). Pooled with trigger finger trials, the advantage over sham was not statistically significant and did not last beyond four weeks (Zhang, Front Physiol 2026).","fit":"Can be discussed for de Quervain's that has not settled with splinting and activity change, particularly for someone who wants to avoid an injection. A cortisone injection with a short period of splinting remains the better-established treatment, and the shockwave evidence is small and short-term. The tendons here lie just under the skin, which suits the radial form.","reviewedOn":"2026-10-09"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No trial names the focused form","evidence":"Searched for shockwave in de Quervain's by device type: 14 records, none of which states that a focused device was used at this site. The one trial that can be read in full used a pressure-wave device dosed in bar, the radial type: 60 people, shockwave equal to high-intensity laser at three months, no sham group (Karakuzu Güngör, Turk J Phys Med Rehabil 2024). The pooled analyses that find shockwave better than placebo in the short term do not report which device the trials used (Chong, J Hand Surg Am 2024). In a meta-analysis that mixed de Quervain's with trigger finger, the focused trials showed no significant reduction in pain (difference -1.27 points, 95% CI -4.08 to 1.53) while the radial trials did (-1.30 points, 95% CI -1.84 to -0.75), with no significant difference between the two forms (Zhang, Front Physiol 2026).","fit":"Where shockwave is tried for de Quervain's, the radial form is the one with a trial behind it and it suits tendons this close to the skin. Focused shockwave can be discussed on the same reasoning, with the absence of trials naming it explained.","reviewedOn":"2026-10-09"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Matched cortisone in small trials","evidence":"Tested against a cortisone injection in three small comparisons, and not against a dummy injection. In a randomised open-label trial of 86 people, ultrasound-guided PRP into the first extensor compartment was judged equivalent to triamcinolone for pain: cortisone was ahead at one week for pain and at one and four weeks for hand function, and the two were level by twelve weeks (Chowley, J Hand Surg Asian Pac Vol 2025). In 60 people randomised to one injection of either, there was no difference between them at any point to a year, with no complications after PRP and skin thinning, loss of pigment or a pain flare in 8 of 30 after cortisone (Kumar, J Wrist Surg 2022). In 40 people cortisone was better at two weeks and PRP at six months (Ashour, Cureus 2024). The contrary reading comes from a network meta-analysis of 14 randomised trials: PRP on its own was no better than placebo for pain in the first six weeks, though it and cortisone both held their pain relief at a year, and the authors keep a cortisone injection with a short period of splinting as the main treatment (Chong, J Hand Surg Am 2024). An uncontrolled series of 67 people given PRP with an anti-inflammatory tablet reported 85% reaching low pain at three weeks, less often in people with diabetes (Iqbal, Cureus 2025).","fit":"An option that can be discussed where splinting and activity change have not been enough and a cortisone injection has already been tried or is best avoided, for example because of the risk of skin thinning or colour change at the wrist. Cortisone works faster in the first few weeks and remains the better-established injection. If used, PRP is placed around the tendons in the first compartment under ultrasound guidance.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy in de Quervain tenosynovitis was found. PubMed searches on 13 October 2026 (prolotherapy, dextrose, hypertonic glucose or hyperosmolar with de Quervain, first dorsal compartment, radial styloid or wrist tenosynovitis) returned two records: a review of upper-limb tendon injection technique that reports no prolotherapy outcomes in this condition (Silva, Skeletal Radiol 2022), and a single case of nerve hydrodissection at the wrist, which is a different condition. Passes restricted to randomised trials and to systematic reviews or meta-analyses found nothing in this condition.","fit":"Can be discussed where pain persists after splinting, activity change and a cortisone injection into the tendon sheath, with the absence of studies explained.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Trialled as an add-on at this tendon sheath, but not offered here. A randomised trial of 75 people compared ultrasound-guided cortisone alone, cortisone followed by saline, and cortisone followed by low-molecular-weight hyaluronic acid. At six months the hyaluronic acid group had far less disability (quickDASH 26 against 51 in both other groups) and fewer recurrences (Orlandi, Eur Radiol 2014). A cadaver study of eighteen wrists found hyaluronic acid cut friction between the thumb tendons and the overlying retinaculum by 18.7% (Rotem, J Wrist Surg 2025).","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and de Quervain's is a tendon sheath problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Nerve mimic, case reports","evidence":"Searched at this site, and what the search returns is about a nerve rather than the tendon sheath. No study tests a series of small dextrose injections just under the skin for de Quervain's. What it does return is the superficial branch of the radial nerve, which crosses the same patch of skin over the radial styloid and can mimic the condition (Wartenberg's syndrome). That nerve has been treated with dilute dextrose twice, both times by hydrodissection rather than by this technique: ten weekly sessions of ultrasound-guided 5% dextrose in a woman whose nerve was snapping over the radial styloid five years after a scaphoid fracture took her pain from 8 to 0 out of 10 and restored thumb extension strength, with nerve conduction returning to normal (Yoon, Diagnostics 2026), and a second case gave lasting relief where nerve conduction studies had been normal (Maroc, Cureus 2025). A cadaveric study of 21 arms showed ultrasound can reach every segment of that nerve, but fluid placed under the fascia reached the layer just beneath the skin - where this treatment works - in only 57% of arms (Meng, Muscle Nerve 2014).","fit":"Considered only where examination finds tender, hypersensitive skin over the radial side of the wrist rather than pain along the tendons themselves. If the numbness or tingling pattern fits the nerve rather than the tendon sheath, that changes the diagnosis, and hydrodissection of the nerve is the better-described option.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"No controlled trials","evidence":"Direct evidence in de Quervain's, and none of it controlled. In 95 people with ultrasound-confirmed de Quervain's tenosynovitis, ultrasound-guided hydrodissection of the first extensor compartment lowered average pain from 7.7 to 1.7 out of 10 within two months, and 90 of the 95 improved; the five who did not all had a septum dividing the compartment and went on to surgery (Vita, JPRAS Open 2024). Note what was injected and where: the fluid goes around the tendons where they pass through the first dorsal compartment of the wrist, lifting them off the tight sheath. That is the same fluid-separation technique used at a nerve, applied to a tendon. There was no control group and no randomised trial, so how much of the improvement is the injection rather than time is not established.","fit":"Reasonable to discuss where a corticosteroid injection is unwanted or has not held. Worth knowing beforehand that a divided compartment on ultrasound predicts a poorer response and may point towards surgical review.","reviewedOn":"2026-09-08"}}},{"slug":"deep-gluteal-syndrome","title":"Deep Gluteal Syndrome (Piriformis Syndrome)","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/deep-gluteal-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line, on weak evidence","evidence":"Physiotherapy is the recommended first step and aligns with guidance for persistent sciatica, but a 2019 review for GPs found no controlled trial of physiotherapy in this condition at all (Hopayian, Br J Gen Pract 2019). The exercises used and the right duration before moving on are therefore not established.","fit":"The starting point: explanation, deep hip rotator and gluteal work, neural mobility, and cutting uninterrupted sitting time where sitting is the clear aggravator. The evidence behind it is weak, and patients are told so.","reviewedOn":"2026-09-25"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No placebo-controlled trial","evidence":"Thirty people with piriformis syndrome and a trigger point in the muscle had an ultrasound-guided injection of lidocaine and betamethasone into the piriformis, with pain and neuropathic pain scores improving most at one week and slipping slightly by one month, in a study with no control group (Terlemez, Agri 2019). Where needling has been compared with something, the needle won without an injectate: in 60 people randomised to trigger-point acupuncture or a corticosteroid injection, the acupuncture group had less pain and disability at two and three months (Liu, Zhen Ci Yan Jiu 2024), and dry needling of the piriformis improved hip extension during walking against a wait-list control in 32 people (Tabatabaei, J Bodyw Mov Ther 2023). No trial has compared a trigger point injection here with a placebo.","fit":"Only where a separate tender band of gluteal or deep rotator muscle is reproducing part of the pain. It does nothing about nerve compression.","reviewedOn":"2026-09-25"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Case series, and a diagnostic role","evidence":"Injection into the piriformis or around the sciatic nerve with local anaesthetic, corticosteroid or botulinum toxin is widely used, but the reports are mostly case series or trials with small numbers and design flaws. One randomised comparison of botulinum toxin against placebo reached statistical significance without clearly reaching clinical significance (Fishman, Muscle Nerve 2017). In 70 people randomised to a single ultrasound-guided piriformis corticosteroid injection or a single session of shockwave, both improved and neither was clearly better at five weeks (Fu, J Formos Med Assoc 2025).","fit":"Reasonable to discuss for persistent symptoms, delivered under ultrasound. A clear response also supports the deep gluteal space as the source, which matters when the lumbar imaging is unrevealing.","reviewedOn":"2026-09-25"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search for local vibration, vibration therapy and whole-body vibration against deep gluteal syndrome, piriformis syndrome and the sciatic nerve returns no records at all. Its low-certainty evidence base sits in myofascial pain generally.","fit":"Not a treatment for sciatic nerve irritation. Considered only where tight gluteal muscle is a separate contributor, and not applied over the sciatic notch.","reviewedOn":"2026-09-25"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Equal to cortisone, no sham trial","evidence":"Three randomised trials have tested shockwave in piriformis syndrome, the commonest form of this condition, and all against another active treatment. Thirty-five people had three weekly sessions of radial shockwave or a single ultrasound-guided methylprednisolone injection: both groups improved in pain and quality of life, the shockwave group improved by the first week where the injection group did not, and there was no difference between them at twelve weeks (Ahadi, J Bodyw Mov Ther 2022). Seventy people randomised to one shockwave session or one guided corticosteroid injection, both with home stretching, improved with no difference in the rate of improvement at five weeks (Fu, J Formos Med Assoc 2025). Forty-eight people had three sessions of radial shockwave or ultrasound-guided dry needling, both with stretching; pain fell from about 8 to about 3 or 4 out of 10 in both groups by three months with no difference between them and no side effects (Dede, Turk J Phys Med Rehabil 2026). No trial has a sham arm, so how much of the gain is the treatment itself is unknown, and no systematic review has assessed shockwave in this condition (PubMed, searched 28 October 2026).","fit":"Worth discussing where a tight, tender piriformis is the main problem, alongside the rehabilitation programme rather than instead of it. It does not address a space-occupying lesion compressing the nerve, and progressive weakness goes to a surgical opinion.","reviewedOn":"2026-10-28"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Radial device tested, not this one","evidence":"The two randomised shockwave trials in piriformis syndrome used a radial device (Ahadi, J Bodyw Mov Ther 2022) or did not state the device at all (Fu, J Formos Med Assoc 2025). No published trial in deep gluteal syndrome or piriformis syndrome reports using a focused device, so the evidence on the shockwave row above does not carry across to this one.","fit":"Not offered as a treatment for this condition. Directing a focused pulse at a major mixed nerve is not a described technique.","reviewedOn":"2026-09-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search for EMTT and magnetotransduction against deep gluteal syndrome, piriformis syndrome and the sciatic nerve returns no records at all, and there is no guideline support in any entrapment neuropathy.","fit":"Not part of managing this condition.","reviewedOn":"2026-09-25"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"One small trial, brief benefit","evidence":"Sixty people with piriformis syndrome were randomised to a single ultrasound-guided injection of platelet-rich plasma or saline. Both groups improved in pain and in the Oswestry Disability Index; the PRP group was clearly further ahead at one week, but by one month the two groups were the same, and the authors suggest a repeat injection would be needed for any longer effect (Öztürk, J Back Musculoskelet Rehabil 2022). That remains the only trial: a 2026 systematic review of PRP for problems around the hip found this one piriformis study and no other (Kuhns, Arthroscopy 2026), and a PubMed search on 28 October 2026 found no further trial and no case series of PRP injection in piriformis or deep gluteal syndrome. One small trial with one month of follow-up and no longer-term data.","fit":"Something to weigh up rather than a standard step, and only after physiotherapy has had a fair trial. The fair framing is a short-lived advantage over a saline injection that had gone by one month.","reviewedOn":"2026-10-28"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"The published material is two case reports, both of a specific structural target rather than the syndrome in general: ultrasound-guided dextrose into a calcified sacrospinous ligament, with pain falling from 10 to 1 out of 10 within a month (Yoon, Life 2025), and six sessions into a piriformis enthesopathy at the greater trochanter, holding at three months (Yoon, Cureus 2026). A narrative review lists deep gluteal syndrome among the pelvic pain conditions where prolotherapy has been described and calls for prospective studies (Cho, Curr Pain Headache Rep 2026). There is no trial.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for hyaluronic acid, hyaluronate, viscosupplementation and hylan against deep gluteal syndrome, piriformis syndrome and the sciatic nerve returns four records and not one is an injection of hyaluronic acid for this condition. The only relevant mention is a review of ultrasound-guided hip procedures, in which viscosupplementation is listed for the hip joint while the piriformis is a target for anaesthetic and corticosteroid instead (Blaichman, Radiographics 2019). There is no joint in the deep gluteal space to viscosupplement.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Perineural injection targets irritated superficial cutaneous nerve branches. The sciatic nerve in the deep gluteal space is a large mixed nerve lying deep to gluteus maximus and is not reachable by that technique.","fit":"Not relevant to this diagnosis.","reviewedOn":"2026-09-25"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Emerging, not established","evidence":"Fifty-three consecutive patients had ultrasound-guided sciatic nerve hydrodissection with 5% dextrose, lidocaine and betamethasone; 73.6% had at least halved their pain at one week and 62.3% at final follow-up between three and nineteen months, some needing up to three injections (Yen, Diagnostics 2024;14:757). That is an uncontrolled case series with no comparison group, so it shows feasibility rather than effectiveness. A separate case report describes the same technique relieving sciatic compression by an anomalous inferior gluteal artery (Wu, Diagnostics 2026).","fit":"Discussed for persistent symptoms after physiotherapy has been given a fair trial, framed as emerging. A space-occupying lesion compressing the nerve needs treating on its own terms, and progressive weakness goes to a surgical opinion.","reviewedOn":"2026-09-25"}}},{"slug":"dupuytrens-disease","title":"Dupuytren's Disease","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/dupuytrens-disease","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"A search of PubMed for shockwave and Dupuytren's disease or palmar fibromatosis (20 records, all read) found one radial report: a single 79-year-old man whose hand function improved over four weekly radial sessions and held at four months (Brunelli, Medicine 2020). A series of 23 people treated weekly for six weeks with a Roland E-SWT 2 device improved briefly on pain and hand scores, but pain and DASH were back to baseline at the final follow-up, and the paper does not say whether the device was radial or focused (Aykut, Sisli Etfal Hastan Tip Bul 2018). The only placebo-controlled trial used a focused device (Knobloch, Lasers Med Sci 2021), and that evidence sits in the focused row.","fit":"If shockwave is considered for a painful nodule, the focused device is the one with trial evidence; radial treatment has a single case behind it. Either way it sits alongside hand therapy, not in place of it.","reviewedOn":"2026-10-22"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat placebo in one 52-person trial","evidence":"One single-centre, blinded, placebo-controlled randomised trial in 52 people with painful Dupuytren's nodules before any contracture: three weekly sessions of focused electromagnetic shockwave (Storz Duolith) lowered pain from 3.6 to 1.9 out of 10 at three months and held at 1.9 at eighteen months, while pain in the placebo group rose from 2.2 to 3.1. Grip strength did not change in either group, the placebo group started with less pain, and the need for a later Dupuytren procedure (26% against 36%) was not significantly different (Knobloch, Lasers Med Sci 2021). Uncontrolled focused series agree in direction but are small: 20 people improved on hand function (DASH 60 to 47) and contracture angle (24 to 20 degrees) at fourteen weeks with little change in pain (Taheri, Adv Biomed Res 2022), and seven hands improved on pain in a diabetic series (Abdulsalam, Eur J Phys Rehabil Med 2018). A 45-person trial against laser and stretching reported pain and function gains in the shockwave group without a sham arm (Notarnicola, J Biol Regul Homeost Agents 2017). A 2024 systematic review of six studies (145 cases) rated the certainty moderate for pain and function and noted pain may return over time (Yazdani, Arch Phys Med Rehabil 2024). No study shows shockwave reverses an established contracture.","fit":"Discussed for painful nodules in the early stage of the disease, alongside hand therapy and stretching, to settle pain so the hand can be used and loaded normally. It is not a treatment for an established finger contracture, which remains a needle, enzyme or surgical decision.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study in people has tested a PRP injection for Dupuytren's disease. A PubMed search in October 2026 pairing platelet-rich plasma, platelet concentrate and platelet lysate with Dupuytren's disease and palmar or plantar fibromatosis returned four records, and none is a clinical study of PRP for the nodules, the cords or the contracture. The only PRP work is in the laboratory: human Dupuytren cells transplanted into rats' paws showed fewer markers of fibrosis after PRP combined with fat-derived stem cells (Ziegler, J Hand Surg Am 2023). A related product has been tried for a different purpose. In a randomised trial that analysed 64 people, a platelet-rich fibrin dressing laid on the open palm wound after Dupuytren's surgery shortened healing from a median of 29 days to 24 (Chignon-Sicard, Plast Reconstr Surg 2012). That is a wound dressing after an operation, not an injection, and the trial did not measure the contracture or whether it came back.","fit":"Not offered for the nodules, the cords or the contracture. Needle fasciotomy, collagenase where available, and surgery are the treatments that address the fibrous tissue itself. Considered only for a separate, clearly identified problem in the same hand.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested prolotherapy in Dupuytren's disease. A single case report describes a painless palmar nodule becoming smaller and softer after six sessions of isotonic dextrose injection, and its authors state that randomised trials are needed before the technique can be judged (Kersschot, Cureus 2022).","fit":"Does not release the cords or the contracture: needle fasciotomy, collagenase where available, and surgery are the treatments that address the fibrous tissue itself. Prolotherapy is offered here and can be discussed on the understanding that it rests on a single case report.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report","evidence":"One published report uses this exact technique in this condition. A 75-year-old man with a painless nodule in the palm was given glucopuncture - isotonic sugar water injected into the skin and palmar fascia - and after six sessions the nodule was markedly softer and smaller (Kersschot, Cureus 2022). The authors describe the technique as novel, propose an imaged case series as the next step, and say randomised trials of adequate size are needed before its value can be judged. That is the whole human literature here: no controlled trial, no comparison with needle aponeurotomy, collagenase or surgery, and nothing at all about the contracture as opposed to the nodule.","fit":"Worth raising only for a tender or painful early nodule where there is no contracture to correct. It will not straighten a finger that is already bent, and an established contracture belongs with a hand surgeon.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":false}}},{"slug":"femoroacetabular-impingement","title":"Femoroacetabular Impingement (FAI Syndrome)","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/femoroacetabular-impingement","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested radial shockwave in FAI syndrome, and it cannot alter cam or pincer morphology. The reason it is available here is the extra-articular pain that commonly accompanies FAI (gluteal tendinopathy, external snapping hip and greater trochanteric pain syndrome) for which shockwave is a recognised option (Zhang, Arthroscopy 2022).","fit":"Offered for a coexisting tendon or bursal target identified on examination, not for the impingement itself. If no such target is found, it is not the right treatment.","reviewedOn":"2026-09-06"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested shockwave for FAI syndrome itself, and it cannot change the cam or pincer shape of the bone. Its role here is for the problems that sit alongside FAI: an Arthroscopy editorial recommends extracorporeal shockwave, physiotherapy or local injection for mild external snapping hip in people with FAI rather than surgical release of the iliotibial band, and notes how often greater trochanteric pain syndrome accompanies FAI (Zhang, Arthroscopy 2022).","fit":"Offered when the examination finds a treatable target outside the joint (gluteal tendinopathy, a snapping iliotibial band, greater trochanteric pain), which is common in FAI and is often the part actually driving the symptoms. Not offered as a treatment for the impingement.","reviewedOn":"2026-09-06"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Tested: no benefit","evidence":"This is one of the few places where the answer is not \"untested\" but tested and negative. A randomised trial of 113 people having arthroscopic FAI surgery found platelet-rich plasma no better than a saline placebo on the iHOT-12 hip score at two years, and no better on the two other hip scores either (Foo, J Hip Preserv Surg 2021). A systematic review of eleven studies and 440 patients found PRP groups no different from controls, with one group scoring worse on pain and hip function; what benefit that review found came from cell-based therapies, not from PRP (George, Knee Surg Sports Traumatol Arthrosc 2023).","fit":"Not offered for FAI. That is a decision based on trials that tested it and did not find a benefit, rather than a gap in the evidence.","reviewedOn":"2026-09-06"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not established","evidence":"A PubMed search for prolotherapy or dextrose injection in femoroacetabular impingement returns no study of any design. Unlike PRP, which has been trialled here and did not work, prolotherapy has simply never been tested in this condition, and no injection changes the cam or pincer shape of the bone that causes the impingement.","fit":"Not offered for FAI. Where a separate ligament or attachment problem is found alongside the impingement, that is assessed and treated on its own terms.","reviewedOn":"2026-09-06"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"fibromyalgia","title":"Fibromyalgia (Chronic Widespread Pain)","region":"General","url":"https://www.backpaindoctor.com.au/conditions/fibromyalgia","pairings":{"rehab":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Strongest guideline recommendation","evidence":"Exercise is the one therapy with a strong recommendation in the EULAR revision, which reviewed 107 systematic reviews and meta-analyses (Macfarlane, Ann Rheum Dis 2017). A 2026 network meta-analysis of 21 randomised trials (1,638 people) found aerobic, resistance and mind-body exercise each improved pain or fatigue versus routine care (Pan, Pain Res Manag 2026), and a 2026 systematic review of six trials found aerobic and resistance exercise both improved pain and quality of life with no consistent difference between them (de Freitas, Pain Manag Nurs 2026). Medicines give modest benefit at best: a Cochrane review of 18 trials (7,903 people) found no clinically relevant advantage of duloxetine or milnacipran at 50 per cent pain relief (Welsch, Cochrane 2018).","fit":"Where care starts: education, graded exercise started low and progressed slowly, with a plan for flare-ups, plus sleep and mood support. Delivered alongside the GP and, where needed, a psychologist or rheumatologist.","reviewedOn":"2026-10-11"},"wetNeedling":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"One trial, pressure pain only","evidence":"Evidence is limited. One sham-controlled randomised trial of dry needling in fibromyalgia reported benefit on pressure pain threshold only, in the short term (Vicente-Mampel, 2024). A single trial with a narrow outcome does not establish an effect on pain or function.","fit":"A short-term option to discuss for a tender regional band, with the weak evidence stated. It does not replace exercise or sleep and mood care.","reviewedOn":"2026-10-11"},"guidedInjection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search of fibromyalgia with injection terms found no trial of image-guided local injection as treatment for fibromyalgia. The nearest is a single-centre, single-blind sham-controlled trial of stellate ganglion block in 68 people on stable duloxetine, which reported FIQR 29.9 points better than sham at one week and 22.9 at one month, with the authors cautioning that unblinding and placebo effects may explain part of it (Dadakci, Pain Res Manag 2026).","fit":"Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.","reviewedOn":"2026-10-11"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing fibromyalgia with vibration or percussive devices found no trial of handheld percussive devices in fibromyalgia.","fit":"Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.","reviewedOn":"2026-10-11"},"radialShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"One trial, mostly no difference","evidence":"The one sham-controlled randomised trial of radial shockwave in fibromyalgia found no statistically significant between-group differences on most measures, though visual analogue scale changes in the shockwave group reached the minimal clinically important difference, and it was reported as safe (Sanzo, Physiother Theory Pract 2024). A 2022 scoping review of 19 studies found benefit in localised myofascial pain but no evidence in fibromyalgia (Paoletta). A 2023 meta-analysis of 27 trials found shockwave beat control in myofascial pain syndrome but no better than dry needling, exercise or injections (Avendano-Lopez, Am J Phys Med Rehabil 2024). Myofascial pain is a regional condition, not fibromyalgia.","fit":"Only for a separate localised myofascial or tendon problem found on examination, not as treatment for fibromyalgia, with the single negative-leaning trial stated.","reviewedOn":"2026-10-11"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search of fibromyalgia with shockwave terms found one randomised trial, of radial shockwave (see that row), and none of focused shockwave.","fit":"Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.","reviewedOn":"2026-10-11"},"emtt":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Low quality, short term","evidence":"Evidence is low quality. A 2025 meta-analysis of six sham-controlled randomised trials of peripheral magnetic stimulation found low-quality evidence of short-term benefit, with long-term effects unknown (Leenus, 2025). For pulsed electromagnetic fields only a three-patient case series combined with ozone therapy was found (Lara-Reyes, 2026).","fit":"Offered only as an adjunct once exercise, education and sleep and mood care are under way, with the low-quality, short-term evidence explained first. Much of the device literature is manufacturer-linked.","reviewedOn":"2026-10-11"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing fibromyalgia with platelet-rich plasma found no trial.","fit":"Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing fibromyalgia with prolotherapy or dextrose found no trial.","fit":"Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.","reviewedOn":"2026-10-11"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Hyaluronic acid is for intra-articular problems. Fibromyalgia is a widespread pain condition, not a joint problem, and no trial of hyaluronic acid in it was found.","fit":"Not offered for fibromyalgia.","reviewedOn":"2026-10-11"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing fibromyalgia with perineural injection or nerve block found no trial beyond the stellate ganglion block trial described under guided injection.","fit":"Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.","reviewedOn":"2026-10-11"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing fibromyalgia with hydrodissection found no trial.","fit":"Not a treatment for fibromyalgia. Considered only where a separate regional problem is found on examination, and the evidence gap is stated.","reviewedOn":"2026-10-11"}}},{"slug":"finger-sprain","title":"Finger Sprains","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/finger-sprain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Injection only to free a locked joint","evidence":"Searched 8 November 2026 (PubMed: wrist, finger or thumb with sprain, ligament injury or collateral ligament and corticosteroid, steroid, triamcinolone or anaesthetic injection, 13 records; no trial). No study has tested a corticosteroid injection as treatment of a finger or thumb sprain. In two Japanese series, local anaesthetic injected into a knuckle joint locked by a caught collateral ligament or palmar plate allowed it to be freed by manipulation in 4 of 16 thumbs and 5 of 21 index fingers; the rest needed open surgery (Inoue, J Hand Surg Br 1988; Inoue, Orthop Rev 1991). Steroid injection at the index metacarpal tubercle, for pain the authors attribute to a subacute radial collateral ligament injury, relieved pain at four weeks in 5 of 9 hands, with 4 recurring by about three months (Brown, J Hand Surg Glob Online 2020). Local anaesthetic finger injections that let professional footballers play are described as among the safer injections, without figures (Orchard, Sports Med 2004).","fit":"Not a treatment for a finger sprain, which is buddy taping or splinting and early movement, with review for a ligament rupture or an unstable joint. Considered only for a specific complication identified on assessment.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave, radial or focused, in a finger or thumb sprain. A PubMed search for shockwave with the thumb, finger joints or wrist and ligament or injury terms (8 records, all read) found none for a finger ligament, and a trial and systematic-review pass over shockwave in ligament injuries (17 records) found none in the hand.","fit":"Not part of finger sprain care, which is splinting or buddy-strapping and early guided movement. Not a treatment expected to be used here.","reviewedOn":"2026-10-23"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a finger or thumb sprain. A PubMed search for shockwave with the thumb, finger joints or wrist and ligament or injury terms (8 records, all read) found shockwave used for slow-healing fractures and none for a finger ligament, and a trial and systematic-review pass over shockwave in ligament injuries (17 records) found none in the hand.","fit":"Not part of finger sprain care, which is splinting or buddy-strapping and early guided movement. Not a treatment expected to be used here.","reviewedOn":"2026-10-23"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study in people has tested PRP for a sprained finger or thumb, whether the side ligaments or volar plate of a finger joint, a skier's thumb or a pulley injury. A PubMed search in October 2026 pairing platelet-rich plasma and platelet concentrate with those terms returned 12 records, and a second pass adding orthobiologics and prolotherapy returned seven. None is a clinical study of PRP for a finger or thumb ligament; the records in people concern other problems in the hand, such as rheumatoid finger joints (Shively, Cureus 2021).","fit":"Not offered for this. These settle with protection, graded loading and time, and no trial has shown an injection shortens that.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy for a finger or thumb ligament sprain, including the thumb's ulnar collateral ligament, was found. PubMed search, 14 October 2026: prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain or collateral ligament terms (21 records), and prolotherapy with ligament, finger or thumb terms (121 records, all screened), each with randomised-trial and systematic-review passes; the finger and thumb records returned concern arthritis, trigger finger or Dupuytren's disease. The nearest controlled evidence is in a different condition, finger and thumb-base arthritis, where a placebo-controlled trial of 27 people injected dextrose either side of the arthritic joints (Reeves, J Altern Complement Med 2000).","fit":"A complete ligament tear that needs surgical repair has to be excluded first. Prolotherapy can be discussed for a finger or thumb ligament that stays sore after splinting and hand therapy, with the absence of studies stated.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Untested, rather than tested and found not to work. A search pairing hyaluronic acid with finger, thumb and wrist sprain and ligament injury terms returned one record: a meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems. Its only hand condition was trigger finger, which is a tendon problem and not a sprain, and the benefit there was uncertain across two trials (Khan, Sports Health 2022). No study has used the injection for a sprained finger joint.","fit":"Not offered for this problem. A sprained finger settles with protection, graded movement and time.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested dextrose injections of any kind for a sprained finger or thumb. Searching dextrose, prolotherapy, glucopuncture and perineural injection against wrist, finger and thumb sprain, collateral ligament and volar plate injury returns 15 records, none of them a study of a finger or thumb ligament injury. The dextrose evidence in the fingers is in arthritis and uses a different injection. In a double-blind trial of 27 people with osteoarthritic finger and thumb joints, 10% dextrose injected at the sides of each joint improved pain with movement by 42% against 15% with the control solution at six months, while pain at rest and with grip did not differ significantly (Reeves, J Altern Complement Med 2000). The technique in this row has one report at the hand: an older woman with severe thumb-base arthritis whose pain fell from 8-9 to 0-1 out of 10 after three sessions of glucopuncture, small 5% glucose injections placed by feel, held at one year (Lam, Cureus 2025). That is one case, and arthritis rather than a sprain. There is also a harm report in the finger: repeated prolotherapy for a trigger finger left a 47-year-old with worse tendon sheath inflammation and a fibrous nodule that had to be removed surgically (Oh, J Surg Case Rep 2023).","fit":"Not part of treating a finger sprain, where protection and graded movement do the work. Considered only if tender, hypersensitive skin along the side of the finger persists after the ligament has healed.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with sprain, ligament injury, collateral ligament or volar plate, 5 records, none in the hand; the same terms with the digital nerves, 12 records; a randomised-trial and systematic-review pass returned none). No study has tested hydrodissection for a sprained finger or thumb. The hand records concern other problems, such as tendon adhesions after surgery (Schwartz, Ann Plast Surg 2026; Girón Mariñas, Rehabilitacion 2021), and a retrospective series of nerve injections in the arm included a single digital nerve (Walsh, AJR 2019).","fit":"Not part of treating a finger sprain, where protection and graded movement do the work. Considered only if a nerve along the side of the finger is found to be caught after the ligament has healed.","reviewedOn":"2026-11-10"}}},{"slug":"frozen-shoulder","title":"Frozen Shoulder","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/frozen-shoulder","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No controlled trial has tested trigger point injection in frozen shoulder. The injection evidence is five case reports of subscapularis trigger point infiltration combined with a subscapular nerve block in people who had not responded to usual treatment (Jankovic, Acta Anaesthesiol Belg 2006). The needling evidence is stronger but still limited: 70 people given dry needling of shoulder girdle trigger points alongside physiotherapy improved in pain, range and disability over twelve days, in a study with no control group (Kalia, J Bodyw Mov Ther 2020), and a randomised trial of 88 people compared intramuscular electrical stimulation with dry needling, both with exercise, where both arms improved and the difference between them fell below what patients notice (Shanmugam, Int J Surg Protoc 2021). Neither trial included a group that had no needling.","fit":"Aimed at the tight shoulder girdle muscles that often accompany a frozen shoulder, not at the capsule itself. Considered where those muscles are reproducing part of your pain and are limiting the movement work.","reviewedOn":"2026-09-11"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"A double-blind randomised trial found ultrasound guidance made glenohumeral injection 100% accurate against 71% blind, yet produced no difference in pain, function or range of movement out to 12 weeks (Cho, Bone Joint J 2021).","fit":"Injection has a real place in the painful phase. Guidance is used where the joint is difficult to enter rather than as a routine.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Searched 27 October 2026: shockwave, shock wave or ESWT with frozen shoulder or adhesive capsulitis (40 records, all read), with a trial and review pass (14). Radial shockwave has beaten a dummy treatment in three randomised trials. In 30 people all doing a physiotherapy program, six weeks of radial shockwave eased pain by 3.3 points out of 10 more than sham and improved disability (DASH) by about 25 points at twelve weeks (Sharahili, Saudi Med J 2025). In 60 people who all had a cortisone and local anaesthetic injection and a strengthening program, twelve radial sessions gave about 2 points more pain relief than a placebo head, still present at six months (Nambi, Pain Ther 2024). In 39 people with type 2 diabetes, two energy levels of radial shockwave both improved function more than placebo at six weeks (Saldiran, Eur J Phys Rehabil Med 2022). In 103 people with diabetes, four radial sessions gave better pain (1.6 against 2.8 out of 10) and function than a guided cortisone injection at twelve weeks, with similar movement (El Naggar, J Shoulder Elbow Surg 2020). All of these are small single-centre trials, and the most cautious review, which judged every one of its 23 trials at high risk of bias, rated the certainty very low and did not recommend shockwave for frozen shoulder (Brindisino, Disabil Rehabil 2023). No harms beyond short-lived soreness were reported.","fit":"Used alongside the mobility and loading program, where pain is limiting progress through the stiff phase. It can sit with a guided injection rather than replace it. Expect easier pain and some gain in movement over weeks; the capsule still takes months to settle.","reviewedOn":"2026-10-27"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat sham in one small trial","evidence":"Searched 27 October 2026 (the 40 frozen-shoulder shockwave records named in the radial row, all read). Most of the frozen-shoulder trials used radial devices; the focused evidence is thinner. In one randomised trial of 36 people, all of whom first had a cortisone injection and exercises, four weekly sessions of focused (electromagnetic) shockwave improved pain, disability and most directions of movement more than sham, though not internal rotation (Vahdatpour, Int J Prev Med 2014). A later analysis of a placebo-controlled trial in people with diabetes reported improvement in pain in 86% of those given focused shockwave against 36% on placebo at four weeks, without a formal comparison (Rai, Ann Rehabil Med 2026). The other focused studies are a non-randomised comparison with physiotherapy (Lee, J Phys Ther Sci 2017), a dose comparison with no untreated group (Tseng, JSES Int 2026; bruising or swelling in 5 of 48) and an uncontrolled series of 94 (Mercurio, Orthop Traumatol Surg Res 2026). A meta-analysis of 20 randomised trials found shockwave added to usual treatment improved pain and function in the short term, but it did not separate focused from radial devices and long-term results were inconsistent (Zhang, Orthop J Sports Med 2022); a second review rated the evidence very low certainty (Brindisino, Disabil Rehabil 2023).","fit":"An adjunct to the mobility and loading work, discussed where pain is limiting progress through the stiff phase. The radial device has the stronger frozen-shoulder trials.","reviewedOn":"2026-10-27"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Outlasted cortisone in pooled trials","evidence":"Tested in more than a dozen randomised trials in frozen shoulder, nearly all against a cortisone injection rather than a dummy injection. Pooled, the two were level for the first month and PRP was ahead later: across 7 trials and 692 people pain was lower by about 1 point out of 10 and shoulder disability (SPADI) by 17 points out of 100 at six months, on evidence its authors grade low to moderate (Peng, J Back Musculoskelet Rehabil 2026), and across 13 trials and 1,056 people pain was lower by 1.8 points at six months with no difference at one or three months (Xu, Front Med 2026). Most of those trials were small, single-centre and unblinded. Against a saline dummy injection there is one small triple-blind trial: 32 people had three injections a fortnight apart with an exercise program, and pain, disability and movement were better with PRP at three months (Ünlü, Int Orthop 2020). The contrary findings matter. In the one three-arm trial with both a cortisone and a saline group (90 people, ultrasound-guided, all with physiotherapy), cortisone was clearly better than PRP from one month through six, and all three groups improved (Hsieh, Arch Phys Med Rehabil 2026). Added to a home exercise program, two ultrasound-guided PRP injections improved movement but not pain or disability at twelve weeks in 40 people (Karabaş, Turk J Phys Med Rehabil 2021), and a single injection did no better than six weeks of physiotherapy in 64 (Thu, J Int Med Res 2020).","fit":"An option that can be discussed for a frozen shoulder that is still painful and stiff after time and a stretching program, particularly where a cortisone injection has worn off or is best avoided. Cortisone usually works faster in the first month, and Patients are told so. If used, PRP is injected into the shoulder joint under ultrasound guidance alongside the exercise program, and the response is reviewed at about three months.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Two randomised trials, pointing different ways. Ultrasound-guided capsule-preserving hydrodilatation with 20 mL of 5% dextrose matched 40 mg triamcinolone on pain, disability and range of motion at twelve weeks in 84 people, though the dextrose group used more anti-inflammatories at eight weeks (Liu, J Shoulder Elbow Surg 2025). Against saline, however, prolotherapy improved pain and function no more than the saline injection did, separating only on some range-of-motion measures (Sam, Medicine 2023). Read together, much of the benefit may come from the volume of fluid distending the capsule rather than from the dextrose.","fit":"Of interest mainly where a corticosteroid injection is unsuitable: poorly controlled diabetes, or repeated steroid exposure already. It buys a window for the stretching and loading work; it does not shorten the condition on its own.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Hyaluronic acid has been tested here and has not stood out. A network meta-analysis of 31 studies found intra-articular hyaluronate (2 randomised trials, 42 people) gave no benefit over physiotherapy at twelve weeks, while cortisone (8 trials, 340 people) and PRP (3 trials, 177 people) did (Berner, Rheumatology 2024). A later randomised trial of 56 people found the high-molecular-weight form outperformed the low-molecular-weight form, but it had no untreated comparison group (Mir, Future Sci OA 2025).","fit":"Not a first choice here. Raised only where cortisone is unsuitable, and with the weakness of the evidence stated at the time.","reviewedOn":"2026-09-07"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Dextrose tested as a different procedure","evidence":"No study has tested a series of subcutaneous dextrose injections in frozen shoulder. The dextrose evidence at this shoulder belongs to two other procedures. A noninferiority randomised trial gave 84 people three capsule-preserving hydrodilatations with either 20 mL of 5% dextrose or triamcinolone and found the two equivalent on pain, disability and range of motion through twelve weeks (Liu, J Shoulder Elbow Surg 2025), which distends the joint capsule rather than treating a nerve. A narrative review sets out ultrasound-guided hydrodissection of the suprascapular, axillary and subscapular nerves as the nerve-targeted option, and calls its own framework preliminary and in need of prospective testing (Chang, Life 2026).","fit":"Considered where tender, hypersensitive skin is found over the shoulder rather than the deep, stiff, end-of-range pain that defines this condition.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"The frozen shoulder evidence is for hydrodilatation, not nerve hydrodissection. A scoping review that screened 138 studies and included 21 reports adhesive capsulitis among the conditions where the technique may relieve pain and improve function, but pools hydrodissection with hydrodilatation: distending the joint capsule with fluid, which is a different procedure aimed at the capsule rather than at a nerve (Leahy, Front Pain Res 2026). No trial of nerve hydrodissection in frozen shoulder was found.","fit":"Only where assessment finds a nerve contributing alongside the stiff capsule; suprascapular nerve pain is the pattern that occasionally fits. Capsular hydrodilatation is a different procedure and a separate conversation.","reviewedOn":"2026-09-08"}}},{"slug":"ganglion-cyst","title":"Ganglion Cyst of the Wrist and Hand","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/ganglion-cyst","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No radial studies","evidence":"A tested absence for the radial device. On 11 November 2026 shockwave, shock wave and ESWT crossed with ganglion cyst, wrist ganglion, hallux valgus and bunion returned three records. One is a single case of a finger tendon-sheath ganglion treated with shockwave, whose abstract gives no device, dose or result (Lemhoefer, Hand Surg Rehabil 2025). The other two are unrelated: a review of implant reactions and a surgical series. No study of radial shockwave for a ganglion was found.","fit":"Not used for the cyst itself. Considered only for a separate tendon or muscle problem in the same limb.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"A search of PubMed for shockwave terms with ganglion cyst, ganglion cysts or wrist ganglion, with a trial and systematic-review pass, found one clinical report: a single finger tendon-sheath ganglion treated with shockwave, whose abstract gives no device, dose or result (Lemhoefer, Hand Surg Rehabil 2025; full text not available through PubMed). The other records concerned nerve ganglia or kidney-stone lithotripsy.","fit":"Considered only for a coexisting tendinopathy, not for the cyst itself.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A PubMed search for platelet-rich plasma or prolotherapy in ganglion cyst returns four records, and in none of them is the cyst itself the target. Two are case reports where the injection was aimed at something else: platelet-rich plasma given during surgical excision of a tibialis anterior tendon ganglion (Sajeev, J Orthop Case Rep 2026), and dextrose prolotherapy to a triangular fibrocartilage enthesis after the cyst had been aspirated (Yoon, Cureus 2026). There is no study of platelet-rich plasma as a treatment for a ganglion.","fit":"Not offered. A ganglion is a pocket of joint or tendon-sheath fluid, not a degenerate tendon, so there is nothing here for platelet-rich plasma to act on. Many settle on their own; where one is painful or in the way, ultrasound-guided aspiration or surgical excision are the options with a track record.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested prolotherapy in ganglion cysts. One case report describes aspiration followed by 10% dextrose injected into the adjacent wrist enthesis, with pain resolving over five sessions, and it frames the prolotherapy as treating the underlying joint problem rather than the cyst (Yoon, Cureus 2026).","fit":"Does not remove a cyst. Where a ganglion is symptomatic, aspiration or surgical excision addresses the cyst; any injection would be aimed at a separately identified joint or ligament problem sitting behind it.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a compressed nerve","evidence":"Nothing tests small dextrose injections under the skin for a ganglion. The dextrose report at a wrist ganglion is a different procedure: the cyst was aspirated under ultrasound and 10% dextrose was then injected into the triangular fibrocartilage attachment it arose from, five sessions two weeks apart, with the pain resolving (Yoon, Cureus 2026). Where this row does become relevant is a ganglion pressing on a nerve. Across 242 ultrasound-guided perineural procedures on the upper limb, a ganglion cyst was the compressing lesion in four; of 89 patients with follow-up, 52 had a period of relief averaging 125 days and six had complete resolution, with no complications attributable to the injections (Walsh, AJR 2019) - but those injections were placed around the nerve under ultrasound, not as a series just beneath the skin.","fit":"Considered only where the cyst is irritating a nearby nerve and the skin over it is tender and hypersensitive. A cyst that is simply a lump, or one causing mechanical catching, is not what this treats.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":false}}},{"slug":"gout","title":"Gout","region":"General","url":"https://www.backpaindoctor.com.au/conditions/gout","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Education and lifestyle advice sit alongside urate-lowering treatment, not instead of it. The EULAR recommendations make education about the disease and its treatment, together with lifestyle advice including weight loss where appropriate, cutting back alcohol and sugary drinks, and regular exercise, an overarching principle of gout care, with urate-lowering treatment to keep uric acid below 360 µmol/L (Richette, Ann Rheum Dis 2017). The American College of Rheumatology guideline likewise recommends treating to a uric acid target and gives conditional recommendations on alcohol, diet and weight loss (FitzGerald, Arthritis Care Res 2020). The strongest trial evidence is for education and engagement: in a multicentre randomised trial of 517 people in UK general practice, nurse-led care built on individual education and shared decision making got 95% to target uric acid at two years against 30% with usual care, with fewer flares and fewer tophi (Doherty, Lancet 2018). That benefit came through better uptake of urate-lowering treatment; the exercise advice in these guidelines is general lifestyle guidance rather than the result of trials of an exercise programme in gout.","fit":"This does not replace medical treatment. In gout, what prevents flares and joint damage is getting the uric acid level down and keeping it there, so assessment here is aimed at recognising the pattern, making sure that treatment is in place, and keeping you moving and loading the affected joints as flares settle.","reviewedOn":"2026-11-04"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Guideline-backed, no trials","evidence":"Injecting corticosteroid into a gouty joint is standard practice that has never been put through a randomised trial. A Cochrane review looking for trials of corticosteroid injection in acute gout found none (Wechalekar, Cochrane Database Syst Rev 2013), and searches of PubMed in October and November 2026 for any randomised or controlled trial since, or any comparison of guided with unguided injection, found none. It rests on guidelines instead: the American College of Rheumatology strongly recommends colchicine, anti-inflammatories or corticosteroid (by mouth, into the joint or into muscle) for a flare (FitzGerald, Arthritis Care Res 2020), EULAR lists an injection into the joint among its first-line options (Richette, Ann Rheum Dis 2017), and Chinese guidelines prefer an injection into the joint over corticosteroid tablets for people who also have cardiovascular disease or diabetes (Li, Int J Rheum Dis 2025). In one uncontrolled study of this row's exact procedure, 21 people with an acute attack in the big toe joint had ultrasound-guided triamcinolone: pain fell by an average of 48 points out of 100 within 48 hours, with no adverse events and no comparison group (Kang, J Clin Ultrasound 2015).","fit":"Useful for a single hot, swollen joint when tablets are unsuitable or have not settled it, once infection has been ruled out, which may mean taking fluid from the joint for testing first. It treats the flare, not the urate level that causes flares, so it is coordinated with your GP or rheumatologist and your long-term treatment, not used instead of it.","reviewedOn":"2026-11-05"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 27 October 2026: shockwave, shock wave, ESWT or pressure wave with gout, gouty, tophus, tophi or tophaceous, excluding kidney-stone records (2 records, neither a treatment study), and radial device terms with gout (0 records). The trial and review pass for this condition is named in the focused row. No study has tested radial shockwave in gout. Gout is treated by lowering urate and settling flares, and a pressure wave over an inflamed joint has no tested role in either.","fit":"Considered only for a separate muscle or tendon problem alongside it, never over a joint that is flaring.","reviewedOn":"2026-10-27"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search of PubMed for shockwave terms with gout or gouty, and separately with tophus, tophi, tophaceous, crystal arthritis or monosodium urate, with a trial and systematic-review pass, found no study of shockwave as a treatment for gout: every record concerned kidney-stone lithotripsy or a different crystal disease. Gout is managed by lowering urate and settling flares, and shockwave has no tested role in either.","fit":"Considered only for a separate mechanical problem alongside it.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.","fit":"Not part of the plan here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not a gout treatment; flares reported","evidence":"No study has tested PRP as a treatment for gout. A PubMed search in October 2026 pairing platelet-rich plasma with gout, tophi, urate and the other crystal arthritis terms returned 19 records, and none is a trial or a case series of PRP for a gouty joint. What the literature holds instead is reports of crystal arthritis set off by PRP given for something else: a first attack of gout in several joints after a PRP injection (Porter, Scand J Rheumatol 2023), a knee that swelled within an hour of PRP and was shown to contain pseudogout crystals, settling over two weeks (Andrews, Clin J Sport Med 2026), and a case series of pseudogout flares after PRP (Schroeder, PM R 2022). In a review of 225 people given PRP for knee osteoarthritis at three hospitals, those whose uric acid was poorly controlled were among those with marked pain and swelling afterwards; the report gives no figures for this (Chen, J Orthop Surg (Hong Kong) 2024). A platelet gel has also been used as a dressing on a gouty ulcer in a single case (Chen, Indian J Dermatol 2020), which is wound care and not joint treatment.","fit":"Not a treatment for gout, which is managed by settling attacks and lowering uric acid with your GP or rheumatologist. PRP is considered only for a separate tendon or joint problem, between attacks, and patients are told that flares after PRP have been reported, particularly where uric acid is not well controlled.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not a gout treatment","evidence":"No study has tested prolotherapy as a treatment for gout. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose, hyperosmolar dextrose or regenerative injection therapy with gout, gouty, crystal arthritis or inflammatory arthritis, then randomised-trial and systematic-review passes) returned no trial, case series or case report of prolotherapy for a gouty joint; the records that matched were reviews of other injections that mention gout in passing.","fit":"Not a treatment for gout, which is managed by settling attacks and lowering uric acid with your GP or rheumatologist. Prolotherapy is considered only for a separate ligament or tendon problem, between attacks, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has treated gout itself with hyaluronic acid. What the literature answers is the opposite question (whether a history of gout rules out viscosupplementation for osteoarthritis in the same joint) and the EUROVISCO consensus answers no: it supports intra-articular hyaluronic acid in knee osteoarthritis in people with a history of gout or calcium pyrophosphate deposition, while recommending against injecting during an active flare (Conrozier, Cartilage 2024). In calcium pyrophosphate disease, a different crystal arthritis, a systematic review of 22 studies and 403 patients found intra-articular hyaluronic acid associated with symptomatic improvement, but only in uncontrolled reports (Parperis, Semin Arthritis Rheum 2020).","fit":"Not a treatment for gout, which is managed by lowering urate and settling attacks. Discussed only where a joint is left with established osteoarthritis between attacks, and not while a joint is flaring.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"greater-trochanteric-pain-syndrome","title":"Greater Trochanteric Pain Syndrome (Hip)","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/greater-trochanteric-pain-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"The strongest evidence here is what does not work. In a placebo-surgery controlled trial, arthroscopic subacromial decompression gave no benefit over a sham operation or over exercise therapy, at two years, at five, and at ten (Paavola, BMJ 2018; Paavola, Br J Sports Med 2020; Kanto, BMJ 2025). A network meta-analysis of 54 trials and 3,893 patients found shoulder-specific exercise reduced pain out to 52 weeks, and that adding injections, manual therapy or electrotherapy to it added little (Silveira, PLoS One 2024).","fit":"Loading the shoulder properly is the treatment. An injection is occasionally used to settle pain enough to start, which is a different claim from treating the problem.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Dry needling studied, not injection","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, intramuscular injection or wet needling with greater trochanteric, gluteus medius, gluteal tendinopathy or lateral hip pain, 6 records, none a clinical study of this treatment; and a randomised-trial and systematic-review pass with dextrose, trigger point, dry needling or local anaesthetic, 12 records). No study has injected a buttock-muscle trigger point in this condition, with glucose or anything else. The nearest evidence is dry needling, which uses the same needle with nothing injected and is not offered here: in a 43-person trial, six weeks of dry needling was not inferior to a cortisone injection for pain and function at six weeks, with no adverse effects reported (Brennan, J Orthop Sports Phys Ther 2017), and a review of trials comparing the two found no difference in this condition, at very low certainty (Sousa Filho, Chiropr Man Therap 2021). In a network meta-analysis of 13 trials, only PRP and shockwave beat no treatment for pain at one to three months, and no treatment did at six to twelve months (Gazendam, Clin J Sport Med 2021).","fit":"Considered only where examination finds a tender buttock-muscle band contributing to the pain, as an adjunct to the loading program, which treats the tendon itself.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Bursal and sheath targets are small, often deep, and poorly identified by surface landmarks; ultrasound guidance improved accuracy across shoulder girdle targets and improved efficacy where the target was a sheath rather than a large space (Aly, Br J Sports Med 2014).","fit":"Where an inflamed bursa is the identified target, this is a reasonable step, with the number of injections kept low. See the note on cortisone.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Outlasted cortisone, no sham win","evidence":"Radial shockwave is the form the first trials at the outer hip used. In 229 people allocated in turn to home training, one cortisone injection or low-energy radial shockwave, cortisone was well ahead at one month (75% recovered or much improved, against 13% with shockwave), shockwave was ahead of both at four months (68% against 51% and 41%), and at fifteen months shockwave and home training (74% and 80%) were both ahead of cortisone (48%) (Rompe, Am J Sports Med 2009). A non-randomised comparison of 66 people, classed as radial by later reviews, found less pain than usual care at one, three and twelve months (Furia, Am J Sports Med 2009). In a randomised trial of 60, three sessions with a radial device matched a cortisone injection at three weeks and three months (Çağlar Yağcı, Turk J Phys Med Rehabil 2023). What is missing is a win against a sham. The one double-blind trial, in 120 people who also did a home exercise program, found the recommended dose no better than a minimal dose at any point to six months (Wheeler, Clin J Sport Med 2022). Pooling eight randomised trials and 754 people, five of focused and three of radial devices, shockwave gave a modest reduction in pain at two to four months, the focused form reduced pain more than the radial form, and seven of the eight trials were at high risk of bias (Rhim, JBJS Rev 2024).","fit":"A reasonable option to discuss for gluteal tendon pain that has not settled with education and loading, as an alternative to repeating cortisone. The focused form has the stronger evidence at this site, including the only positive sham-controlled trial, and that is said when the two are compared. Either way it is added to the loading program, not used instead of it.","reviewedOn":"2026-10-09"},"focusedShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Focused shockwave has the only sham-controlled trial at the outer hip, and it was positive. Across several centres, 103 people with long-standing pain did the same exercise program with three weekly sessions of focused shockwave or a sham. Pain fell from 6.3 to 2.0 out of 10 with treatment against 4.7 with the sham at two months, 87% were counted a success, and the difference held to six months with no complications (Ramon, J Bone Joint Surg Am 2020). Against an ultrasound-guided cortisone injection in 104 people there was no difference at three months and focused shockwave was ahead at twelve, pain 37 against 55 out of 100 (Heaver, Hip Int 2023). It reduced pain more than therapeutic ultrasound at two and six months in 50 people (Carlisi, Clin Rehabil 2019), and added to eccentric exercise it reduced pain more than exercise alone at two and six months in 53 (Shi, Zhongguo Gu Shang 2021). The contrary findings are these. In 44 people it was no different from an exercise program over six months (Notarnicola, J Pers Med 2023). Pooled across eight trials, the gain in function at six months was below the smallest change people notice, and seven of the eight trials were at high risk of bias (Rhim, JBJS Rev 2024). A second pooled analysis found no statistically significant advantage over control for pain or function (Harding, Musculoskeletal Care 2024). The older reviews that first supported shockwave here were written when the only trials were of the radial form (Mani-Babu, Am J Sports Med 2015; Korakakis, Br J Sports Med 2017).","fit":"A reasonable option where a gluteal tendinopathy has not settled with loading, and a better long-term bet than repeated corticosteroid.","reviewedOn":"2026-10-09"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Beat cortisone, not placebo","evidence":"Tested in five randomised trials at the outer hip, and they divide by what PRP was compared with. Against a cortisone injection it came out ahead. In a double-blind Melbourne trial of 80 people with gluteal tendinopathy, one ultrasound-guided injection into the tendon left the hip score at 74 out of 100 with PRP against 67 with cortisone at twelve weeks, and 78 against 66 at 24 weeks. The people who had PRP were at 83 two years later, in follow-up that was by then neither blinded nor controlled (Fitzpatrick, Am J Sports Med 2018 and 2019). A trial of 24 found the same direction at 24 weeks (Begkas, Cureus 2020), and in 92 people PRP was ahead of needling of the tendon attachment on sporting function at a year (Atilano, Orthop J Sports Med 2024). Against a dummy injection it was not ahead. In a double-blind trial of 79 people, ultrasound-guided PRP into the bursa and gluteus medius tendon was no different from placebo on any measure at any point to twelve months, and its authors do not support routine use (Atchia, J Bone Joint Surg Am 2025). A New Zealand trial of one injection against saline, both with an exercise program, found no difference in any outcome over a year (Thompson, N Z Med J 2019). A network meta-analysis of 13 trials and 1,034 people, completed before the larger placebo trial, found PRP better than no treatment for pain at one to three months and not beyond (Gazendam, Clin J Sport Med 2021).","fit":"Can be discussed for gluteal tendon pain that has not settled with education and a loading program, especially where a cortisone injection has helped only briefly. The position is that PRP has outlasted cortisone in trials but has not beaten a dummy injection, so some of the improvement may be time and exercise. If used, it is placed into the tendon under ultrasound guidance, the loading program continues, and the response is reviewed at about three months.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report only","evidence":"No trial or case series of prolotherapy at the outer hip was found. PubMed searches on 13 October 2026 (prolotherapy, dextrose, hypertonic glucose or hyperosmolar with trochanteric, greater trochanter, gluteal, gluteus, gluteal tendinopathy, hip bursitis or lateral hip pain) returned 19 distinct records, and passes restricted to randomised trials and to systematic reviews or meta-analyses found nothing in this condition. The one clinical record is a published case letter describing ultrasound-guided prolotherapy for gluteus medius tendinopathy that presented as a snapping hip; it has no abstract and its outcome has not been read (Hung, Pain Med 2015). The rest concerned the deep buttock, the sciatic nerve, the low back or unrelated uses of dextrose. The prolotherapy trials sit at other tendons, chiefly the elbow, the shoulder and the plantar fascia (Capotosto, Orthop J Sports Med 2024).","fit":"Can be discussed where outer-hip pain persists despite a well-run gluteal loading program and load advice, with the absence of studies stated. Shockwave has controlled trials at the outer hip; prolotherapy does not.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Hyaluronic acid was one of the treatments compared in a network meta-analysis of 13 randomised trials and 1,034 people with this exact condition, and it did not separate from no treatment at any time point. PRP and shockwave both beat no treatment for pain at one to three months, and structured exercise was the only treatment to improve function (Gazendam, Clin J Sport Med 2021).","fit":"Not offered for this problem. Loading exercise, shockwave and PRP are the options with trial support at this site.","reviewedOn":"2026-09-07"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for perineural injection, neural prolotherapy or perineural dextrose combined with trochanteric or gluteal pain returns no study in this condition.","fit":"Not offered. Gluteal tendon loading and reducing the compressive positions that irritate the tendon are the treatments with evidence behind them here.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Named in a review, with no primary study behind it that could be found. A scoping review of hydrodissection and hydrodilatation for joint pain screened 138 studies and included 21, and lists greater trochanteric pain syndrome among the conditions where the technique may relieve pain and improve function, with consistently low complication rates but wide variation in technique and injectate (Leahy, Front Pain Res 2026). A search for hydrodissection or hydrorelease against trochanteric, gluteal tendinopathy and snapping hip returned no trial of the technique in this condition.","fit":"Only where a nerve is separately implicated, most often the lateral femoral cutaneous nerve or a gluteal branch. The tendon and bursa are treated by the options higher up this page.","reviewedOn":"2026-09-08"}}},{"slug":"hallux-rigidus","title":"Hallux Rigidus (Stiff Big Toe)","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/hallux-rigidus","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested any needling technique in hallux rigidus. A search pairing dry needling, trigger point needling and trigger point injection with arthritis of the shoulder, elbow, wrist, thumb base and big toe, including the terms hallux rigidus, hallux and first metatarsophalangeal joint, returned 19 records and none at the big toe; a second pass restricted to clinical trials returned none at the big toe either.","fit":"Only where a separate tender muscle band in the foot or calf is reproducing part of the pain. It does not treat the stiff, arthritic joint.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Guided no better than blind","evidence":"At the big toe joint, guidance was tested and did not change the result. In a single-blind randomised trial of 50 people, landmark-guided and ultrasound-guided corticosteroid injection improved pain and function equally at six weeks, with both groups improving significantly from baseline and no complications in either (Emami Razavi, Foot Ankle Int 2021). The injectate that has been tested against a dummy injection did not work: a Cochrane review of six trials in 547 people found, at moderate certainty, that a single hyaluronic acid injection gave no clinically important benefit over placebo, drawing on a randomised trial of 151 people (Munteanu, Cochrane Database Syst Rev 2024; Munteanu, Ann Rheum Dis 2011). No placebo-controlled trial of corticosteroid at this joint appears in that review.","fit":"An option for settling a flare enough to get footwear and loading changes underway, rather than something to repeat. A rocker sole or stiff-soled shoe does more for this joint over time.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Technique report only","evidence":"There is no trial of shockwave of either device in hallux rigidus, and a search restricted to randomised trials returns nothing at this joint. What exists is a single technique report from a sports medicine group, who apply radial pressure waves over the big toe joint and the tendons and sesamoid bones around it, about 3,000 pulses at 2 to 3 bar, alongside foot strengthening and joint mobilisation. They report better toe extension and less pain with activity as clinical experience, with no control group and no outcome figures, and note that radial pulses over bone are painful and that the focused form may be better tolerated (Reilly, Video J Sports Med 2022).","fit":"Considered for the tight, tender calf and foot muscle and the soft tissue around a stiff big toe joint, alongside the footwear change, a stiff-soled or rocker shoe and the mobility work that make the real difference. Over the joint itself it is uncomfortable, and the focused form is usually the better choice there.","reviewedOn":"2026-10-04"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Described, not yet trialled","evidence":"Shockwave for a stiff, painful big toe joint has been described but not trialled. A sports medicine group reports using it alongside foot strengthening and joint mobilisation, applying it over the joint and the soft tissue around it, and notes that the focused form is better tolerated over bone than radial pressure waves. They report better toe extension and less pain with activity as clinical experience, without a control group or outcome figures (Reilly, Video J Sports Med 2022). No randomised trial exists at this joint; the trial evidence for shockwave in osteoarthritis is at the knee and hip (Tang, Int J Surg 2024; Şah, J Pers Med 2022).","fit":"A reasonable option to try for a painful big toe joint that has not settled with footwear changes and mobility work, with the gap in the evidence explained. Treatment over the joint is uncomfortable while it is being done. It will not restore movement that is blocked by bone spurs.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Only studied alongside surgery","evidence":"No study of a PRP injection for an arthritic big toe joint was found. Searches on 8 October 2026 across hallux rigidus, hallux limitus, the first metatarsophalangeal joint and the great toe returned 8 and then 15 records, and the only one indexed as a randomised trial was in horses. In people, PRP at this joint has been reported as part of an operation: 45 people had the joint surface resected and covered with a PRP-soaked implant, with better scores and movement at one and two years but no comparison group, so the PRP cannot be separated from the surgery (Siclari, Foot Ankle Surg 2017). The nearest controlled evidence is from the ankle, where PRP was no better than saline in a trial of 100 people (Paget, JAMA 2021), and across foot and ankle trials PRP was followed by more pain at the injection site than comparison injections (odds ratio 2.23), with one extra complication for about every 13 people treated (Fucaloro, Arthroscopy 2025).","fit":"Can be discussed on the knee-based rationale where a stiff-soled or rocker shoe and load changes have not been enough, with it stated that nobody has studied the injection at this joint and that the nearest trial, at the ankle, found no benefit over saline. Not a first-line option.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy in big-toe arthritis. A search on 12 October 2026 for dextrose or prolotherapy in arthritis of the elbow, wrist or big toe returned four records. The only foot report was a professional dancer who had big-toe arthritis on imaging but was given prolotherapy, among several treatments, for instability of the second toe joint (Ojofeitimi, J Orthop Sports Phys Ther 2016). The trials of dextrose injection into an arthritic joint are in the knee and the fingers (Chen, Clin Rehabil 2022; Reeves, J Altern Complement Med 2000).","fit":"Prolotherapy is offered here and can be discussed for big-toe arthritis pain that persists despite stiff-soled or rocker-bottom footwear and activity changes, with the absence of studies at this joint stated. It does not remove a bone spur that is blocking the joint.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No better than saline in a large trial","evidence":"Searched PubMed for the same hyaluronic acid terms with hallux or first metatarsophalangeal (16 records; 2 trials and 2 reviews). This is evidence of absence, not absence of evidence. In the one placebo-controlled trial, 151 people had a single image-guided hylan injection or saline into the big-toe joint; foot pain at three months was no different and there were few differences on any other measure (Munteanu, Ann Rheum Dis 2011). A Cochrane review rated this as moderate-certainty evidence of little or no difference in pain or function (Munteanu, Cochrane Database Syst Rev 2024). The more positive studies have no placebo group: hyaluronic acid eased walking pain more than cortisone at four and eight weeks in 37 people (Pons, Foot Ankle Int 2007), and pain fell from 6.5 to 2.8 out of 10 at three months in an uncontrolled series of 65, 15 of whom had a temporary flare (Galois, Clin Med Insights Arthritis Musculoskelet Disord 2022).","fit":"Not a first-line option for big-toe arthritis: the one trial that compared it with saline found no difference. Footwear changes, a stiff or rocker-sole insert and a loading program come first, with other guided injections considered if these are not enough.","reviewedOn":"2026-10-26"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Nerve targets only","evidence":"Searched at the great toe, and every human result is about a nerve rather than the joint. The largest series is 59 ultrasound-guided perineural injections in 46 people at the foot and ankle, where the commonest single target was the hallux branch of the medial plantar nerve (17 of 59); 43 of 45 reported immediate relief and 23 of 38 with follow-up had a period of lasting relief, with one complication - but the injectate was local anaesthetic and the indication was nerve pathology, most often a thickened, scarred nerve (Walter, Skeletal Radiol 2017). No study injects dilute dextrose under the skin for an arthritic big toe joint. Two of the five records the great-toe search returned were veterinary studies of sesamoid nerve blocks in horses, so the small count overstates the human literature.","fit":"Considered only where a tender, hypersensitive skin nerve territory is found over the forefoot rather than pain arising from the joint itself. Stiffness and pain at the end of range in the joint is not what this treats.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":false}}},{"slug":"heel-fat-pad-syndrome","title":"Heel Fat Pad Syndrome","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/heel-fat-pad-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line, unproven","evidence":"A 2022 scoping review found seven original studies of heel fat pad syndrome and not one randomised trial of any treatment, including the commonly recommended heel cups and taping (Chang, J Foot Ankle Res 2022). The best available data are an uncontrolled study of 19 people in whom low-Dye taping reduced walking pain immediately, and a single case treated with silicone heel cups. Standard advice is to reduce pressure on the heel with heel cups, cushioned footwear, taping, rest and analgesia (Tu, Am Fam Physician 2018).","fit":"The starting point, and what most people need: explaining how this differs from plantar fasciitis, cushioning with heel cups and supportive footwear, avoiding bare feet on hard floors, taping, and a temporary cut in prolonged standing and impact. This rests on reasoning, not trials.","reviewedOn":"2026-09-28"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No muscle target","evidence":"A combined search for dry needling with heel fat pad terms returned no study treating this condition. The fat pad contains no muscle for needling to act on.","fit":"Not offered for this problem. A separate calf or foot muscle problem would be assessed on its own terms.","reviewedOn":"2026-09-28"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Steroid can cause it","evidence":"Previous corticosteroid injection into the heel is a recognised contributor to heel pad damage and atrophy (Tu, Am Fam Physician 2018; Chang, J Foot Ankle Res 2022), and fat pad atrophy is a documented risk of steroid injections given for plantar fasciitis. No study supports injecting the fat pad with steroid.","fit":"Not offered. Ultrasound is used diagnostically instead, to look at the fat pad and plantar fascia when the picture is mixed.","reviewedOn":"2026-09-28"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No target","evidence":"A combined search for vibration therapy with heel fat pad terms returned no study treating this condition, and there is no muscular target in the heel pad for a vibration device.","fit":"Not offered for this problem.","reviewedOn":"2026-09-28"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong tissue","evidence":"A search pairing shockwave with heel pad and fat pad terms returned eight records and none treats heel fat pad syndrome; the heel-pain shockwave literature concerns plantar fasciitis, a different tissue. The review of this condition identified no shockwave study at all (Chang, J Foot Ankle Res 2022). The problem here is lost or damaged cushioning, which there is no reason to expect pressure waves to restore.","fit":"Not offered for fat pad pain. Where plantar fasciitis is also present, that is assessed and treated as its own problem on its own page.","reviewedOn":"2026-09-28"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong tissue","evidence":"No study of focused shockwave in heel fat pad syndrome was identified. The randomised shockwave evidence in heel pain is in chronic plantar fasciitis and does not transfer to the fat pad.","fit":"Not offered for this problem.","reviewedOn":"2026-09-28"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No rationale","evidence":"A combined search for electromagnetic and magnetotransduction therapy with heel fat pad terms returned no study, and there is no proposed mechanism by which it would restore the pad.","fit":"Not offered for this problem.","reviewedOn":"2026-09-28"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report","evidence":"The only report is a single case of ultrasound-guided PRP into the heel fat pad (Garcia Garrido, Rehabilitacion 2022). One case cannot show benefit.","fit":"Not offered routinely. It would only be discussed as experimental after cushioning, footwear and taping have been given a proper trial, and it is not a way to rebuild the pad.","reviewedOn":"2026-09-28"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No rationale","evidence":"A search pairing heel fat pad terms with prolotherapy and dextrose returned no study treating this condition, and there is no ligament or tendon attachment in the fat pad for prolotherapy to target.","fit":"Not offered for this problem.","reviewedOn":"2026-09-28"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Filler, not viscosupplement","evidence":"The closest evidence is a cross-linked hyaluronic acid dermal filler injected into atrophic plantar fat pads: in a case series of 28 patients, pain fell from about 6.9 to 3.5 out of 10 at 24 weeks, with pain, inflammation and filler migration in six, and no control group (Ko, J Foot Ankle Surg 2025). That is a volumising filler, not the joint lubricant used for knee osteoarthritis. Autologous fat grafting, a surgical option, improved pain in a 13-patient randomised crossover trial, although fat pad thickness returned to baseline by six months (James, Aesthet Surg J 2021).","fit":"Not offered in this clinic. For persistent disabling pain with confirmed atrophy, referral to discuss fat grafting or filler is possible, framed as experimental.","reviewedOn":"2026-09-28"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial of perineural dextrose in heel fat pad syndrome was identified.","fit":"Considered only if examination finds a separate superficial nerve pain pattern in the heel. Compression of Baxter's nerve and tarsal tunnel syndrome are separate diagnoses assessed on their own terms.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A combined search for hydrodissection with heel fat pad terms returned no study treating this condition. Heel pain from a compressed nerve is a different diagnosis.","fit":"Only relevant if ultrasound and examination identify a separately compressed nerve, such as Baxter's nerve, as the actual source. Not a treatment for the fat pad.","reviewedOn":"2026-09-28"}}},{"slug":"hip-osteoarthritis","title":"Hip Osteoarthritis","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/hip-osteoarthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Dry needling evidence","evidence":"The needling evidence at this joint comes from one research group, and all of it is dry needling rather than the injected form this row describes. In a double-blind trial of 30 people with hip osteoarthritis, three sessions of dry needling to tender bands in the iliopsoas, rectus femoris, tensor fasciae latae and gluteus minimus reduced pain and improved range and physical function, while sham needling did not (Ceballos-Laita, Musculoskelet Sci Pract 2019). A second double-blind trial of 45 people, against both sham needling and no treatment, found less pain and better WOMAC function and hip strength with real needling (Ceballos-Laita, Arch Phys Med Rehabil 2021), and a third trial of 38 found three needling sessions improved hip muscle flexibility more than three weeks of self-stretching (Ceballos-Laita, Complement Ther Clin Pract 2022). All three measured the effect straight after the course of treatment, and a systematic review of needling at the hip called the results promising but lacking strong certainty, with small samples and short follow-up (Forogh, Acupunct Med 2023). The injected form has a single case report at this joint, in which trigger point injection was combined with acupuncture and cupping (Chantasirivisal, Cureus 2026).","fit":"Directed at a tender band in the hip flexors or gluteal muscles that reproduces part of your hip pain, alongside the loading programme. It does not treat the joint itself, and the trials behind it used a needle without an injectate and measured the effect over days rather than months.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Short-term relief","evidence":"The hip is the joint where this row's exact procedure has been tested in a large trial. In 199 people with hip osteoarthritis, a single ultrasound-guided injection of triamcinolone and lignocaine added to advice and education reduced pain over six months by 1.43 points out of 10 more than advice and education alone (95% CI -2.15 to -0.72). It was not significantly better than an ultrasound-guided injection of lignocaine alone (-0.52, -1.21 to 0.18), and it worked better where ultrasound showed an inflamed or swollen joint. One participant with a replacement heart valve died of a heart-valve infection four months after the corticosteroid injection, judged possibly related (Paskins, BMJ 2022). An earlier systematic review found five small trials, all showing less pain at three to four weeks and two showing benefit to eight weeks (McCabe, Osteoarthritis Cartilage 2016). The risk worth knowing about is rapid joint destruction. Among 688 hips injected under X-ray guidance, 5.4% developed rapidly destructive hip disease at an average of five months; the risk was low after a single dose of 40 mg or less and higher with doses of 80 mg or more and with repeated injections (Okike, J Bone Joint Surg Am 2021). No trial has compared ultrasound with X-ray guidance head to head at this joint (Brookes, Musculoskeletal Care 2024).","fit":"Most useful when a flare of pain is preventing rehabilitation, particularly where ultrasound shows the joint is inflamed. Used sparingly, at a low dose and not as a repeated series: see the note on cortisone.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Focused device did better","evidence":"There is one randomised trial of shockwave at this joint, and it tested both devices against a dummy treatment. One hundred and forty-eight people with hip osteoarthritis were randomised to focused, radial or sham treatment: pain and every WOMAC score fell in both treated groups at four and eight weeks and not in the sham group, and the focused device was clearly ahead of the radial one on every comparison (Şah, J Pers Med 2022). That is a single trial of pilot size in each arm with eight weeks of follow-up, and there is no synthesis at the hip. The pooled shockwave evidence in osteoarthritis is all knee (Liao, Biomedicines 2022). A fresh search in October 2026 for shockwave or pressure-wave treatment in hip osteoarthritis (16 records) found no second human trial; the other records were studies in dogs or in other hip conditions such as osteonecrosis.","fit":"Worth discussing for the tender gluteal and lateral hip muscle that usually accompanies an arthritic hip, which is often a bigger part of the day-to-day pain than the joint is. A hip joint sits too deep for a radial pulse to reach it, so where the joint itself is the target the focused form is the one with the evidence.","reviewedOn":"2026-10-24"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat sham in a 148-person trial","evidence":"Shockwave has been tested at the hip against a dummy treatment, and the focused form came out best. One hundred and forty-eight people with hip osteoarthritis were randomised to focused, radial or sham shockwave: pain and every WOMAC score improved in both treated groups at four and eight weeks and not in the sham group, and focused was clearly ahead of radial on every comparison (Şah, J Pers Med 2022). It is the first and so far the only trial at this joint, from a single centre with eight weeks of follow-up, so how long the benefit lasts is not yet known. The larger body of evidence sits at the knee, where pooled trials favour shockwave over sham for pain and function (Tang, Int J Surg 2024; Silva, Clin Rehabil 2022). A fresh search in October 2026 for shockwave or pressure-wave treatment in hip osteoarthritis (16 records) found no second human trial; the other records were studies in dogs or in other hip conditions such as osteonecrosis.","fit":"A reasonable, non-invasive option for hip arthritis pain, and the right form for a joint this deep: the focal point can be set at the depth of the hip, which a radial pulse cannot reach. Offered alongside the strength and weight-management work, and worth trying before or between injections. It treats pain and function, not the joint surface.","reviewedOn":"2026-10-24"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Edge over hyaluronic acid, not saline","evidence":"Tested in a series of randomised trials at the hip, and they do not agree. Most compared PRP with hyaluronic acid rather than with a dummy injection. Pooling seven of them (465 people), PRP was ahead on pain at six months by a small margin (standardised difference -0.38) and on WOMAC pain at six and twelve months, with no difference in hip function, and the authors call the effect limited (Zhang, Pain Res Manag 2026); an earlier pooled analysis of six trials found no difference between the two (Belk, Arthroscopy 2021). In the largest single trial, 111 people had three weekly ultrasound-guided injections and the PRP group had the lowest pain at every follow-up - 21 out of 100 against 44 for hyaluronic acid at six months (Dallari, Am J Sports Med 2016). The one trial against a saline dummy injection found no advantage: in 60 people given three weekly ultrasound-guided injections there was no difference in pain, function or quality of life over six months (Topaloglu, Turk J Phys Med Rehabil 2024). Two network meta-analyses point the same way from a wider base. Across 11 trials and 1,353 people, and again across 14 studies and 1,254 people, no hip injection, PRP included, did better than a saline or standard-care comparison, while saline itself was followed by a clinically important fall in pain (Gazendam, Br J Sports Med 2020; Liu, Orthop J Sports Med 2026).","fit":"An option that can be discussed for hip arthritis pain that has not settled with exercise, weight management and simple pain relief, on the understanding that the one placebo-controlled trial found it no better than a saline injection. If used, it is given into the joint under ultrasound guidance, the response is reviewed at about three months, and it is not repeated without a clear benefit. It is not expected to rebuild cartilage.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat exercise in one small trial","evidence":"Tested once in a randomised trial at the hip, in arthritis caused by hip dysplasia. 41 people (46 hips) on a waiting list for hip replacement had either up to six sessions of ultrasound-guided dextrose injections three weeks apart, into the tendon attachments around the hip and, in the milder forms of dysplasia, into the joint itself, together with home exercise, or a supervised 12-week strengthening program. At twelve months pain had fallen by 4.5 points out of 10 against 2.9, and the Harris hip score had risen by 24 points against 17 (Gül, Med Sci Monit 2020). There was no dummy-injection group, patients knew which treatment they had, and three people had severe pain at the injection sites for up to a week. No trial has studied ordinary hip osteoarthritis, and a 2025 review of hip and knee injections found the evidence insufficient to support routine use of prolotherapy (Seah, J Bone Joint Surg Am 2025). A search on 12 October 2026 for dextrose or prolotherapy in hip arthritis returned six records, with this the only trial.","fit":"Prolotherapy is offered here and can be discussed for hip arthritis pain that persists despite a properly dosed strengthening program, with the limits stated: one small trial, in dysplastic hips, without a placebo group. As in that trial, it is given alongside continued exercise as a way of loading the hip with less pain, and it is not expected to change the joint or to replace a hip replacement when one is needed.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No better than saline in trials","evidence":"This is evidence of no benefit rather than an absence of evidence: hyaluronic acid has been tested against a dummy injection at the hip several times. In the largest trial, 357 people had a single image-guided injection of hylan G-F 20 or saline, and pain on walking fell by the same amount in both groups over 26 weeks (2.19 against 2.26 points out of 10), with pain falling by about 35% after saline alone (Brander, Osteoarthritis Cartilage 2018). A multicentre trial of 85 people found a single X-ray-guided injection no more effective than placebo at three months, with a third of each group responding (Richette, Arthritis Rheum 2009). Pooling five placebo-controlled trials in 591 people, hyaluronic acid was not better than placebo for pain or function at any time point (Liao, Med Sci Monit 2019), and a second meta-analysis concluded that viscosupplementation is not recommended for hip osteoarthritis (Leite, Arch Phys Med Rehabil 2017). A review of 25 osteoarthritis guidelines found that the higher-quality ones consistently recommend against hyaluronic acid at the hip (Gibbs, Osteoarthritis Cartilage 2023). Two things point the other way and are named for completeness. A hyaluronate chemically linked to diclofenac reduced hip pain by 0.81 points out of 10 more than placebo over 12 weeks in 90 people (Kubo, BMC Musculoskelet Disord 2022), which is a different product and says more about the diclofenac than about viscosupplementation. And a European panel of viscosupplementation specialists supports its use at the hip, citing observational studies and its own experience (Migliore, Cartilage 2026).","fit":"Not offered for hip arthritis, because the placebo-controlled trials at this joint consistently show it does no better than a saline injection. Where an injection is appropriate for a hip flare, the ultrasound-guided corticosteroid injection earlier in this pathway is the one with trial evidence behind it.","reviewedOn":"2026-10-08"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for perineural or hydrodissection injection with dextrose in hip osteoarthritis returns no study of any design.","fit":"Not offered. The hip joint is deep and the pain comes from the joint rather than from a compressed superficial nerve, so the rationale for a perineural injection does not apply.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested hydrodissection for hip osteoarthritis. A scoping review that screened 138 studies of the technique for joint pain searched the hip among other joints, and the conditions it found a signal in were adhesive capsulitis, greater trochanteric pain syndrome and knee osteoarthritis rather than hip arthritis (Leahy, Front Pain Res 2026). Searching hydrodissection and hydrorelease directly against hip osteoarthritis, the hip joint and coxarthrosis returns nothing on the subject.","fit":"Only where the assessment finds a nerve contributing separately to the hip or groin pain. The arthritis itself is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"hypermobility-spectrum-disorder","title":"Hypermobility Spectrum Disorder & hEDS","region":"General","url":"https://www.backpaindoctor.com.au/conditions/hypermobility-spectrum-disorder","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Mainstay, on limited evidence","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Exercise and physiotherapy are the mainstay in the AFP review, delivered as low-impact, low-resistance strengthening, proprioception and joint protection. The evidence is weaker than that suggests: a 2013 systematic review of four studies found no convincing evidence that exercise beat control or that one type was better (Palmer), and a 2021 review of six small trials (20 to 57 participants, 4 to 8 weeks) found improved pain and proprioception whatever the programme while noting that robust trials are missing (Reychler). A 21-person trial of two home shoulder programmes found both improved with no difference between them and no control arm (Spanhove), and compression garments added to physiotherapy improved some balance measures but not pain at 4 weeks in 36 people (Benistan). The largest trial randomised 100 adults with HSD and shoulder symptoms to 16 weeks of heavy full-range or light mid-range strengthening: function improved more with heavy loading at 16 weeks (174.5 points on WOSI, below the 252-point minimal important difference), with no serious adverse events but more transient soreness and headache, and the difference was not significant at one year (Liaghat, Br J Sports Med 2022 and 2024).","fit":"The starting point: explanation, progressive strengthening through range (heavier loading is safe), control and fitness work, pacing and a flare plan, with physiotherapy or exercise physiology. The average benefit in trials is modest, and results depend on keeping it going for months.","reviewedOn":"2026-10-24"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Needling is not among the management options in the AFP review. The review notes that bleeding, bruising, poor response to local or regional anaesthesia and iatrogenic injury are common across Ehlers-Danlos forms, so invasive procedures need careful review.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Injection is not among the AFP management options. The review warns of bleeding, poor response to local anaesthetic and procedural injury across Ehlers-Danlos forms, and advises avoiding drugs that reduce platelet function where bruising is easy.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Vibration-based devices are not part of the management described in the sources reviewed, and no trial in hypermobility was identified.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Shockwave is not part of the management described in the sources reviewed, and no trial in hypermobility spectrum disorder or hEDS was identified. The tissue-fragility cautions in the AFP review apply.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Shockwave is not part of the management described in the sources reviewed, and no trial in hypermobility spectrum disorder or hEDS was identified.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Magnetotransduction therapy is not part of the management described in the sources reviewed.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Platelet-rich plasma is not part of the management described in the sources reviewed, and the review's cautions about bruising and procedural injury apply.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Prolotherapy is not part of the management described in the sources reviewed, and no trial in hypermobility spectrum disorder or hEDS was identified.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong problem","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Hyaluronic acid is a treatment for osteoarthritis and is not part of the management described in the sources reviewed.","fit":"Not offered for hypermobility. Coexisting osteoarthritis would be assessed separately.","reviewedOn":"2026-10-24"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Perineural injection is not part of the management described in the sources reviewed.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the condition","evidence":"The sources reviewed for this page were the American Family Physician review of hypermobile EDS and hypermobility spectrum disorders (Yew, 2021), the 2017 international classification criteria (Malfait, Am J Med Genet C 2017), and the exercise literature (Palmer, Physiotherapy 2013; Reychler, Am J Med Genet A 2021; Spanhove, Disabil Rehabil 2022; Benistan, Disabil Rehabil 2023). No Australian guideline was retrieved. Hydrodissection addresses nerve entrapment and is not part of the management described in the sources reviewed.","fit":"Not offered for hypermobility spectrum disorder or hypermobile EDS. A separately diagnosed local problem would be assessed on its own page, with the tissue-fragility cautions applied.","reviewedOn":"2026-10-24"}}},{"slug":"it-band-syndrome","title":"Iliotibial (IT) Band Syndrome","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/it-band-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Dry needling trials only","evidence":"Searched 18 October 2026: iliotibial with needling, trigger point, acupotomy, needle knife or wet needling (8 records, all read). No trial of wet needling or trigger point injection in this condition. The nearest evidence is dry needling, a different procedure: in 40 adults with this condition, dry needling plus stretching lowered pain from 9.0 to 1.8 out of 10 four weeks after treatment, ahead of radial shockwave (3.6), with no difference in function (Maghroori, Galen Med J 2021), and in 38 athletes with a tight iliotibial band (not a confirmed diagnosis of this syndrome), three sessions of dry needling with stretching beat stretching alone straight after treatment (Singh, J Bodyw Mov Ther 2024). Neither trial had a sham. A 24-study review mentions a needling trial against cortisone that this search did not find (Ferrero, Orthop Res Rev 2026).","fit":"Considered where examination finds a tender muscle band in the outer thigh or hip contributing to the pain, as an adjunct to the loading program.","reviewedOn":"2026-10-18"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial, two weeks","evidence":"One small randomised trial: in 18 runners with iliotibial band syndrome of less than two weeks, 40 mg methylprednisolone with local anaesthetic, injected where the band crosses the outer knee, reduced pain during a treadmill run more than local anaesthetic alone between day 7 and day 14 (p = 0.01; p = 0.07 at day 7). Follow-up ended at two weeks, and the injection was not ultrasound-guided (Gunter, Br J Sports Med 2004). In an older series of 100 knees in runners, 30 settled with one steroid injection and reduced training, and 29 needed a second or third (Noble, Am J Sports Med 1980). A case report describes rupture of the iliotibial band after several steroid injections (Pandit, Mil Med 2014). A 2007 systematic review found limited evidence that any conservative treatment helps (Ellis, Man Ther 2007).","fit":"Load management and hip and knee strength work come first. For a recent flare that is stopping running, a single guided injection under the band may be discussed for short-term relief, with the number kept low. See the note on cortisone.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Two small trials, no sham","evidence":"Searched 18 October 2026: shockwave, shock wave, ESWT or pressure wave with iliotibial, IT band or ITBS (10 records), and a systematic-review pass on the iliotibial band (53 records), all read. The old line here said the trials used focused devices; both trials in this condition used radial. In 24 runners, all doing an exercise program, three weekly sessions of radial shockwave reduced running pain by 51% at four weeks and 75% at eight, level with manual therapy (Weckström, J Back Musculoskelet Rehabil 2016). In 40 adults, both groups stretching, four weekly sessions lowered pain from 8.3 to 3.6 out of 10 four weeks after treatment, but dry needling did better (1.8, P = 0.023), with no difference in function and no complications in either group (Maghroori, Galen Med J 2021; allocation by odd and even number). Neither trial had a sham or exercise-only group, so whether shockwave adds anything to exercise here is not known (Ferrero, Orthop Res Rev 2026, a review of 24 studies).","fit":"Can be discussed as an adjunct to a hip-strengthening and running-load program when outer-knee pain has not settled. In the two trials it did about as well as hands-on therapy and less well than dry needling.","reviewedOn":"2026-10-18"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No focused-device trial","evidence":"Searched 18 October 2026 (the searches named in the radial row: 10 shockwave records and 53 systematic-review records on the iliotibial band): no trial of a focused device in this condition. Both trials used radial shockwave (Weckström, J Back Musculoskelet Rehabil 2016; Maghroori, Galen Med J 2021), and a 24-study systematic review found no evidence that any device treatment adds to exercise here (Ferrero, Orthop Res Rev 2026).","fit":"Plausible where the band's attachment near the knee is the tender point, and can be discussed on that basis, but patients are told the trials in this condition used the radial device.","reviewedOn":"2026-10-18"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small placebo-controlled trial","evidence":"One randomised trial, and it is positive. Sixty people aged 18 to 50 whose iliotibial band syndrome had not settled after at least twelve weeks of conservative treatment had a single ultrasound-guided injection of PRP or saline at the outer knee, with patients and assessors blinded. At six months pain had fallen by 4.7 points out of 10 with PRP against 2.5 with saline, function scores were higher, and 83% against 57% were back at their previous sport. There were no serious side effects, and short-lived soreness after the injection was a little more common with PRP, 17% against 10% (Elazab, Apunts Sports Med 2026). The limits are real: one hospital, six months of follow-up, no registration in advance, and about one in eight participants missing at the end. A systematic review of 24 studies of this condition calls the result promising but not yet repeated by anyone else, notes that PRP was never compared with a rehabilitation program, and keeps structured rehabilitation as the first treatment (Ferrero, Orthop Res Rev 2026). The trial does not apply to newly diagnosed pain.","fit":"Rehabilitation comes first: hip strengthening, changes to running load and time settle most cases. For pain that has persisted beyond about three months of a proper program, an ultrasound-guided PRP injection can be discussed as a way of getting back to loading, on the understanding that it rests on a single trial of 60 people.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"No study of prolotherapy in iliotibial band syndrome. A 2026 systematic review of 24 studies and 1,012 people with this condition states that it found no evidence specific to iliotibial band syndrome for prolotherapy (Ferrero, Orthop Res Rev 2026). PubMed searches on 16 October 2026 (prolotherapy, dextrose, hypertonic glucose or hyperosmolar with iliotibial, IT band, ITB or lateral knee pain) returned two records, neither a study of dextrose in this condition, and passes restricted to randomised trials and to systematic reviews found only that review. The injection trials in this condition tested cortisone and PRP, not dextrose.","fit":"Can be discussed where pain at the outer knee persists despite a well-run program of load management and hip strengthening, with the absence of studies stated. It sits alongside that program, not in place of it.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here, and not studied. A 2026 systematic review of 24 studies and 1,012 people with iliotibial band syndrome found no controlled study of hyaluronic acid in this condition (Ferrero, Orthop Res Rev 2026), and PubMed searches pairing hyaluronic acid with iliotibial terms found no other treatment study. This is an absence of evidence, not evidence that it fails.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this pain arises outside the knee joint. Rehabilitation comes first, and PRP has the stronger evidence for pain that persists.","reviewedOn":"2026-11-09"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A PubMed search for dextrose, prolotherapy, perineural injection or hydrorelease combined with iliotibial band syndrome, runner's knee or lateral knee pain returns one record, a case report of ischiofemoral impingement treated with a different injectate. No study of any design has tested perineural injection at the lateral knee.","fit":"Not offered for the band itself. Iliotibial band syndrome is a compression problem at the lateral femoral condyle and it responds to running volume and cadence changes, hip abductor strength and time. An injection around a superficial nerve would only be considered if the lateral knee skin proved hypersensitive on examination.","reviewedOn":"2026-09-09"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searching hydrodissection and hydrorelease against the iliotibial band and iliotibial band syndrome returns no records, so the technique has not been reported at this site. A scoping review that screened 138 studies of hydrodissection and hydrodilatation for joint pain found its signals in adhesive capsulitis, greater trochanteric pain syndrome and knee osteoarthritis, and does not cover the iliotibial band (Leahy, Front Pain Res 2026).","fit":"Only where the assessment finds a nerve contributing separately to the outer knee or thigh pain; the common peroneal nerve at the fibular head is the one that sits close enough to be confused with this. The iliotibial band problem itself is a loading problem and is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"knee-osteoarthritis","title":"Knee Osteoarthritis","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/knee-osteoarthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Dry needling evidence","evidence":"The needling evidence at this joint is substantial, but all of it is dry needling rather than the injected form this row describes. A meta-analysis of 20 randomised trials in 1,234 people with knee osteoarthritis or patellofemoral pain found that needling myofascial trigger points reduced pain (weighted mean difference -1.25, 95% CI -1.58 to -0.92) and improved the WOMAC function score (-6.59, -8.88 to -4.29) at moderate certainty, with the authors cautioning that blinding was poor and follow-up short (Hu, PLoS One 2026). Adding trigger point dry needling to a physiotherapy programme in 40 people improved pain by a further 1.96 points and the WOMAC score by 11.86 at four weeks and three months (Morshedlou, Physiother Theory Pract 2025), and needling of the popliteus alongside exercise in 38 people held an advantage in pain and function at six months over sham needling with the same exercise (Agost-González, Sci Rep 2025). For the injected form the base is empty: a search of trigger point injection trials at the knee, quadriceps and calf returned one record, and it tested a vibrating device for making the injection more comfortable rather than whether the injection helps knee osteoarthritis (Moon, Arch Phys Med Rehabil 2019).","fit":"Directed at a tender band in the quadriceps, calf or popliteus that reproduces part of your knee pain, alongside the loading programme. It does not treat the joint surface, and the trials behind it used a needle without an injectate.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Short-term relief","evidence":"At the knee this is the best-tested injection there is, and the benefit is real but brief. A Cochrane review of 27 trials in 1,767 people found a corticosteroid injection reduced pain by about 1 point out of 10 more than a dummy injection or no injection (SMD -0.40, 95% CI -0.58 to -0.22; number needed to treat 8), with the effect moderate at one to two weeks, small by 13 weeks and absent at 26, and the evidence graded low quality (Jüni, Cochrane Database Syst Rev 2015). A later meta-analysis of 11 placebo-controlled trials in 842 people found the advantage over placebo was large enough to matter only in the first six weeks (Bensa, Knee Surg Sports Traumatol Arthrosc 2024). Repeating it does not help: in 140 people given triamcinolone or saline every three months for two years, pain was no different and the corticosteroid group lost more cartilage (-0.21 mm against -0.10 mm) (McAlindon, JAMA 2017). In 156 people randomised to a corticosteroid injection or to physiotherapy, the physiotherapy group had less pain and disability at one year (WOMAC 37.0 against 55.8 out of 240) (Deyle, N Engl J Med 2020). Guidance itself has been tested here: across 13 studies, ultrasound-guided knee injections were accurately placed 95.4% of the time against 82.0% by landmarks, and all but one of the studies that measured outcome favoured guidance (Kasitinon, Am J Phys Med Rehabil 2026). The American College of Rheumatology strongly recommends corticosteroid injection for knee osteoarthritis (Kolasinski, Arthritis Rheumatol 2020).","fit":"Most useful as a short bridge when a flare of pain is stopping you from doing the strengthening work that has the longer-lasting evidence. Not a treatment to repeat on a schedule: see the note on cortisone.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Focused device did better","evidence":"Radial shockwave has been tested against a sham or placebo at this joint in four randomised trials, and three were positive. In 104 people all doing the same physiotherapy and home exercise, three weekly radial sessions gave better pain, WOMAC, walking and strength scores than a sham device at the end of treatment and at one and three months (Uysal, Int Orthop 2020). Eighty-nine people randomised across four radial doses or a very-low-dose placebo had less pain and a better WOMAC score at four weeks with every treated dose, by about 2 to 3.6 points out of 10 for pain, and the higher energy did more (Zhang, J Rehabil Med 2021). A smaller unblinded trial of 45, all doing strengthening, found pain and function improved with low- and medium-energy radial treatment and not with sham (Hammam, J Taibah Univ Med Sci 2020). The contrary trial is real: in 105 women with severe, long-standing knee arthritis, three low-energy radial sessions were no better than placebo for pain on movement at three months, the main outcome, with a difference only in WOMAC pain (Imamura, J Rehabil Med 2017). Head to head, the focused form did better: in 42 people with arthritis in both knees, pain fell by 4.5 points with focused against 2.6 with radial (Ko, Int J Environ Res Public Health 2022). The trials are single-centre with follow-up of one to three months, so nothing is known beyond that, and one review found shockwave added to an exercise program gave less than a clinically important extra benefit (French, Osteoarthr Cartil Open 2024).","fit":"A reasonable option for knee arthritis pain, alongside the strength and weight work rather than instead of it, and particularly where the muscle and fascia around the knee are tender as well as the joint. Where the joint itself is the target, the focused form above has the better head-to-head result and the depth to reach it. Neither changes the joint surface, and the benefit has only been followed to three months.","reviewedOn":"2026-10-24"},"focusedShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Knee osteoarthritis is where shockwave has its deepest trial base outside tendon problems, and the results favour it consistently. An umbrella review pooling eight meta-analyses found shockwave better than sham treatment for pain, by 2.0 points out of 10 (95% CI 1.5 to 2.5), and better for the WOMAC score, the Lequesne index and knee range of movement (Tang, Int J Surg 2024). A meta-analysis of 12 randomised trials found it ahead of sham for pain at short, medium and long-term follow-up and for function in the short term (Silva, Clin Rehabil 2022), and a network meta-analysis of 74 randomised trials in 3,707 people ranked shockwave first among physical treatments for WOMAC improvement beyond three months, at moderate confidence (Zhang, Front Med 2025). Energy level and treatment duration predict the response (Liao, Clin Rehabil 2019), and when the two devices were compared head to head in 42 people, the focused form reduced pain by 4.5 points against 2.6 with radial (Ko, Int J Environ Res Public Health 2022). The American Academy of Orthopaedic Surgeons guideline lists shockwave as an option that may be used for pain and function, at limited strength (Brophy, J Am Acad Orthop Surg 2022). Two limits: the trials are small and vary in dose, and where shockwave was added to an exercise programme, one review found the extra benefit over exercise alone fell short of clinically important (French, Osteoarthr Cartil Open 2024).","fit":"A good option for knee arthritis pain, and the form of shockwave to choose when the joint itself is the target. It suits people whose pain is holding back the strength work and those who want to avoid or defer an injection. It reduces pain and improves function; it does not regrow cartilage or change what the X-ray shows, and it works alongside exercise and weight management rather than replacing them.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Beat placebo in pooled trials","evidence":"The best-studied use of PRP in arthritis, with pooled placebo-controlled trials in its favour and some important trials against. Pooling 18 randomised trials in 1,995 people that compared PRP with a dummy injection, PRP was statistically better on pain and function at every follow-up from one to twelve months; the gain in function (WOMAC) was larger than the smallest difference patients notice at all four time points, and the gain in pain did so at three and six months, with higher-platelet preparations doing better (Bensa, Am J Sports Med 2025). A second meta-analysis of 11 saline-controlled trials in 1,616 people was more reserved: pain was 1.1 points out of 10 lower at three months and 2.0 lower at six, with nothing at twelve, function was better at three months only, and its authors call the efficacy weak and its clinical relevance debatable (Auroux, Joint Bone Spine 2025). The largest single trial, 610 people across nine hospitals in China, found PRP better than sham saline on pain and function from six months through to five years (Chu, Knee Surg Sports Traumatol Arthrosc 2022). The best contrary evidence is Australian. In the RESTORE trial, 288 people in Sydney and Melbourne had three weekly injections of leukocyte-poor PRP or saline: at twelve months pain had fallen by 2.1 against 1.8 points out of 10 (difference -0.4, 95% CI -0.9 to 0.2) and cartilage volume on MRI was no different (Bennell, JAMA 2021). A 102-person trial in Launceston found neither one nor three injections better than saline up to twelve months (Lewis, Bone Joint J 2022). Expert bodies are split for the same reason: the RESTORE authors noted that most clinical guidelines do not recommend PRP for knee osteoarthritis, while a European sports-orthopaedic consensus regards it as a valid option for mild to moderate disease (Laver, Knee Surg Sports Traumatol Arthrosc 2024). It is not free of side effects. Across 24 trials, complications were recorded at a rate of 18.7% with PRP against 9.1% with comparison injections - about one extra for every 11 people treated - nearly all of them mild to moderate and self-limiting (Fucaloro, Arthroscopy 2025).","fit":"A reasonable option for mild to moderate knee osteoarthritis that has not responded to exercise, weight management and simple pain relief. The expectation set beforehand is an improvement in pain and function over the following three to twelve months in a proportion of people - not a guarantee, and not cartilage regrowth - and the Australian trial that found no benefit over saline is part of that conversation. The knee is often more sore for a few days afterwards. Response is reviewed at about three months.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"A meta-analysis of 14 trials and 978 patients found dextrose prolotherapy favourable against both placebo injection and non-invasive control for pain, global function and quality of life, with dose- and time-dependent effects (Chen, Clin Rehabil 2022). A network meta-analysis of 80 trials and 6,934 patients found dextrose prolotherapy combined with physical therapy the MOST effective of ten injection-plus-therapy regimens for both pain (SMD -2.54) and global function (SMD 2.28) (Liao, Int J Mol Sci 2023). An open-label follow-up reported progressive improvement sustained to 2.5 years (Rabago, Complement Ther Med 2015).","fit":"One of the better-supported uses of prolotherapy anywhere, and the evidence is strongest when it is combined with a loading programme rather than given alone.","reviewedOn":"2026-08-30"},"viscosupplementation":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Trialled more than any other knee injection, and the best evidence is that the average effect over a dummy injection is too small to feel. A BMJ meta-analysis of 169 trials and 21,163 people based its main analysis on the 24 large placebo-controlled trials (8,997 people): hyaluronic acid reduced pain by 2 mm on a 100 mm scale more than placebo (95% CI 0.5 to 3.8), short of the smallest difference that matters to patients, and was followed by more serious adverse events (relative risk 1.49, 95% CI 1.12 to 1.98); it also found signs that small studies and selective publication had inflated earlier estimates (Pereira, BMJ 2022). Guideline bodies genuinely disagree on what to do with that. The American College of Rheumatology and Arthritis Foundation do not recommend it, while OARSI and the United States Veterans Affairs guideline do (Sabha, Osteoarthr Cartil Open 2021), and a review of 25 guidelines found the higher-quality ones inconsistent on hyaluronic acid at the knee (Gibbs, Osteoarthritis Cartilage 2023). Part of the difficulty is that injection itself often helps in trials, which makes the specific effect of the hyaluronic acid hard to isolate. A randomised trial of 104 people found hyaluronic acid combined with hypertonic dextrose outperformed hyaluronic acid with saline on physical function at six months (Hsieh, Arch Phys Med Rehabil 2022).","fit":"Discussed where corticosteroid is unsuitable or has already been used repeatedly, and where you would like a non-steroid option before a surgical opinion. The small average effect and the disagreement between guidelines are stated rather than glossed over.","reviewedOn":"2026-10-08"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No controlled trial has tested perineural dextrose injection in knee osteoarthritis. The only published series is a retrospective review of 10 patients given three monthly ultrasound-guided injections of 5% dextrose around the back of the knee, reporting a 52% fall in WOMAC score held at twelve months, and its authors state that placebo, regression to the mean and natural fluctuation cannot be excluded at that sample size (Lam, Diagnostics 2026).","fit":"Not one of the established options for knee osteoarthritis, and it should not be confused with the injections given into the joint itself, which have their own separate evidence. Discussed only as unproven.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Knee osteoarthritis appears in the hydrodissection literature, but as joint distension rather than nerve treatment. A scoping review of 21 included studies lists it among the conditions where ultrasound-guided hydrodissection and hydrodilatation may improve pain and function, while pooling the two techniques and noting the evidence is early and heterogeneous (Leahy, Front Pain Res 2026). The row here is hydrodissection of a nerve, a different procedure with a different target, and no trial has tested that for knee osteoarthritis.","fit":"Only where a nerve is contributing separately to the knee pain. The arthritis itself is treated by the options higher up this page.","reviewedOn":"2026-09-08"}}},{"slug":"low-back-pain","title":"Low Back Pain","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/low-back-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Searched 1 November 2026 (PubMed: trigger point injection, lignocaine or dextrose in low back pain; 13 randomised trials, plus a systematic-review pass). The trials disagree. The largest, in 180 emergency patients with muscular low back pain, found no added benefit from injecting bupivacaine or saline into trigger points over standard treatment alone, for pain or function at one hour or at three days (Lajeunesse, Ann Emerg Med 2025). A 196-person emergency trial in neck or back pain found ultrasound-guided injection no better than an anti-inflammatory plus a muscle relaxant by the time of discharge, although pain fell faster and fewer people needed rescue medicine (Farrow, J Ultrasound Med 2022). Smaller emergency trials were positive: injection beat an intravenous anti-inflammatory in 54 people (Kocak, Am J Emerg Med 2019; the authors note several methodological limitations) and beat dry needling at 30 minutes in 49 (Sengun, Med Sci Monit 2026). An older double-blind trial in 63 people with low back strain found treatment of the trigger point without any injected drug (needling, or cold spray with pressure) at least as effective as lignocaine injection, 63% against 42% improved (Garvey, Spine 1989). No trial of this row's dilute glucose injected into back muscle was found. A 40-person uncontrolled series of 10% dextrose injected between the fascial layers of the back muscles reported pain falling from 7.6 to 3.3 out of 10 at three months (Pirrotta, Pain Pract 2026), but that is a different procedure with no comparison group. Most of the trials followed people for hours to days, not months.","fit":"Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.","reviewedOn":"2026-11-01"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a specific target","evidence":"For back pain without a specific target, injection is not the recommended path. A current review of chronic low back pain states that epidural corticosteroid injections are not recommended except for short-term relief of radicular pain (Maharty, Am Fam Physician 2024), and the American College of Physicians guideline places exercise, multidisciplinary rehabilitation and a list of non-drug therapies first for chronic low back pain (Qaseem, Ann Intern Med 2017). Where one structure is implicated the question changes, but the reach of ultrasound at lumbar targets is itself a limit: ultrasound-guided medial branch blocks were misplaced 11% of the time and facet joint injections 13% of the time when checked against X-ray or CT (Ashmore, Pain Rep 2022). The most favourable ultrasound-guided report is a single-centre audit of 42 people given facet or nerve root injection, 90% of whom improved by more than 30% at three months, with no control group (Tay, Asian Spine J 2020).","fit":"Not a first step, and not something to build a plan around when the pain has no clear target. Considered where examination and, if needed, imaging point to one specific structure and pain is blocking rehabilitation, and where the target is one ultrasound can actually reach. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Radial shockwave has been tested against a dummy treatment in chronic low back pain. In a randomised trial of 40 people all doing stabilisation exercises, ten sessions of radial shockwave left pain slightly worse than sham straight after the course but clearly better at three months (pain 2.0 against 4.4 out of 10; Oswestry disability 9.3 against 17.8) (Walewicz, Clin Interv Aging 2019). In a triple-blind trial of 81 people a single radial session lowered pain by about two points more than a placebo, measured only immediately afterwards (Back, Clin Rehabil 2024), and adding radial shockwave to an exercise programme beat exercise alone over six weeks in 30 people (Elgendy, Ortop Traumatol Rehabil 2022). Meta-analyses that pool radial and focused devices find a short-term benefit: 22 studies and 1,749 people, pain about one point lower out of 10 and still lower at three months (Wu, Medicine 2023), and better than sham in a network analysis of 14 trials (pain SMD -1.22), though without a clear effect on function (Qiao, Front Physiol 2026). The limits: every trial is small and single-centre, follow-up rarely passes three months, no meta-analysis separates radial from focused devices, one found no pain difference at three months (Li, Medicine 2022), and an earlier review found the evidence did not support shockwave (Seco, Spine J 2011). For tender trigger points in particular it is no better than dry needling or trigger point injection (Zhang, Arch Phys Med Rehabil 2020).","fit":"Used on tender back and buttock muscle as part of your exercise programme, which does the long-term work; the trial with lasting benefit paired it with stabilisation exercise. It is not aimed at the disc, facet joint or nerve. Expect a course of several sessions and judge it at around three months.","reviewedOn":"2026-10-19"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat sham; lasting only in facet pain","evidence":"Focused shockwave has two sham-controlled trials in low back pain. In 40 people with chronic low back pain and a worn L5/S1 disc, all doing stabilisation exercise, it eased pain more than sham straight after the course, but the groups were level at one and three months and disability never differed (Rajfur, Med Sci Monit 2022). In 128 people whose pain had been traced to the facet joints with a nerve block, five sessions aimed at those joints beat sham to twelve months (pain down 64%, Oswestry disability down 42% against 13%) (Nedelka, Int J Surg 2025), a single-centre trial not yet repeated. A review limited to focused devices found three small trials, all against other conservative care, with gains to one month that were no longer significant at three (Ferdinandov, Front Med 2024).","fit":"Worth discussing where the pain has been traced to the facet joints, alongside your exercise programme. For general back pain the benefit over sham has been short-lived, and radial shockwave on tender muscle has more trials behind it.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Not into the disc; small trials","evidence":"Tested in back pain, and the answer depends on where the injection goes. Into a disc: an early double-blind trial of 47 people found less pain and better function than a contrast injection over eight weeks (Tuakli-Wosornu, PM R 2016), but the largest trial, 98 people whose painful disc was confirmed by discography, found no difference from saline with an antibiotic in pain, disability or general health at twelve months and had one disc infection after PRP (Schepers, Interv Pain Med 2022), and a second saline-controlled trial of 26 saw improvement in 17% against 13% at eight weeks (Zielinski, Pain Physician 2022). Pooling eleven randomised trials and 623 people with disc-related back pain, PRP was no better than the comparison treatments for pain or function at any time point, with a non-significant lean towards PRP at three and six months, very low certainty, and two serious adverse events, both after PRP (Madrazo-Ibarra, PM R 2026). Into the facet joints the trials against cortisone are split, as set out in the lumbar facet joint pain guide. Into the ligaments of the lower back and pelvis: one double-blind trial of 34 people with non-specific back pain compared PRP with local anaesthetic, each followed by glucose prolotherapy, and found pain lower by 0.9 points on the pain scale at six months, with no difference at four weeks or three months and none in disability (Won, Medicine 2022). Into the back muscles under ultrasound: one look back through the records of 58 people found more improvement in pain at twelve weeks than with saline and a meaningful gain in disability scores, without randomisation (Chen, BMC Musculoskelet Disord 2026). None of these studies compared PRP with an exercise program.","fit":"Never injected into a disc here: the largest disc trial found no benefit over saline, and one participant developed a disc infection. PRP is considered for back pain only where assessment points to a specific source it is used for in this clinic, the facet joints, the sacroiliac joint or the spinal ligaments, and only after a proper rehabilitation program has not been enough on its own. The evidence for those targets is small trials with mixed results, set out here and in the facet joint and sacroiliac joint guides. The injection is there to make loading and rehabilitation more manageable, not to replace them.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"A Cochrane review of five trials and 366 patients addressed exactly this condition. Prolotherapy injections ALONE were no more effective than control injections for chronic low back pain: no difference in pain or disability at six months, and no difference in the proportion improving by more than half. Two trials in which the injections were given alongside spinal manipulation and exercise did show benefit, but the co-interventions make it impossible to attribute that to the injection (Dagenais, Cochrane Database Syst Rev 2007). A 2026 pragmatic randomised trial adds a positive result against an active treatment rather than a placebo. In 104 people with at least three months of low back pain with leg pain (referred or radiating) scoring at least 6 out of 10, up to five monthly dextrose prolotherapy treatments beat up to three epidural steroid injections at 6 months (pain 5.1 against 7.2 out of 10) and 12 months (5.2 against 6.9), with better Oswestry disability scores (34 against 42 at 12 months) and no adverse events. Nobody was blinded, there was no dummy-injection group, and the abstract does not say where the dextrose was injected (Wende, PM R 2026).","fit":"Only ever alongside an active rehabilitation programme, never as the treatment on its own. That combination is the only condition under which the evidence has been positive, and the exercise is doing work the injection cannot do by itself.","reviewedOn":"2026-10-29"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Hyaluronic acid has been injected into the lumbar facet joints and compared with cortisone, but only in people whose back pain had already been traced to those joints. A randomised trial of 60 people found sodium hyaluronate no worse than triamcinolone out to six months (Fuchs, J Vasc Interv Radiol 2005), a double-blind trial of 30 found no difference between the two (Annaswamy, Am J Phys Med Rehabil 2018), and a pilot in 13 people found no change in pain or disability at six weeks (Cleary, J Spinal Disord Tech 2008). Pooling 18 studies and 1,496 people, these injections gave little short-term or no benefit overall (Ambrosio, Global Spine J 2022). No trial has tested it for back pain that has not been traced to a particular joint, and there is a reported case of widespread inflammatory joint pain two days after a lumbar facet injection of hylan G-F 20 (Kocak, Am J Phys Med Rehabil 2018).","fit":"Not offered for this problem. Back pain that has not been traced to one specific joint is not a target for a joint injection of any kind.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Tested by a different route","evidence":"The dilute dextrose used in this treatment has been tested in chronic low back pain, but delivered into the caudal epidural space rather than as a series of small injections just under the skin. In a double-blind randomised trial, 35 people with chronic low back pain radiating to the buttock or leg had a single 10 mL injection of 5% dextrose or saline: 84% of the dextrose group reported at least half their pain gone at four hours against 19% of the saline group, with no difference left at two weeks (Maniquis-Smigel, Anesth Pain Med 2016). Repeating it helped further, with 32 people given an average of 5.5 injections over a year improving by 3.4 points on a 10-point pain scale and 18.2 percentage points on the Oswestry disability index, though nobody in that study went without treatment for comparison (Maniquis-Smigel, J Altern Complement Med 2018). No trial of the subcutaneous technique described here was found in low back pain.","fit":"Considered where examination finds tender, hypersensitive skin over the low back rather than deep or leg-dominant pain. The randomised evidence above is for a deeper injection, so what is offered here carries less certainty than those numbers suggest.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"The evidence sits in identifiable subgroups rather than in non-specific back pain. In 36 people with superior cluneal nerve entrapment (an overlooked cause of low back pain) ultrasound-guided dextrose hydrodissection produced initial success in 77.7%, with symptoms returning in a quarter of those and recurrence more common where there was scoliosis (Wu, Insights Imaging 2023). A retrospective comparison of 33 patients with the same neuropathy found perineural dextrose better than corticosteroid for pain and Roland-Morris disability at one week (Yıldırım Uslu, Cureus 2024). In myofascial low back pain, all 58 patients in a retrospective cohort received hydrodissection of longissimus lumborum trigger points and both arms improved at 12 weeks (Chen, BMC Musculoskelet Disord 2026), but no group went without it. No trial testing hydrodissection against placebo in low back pain was found.","fit":"Considered where examination and ultrasound identify a specific target (most often superior cluneal nerve entrapment at the iliac crest, or a painful thoracolumbar fascial plane) rather than for back pain in general.","reviewedOn":"2026-09-06"}}},{"slug":"lumbar-disc-herniation","title":"Lumbar Disc Herniation","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/lumbar-disc-herniation","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Needling aimed at myofascial trigger points has been tested in this condition. A randomised trial of 100 people with lumbar disc herniation found trigger-point-directed needling improved pain, lumbar range of movement and quality of life more than standard acupuncture, and reduced the number of tender points in quadratus lumborum, multifidus and iliocostalis (Li, Zhen Ci Yan Jiu 2024). That trial used a needling technique rather than an injection, and the largest trial of trigger point injection in low back pain (180 people, three arms) found no benefit over standard care at all (Lajeunesse, Ann Emerg Med 2025). Nothing has tested 5% glucose here.","fit":"Aimed at the paraspinal or gluteal muscle that has tightened around the problem, not at the disc. Considered alongside the loading programme where examination finds a tender band that reproduces part of your pain.","reviewedOn":"2026-09-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small, short-term effect","evidence":"The evidence belongs to epidural corticosteroid injection placed under X-ray or CT, not to an ultrasound-guided injection. Across 25 placebo-controlled randomised trials in 2,470 people with disc-related leg pain, epidural corticosteroid probably beat a placebo injection on short-term leg pain by 4.9 points on a 0 to 100 scale (95% CI -8.8 to -1.1) and on disability by 4.2 points (-6.0 to -2.2), at moderate quality (Oliveira, Spine 2020). The American Academy of Neurology review of 90 randomised trials reports about one extra person helped for every four treated for short-term pain and one in six for short-term disability, with insufficient evidence on long-term pain (Armon, Neurology 2025). Adverse events were mostly minor and no more common than after a placebo injection. Nothing in this literature shows an injection changes what the disc does; most herniations resorb regardless.","fit":"Not performed here, and not a substitute for the loading and education that carry the evidence. Where leg pain is severe or persistent, this is a referral conversation about an X-ray or CT-guided epidural, weighed against the natural history. Most disc-related leg pain settles with time. New or progressive weakness, numbness or bladder change needs assessment rather than an injection. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the disc","evidence":"A tested absence: a search pairing lumbar disc herniation, disc herniation, sciatica and radiculopathy with shockwave, shock wave and ESWT returned nine records, none of them a trial of shockwave in disc herniation. The nearest human reports are a single adolescent treated with a multimodal chiropractic protocol that included shockwave (Chu, Cureus 2025) and a randomised trial in piriformis syndrome, which is a muscle problem outside the spine (Dede, Turk J Phys Med Rehabil 2026). The meta-analyses showing short-term benefit from shockwave in low back pain are all in non-specific back pain rather than in disc herniation (22 studies, 1,749 patients: pain -1.14, 95% CI -1.47 to -0.80) (Wu, Medicine 2023).","fit":"Not a treatment for the disc or for a compressed nerve root. Offered only for the tender paraspinal and gluteal muscle that often accompanies a disc problem, and only once the leg symptoms are being managed on their own terms.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the disc","evidence":"A tested absence for the disc and nerve root: shockwave, shock wave and ESWT crossed with disc herniation, herniated, radiculopathy, sciatica, spinal stenosis and spondylolisthesis returned ten records on 19 October 2026, and none is a trial of shockwave for a herniated disc. The nearest controlled evidence is a sham-controlled trial of focused shockwave in 40 people with chronic low back pain and a worn L5/S1 disc, not selected for nerve-root symptoms, in which the benefit over sham lasted only to the end of treatment and disability never differed (Rajfur, Med Sci Monit 2022). Otherwise there is a single case report of multimodal care that included shockwave (Chu, Cureus 2025).","fit":"Not a treatment for the disc or a compressed nerve root. Considered only for a separate tender muscle or attachment contributing to the pain, once the leg symptoms are being managed on their own terms.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Tested for the leg pain of a lumbar disc herniation as an injection beside the affected nerve root, always against cortisone and never against a dummy injection. The largest trial gave 124 people an ultrasound-guided injection of PRP or cortisone and found no difference in pain, disability or nerve testing at any point over twelve months, with no complications in either group (Xu, Neural Plast 2021). The smaller trials show a pattern rather than a winner, with cortisone ahead in the first weeks and PRP ahead later: at six and twelve weeks in a trial of 107 (Sonkar, J Clin Orthop Trauma 2026), at six months in a trial of 60 (Saraf, Indian J Orthop 2023), and at six weeks and six months in a trial of 46 that found no difference at one year, by which time 16 people in the PRP group and 17 in the cortisone group had gone on to a repeat injection or surgery (Gupta, Asian Spine J 2024). Pooling seven studies and 416 people, cortisone gave better function at four weeks (standardised difference 0.48, 95% CI 0.20 to 0.75) and nothing separated the two at any later point (Wang, J Orthop Surg Res 2025). Two later syntheses lean towards PRP after the first month: in three trials and 132 people cortisone was better at one month and PRP 1.5 points better on the 0 to 10 pain scale at six months (Ermawan, Spine Surg Relat Res 2025), and a review of 13 spinal trials found PRP ahead at three to six months in the four nerve-root trials (Zhang, Eur Spine J 2026). PRP into the disc itself is a different procedure, tested for back pain rather than leg pain, and was no better than saline at twelve months in the largest trial, with one disc infection (Schepers, Interv Pain Med 2022).","fit":"Not offered here: PRP is not injected into a disc or beside a nerve root in this clinic. Where leg pain from a disc herniation has not settled, an image-guided injection beside the nerve root is a referral conversation with a radiologist or pain medicine specialist, and on these trials PRP is an alternative to cortisone there rather than a clear improvement on it. Most disc-related leg pain eases over weeks to months, and the rehabilitation program is what carries people through that time.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Prolotherapy has been studied in disc-related back and leg pain and the results conflict. A 2026 systematic review of twelve studies reported pain relief lasting six to twenty-four months, but only three of the twelve were randomised (Nazwar, J Anaesthesiol Clin Pharmacol 2026). Against that, an American Pain Society evidence review concluded prolotherapy is not effective for low back pain (Chou, Spine 2009), and the single randomised trial of epidural prolotherapy showed no benefit beyond forty-eight hours (Desai, Pain Practice 2020).","fit":"Not directed at the disc itself and not a way to shrink a herniation. Considered only for ligament and attachment pain that persists after core care, once the leg symptoms have settled.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Hyaluronic acid has been put into a lumbar disc, but as the carrier for something else. In trials of intradiscal stem-cell injection it is the fluid the cells are suspended in and one of the comparison arms, not the treatment being tested: 100 people in the first (Amirdelfan, Spine J 2020) and 404 in a larger trial whose main measure of success was not met (Beall, Spine J 2025). Its other use is as an additive to a nerve root block, where in 44 people it reduced the flare of pain in the first fortnight but made no difference by six weeks or to function (Ko, Spine J 2018). Neither is lubrication of a joint.","fit":"Not offered for this problem. A disc is not a joint that can be lubricated, and most herniations settle without any injection.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. No controlled study has tested dextrose injected just under the skin for a herniated disc. One uncontrolled series of 654 people with low back pain or disc herniation, not reported separately, used a subcutaneous 5% dextrose injection as a test before a course of 5% dextrose prolotherapy, reporting pain falling from 7.2 to 0.9 out of 10 at a year; there was no comparison group and the route of the treatment injections is not described (Solmaz, J Back Musculoskelet Rehabil 2022). The only randomised dextrose trial in back pain with leg symptoms injected into the epidural space, a different route, and its benefit over saline had gone by two weeks (Maniquis-Smigel, Anesth Pain Med 2016).","fit":"Not a treatment for a disc pressing on a nerve root. Considered only where a separate tender superficial nerve in the back or buttock is also part of the picture.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. No study has tested nerve-root hydrodissection specifically for a herniated lumbar disc. The nearest is an uncontrolled series of 46 people with lumbar radiculopathy of unstated cause, in whom saline-and-lignocaine hydrodissection of the nerve root under ultrasound lowered leg pain from 7.1 to 3.8 out of 10 at three months (Arima, Spine Surg Relat Res 2026). The controlled trials in disc herniation tested cortisone against saline: in 158 people an epidural of saline did almost as well as cortisone, with no difference in function at three months or in surgery at a year (Carette, N Engl J Med 1997), and in 106 people with recent sciatica from a herniated disc a 20 mL caudal epidural of saline did no worse than dexamethasone up to six months, with fewer side effects (Maugars, Eur J Pain 2026). None of those tested hydrodissection as a treatment.","fit":"Considered where leg pain from a disc has not settled with time and rehabilitation and the examination points to a single irritated nerve root, as an alternative to a cortisone nerve-root injection, with the absence of a disc-specific study stated. Most disc herniations settle on their own over weeks to months.","reviewedOn":"2026-10-29"}}},{"slug":"lumbar-facet-joint-pain","title":"Lumbar Facet Joint Pain","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/lumbar-facet-joint-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in facet joint pain","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, dry needling or trigger point with facet joint, facet syndrome, zygapophyseal or sacroiliac, 43 records, plus a randomised-trial and systematic-review pass on injection of the piriformis, gluteal, quadratus lumborum and multifidus muscles, 35 records). No study has given trigger point injection or needling to people diagnosed with facet joint pain. In a 43-person trial in older people with chronic low back pain, trigger point injection relieved pain less than a nerve block at the back of the L4-5 segment for up to seven days (Miyakoshi, Joint Bone Spine 2007). In muscular low back pain the trials of trigger point injection disagree, and the largest, in 180 emergency patients, found no benefit over standard care (Lajeunesse, Ann Emerg Med 2025). An evidence review concluded that trigger point injections, like facet joint injections, have not clearly been shown to be effective for low back pain (van Tulder, Eur Spine J 2006). No trial of this row's dilute glucose in back muscle was found.","fit":"Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Diagnostic use, under X-ray","evidence":"Two separate questions were asked here, and both matter. On the injection: in a double-blind randomised trial, 28 people whose facet pain had been confirmed by dual comparative medial branch blocks received either corticosteroid or saline into the joint under X-ray, and the steroid made no difference to how many went on to need radiofrequency neurotomy (91% against 75%) or to how soon they needed it (Kennedy, Am J Phys Med Rehabil 2018). On the guidance: pooling seven studies, ultrasound-guided lumbar medial branch blocks were in the wrong place 11% of the time when checked against X-ray, and ultrasound-guided facet joint injections 13% of the time when checked against CT (Ashmore, Pain Rep 2022); in a learning-curve study, anaesthetists experienced in regional blocks reached the target in only 29 of 40 attempts, and the authors concluded ultrasound is not a satisfactory replacement for X-ray at this target (Putzu, Anesth Essays Res 2022). What the blocks are genuinely good for is diagnosis: twelve randomised trials support radiofrequency neurotomy of the medial branches where the diagnosis has first been confirmed by controlled blocks (Janapala, J Pain Res 2021).","fit":"Not treated with an ultrasound-guided injection here, because ultrasound cannot reliably reach this target and the injection itself did not beat saline. Where the facet joints look like the source and pain is not settling, the useful step is referral for X-ray-guided diagnostic medial branch blocks, which answer whether radiofrequency neurotomy is worth doing. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Evidence is for focused","evidence":"The class-level claim that spinal shockwave evidence is limited and inconsistent no longer holds at this joint, but what has been tested is the focused device rather than this one. In 128 people whose facet pain was confirmed by medial branch block, high-energy focused shockwave beat sham with a 64.4% fall in pain at twelve months (Cohen's d 1.12), a 42.3% fall in Oswestry disability against 12.5% in the sham group, and resolution of bone marrow oedema on MRI in 58.8% of treated patients against none of the controls (Nedelka, Int J Surg 2025). Six published letters and comments have since questioned its methods and reporting, so this is not settled evidence, and the trial's own reason for choosing a focused device was depth of penetration, which is exactly what a radial pressure wave lacks. Meta-analyses showing short-term benefit from shockwave in low back pain are in non-specific back pain rather than facet-confirmed pain (22 studies, 1,749 patients: pain -1.14, 95% CI -1.47 to -0.80; Oswestry -6.01, -7.97 to -4.05) (Wu, Medicine 2023).","fit":"For the tender paraspinal and gluteal muscle that usually accompanies facet pain, rather than for the joint. Where the facet joint itself is the target, focused shockwave is the form with a trial behind it.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat sham in one 128-person trial","evidence":"Searched 17 October 2026: shockwave, shock wave or ESWT with facet, zygapophyseal or zygapophysial joint pain (11 records, all read). There is one randomised trial, and it used this device. In 128 people whose facet pain was confirmed by medial branch block, five weekly sessions of high-energy focused shockwave (0.35 mJ/mm2) to the facet joints beat sham: pain fell 64.4% at twelve months (Cohen's d 1.12), Oswestry disability fell 42.3% against 12.5% with sham, and bone marrow oedema at the joint resolved on MRI in 58.8% of treated patients against none of the controls; no adverse effects were reported (Nedelka, Int J Surg 2025). It is a single-centre trial run partly from the lead author's private spine clinic, and six published letters and comments have questioned it: whether single or double diagnostic blocks were used, missing detail on randomisation, concealment and blinding, an effect size unusually large for a pain treatment, uncorrected multiple comparisons, and a sham that was not shown to block the energy (Sun, Int J Surg 2025; Zhang, Int J Surg 2026). The same group's earlier retrospective comparison of 62 people reported shockwave holding up better than facet steroid injection and slightly worse than radiofrequency neurotomy, without figures in the abstract (Nedelka, Neuro Endocrinol Lett 2014). No independent group has repeated the result.","fit":"Worth discussing for confirmed facet joint pain that has not settled with a good rehabilitation program, as a non-invasive step before radiofrequency denervation. It is there to make the exercise program possible, not to replace it, and patients are told it rests on one trial that has not yet been repeated.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Cortisone trials split; no placebo arm","evidence":"Five randomised trials were found, every one against a cortisone injection and none against a dummy injection, and they disagree. The largest, a double-blind trial of 76 people, found no difference in pain at three, six or twelve months: 6 people in the PRP group and 5 in the cortisone group had their pain halved at six months, a function score favoured PRP at three months only, and the authors concluded the results do not support PRP for facet joint pain (Geoffroy, Joint Bone Spine 2025). A trial of 59 found no difference in pain or disability to three months (Santos, Acta Ortop Bras 2026), and one of 30 found both groups improved, with PRP ahead only on an MRI measure of joint inflammation (Kotb, Saudi Med J 2022). Against that, a triple-blind trial across several centres, in 50 people whose facet pain was confirmed by two test injections, found that at six months more of the PRP group had a meaningful gain in function and had their pain halved, while average pain scores and satisfaction did not differ significantly (Cauchon, Interv Pain Med 2024), and in a trial of 46 the success rate after cortisone fell from 85% at one month to 20% at six months while it rose over time after PRP (Wu, Pain Pract 2017). Pooling ten trials at the facet and sacroiliac joints, 392 people, pain was lower with PRP than with cortisone by 1.3 points out of 10 at three months and 1.7 at six, with no significant difference in disability, and the authors call the evidence inconclusive (Alatefi, Pain Med 2026). Cortisone is a modest standard to match here: in the one saline-controlled trial at this joint it did not reduce or delay the need for nerve ablation (Kennedy, Am J Phys Med Rehabil 2018). Where the route is reported the injection went inside the joint, and the one trial that reports its guidance used X-ray.","fit":"Offered here where the facet joints have been identified as the pain source and a proper rehabilitation program has not been enough on its own. The realistic expectation, said before any money changes hands, is a result about level with cortisone that may last longer: two trials found PRP ahead at six months and the largest found no difference. Its purpose is to make loading and rehabilitation more manageable, not to replace them.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Only trial found no benefit","evidence":"Tested in one small randomised trial, which was negative. Thirty-eight people whose facet joint pain had been confirmed by a numbing block were randomised to 1 mL of 75% glucose injected into the facet joint or to conservative care alone. Both groups improved; the glucose group scored worse on pain (median 5 against 4 out of 10) and on disability at three months, there was no difference at six months, and the authors found no effect attributable to the glucose (Pereira Pires, Medicine 2023). The positive reports are uncontrolled: a retrospective series of 177 people with neck, mid-back or low back pain given 20% dextrose into the facet joint capsules and nearby ligaments, 91% of whom reported less pain at two months to two and a half years (Hooper, J Altern Complement Med 2004), and three people given 50% dextrose into the L4/5 and L5/S1 facet joints together with magnetic stimulation (Wu, J Pain Res 2024). An older double-blind trial of 79 people that injected a dextrose-glycerine-phenol solution into the low back ligaments and joint capsules favoured the injection at six months (30 of 39 against 21 of 40 improved by half; Klein, J Spinal Disord 1993), but it did not select facet pain and the solution was not plain dextrose. Serious harms after spinal prolotherapy are rare but recorded, including meningitis and spinal cord injury in a survey of practitioners (Dagenais, Arch Phys Med Rehabil 2006). PubMed searches on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with facet, zygapophysial or zygapophyseal, 18 records; then randomised-trial and systematic-review passes across low back pain) found no other trial at the facet joint.","fit":"Prolotherapy can be discussed here, but the one controlled trial at the facet joint found no benefit and patients are told that before it is used. It is considered only where facet pain has been confirmed and a well-run strengthening and movement program has stalled, and it sits alongside that program rather than replacing it.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Searched PubMed for the same hyaluronic acid terms with facet or zygapophyseal and lumbar or low back (15 records; 3 trials and 3 reviews). No trial has compared it with a placebo injection. Two randomised trials compared it with cortisone in the facet joints: in 60 people, CT-guided weekly hyaluronic acid was no worse than triamcinolone, with somewhat more benefit at six months (Fuchs, J Vasc Interv Radiol 2005); in 30 people, a single hylan injection and triamcinolone did not differ at one, three or six months, and most of the hyaluronic acid group's early pain relief had faded by six months (Annaswamy, Am J Phys Med Rehabil 2018). Uncontrolled pilots point both ways: gains to six months, lost by twelve, in 15 people (DePalma, PM R 2009), and no improvement at six weeks in 13 (Cleary, J Spinal Disord Tech 2008). Widespread joint inflammation starting two days after a facet hylan injection has been reported once (Kocak, Am J Phys Med Rehabil 2018). A review of 18 studies and 1,496 people found hyaluronic acid no different from cortisone on pain or satisfaction, these facet injections overall of little short-term or no benefit, and PRP better than cortisone in the longer term (Ambrosio, Global Spine J 2022).","fit":"Not offered for this problem. Medial branch blocks and radiofrequency denervation are the established route once the facet joints are confirmed as the source.","reviewedOn":"2026-10-26"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"No trial of perineural injection in facet joint pain. Searching perineural injection, neural prolotherapy, subcutaneous dextrose and glucopuncture terms against the lumbar spine and the facet joints returns one facet-specific report: a 92-year-old woman with severe refractory back pain treated in an emergency department with ultrasound-guided 5% dextrose into the multifidus muscle, which the authors describe as novel in that setting (Rose, Am J Emerg Med 2025). That injection went into muscle rather than under the skin, and a single case cannot show cause. The randomised dextrose evidence in low back pain used a caudal epidural and did not separate out facet joint pain (Maniquis-Smigel, Anesth Pain Med 2016).","fit":"Only where examination finds tender, hypersensitive skin over the affected segment. The nerve branches that carry facet joint pain run deep, so this treatment is not aimed at the joint itself.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search of hydrodissection against facet joint, zygapophyseal, medial branch and facet arthropathy found two records, neither a treatment study for facet pain: one was brachial plexus hydrodissection in the neck, the other an intraoperative surgical exposure technique. Hydrodissection separates a nerve from the tissue compressing it; it does not act on a painful facet joint.","fit":"Not a treatment for the facet joint. It is relevant only if assessment also finds an entrapped nerve contributing to the pain. The superior cluneal nerve at the iliac crest is the usual one.","reviewedOn":"2026-09-06"}}},{"slug":"lumbar-spinal-stenosis","title":"Lumbar Spinal Stenosis","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/lumbar-spinal-stenosis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Needling has been tested directly in this condition. A multicentre randomised trial of 128 people with lumbar spinal stenosis found electrical dry needling and spinal manipulation added to standard physiotherapy gave greater improvement in back, buttock and leg pain and in disability at three months, with medium effect sizes, although no difference at two or six weeks (Young, Spine J 2023). In 99 people with residual pain after decompression surgery, lignocaine trigger point injections reduced pain considerably more than drug treatment alone and held that gain at two months, but that study was not randomised (Al-Zamil, J Clin Med 2024).","fit":"Aimed at the tender paraspinal and gluteal muscle that accumulates when walking distance falls, as an adjunct to the flexion-biased loading programme. It does not open a narrowed canal.","reviewedOn":"2026-09-07"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Little effect on pain","evidence":"Tested, and the answer splits by outcome. The American Academy of Neurology review found that in lumbar spinal stenosis epidural corticosteroid injection possibly reduces disability in the short term (success rate difference -26.2%, 95% CI -52.4 to 3.6) and in the long term (-11.8%, -26.9 to 3.8), but does not reduce short-term pain (-3.5%, -12.6 to 5.6), with too little evidence to judge long-term pain (Armon, Neurology 2025). A meta-analysis of ten randomised trials in 1,010 people found only limited short- and long-term benefit, and minimal evidence that adding steroid beat local anaesthetic alone (Liu, Drug Des Devel Ther 2015). A review of the condition concludes that long-term benefit from these injections has not been demonstrated (Katz, JAMA 2022). All of this is epidural injection under X-ray or CT rather than ultrasound.","fit":"Not performed here, and not something to plan around. Where walking distance is the problem, the evidence sits with conditioning, flexion-based exercise and weight management, and with a surgical opinion if those fail. An epidural is a referral question worth asking where a specific nerve root is implicated and pain is blocking rehabilitation. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the narrowing","evidence":"A tested absence. On 11 November 2026 shockwave, shock wave and ESWT crossed with spinal stenosis, spondylolisthesis and neurogenic claudication returned four records: two were unrelated to the spine and none was a trial. The only report is a single case of a 69-year-old with severe central canal narrowing and a slipped vertebra, treated over nine months with several therapies including radial shockwave to the soft tissues; the authors state that the effective part cannot be identified (Chu, Cureus 2026). A second search using radial and pressure-wave wording with stenosis, radiculopathy and sciatica returned one record, a study of scarring after spinal surgery and not of stenosis (Rashad, Ann Rehabil Med 2025).","fit":"Not a treatment for the narrowing or the nerves. Considered only for a separate tender muscle contributing to the back or buttock pain, alongside your walking and exercise programme.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the narrowing","evidence":"A tested absence: shockwave, shock wave and ESWT crossed with spinal stenosis, spondylolisthesis, radiculopathy and disc herniation returned ten records on 19 October 2026 and no trial in spinal stenosis. The only report is a single case of a 69-year-old with severe central canal narrowing and a slipped vertebra treated over nine months with several therapies, including radial shockwave to the soft tissues; the authors say the effective part cannot be identified (Chu, Cureus 2026).","fit":"Not a treatment for the narrowing or the nerves. Considered only for a separate tender muscle or attachment contributing to the back pain, alongside your walking and exercise programme.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search for platelet-rich plasma in lumbar spinal stenosis found no randomised trial of it as a treatment injection. What the search returned was two different things: platelet-rich plasma added to bone graft during lumbar fusion surgery in 40 older patients (Wang, Int Orthop 2024), and one clinic's retrospective records in which 37 stenosis patients were rated on a satisfaction scale with no comparison group (Godek, Ortop Traumatol Rehabil 2022).","fit":"Plausible on mechanism is not the same as tested, and stenosis is a narrowed canal. An injection does not widen it. Walking tolerance, conditioning and load management are where the effort belongs, with a surgical opinion if leg symptoms are limiting or progressive.","reviewedOn":"2026-09-03"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"One comparative study in 211 older adults with lumbar spinal stenosis found 5% dextrose injected into multifidus improved back pain, leg pain and walking distance at one and three months, but the authors described the effect as moderate and lasting only about three months, and it was consistently smaller than the comparison treatment at one, three and six months (Chen and Suputtitada, J Pain Res 2023).","fit":"Does not widen the canal and does not change the walking limit that comes from the narrowing. Occasionally considered for the muscle and ligament pain sitting alongside stenosis, with the short duration of benefit made clear first.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"The one randomised trial of hyaluronic acid in lumbar spinal stenosis did not lubricate a joint. Forty-four people with leg pain had a selective nerve root block containing either cortisone or a sodium hyaluronate and carboxymethylcellulose solution, and the two were no different on pain, disability or quality of life out to twelve weeks, with the gap between them staying inside what a patient could notice (Ko, Pain Pract 2021). That is an injection placed around a nerve root, which belongs to the guided-injection row rather than this one. No trial has injected hyaluronic acid into a spinal joint for stenosis.","fit":"Not offered for this problem. The narrowing that causes the symptoms is bone and ligament, which an injection into a joint does not alter.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. No study has tested dextrose injected just under the skin in lumbar spinal stenosis. The one dextrose study in stenosis used a different route: in a review of 211 people's records, ultrasound-guided 5% dextrose into the multifidus muscle had only a moderate effect lasting about three months and did worse than needling with sterile water at one, three and six months (Chen, J Pain Res 2023).","fit":"Not a treatment for a narrowed spinal canal. Considered only where a separate tender superficial nerve in the back or buttock is also part of the picture.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. No study has tested nerve-root hydrodissection in lumbar spinal stenosis. The only lumbar series (46 people with nerve-root leg pain of unstated cause, saline and lignocaine around the root, leg pain 7.1 to 3.8 out of 10 at three months, no comparison group) did not report stenosis separately (Arima, Spine Surg Relat Res 2026). In stenosis specifically, the saline arm of a randomised epidural trial did poorly: a good result at one week in 12.5% of 53 people with walking limited to under 20 metres, against 55.5% with local anaesthetic (Fukusaki, Clin J Pain 1998).","fit":"Only where one nerve root is clearly the source of the leg pain. Walking-related leg pain from a narrowed canal, often at more than one level, is not something fluid around one nerve can address; a rehabilitation program and, where function is limited, a surgical opinion are the evidence-based options.","reviewedOn":"2026-10-29"}}},{"slug":"lumbar-spondylolisthesis","title":"Lumbar Spondylolisthesis","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/lumbar-spondylolisthesis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search of spondylolisthesis against trigger point, dry needling, prolotherapy and myofascial found ten records but no trial of needling or injection in this condition. What exists is case-level: myofascial tender points reproducing the pain in a woman with a symptomatic slip (Halpin, J Bodyw Mov Ther 2011), and the same after fusion for spondylolisthesis (Salik, J Chiropr Med 2021). The nearest trial evidence, in non-specific low back pain, disagrees with itself: positive for corticosteroid injection into quadratus lumborum at two weeks (Eftekharsadat, BMC Musculoskelet Disord 2020), wholly negative in a 180-person randomised trial (Lajeunesse, Ann Emerg Med 2025).","fit":"Reasonable to consider where a tender muscle band clearly reproduces part of your pain, with the absence of any direct study explained. The pain from an unstable segment is not treated by needling the muscle around it.","reviewedOn":"2026-09-07"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Little effect on outcomes","evidence":"There is no randomised trial of injection in this diagnosis, but there is comparative data and it is not encouraging. Following 266 surgical candidates with degenerative spondylolisthesis for four years, an epidural steroid injection made no difference to any patient-reported outcome among those who had surgery, was associated with less pain improvement through three years among those treated without surgery, and did not change how many crossed over to surgery (Gerling, J Bone Joint Surg Am 2020). A prospective series of 33 people given X-ray-guided transforaminal epidural steroid found pain scores better from two weeks through twelve months, but standing and walking tolerance no better after the first fortnight, satisfaction falling away with time, and 13% having surgery within the year (Kraiwattanapong, Asian Spine J 2014). Reviews list epidural steroid among the conservative options for a low-grade slip presenting with leg pain or limited walking distance (Bydon, Neurosurg Clin N Am 2019).","fit":"Considered only where the slip is producing leg pain or shortening walking distance, and then as a referral for an X-ray-guided epidural rather than anything injected here. It does not stabilise the slip. Back pain coming from the slip itself is a loading and conditioning problem, and that is where the work goes.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the slip","evidence":"A tested absence. A search on 11 November 2026 (shockwave, shock wave and ESWT with spondylolisthesis, spinal stenosis and neurogenic claudication: four records) found no trial of any form of shockwave for a slipped vertebra. The one report is a single case with a grade I slip, in which radial shockwave to the soft tissues was one of several treatments over nine months. Pain improved, and a follow-up MRI measured the slip at 0.53 cm against 0.65 cm, but the authors say this does not establish that the slip reduced and that the effective treatment cannot be identified (Chu, Cureus 2026).","fit":"Does not move, stabilise or otherwise change the slip. Considered only where examination finds a separate tender muscle contributing to the pain, alongside your strengthening programme.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Focused shockwave is not aimed at a disc, a facet joint or a nerve root, and there is no trial evidence for it in these conditions.","fit":"Considered only where examination finds a separate tender muscle or tendon contributing to the pain.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search for platelet-rich plasma in spondylolisthesis returns no trial of it on its own. The nearest study gave 96 patients with grade I spondylolisthesis pulsed radiofrequency and platelet-rich plasma together, with no control group, so none of the improvement can be attributed to the platelet-rich plasma (Le, Sci Rep 2025). The only other use found was as an additive to bone graft during fusion surgery (Wang, Int Orthop 2024).","fit":"Not offered for a slipped vertebra. The work that has evidence behind it is trunk and hip strengthening and managing the positions and loads that provoke it, with imaging repeated only if the clinical picture changes.","reviewedOn":"2026-09-03"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for prolotherapy or dextrose injection in spondylolisthesis returns no trial. Reviews of prolotherapy for chronic low back pain list spondylolisthesis among the possible underlying causes but report no study in which the slip was the diagnosis treated (Mociu, Medicina 2025).","fit":"Not offered for the slip. Any injection decision would be made about a separately identified pain source, not about the spondylolisthesis.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Searching hyaluronic acid, hyaluronate, viscosupplementation and hylan against spondylolisthesis, spondylolysis and pars defect returns no records at all, not a trial, not a series, not a case report. The nearest tested target is the lumbar facet joint, where a systematic review of 18 studies and 1,496 people found the injection no different from cortisone and of little or no overall benefit (Ambrosio, Global Spine J 2022).","fit":"Not offered for this problem. A slipped vertebra is a structural problem, and lubricating a joint does not change the slip or what it is doing to the nerves.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies found","evidence":"No study of perineural injection in spondylolisthesis, of any design. Searching perineural, perineural injection, neural prolotherapy, dextrose and glucopuncture terms against spondylolisthesis and spondylolysis returns ten records and not one is a treatment study: they are imaging prevalence surveys, a review of epidural balloon decompression, and a systematic review of prolotherapy for chronic low back pain that lists spondylolisthesis only as one possible cause and reaches no conclusion about it (Mociu, Medicina 2025).","fit":"Only where examination finds tender, hypersensitive skin over the low back. It does nothing about the slipped vertebra itself.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested hydrodissection as a treatment for spondylolisthesis. A search against spondylolisthesis and spondylolysis returned one record, and it described hydrodissection of Wiltse's plane to open the surgical approach during fusion rather than any pain treatment (Tataryn, Cureus 2017). Where a slip produces radicular pain, the nearest evidence is an uncontrolled series of 46 people with lumbar radiculopathy in whom ultrasound-guided nerve root hydrodissection lowered pain from 7.1 to 3.8 and disability from 42 to 28 by three months (Arima, Spine Surg Relat Res 2026).","fit":"It does not treat the slip or the instability. It is considered only for a separate nerve-related component identified on examination and ultrasound, alongside the loading and strengthening programme that remains the main treatment.","reviewedOn":"2026-09-06"}}},{"slug":"mcl-injury","title":"MCL Injury","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/mcl-injury","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials in this condition","evidence":"Searching the medial collateral ligament against dry needling, trigger point work and trigger point injection returned no treatment study at this ligament. The only medial-knee record is an observational mapping of tender points across 483 people with knee pain, in which 76 with medial-side diagnoses including collateral ligament injury had tender points on the medial knee and referred pain into the adductors and medial calf (Qin, Zhen Ci Yan Jiu 2020). There is no trial of needling for a medial collateral ligament injury, and nothing supports needling while the ligament is healing.","fit":"Not used in the acute phase. Considered later only if a separate tender muscle band is still reproducing part of your pain.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Series, persistent pain only","evidence":"Searched 8 November 2026 (PubMed: medial collateral ligament with corticosteroid, steroid, triamcinolone, methylprednisolone, betamethasone, anaesthetic or lidocaine injection, within a 51-record sprain search; and a randomised-trial and systematic-review pass, which found no trial). No controlled trial exists, and no study treated a fresh sprain. In 34 consecutive people with knee pain persisting after a grade I or II MCL sprain and scarring of the deep MCL on MRI, one ultrasound-guided injection of local anaesthetic and triamcinolone into the deep ligament was followed by resolution of medial knee pain in all those followed up, and 25 (96%) were back at sport at an average of 20 months; eight of the 34 were excluded or lost, and there was no comparison group (Jones, Knee 2008). In 16 people with persistent MCL injury, a 10 mL local anaesthetic injection with 25 to 50 mg hydrocortisone beneath the ligament's attachment to bone was followed by a 75% average fall in pain and a 42% improvement in the IKDC knee score; only 19 of 28 returned the questionnaire (Drumm, Clin Radiol 2014). In rabbits, betamethasone injected around a freshly cut MCL weakened the healing ligament at three weeks (Wiggins, Am J Sports Med 1994), which is a reason not to inject an acute tear.","fit":"Not a treatment for a fresh MCL sprain, which is bracing where needed and progressive strengthening. Where medial knee pain persists months after a low-grade sprain and imaging places it in the ligament, a guided injection may be discussed alongside the rehabilitation program. See the note on cortisone.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Case reports: calcified ligament only","evidence":"No study has tested shockwave in a fresh medial collateral ligament sprain. A PubMed search for shockwave with collateral ligament, MCL and related terms (15 records, all read) found one radial report: a 64-year-old woman with a calcified MCL, not after injury, treated with radial shockwave and iontophoresis, whose pain and calcification improved (Fernandez-Cuadros, Rehabilitacion 2021). The other reports are of calcification after injury with the device not stated (Rodriguez-Alonso, Rehabilitacion 2026; Maroc, Cureus 2025), and a radial report at the outer knee ligament (Sousa, Cureus 2025). There is no trial.","fit":"Not part of the care of a fresh MCL sprain. Considered only for a painful calcified ligament, or for tender muscle around a knee that is slow to settle, alongside the rehabilitation program, and on case reports alone.","reviewedOn":"2026-10-23"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Case reports: calcified ligament only","evidence":"No study has tested shockwave in a fresh medial collateral ligament sprain. A PubMed search for shockwave with collateral ligament, MCL and related terms (15 records, all read) found only case reports of a calcified or ossified ligament long after injury (Pellegrini-Stieda syndrome): one woman whose pain fell from 8 to 0 out of 10 after shockwave that followed a needle lavage, with the device type not given in the abstract (Rodriguez-Alonso, Rehabilitacion 2026), and one woman with bilateral calcification after a spinal cord illness who improved (Maroc, Cureus 2025). A trial and systematic-review pass over shockwave in ligament injuries (17 records) found no trial in this ligament.","fit":"Not part of the care of a fresh MCL sprain, which heals well with bracing and rehabilitation. Considered only for a painful calcified ligament months after injury, and then on case reports alone.","reviewedOn":"2026-10-23"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No randomised trial of PRP in MCL injury. The human evidence is uncontrolled: a series of 52 people with persistent pain after a low-grade MCL injury reported better IKDC scores after three weekly intra-articular PRP injections, but without a control group there is no way to separate the injection from time (Zou, J Int Med Res 2020), and beyond that there are three case reports (Yoshida, Clin J Sport Med 2019). The animal work disagrees with itself. PRP improved the structural properties of healing rabbit MCL (Yoshioka, Knee Surg Sports Traumatol Arthrosc 2013) but produced no difference in load to failure, stiffness or histology in rats (Amar, Arch Orthop Trauma Surg 2015).","fit":"Most MCL injuries heal without an injection, so this rarely arises. If it does, it is only after a proper rehabilitation attempt has failed, and the absence of trial evidence is stated before any cost is discussed.","reviewedOn":"2026-09-02"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report only","evidence":"No controlled trial of prolotherapy for a medial collateral ligament (MCL) injury was found. The only direct record is a single case: a rugby player with a grade 2 MCL sprain had 15% dextrose with lidocaine alongside exercise therapy and was pain-free with full movement at three weeks (Ada, Altern Ther Health Med 2015). One case cannot separate the injection from natural healing, which is usually good in this ligament. Rat studies of dextrose in the MCL are laboratory work and carry no weight here. PubMed search, 14 October 2026: prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain, collateral ligament or ligament injury terms (21 records), and prolotherapy with ligament terms (121 records, all screened), each with randomised-trial and systematic-review passes.","fit":"Most MCL sprains heal well with bracing where needed and rehabilitation. Prolotherapy can be discussed for an MCL that stays sore or lax months after a completed program, with the lack of trials stated.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Untested in people. A search pairing hyaluronic acid with the medial collateral ligament of the knee returned eight records and none treated an injured ligament. All eight were animal experiments, most of them cutting the ligament to bring on arthritis and then testing the injection on the joint cartilage (for example Kawano, Arthritis Rheum 2003). The only sprain in which hyaluronic acid has been trialled is the ankle (Petrella, Clin J Sport Med 2007). This is absence of evidence, not evidence that it fails.","fit":"Not offered for this problem. Most MCL injuries heal without an injection, with graded loading and time.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Different injection target","evidence":"The one dextrose report at this ligament injected the ligament, not the skin over it: a rugby player with a grade 2 medial collateral ligament sprain was given 15% dextrose with lignocaine alongside exercise and was pain free with full movement at three weeks, against a usual 4 to 8 weeks for conservative care of a complete tear (Ada, Altern Ther Health Med 2015). That is a single uncontrolled case of a different procedure, compared against a historical figure rather than a control group. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose and glucopuncture terms against this ligament returns no study of small injections placed just under the skin.","fit":"Not part of treating the ligament itself. Considered only if tender, hypersensitive skin over the inner knee persists once the sprain has otherwise settled.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 6 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with medial collateral ligament, MCL, Pellegrini-Stieda, or the saphenous nerve or its infrapatellar branch at the knee, 5 records; the sprain search for this programme found no knee ligament study). No study has tested hydrodissection for a medial collateral ligament injury. The nearby reports concern the saphenous nerve, which runs past the inner knee: one case of saphenous nerve entrapment above the knee treated with fascial hydrodissection alongside rehabilitation, with no outcome figures in the abstract (Eliot Hu, Clin J Sport Med 2022), and a retrospective series of 16 people with inner-knee pain after knee replacement, in whom hydrodissection of the nerve's branch below the kneecap followed by corticosteroid brought pain to 0 or 1 out of 10 in nine; the authors called for a placebo-controlled trial (Clendenen, Clin Orthop Relat Res 2015).","fit":"Not a treatment for the ligament, which heals with bracing where needed and progressive loading. Considered only where inner-knee pain is burning or numb in the pattern of the saphenous nerve or its branch below the kneecap.","reviewedOn":"2026-11-06"}}},{"slug":"meniscus-knee-pain","title":"Meniscus-Related Knee Pain","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/meniscus-knee-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials in this condition","evidence":"Searching dry needling, trigger point work and trigger point injection against the meniscus returned two records and neither is a treatment study: an observational mapping of tender points and referred pain in 483 people with knee pain, in which medial meniscal lesions sat among the medial-knee diagnoses (Qin, Zhen Ci Yan Jiu 2020), and a case report of a glomus tumour that matched only on the phrase (Okahashi, Arch Orthop Trauma Surg 2004). Needling has not been tested as a treatment for meniscal knee pain.","fit":"Considered only where examination finds a separate tender muscle band reproducing part of your pain. A needle does not reach or repair a meniscal tear.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No human study has tested radial shockwave in a meniscal tear. A PubMed search on 25 October 2026 for radial device terms with knee tears, meniscus or repair (12 records, all read) found only a rat study, in which one radial session improved healing of a surgically made tear (Huang, Am J Sports Med 2024). The one human trial in a degenerative meniscal tear used a focused device and sits on the row above (Hashimoto 2024); a retrospective study of shockwave in osteoarthritis with a meniscal injury does not say which device it used (Li, Pak J Med Sci 2024).","fit":"May ease the tender muscle and tendon around the knee. Not a treatment for the tear itself; the focused trial is the nearer evidence.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small sham trial","evidence":"Tested in one small sham-controlled trial. In 27 people, average age 64, with a degenerative medial meniscal tear, three weekly sessions of focused shockwave improved the MRI signal of the meniscus at twelve months and left less knee pain than sham (p = 0.04), but the knee function scores were no different, and no adverse events were reported (Hashimoto, Knee Surg Sports Traumatol Arthrosc 2024). A retrospective comparison of 128 people with knee osteoarthritis and a medial meniscal injury found shockwave alone did less well than shockwave combined with PRP; it had no untreated group and does not say which device it used (Li, Pak J Med Sci 2024). Searched on PubMed 25 October 2026: shockwave terms with meniscus, meniscal or menisci (8 records, all read; the others were a case report, a computer model and two unrelated papers), plus trial and systematic-review passes.","fit":"Worth discussing for a painful degenerative meniscal tear in an older knee where surgery is not indicated, alongside the strengthening program. Not a treatment for a locked knee or a displaced tear.","reviewedOn":"2026-10-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small double-blind trial","evidence":"Tested as an injection for degenerative meniscal tears, in small studies. In the one double-blind placebo-controlled trial, 72 people with a long-standing tear had the meniscus needled through the skin with or without PRP injected into it. The tear failed to heal in 48% with PRP against 70% without, 8% against 28% went on to keyhole surgery, and more of the PRP group had a meaningful improvement in pain (Kaminski, Int J Mol Sci 2019). That trial tested PRP added to needling rather than an injection on its own, and about half the tears still did not heal. In a three-group trial of 54 people with a degenerative tear and early arthritis, those given two PRP injections into the knee joint a month apart had about a fifth less pain at nine months while the saline group got worse, and a third product did better than either (Bishnoi, J Orthop Case Rep 2026). Uncontrolled series point the same way: 69 people given four weekly injections improved to twelve months and none needed surgery (Alessio-Mazzola, Sports Health 2022), and a review of ten studies and 686 people found improvement by three months that lasted a year, while noting the lack of high-quality studies (Elphingstone, J Orthop 2024). Against that, in 90 people whose partial meniscal tear was injected during cruciate ligament surgery, healing and symptoms were not significantly better at six or twelve months than leaving it alone (Shayan, Int J Burns Trauma 2025), and an international panel of 20 experts agreed that PRP is not a good option for degenerative tears (Hohmann, Arthroscopy 2020). A pooled analysis of 18 randomised trials and 1,143 people with a meniscal injury found a little less pain, 0.7 points on the pain scale, and better function with PRP than with no added treatment. Read in full, 16 of those 18 trials gave PRP during or after an arthroscopic meniscal repair, only one had a placebo control, 13 were open-label, and the two without surgery (the Kaminski needling trial above and a single injection in 36 people doing rehabilitation) were not analysed separately (Liang, Orthop J Sports Med 2025). It says little about an injection given in the clinic, and searched on 20 October 2026 it does not change the rung.","fit":"Most degenerative meniscal tears settle with a strengthening program and time, and that comes first. For knee pain that persists after a proper program, a PRP injection can be discussed as a way of making loading more comfortable, with the size of the trials and the expert panel's reservations stated. A locked knee, or a repairable tear after an injury in a younger person, is a surgical question and not an injection one.","reviewedOn":"2026-10-20"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested prolotherapy in meniscal injury. The published material is a three-case imaging report suggesting tissue change at the medial meniscus after injection (Fullerton, Arch Phys Med Rehabil 2008) and a single Baker's cyst case (Centeno, Pain Physician 2008). A 2026 review of regenerative injections for meniscal lesions describes the evidence as highly heterogeneous, at high risk of bias, and limited by small samples and short follow-up (Drakonaki, Radiol Clin North Am 2026).","fit":"The knee osteoarthritis evidence does not transfer to a meniscal tear. They are different problems. If osteoarthritis is also present, that is the diagnosis the injection would be aimed at, and it is discussed on those terms.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested perineural injection in meniscal pain. The one directly relevant report runs the other way: an elite badminton player with an ultrasound-confirmed partial tear of the medial meniscus posterior horn, already recommended for surgery, turned out on examination to have pes anserinus tendon pain, and four weekly ultrasound-guided injections of 5% dextrose at the sartorius, gracilis and semitendinosus tendon traction points took his pain from 8 to 1 out of 10 and returned him to competition (Yang, Int Med Case Rep J 2026).","fit":"Not a treatment for the meniscus. Its value here is in the assessment. A tear on the scan is not always the source of the pain, and where the tenderness sits over the medial tendons rather than the joint line, that is a different problem with a different treatment.","reviewedOn":"2026-09-09"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested hydrodissection for meniscal knee pain, and searching the technique against meniscus and meniscal returns nothing on the subject. What the knee hydrorelease literature does contain is case reports of freeing scar tissue and fat-pad adhesions after arthroscopic knee surgery, where the stiffness and front-of-knee pain came from tissue that had stopped gliding rather than from the cartilage: one patient regained full extension immediately, another improved on the Kujala score from 62 to 82 at four weeks (Machida, Cureus 2020; Machida, Cureus 2022).","fit":"Not a treatment for a meniscal tear. Considered only where a nerve, or a tissue plane scarred after previous knee surgery, is contributing separately to the pain or the stiffness.","reviewedOn":"2026-09-15"}}},{"slug":"meralgia-paraesthetica","title":"Meralgia Paraesthetica","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/meralgia-paraesthetica","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Remove the pressure first","evidence":"Around 85% of people recover with conservative management. The measures with the clearest rationale are removing external pressure (belts, waistbands, tool belts, tight garments) and weight loss where excess weight is contributing. Physiotherapy has not been shown to be an effective treatment for this condition specifically.","fit":"Explanation, pressure relief and activity advice are the starting point, and for most people they are the whole treatment.","reviewedOn":"2026-09-13"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial of trigger point injection at this nerve. The only needling report is a case series of 10 people treated with electroacupuncture, in which every pain score improved by at least 50% and all ten were tender over a point on the outer thigh before treatment (Alexander, Acupunct Med 2013). That is dry needling in ten people without a control group, not an injection trial.","fit":"Only where a separate tender band of muscle in the thigh or buttock is reproducing part of the pain. It does nothing about the compression itself.","reviewedOn":"2026-09-14"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Local anaesthetic with or without corticosteroid around the lateral femoral cutaneous nerve is the standard next step for persistent symptoms, and it confirms the diagnosis at the same time. In a randomised double-blind trial of 56 people, the corticosteroid arm improved significantly on pain and quality of life at one, three and four months, though 5% dextrose was ahead of it by four to six months and caused no side effects where corticosteroid caused six (Shi, Pain Physician 2024). Ultrasound-guided technique at this nerve is well described (Blaichman, Radiographics 2019).","fit":"Considered where symptoms persist beyond one to two months despite pressure relief, or where the diagnosis needs confirming against lumbar nerve root pain. The nerve is superficial and reachable under ultrasound.","reviewedOn":"2026-09-14"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search for vibration therapy in meralgia paraesthetica returned no records at all. Vibration has not been tested in this condition, and the wider case for local vibration sits in myofascial pain rather than in nerve compression.","fit":"Not a treatment for the compressed nerve, and not applied over it. Considered only where tight muscle in the thigh is a separate contributor.","reviewedOn":"2026-09-14"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial of shockwave in meralgia paraesthetica was found. The shockwave literature in nerve entrapment is almost entirely carpal tunnel syndrome, and it does not transfer to a purely sensory nerve compressed at the pelvis.","fit":"Not offered as a treatment for this condition.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial in meralgia paraesthetica. Applying a focused pulse over the front of the pelvis is not a described technique for this nerve.","fit":"Not offered as a treatment for this condition.","reviewedOn":"2026-09-13"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of EMTT in meralgia paraesthetica, and no guideline support in any entrapment neuropathy.","fit":"Not part of managing this condition.","reviewedOn":"2026-09-13"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of PRP in meralgia paraesthetica.","fit":"Not offered for this condition.","reviewedOn":"2026-09-13"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial of prolotherapy in meralgia paraesthetica. Dextrose has been tested at this nerve, but as a single perineural bolus placed around the nerve under ultrasound (Shi, Pain Physician 2024), which is the hydrodissection row below rather than a course of injections into ligament and tendon attachments.","fit":"Not relevant to this diagnosis. There is no painful attachment to treat.","reviewedOn":"2026-09-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for hyaluronic acid, hyaluronate or viscosupplementation at the lateral femoral cutaneous nerve returned no study of this treatment in this condition. There is also no joint here to inject.","fit":"Not offered for this problem.","reviewedOn":"2026-09-14"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"The one randomised trial of dilute dextrose at this nerve delivered it as a single 10 mL perineural injection under ultrasound rather than as the series of small injections just under the skin that this treatment involves (Shi, Pain Physician 2024). It found the dextrose better than corticosteroid at four to six months with no side effects. Applied as a subcutaneous series, the evidence remains case series, so certainty is low, though the safety profile of dilute dextrose is favourable.","fit":"Considered for persistent skin hypersensitivity over the outer thigh once the diagnosis is settled.","reviewedOn":"2026-09-14"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One randomised trial","evidence":"Fifty-six people with meralgia paraesthetica were randomised in a double-blind trial to a single ultrasound-guided hydrodissection of the nerve with either 10 mL of 5% dextrose or corticosteroid with local anaesthetic. Both improved, and the dextrose group was further ahead on pain, tingling and quality of life at four and six months, with more people reporting a successful result at six months. No one in the dextrose group reported a side effect, against six in the corticosteroid group (Shi, Pain Physician 2024). That trial had no placebo arm, and a search in November 2026 found no second trial of hydrodissection here, against a dummy injection, conservative care or surgery; the rest is a short published report of dextrose hydrodissection in chronic cases (Su, Pain Pract 2020) and single case reports. In the nearest placebo-controlled trial, of corticosteroid injection beside the nerve in 20 people, pain improved in the saline group too and the two did not differ at 12 weeks (Kloosterziel, Muscle Nerve 2020), which is a reason to be cautious about how much of any injection's effect here is specific.","fit":"Occasionally discussed for persistent symptoms after pressure relief and injection, and a reasonable step where surgery is being avoided.","reviewedOn":"2026-11-05"}}},{"slug":"morton-neuroma","title":"Morton Neuroma and Forefoot Pain","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/morton-neuroma","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Conservative care comes first, and it holds up well. A network meta-analysis of 49 randomised trials and 3,323 patients with carpal tunnel syndrome ranked manual therapy first for both short- and medium-term pain relief, ahead of every injection option including corticosteroid (Chen, Arch Phys Med Rehabil 2025).","fit":"Load management, splinting where it fits, and addressing what is irritating the nerve come before any injection. Where the nerve is being compressed structurally and function is being lost, surgical review is the right conversation rather than more conservative care.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested trigger point needling or injection in Morton's neuroma. A search pairing dry needling, trigger point needling and needling with Morton's, interdigital and intermetatarsal neuroma returned one relevant record, a technical note describing repeated ultrasound-guided needle punctures to break up the fibrous tissue around the nerve between the metatarsal heads, without trial outcomes (Atilano, Muscles Ligaments Tendons J 2016). That is a different procedure aimed at the scar tissue around the nerve, not at a muscle band.","fit":"Rarely relevant. The pain comes from the nerve between the toes rather than a muscle band, so this is considered only where a separate tender muscle in the foot or calf is adding to it.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"This is one of the few places where ultrasound guidance was compared head to head with an unguided injection. In an evaluator-blinded randomised trial, 33 people had landmark-guided corticosteroid injection and 38 had it under ultrasound; pain improvement favoured the guided group out to three years, and satisfaction at three years was 87 per cent against 59 per cent (Santiago, Eur Radiol 2022). A systematic review of ten studies in 695 people found a moderate short- to medium-term benefit over usual care with a low rate of adverse events, though it rated study quality low (Edwards, J Am Podiatr Med Assoc 2021). Expectations should be set against the ceiling: pooling 2,998 patients, complete pain relief followed injection in 43 per cent (95% CI 23 to 64) against 74 per cent (66 to 82) after surgical excision, and 15 per cent of injected patients went on to surgery (Lu, Acta Neurochir 2020).","fit":"A reasonable first step before considering surgery, with footwear and forefoot loading addressed alongside. Repeated corticosteroid into the web space is not the plan: see the note on cortisone.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Two small sham trials; pooled null","evidence":"Searched again 17 October 2026 (14 records, all read). Unlike the other entrapments, the neuroma itself has been trialled, but the work is small, contested, and neither trial says whether a radial or a focused device was used. In 25 feet after more than eight months of failed conservative care, pain fell significantly after shockwave and not after sham over twelve weeks, but each group was compared only with its own starting point (Fridman, J Am Podiatr Med Assoc 2009); that result drew three published letters questioning its analysis and reporting (Payne; Turlik; Landorf, J Am Podiatr Med Assoc 2009). A second sham-controlled trial found the same pattern over four weeks, with no change in satisfaction or in neuroma size on ultrasound (Seok, J Am Podiatr Med Assoc 2016). Pooled, the shockwave trials did not differ significantly from control (pain -5.9 points out of 100, 95% CI -21.9 to 10.1) (Matthews, J Foot Ankle Res 2019). A systematic review of 22 studies of non-operative treatment found shockwave produced a statistically significant improvement but with limits on where it applies, and recommended corticosteroid injection ahead of it (Thomson, Foot Ankle Surg 2019). A review of common foot and ankle conditions lists activity modification, orthoses and interdigital corticosteroid injection as first-line here and does not include shockwave (Cooper, JAMA 2023).","fit":"The neuroma lies shallow enough for a radial device to reach it, so it is not implausible, but corticosteroid injection is the better-evidenced option and comes first. Worth raising only once injection has been tried or declined.","reviewedOn":"2026-10-17"},"focusedShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Two small sham trials; pooled null","evidence":"Searched 17 October 2026: shockwave, shock wave or ESWT with Morton's, interdigital, intermetatarsal or plantar digital neuroma (14 records, all read), plus a systematic-review and randomised-trial pass across nerve entrapments. Two small randomised trials against sham, neither stating whether the device was focused or radial. In 25 feet after more than eight months of failed care, pain fell after shockwave and not after sham over twelve weeks, but each group was compared only with its own starting point, not with the other (Fridman, J Am Podiatr Med Assoc 2009), and three letters in the same journal criticised the analysis and reporting (Payne; Turlik; Landorf, J Am Podiatr Med Assoc 2009). A second sham trial found the same pattern over four weeks, with no change in satisfaction or in the size of the neuroma on ultrasound (Seok, J Am Podiatr Med Assoc 2016). When the shockwave trials were pooled, the difference from control was not significant (pain -5.9 points out of 100, 95% CI -21.9 to 10.1) (Matthews, J Foot Ankle Res 2019), and a review of 22 studies recommended corticosteroid injection ahead of shockwave (Thomson, Foot Ankle Surg 2019).","fit":"Footwear, a metatarsal pad and a corticosteroid injection come first. Shockwave can be raised once those have been tried or declined, with the message that the two small trials and the pooled analysis do not agree.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered; one unblinded trial","evidence":"Trialled once in a Morton neuroma, with a result that favours PRP, and not offered here. Sixty people with a Morton neuroma confirmed on examination and MRI, all of whom had already had at least six months of conservative treatment without success, were randomised to three injections of PRP or a single cortisone injection. Both groups improved, and PRP scored better at three, six and twelve months: at twelve months physical function was 61.8 against 55.2 (higher is better) and pain interference 38.4 against 44.2 (lower is better) on the PROMIS scales, and at six months the neuroma measured 4.2 mm against 5.8 mm on MRI. Complications were few in both groups (Genuth, Foot Ankle Int 2026). The limits are plain: nobody was blinded, the PRP group had three injections to the cortisone group's one, there was no dummy-injection group, and the authors themselves call the result hypothesis-generating until a larger and more rigorous trial repeats it. The only other report is a single case in which pain fell from 9 to 1 out of 10 at twelve months after two injections (Hehsan, Pain Med Case Rep 2026). A JAMA review lists a cortisone injection among the first-line treatments and notes that about three in ten people do not respond to conservative treatment (Cooper, JAMA 2023), and a European radiology consensus puts ultrasound-guided cortisone at its highest level of evidence for this condition (Sconfienza, Eur Radiol 2021).","fit":"Not offered here for a Morton neuroma. Footwear changes, a metatarsal pad or orthotic and, where needed, an ultrasound-guided cortisone injection are the treatments with the strongest evidence, with a surgical opinion where those have not been enough. The single PRP trial is unblinded and has not been repeated.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A search for dextrose or prolotherapy in Morton's and interdigital neuroma returned 11 records, and not one was a trial of either. One was about fungal infection between the toes cultured on dextrose agar. A review of injection treatment for chronic foot pain covers steroid, alcohol, capsaicin and hyaluronic acid for Morton's neuroma and does not include prolotherapy (Urits, Pain Ther 2020).","fit":"Not offered for this. A Morton's neuroma is a thickened nerve between the toes, and the useful first steps are footwear width, a metatarsal dome and offloading rather than an injection aimed at ligament.","reviewedOn":"2026-09-03"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Trialled at this nerve, but not offered here. Forty-four people with 48 affected feet were randomised to three weekly ultrasound-guided injections of either hyaluronic acid or triamcinolone: both groups improved in pain and AOFAS score out to twelve months, cortisone was clearly ahead at one, three and six months, and the two were no different by twelve. A quarter of the cortisone feet developed skin discolouration at the injection site while the hyaluronic acid group had no complications, and nobody in either group went on to have the neuroma removed (Ferreira, Bone Joint J 2024). A separate series of 83 people given the same three-injection course saw walking pain fall from 73 to 23 out of 100 and AOFAS rise from 32 to 87 at twelve months (Lee, Foot Ankle Int 2017). A systematic review of twelve injection studies in 1,438 people rates hyaluronic acid well tolerated but still under-researched (Millán-Silva, Pain Manag Nurs 2024). There is no placebo-controlled trial.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and a Morton's neuroma is a nerve problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched 29 October 2026: Morton's, interdigital or intermetatarsal neuroma with dextrose, glucose, prolotherapy, perineural injection, neural prolotherapy, hydrodissection or hydrorelease (13 records); the neuroma with any injection and dextrose, saline, anaesthetic, hyaluronic acid or perineural terms (45); and randomised-trial (18) and systematic-review (24) passes. All were read. No study of any design has tested dilute dextrose injected under the skin or around the nerve for a Morton neuroma. The injection trials at this nerve are of other injectates: a Cochrane review of six trials (373 people) found cortisone with local anaesthetic did not clearly beat local anaesthetic alone on pain (-6.3 points out of 100, 95% CI -14.2 to 1.6, low certainty), and that ultrasound guidance improved the result of the same injection (-15.0, -27.9 to -2.1) (Matthews, Cochrane Database Syst Rev 2024); capsaicin injected into the web space beat placebo at one and four weeks in 58 people (Campbell, Pain 2016). The dextrose trials behind this treatment are at the median nerve in the carpal tunnel, a different nerve.","fit":"Considered only where footwear changes, a metatarsal pad and an ultrasound-guided cortisone injection have not settled the neuroma and surgery is being avoided, with the plain statement that it has not been studied at this nerve.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched 29 October 2026: Morton's, interdigital or intermetatarsal neuroma with dextrose, glucose, prolotherapy, perineural injection, neural prolotherapy, hydrodissection or hydrorelease (13 records); the neuroma with any injection and dextrose, saline, anaesthetic, hyaluronic acid or perineural terms (45); and randomised-trial (18) and systematic-review (24) passes. All were read. No study has tested hydrodissection as a treatment for a Morton neuroma. The only hydrodissection record at this nerve describes fluid used during open surgery to help remove the neuroma, with no clinical outcome reported (Faridi, Foot Ankle Orthop 2024). The nearest evidence is for a smaller-volume cortisone injection beside the nerve, and it is itself mixed: in 131 people, ultrasound-guided methylprednisolone with lignocaine beat lignocaine alone at three months (14.1 points on a 100-point foot health scale, 95% CI 5.5 to 22.8) (Thomson, J Bone Joint Surg Am 2013), a double-blind trial of 41 found no difference from local anaesthetic at three or six months (Lizano-Díez, Foot Ankle Int 2017), and the Cochrane review pooling these trials found no clear difference (Matthews, Cochrane Database Syst Rev 2024). Those are cortisone trials, not hydrodissection.","fit":"Considered where a Morton neuroma has not settled with footwear, padding and a cortisone injection and surgery is being avoided, with the absence of any study of hydrodissection at this nerve explained.","reviewedOn":"2026-10-29"}}},{"slug":"muscle-contusion","title":"Muscle Contusion (Bruise)","region":"General","url":"https://www.backpaindoctor.com.au/conditions/muscle-contusion","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, trigger point, lignocaine or local anaesthetic injection with muscle contusion, muscle strain or muscle injury, 18 records; and a randomised-trial and systematic-review pass, 12 records). No human study of trigger point injection, wet needling or any injection into muscle after a muscle bruise was found; the contusion and muscle-injury records returned were laboratory animal studies.","fit":"Not part of early care for a fresh muscle bruise, which is protected movement and graded loading. Considered later only where a tender band persists and is limiting rehabilitation.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Series without outcome figures","evidence":"Searched 8 November 2026 (PubMed: muscle, thigh or quadriceps contusion and muscle haematoma with corticosteroid or anaesthetic injection, or with ultrasound-guided injection, aspiration or drainage, 39 records across two searches; and a randomised-trial and systematic-review pass, which found no trial). No controlled study exists. A radiology department's 18-year experience of 128 ultrasound-guided drainages and injections in 69 American footballers, including contusions and haematomas, describes the procedures as safe but reports no outcome figures (Dave, AJR Am J Roentgenol 2014). In Australian professional rugby league, local anaesthetic injected so that players could keep playing with iliac crest bruises was among the injections players rated most highly and appeared safe at an average of five years, in a retrospective survey that did not measure recovery (Orchard, Am J Sports Med 2010); that is pain relief to play, not treatment of the bruise. Local anaesthetic injected into muscle damages muscle fibres (Reurink, Sports Med 2014).","fit":"Not a treatment for a fresh bruise, which settles with protected movement and progressive loading. A guided procedure, such as draining a collection, is considered only where ultrasound shows a large haematoma that is holding back the rehabilitation program.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for a fresh bruise","evidence":"No trial has tested shockwave of either device for a fresh muscle contusion. Where shockwave has been used after a muscle bruise is in its calcified complication, myositis ossificans, and with the other device: 24 sportsmen given three sessions of electrohydraulic (that is, focused) shockwave with a rehabilitation programme showed only partial shrinkage of the bone formation on X-ray, but normal range of movement and no weakness by two months, and 87.5% were back to regular sport at three months (Buselli, Ultrasound Med Biol 2010). Uncontrolled, and a different device from the one this row describes.","fit":"Not part of managing a fresh bruise, where the priorities are excluding compartment syndrome, restoring movement and graded loading. Relevant only if the bruise calcifies and stays painful, and that is a question about the focused form rather than this one.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Calcified bruise only: one series","evidence":"Searched 21 October 2026: shockwave terms with muscle injury, strain, tear, lesion, contusion or myositis ossificans in humans (25 records) and a trial and review pass (18). No trial has tested focused shockwave for a fresh muscle bruise. In a series of 20 muscle injuries in professional footballers treated from the day of injury, one buttock bruise was treated with a focused device and the rest with radial, with no comparison group (Morgan, J Orthop Surg Res 2021). The use with some evidence is the calcified complication, myositis ossificans: 24 sportsmen given three sessions of electrohydraulic shockwave, a generator type that focuses its energy, with rehabilitation had normal movement and no weakness by two months and 87.5% were back at sport by three, though the bone formation only partly shrank on X-ray (Buselli, Ultrasound Med Biol 2010; uncontrolled). Shockwave has also been reported as the cause of myositis ossificans in the back muscles, in one case report (Han, Medicina 2022).","fit":"Not part of managing a fresh bruise, where the priorities are excluding compartment syndrome, restoring movement and graded loading. Relevant only if the bruise calcifies and stays painful, alongside rehabilitation.","reviewedOn":"2026-10-21"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not tested in a muscle bruise in people. A search for PRP in muscle contusion, muscle haematoma and myositis ossificans returned eight records: six animal experiments, which disagree with one another, and two reviews, with no clinical study. In the animal study built around muscle function, PRP injected into a bruised rat calf made no difference to strength or healing, and its authors advised against recommending it until clinical studies exist (Delos, Am J Sports Med 2014). The nearest human trial is of a different injury: 71 people with a leg muscle tear and a collection of blood that was drained, in whom recovery took 32 days with PRP and 38 with a dummy procedure, a difference that could have been chance (Martinez-Zapata, Blood Transfus 2016). There is also a reason for caution. The complication to avoid after a deep muscle bruise is bone forming inside the muscle, and at one surgical centre that complication was seen far more often in athletes with groin muscle injuries who had been given PRP, including 22 of 28 professional American footballers against none of 28 matched players. That is an observation from one centre, not proof that PRP caused it (Poor, Am J Sports Med 2024).","fit":"Not offered for a muscle bruise. These injuries are monitored and rehabilitated. A bruised muscle has already bled into itself, so an injection of concentrated platelets is unlikely to add to what is there. Early protection, then restoring movement and strength, is what changes the outcome, and extra bone forming in the muscle is the complication to avoid.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No human trial has tested prolotherapy in muscle contusion, and the animal work points both ways. Dextrose reduced muscle damage markers and promoted satellite-cell regeneration in a mouse contusion model (Tsai, Int J Med Sci 2018), while a rat muscle-injury model reported a prominent inflammatory reaction with necrosis and excess connective tissue, and the authors advised against using it for muscle injuries (Kunduracioglu, Neurosciences 2006). Reviews of orthobiologics for muscle injury report no high-level clinical evidence (Droz, Clin Sports Med 2024).","fit":"Not offered for a bruised muscle. The concern with injecting an injured muscle is added scar, not just absent benefit. Management is protection early, then graded loading.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Untested in people. A search pairing hyaluronic acid with muscle injury, muscle strain, muscle tear, calf strain, hamstring injury, tennis leg and contusion terms returned 39 records. Twenty-five were animal, hydrogel, scaffold or spinal cord studies, and none of the other 14 was a trial of hyaluronic acid for a muscle injury. The nearest were a single case of a torn adductor muscle given hyaluronic acid together with platelet-rich plasma (Giannini, J Sports Med Phys Fitness 2023) and a review of injections in professional footballers, which gives hyaluronic acid a role only for cartilage injury (Jader, Int Orthop 2024). The only record about treating a bruise used the opposite agent: hyaluronidase, an enzyme that breaks hyaluronic acid down, injected into facial bruising after injury in an uncontrolled report (Han, Arch Craniofac Surg 2018). No study has injected hyaluronic acid for a muscle contusion.","fit":"Not offered for an acute muscle injury. A contusion settles with early protection, then graded movement and loading.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested small dextrose injections under the skin for a bruised muscle. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against contusion, muscle injury and muscle tear returns no treatment study of any design, and widening to any dextrose or prolotherapy injection finds no human study of a muscle contusion. Reviews of injection treatments for muscle injury report that high-level clinical evidence is lacking (Droz, Clin Sports Med 2024) and that the few clinical studies are inconclusive (Stephens, Phys Med Rehabil Clin N Am 2023). The one report of a skin nerve trapped after a direct blow is a 31-year-old with nerve pain down the inner shin fifteen years after being struck on the leg. An ultrasound-guided fluid injection around the saphenous nerve gave complete but temporary relief, and surgery was needed to free it (Henderson, J Orthop Case Rep 2025). That is hydrodissection rather than this treatment, and it is one case.","fit":"Not offered for a bruised muscle. Management is protection early, then graded loading. Considered only if a patch of tender, hypersensitive skin or nerve-type pain remains long after the bruise itself has gone.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with contusion (5 records, none a bruise) and with Morel-Lavallée lesion, thigh contusion or myositis ossificans (12 records, none a bruise); the same terms with quadriceps, thigh, rectus femoris or vastus, 24 records; a randomised-trial and systematic-review pass returned none). No study has tested hydrodissection for a muscle bruise or corked thigh. The nearest is a series of seven people with pain persisting at least eight weeks after a hamstring injury (a strain, not a bruise), in whom an ultrasound-guided injection of dilute lignocaine into thickened tissue around a skin nerve was followed by pain falling from 10 to under 1 out of 10, with no comparison group (Shiwaku, J Funct Morphol Kinesiol 2025).","fit":"Not a treatment for a muscle bruise, which settles with early pain-free movement and graded loading. Considered only if nerve-type pain persists in the area long after the bruise has healed.","reviewedOn":"2026-11-10"}}},{"slug":"muscle-cramps","title":"Muscle Cramps","region":"General","url":"https://www.backpaindoctor.com.au/conditions/muscle-cramps","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Conditioning and graded loading are the parts within your control, on the same evidence that supports loading in tendon and muscle problems generally (Challoumas, Sports Med Open 2023; Doherty, Br J Sports Med 2016). No injectable treatment offered here has been shown to prevent cramp.","fit":"Assessment matters more than treatment here, because cramp has medical causes that rehabilitation will not touch: electrolyte and magnesium status, medications, thyroid and neurological contributors. Those are checked before anyone commits to a training fix.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only where there is a cause to treat","evidence":"A blanket claim that there is no evidence in muscle cramp does not survive a search, though what turns up is cramp with a cause behind it rather than ordinary night cramp. In 126 people with lumbar degenerative disease, shockwave given every second day for four weeks reduced pain and also the frequency and duration of their leg cramps, more than a conventional exercise programme did, and the difference held at one and three months; it was a retrospective comparison and the report does not say which device was used (Li, Biomed Res Int 2021). Radial shockwave does reliably reduce muscle tone where increased tone is the cause: 62 stroke patients given four sessions to the forearm muscles improved in tone, movement and hand function (Marek, J Clin Med 2026), and a runner with hereditary spastic paraparesis had less cramping and a better gait with repeated radial treatment (Rovito, Am J Phys Med Rehabil 2021). Nothing has tested it in ordinary idiopathic or night-time cramp.","fit":"Not a treatment for cramp itself. Where the cramping is coming from something treatable (a tight, overloaded muscle, a nerve-root problem, increased muscle tone) this can be part of treating that. Cramp is worked up first for its medical causes, which no local treatment will touch.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No trial in ordinary cramp","evidence":"Searched 27 October 2026: shockwave, shock wave, ESWT or pressure wave with cramp, cramps or cramping (7 records, all read). No study has tested focused shockwave in ordinary muscle or night cramp. The nearest records are a retrospective comparison of 126 people with lumbar degenerative disease, in whom shockwave reduced the frequency and duration of leg cramps more than an exercise program, with the device type not stated (Li, Biomed Res Int 2021), and a placebo-checked series of six people with upper-limb dystonia, including three with writer's cramp, treated with a focused electromagnetic device, in which two of the three with writer's cramp improved (Trompetto, Eur J Neurol 2009). Writer's cramp is a movement disorder rather than a muscle cramp. The radial row on this page names the tone-reduction studies.","fit":"Not offered for this. Cramp is worked up for its medical contributors (electrolytes and magnesium, medications, thyroid and neurological causes) and managed with conditioning and load where those are clear.","reviewedOn":"2026-10-27"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study of PRP for muscle cramps was found. A PubMed search in October 2026 pairing platelet-rich plasma and platelet concentrate with muscle cramps, exercise-associated cramps and night-time leg cramps returned no record about cramp, and a second pass on the words cramp, cramps and cramping returned two, both studies of other conditions in which cramp is mentioned in passing.","fit":"Not offered for cramps. Considered only for a separate, clearly identified tendon or joint problem.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study has tested prolotherapy for muscle cramps. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose or hypertonic glucose with cramp, cramps or cramping, then randomised-trial and systematic-review passes) found no prolotherapy study. The only trials of a concentrated sugar solution for cramps are a different procedure: 50% dextrose given into a vein to stop cramps during kidney dialysis, which relieved more episodes than saline in small double-blind trials (Milutinovich, Ann Intern Med 1979, 15 people; Neal, Arch Intern Med 1981, 12 people) and did no better than saline or mannitol in a later crossover trial (Canzanello, ASAIO Trans 1991, 24 people). That treats the fluid shifts of dialysis, not the muscle, and is not prolotherapy.","fit":"Cramps are managed by looking for the cause (medicines, fluid and electrolyte balance, nerve or vascular problems) and with stretching and conditioning. Prolotherapy is considered only for a separate ligament or tendon problem, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"neck-pain","title":"Neck Pain","region":"Neck","url":"https://www.backpaindoctor.com.au/conditions/neck-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small benefit over placebo, low-quality trials","evidence":"Searched 1 November 2026 (PubMed: trigger point injection, lignocaine or dextrose injected into the neck or trapezius; 21 randomised trials, plus a systematic-review pass). Most trials injected local anaesthetic rather than this row's dilute glucose. A meta-analysis of 15 randomised trials in 884 adults with muscular (myofascial) pain of the head, neck and shoulder found local anaesthetic injection reduced pain by 0.8 points on a 10-point scale more than placebo at two to eight weeks, and by 1.6 points more than dry needling at one to four weeks; the authors rated the evidence low quality, and the advantage over dry needling disappeared when only double-blind trials were counted (Nouged, J Oral Facial Pain Headache 2019). A second meta-analysis of six neck trials found injection ahead of dry needling on pain (about 2 points) but not on disability (Navarro-Santana, Pain Med 2022). In a 102-person trial, injection plus neck stretches beat stretches alone on pain and range of motion at the end of treatment, but by three months the stretching-only group was doing slightly better, though not significantly (Esenyel, Am J Phys Med Rehabil 2000). Against this, a systematic review of injections for mechanical neck disorders found only very low quality evidence for local anaesthetic injected into muscle and concluded that its effectiveness is not confirmed (Gross, Open Orthop J 2013). One randomised trial has tested this row's own technique: 70 people with trapezius pain had three weekly injections of 5% dextrose into the tender muscle or three sessions of radial shockwave, both with an exercise program, and the dextrose group had less pain on activity and better Neck Disability Index scores at two and four weeks (Arslan, Turk J Phys Med Rehabil 2025). That trial ran for four weeks and had no placebo group. Expect a modest, short-term effect.","fit":"Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.","reviewedOn":"2026-11-01"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a specific target","evidence":"Few trials exist for any neck pain treatment, and none supports injection as a general answer. A review of the field found exercise beneficial, the evidence for epidural corticosteroid in radiculopathy conflicting, and only weak positive evidence for radiofrequency denervation of the cervical facet joints (Cohen, Mayo Clin Proc 2015). Where one facet joint is the target, ultrasound can reach it: in 60 joints in 36 people, a lateral ultrasound-guided approach was confirmed intra-articular on contrast arthrography 92% to 98% of the time (Bodor, Spine J 2022). That is an accuracy study rather than an efficacy trial, but it is the opposite of what the same question returns in the lumbar spine, where ultrasound misses the target roughly one time in eight (Ashmore, Pain Rep 2022).","fit":"Considered only where examination points to one identifiable structure and pain is blocking rehabilitation. For neck pain in general the evidence sits with exercise, education and reassurance, and degenerative changes on a scan are near universal and often unrelated to the pain. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Radial shockwave has beaten a dummy treatment and standard care in neck pain driven by tender muscle. In a sham-controlled trial of 57 people with trigger points in the upper trapezius, radial and focused shockwave both relieved pain more than sham after four sessions, although over the one- to six-month follow-ups the difference between groups was no longer significant (p = 0.065) (Senlikci, Lasers Med Sci 2025). In 45 people radial shockwave beat standard care on pain and neck disability at four weeks (Anwar, Am J Transl Res 2022), and in 24 people with non-specific neck pain adding it to manual therapy gave about two points more pain relief out of 10 in the short term (Lopez-Moreno, J Clin Med 2026). A meta-analysis of 10 trials found shockwave better than sham and ultrasound but NO better than dry needling, trigger point injection or laser (Zhang, Arch Phys Med Rehabil 2020), and later head-to-head trials agree: level with dry needling (Luan, Am J Phys Med Rehabil 2019) and with lignocaine injection (Suputtitada, Medicina 2022), and behind 5% dextrose injected into the muscle at two and four weeks in 70 people (Arslan, Turk J Phys Med Rehabil 2025). All the trials are small and short, and nearly all are in trapezius muscle pain rather than pain from the neck joints or discs.","fit":"Directed at tender neck and shoulder muscle, alongside your movement and strengthening programme; it is not aimed at the disc, joint or nerve. Needling or an injection into the muscle do as well or better in head-to-head trials, so the choice is about what suits you.","reviewedOn":"2026-10-19"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Short-term benefit over sham","evidence":"Focused shockwave has been tested against sham in neck and shoulder muscle pain. In 57 people with upper trapezius trigger points it relieved pain as well as radial shockwave and more than sham after the course, with the gap no longer significant at one to six months (Senlikci, Lasers Med Sci 2025). In 64 office workers it reduced pain and muscle stiffness, but the sham group caught up on pain over the last two weeks and neck disability did not differ (Vasvit, Complement Ther Med 2025). A meta-analysis of five trials of focused shockwave in trapezius muscle pain found a modest short-term benefit over other treatments, rated very low certainty (Yoo, Medicine 2020). In cervical spondylosis a 320-person sham-controlled trial was positive (Li, Medicine 2024), though its abstract describes collecting data from five studies and all its authors list one hospital, so it is weighed cautiously.","fit":"Considered for a deep tender point in the neck or shoulder muscle, alongside your exercise programme. Radial shockwave has more trials on this muscle and is usually the first choice.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"The published work sits in one narrow group. Chronic whiplash-associated neck pain in which facet joints were confirmed as the pain source by diagnostic medial branch block. Two prospective case series from the same clinic report that twelve months after cervical facet platelet-rich plasma, 53% had exceeded the smallest worthwhile improvement in pain and 37% had more than half their pain relieved (Smith, Interv Pain Med 2023; Smith, Clin Pract 2025). Neither had a control group, physiotherapy was given alongside, and the authors themselves state that a controlled trial is needed.","fit":"Not done in this clinic. A cervical facet injection should be performed under CT guidance by a radiologist, and the facet joints have to be confirmed as the source by diagnostic blocks first, so this is a referral and not something provided here. For neck pain generally, exercise and understanding the problem carry the evidence and are where care starts; this becomes a conversation only where pain has persisted for months and points clearly at the facet joints.","reviewedOn":"2026-09-03"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small uncontrolled series only","evidence":"No randomised trial of prolotherapy for neck pain was found. PubMed search, 14 October 2026: prolotherapy, dextrose injection, hypertonic dextrose or hypertonic glucose with neck, cervical, whiplash or cervicogenic (33 records, all read), a randomised-trial pass (none) and a systematic-review pass; one Consensus search found none either. The evidence is uncontrolled series. Eighteen consecutive people with chronic neck pain after whiplash had 20% dextrose placed into the cervical facet joints under X-ray guidance; the Neck Disability Index fell from 24.7 to 10.9 at 12 months, with no comparison group (Hooper, Pain Physician 2007). In six people with neck pain after a car crash and measurable slippage between vertebrae, three X-ray-guided injections lowered pain from 5.8 to 3.8 out of 10 (Centeno, Pain Physician 2005). A retrospective series of 177 people with spinal pain given 20% dextrose into the facet joint capsules reported improvement in most, but the neck responded less well than the mid or low back and its figures were not reported separately (Hooper, J Altern Complement Med 2004). Reviews have found only case reports and case series in the neck (Kim, Am J Phys Med Rehabil 2004; Dagenais, Spine J 2005). Harms: one case of spinal cord injury after prolotherapy in the upper neck has been reported (Yun, Ann Rehabil Med 2011), and a practitioner survey recorded serious complications after spinal prolotherapy, including spinal headache, collapsed lung and nerve injury, without separating the neck from the back (Dagenais, Arch Phys Med Rehabil 2006).","fit":"Can be discussed for persistent neck pain traced to the facet joints or ligaments that has not settled with a well-run exercise program, as a way to let that program progress, with the absence of controlled trials and the rare but serious risks of injecting near the cervical spine stated. The exercise program remains the treatment.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Searching hyaluronic acid, hyaluronate and viscosupplementation against the cervical spine, cervical facet joints, neck pain, cervical spondylosis, cervicogenic headache, whiplash and the atlantoaxial joint returns thirteen records, and not one of them is an injection into the neck. The closest is 49 people with jaw joint osteoarthritis and neck pain whose neck disability and movement improved and held for six months after five weekly viscosupplementation injections: given into the jaw joint, not the neck, and with no comparison group (Guarda-Nardini, Cranio 2016).","fit":"Not offered for this problem. Nothing has been injected into a neck joint and measured, so there is no basis for offering it here.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"No controlled trials","evidence":"Uncontrolled evidence only, but consistent. Sixteen people with chronic periscapular myofascial pain that had failed conservative care received ultrasound-guided dextrose to the trapezius, rhomboid minor and levator scapulae together with hydrodissection of the spinal accessory and dorsal scapular nerves; pain fell from 7.1 to 3.3 out of 10 at three months (mean reduction 3.8, 95% CI 2.6 to 5.0) with no major complications (Yadav, Cureus 2025). Two case reports describe 5% dextrose into the superficial fascia of the neck and shoulder girdle: a professional kickboxer with persistent cervicobrachial pain whose Neck Disability Index fell from 77 to 33 over five sessions and held at one year (Lam, Cureus 2025), and a two-year history of neck and arm pain settling over six weeks (Lam, Cureus 2024). No randomised trial has tested it in neck pain.","fit":"Considered for neck and shoulder-girdle pain that has not settled with loading, mobility and work-setup changes, particularly where the skin over the upper trapezius and scapula is tender to a light pinch rather than only deep to it. Discussed as unproven, because every published report so far is uncontrolled.","reviewedOn":"2026-09-09"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Two small randomised trials support it in myofascial neck and shoulder pain. In 41 people with upper trapezius myofascial pain syndrome, ultrasound-guided myofascial hydrodissection matched lidocaine trigger point injection for pain and neck disability across 12 weeks, with a large within-group effect (r = 0.72) and no adverse events (Chen, Sci Rep 2025). In a double-blind trial of 35 people with chronic neck and shoulder myofascial pain, interfascial hydrodissection with 10% dextrose beat a sham subcutaneous injection for pain at 12 weeks, though not for range of movement or function (Hsu, Am J Phys Med Rehabil 2024). Both trials are small and neither has been replicated.","fit":"Considered for persistent myofascial neck pain that has not responded to exercise and manual therapy, particularly where a tender fascial plane or a cutaneous nerve is identified on ultrasound. Expect pain relief rather than a change in movement.","reviewedOn":"2026-09-06"}}},{"slug":"occipital-neuralgia","title":"Occipital Neuralgia","region":"Neck","url":"https://www.backpaindoctor.com.au/conditions/occipital-neuralgia","pairings":{"rehab":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Aimed at the mimic, not the neuralgia","evidence":"The most conservative measures (cervical collar immobilisation and cryotherapy) have not been shown to outperform placebo in this condition (StatPearls, updated 2023). Physiotherapy has a clearer role where upper cervical joint or muscle pain is contributing, which is a different diagnosis that ICHD-3 explicitly separates from occipital neuralgia.","fit":"Worth doing where sustained neck positions, upper cervical stiffness or suboccipital muscle tension are part of the picture. Not presented as a treatment for the neuralgia itself.","reviewedOn":"2026-09-25"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searching trigger point injection, trigger point and dry needling against occipital neuralgia returns no trial of any of them in this condition; what comes back is anatomy and case material, including a case in which an occipital trigger point turned out to be the presenting sign of septic jugular thrombosis (Hanazono, Headache 2024). ICHD-3 makes the point that occipital pain arising from tender points in the neck muscles is a separate diagnosis.","fit":"Relevant to the cervical muscle referral pattern that mimics this condition, not to the neuralgia.","reviewedOn":"2026-09-25"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Diagnostic criterion, and a treatment","evidence":"Temporary relief from a local anaesthetic block of the affected nerve is a required diagnostic criterion for occipital neuralgia (ICHD-3 13.4), and the block is therapeutic as well, with relief ranging from the duration of the anaesthetic to several months and repeatable as needed. A single block is a false positive in up to 40% of cases, so a confirmatory second block is prudent. Ultrasound guidance targets the nerve over the obliquus capitis inferior at C1-C2 rather than infiltrating the nuchal line by landmarks, which improves accuracy (Greher, Br J Anaesth 2010).","fit":"The step that settles the diagnosis and often provides relief at the same time. Done under ultrasound. Pain that keeps returning despite repeated blocks goes to a headache or pain medicine specialist rather than up an in-clinic ladder.","reviewedOn":"2026-09-25"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for local vibration, vibration therapy and whole-body vibration against occipital neuralgia and the occipital nerve returns no records at all, and the caution against applying vibration over an irritated nerve applies here.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"No trial of shockwave has been published in occipital neuralgia. Three randomised trials do exist a few centimetres away, but all of them treat trigger points in the upper trapezius or sternocleidomastoid in cervicogenic headache (Hammam, Am J Phys Med Rehabil 2024 and 2026; Xia, Turk J Phys Med Rehabil 2024): a diagnosis ICHD-3 separates from this one, and a muscle target rather than a nerve at the skull base.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"No trial of shockwave of any kind has been published in occipital neuralgia, and the cervicogenic headache trials that exist nearby used a radial device on muscle trigger points. Directing focused energy at the suboccipital region, where the vertebral artery and the spinal cord are close by, is not a described technique.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search for EMTT and magnetotransduction against occipital neuralgia and the occipital nerve returns no records at all.","fit":"Not part of managing this condition.","reviewedOn":"2026-09-25"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"One pilot trial, no benefit","evidence":"Thirty-two adults with post-traumatic greater occipital neuralgia after concussion were randomised, double-blind, to a single ultrasound-guided injection of platelet-rich plasma, corticosteroid with local anaesthetic, or saline. There was no difference between the groups in headache intensity or frequency; headache impact scores improved at three months in the PRP and saline arms but not the steroid arm (Stone, Front Neurol 2024; NCT04051203). The trial was designed to test feasibility rather than efficacy and is too small to rule out a modest effect, so this is a weak negative result rather than proof that PRP does not work.","fit":"Not offered for this condition. The guided block above is the procedure with evidence behind it at this nerve.","reviewedOn":"2026-09-25"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search for prolotherapy, hypertonic dextrose and dextrose injection against occipital neuralgia, the occipital nerve and cervicogenic headache returns nothing that treats this condition with the technique; the dextrose work at this nerve is hydrodissection, which is a different procedure and sits in the row below.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for hyaluronic acid, hyaluronate, viscosupplementation and hylan against occipital neuralgia and the occipital nerve returns nothing relevant to this condition. There is no joint here to viscosupplement.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"The greater and lesser occipital nerves are cutaneous sensory nerves, and scalp allodynia is a diagnostic feature of this condition, so the target fits the technique. The evidence for dilute dextrose at this nerve remains case reports (Lam, Diagnostics 2024), so certainty is low, though its safety profile appears favourable.","fit":"Occasionally discussed for persistent scalp hypersensitivity once the diagnosis is settled by block. Not a first step.","reviewedOn":"2026-09-25"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Case reports only","evidence":"Ultrasound-guided hydrodissection has been reported at exactly this nerve, but only in single cases: two patients had the greater occipital nerve separated with 5% dextrose, by two different approaches, with sustained relief and better function (Lam, Diagnostics 2024), and an 81-year-old woman had fascial hydrodissection of the semispinalis capitis, obliquus capitis inferior and sternocleidomastoid with saline and lidocaine, with her headaches gone at four weeks (Kaga, Am J Case Rep 2022). There is no controlled trial; the outcome literature at this nerve is otherwise anaesthetic and corticosteroid blocks.","fit":"Not a first step. The guided block above is the evidence-anchored procedure at this nerve, and anything beyond it would be offered on the understanding that the published base is two case reports.","reviewedOn":"2026-09-25"}}},{"slug":"osgood-schlatter-disease","title":"Osgood-Schlatter Disease (Growth-Related Knee Pain)","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/osgood-schlatter-disease","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"The treatment","evidence":"No trial has compared specific exercise with sham or usual care for Osgood-Schlatter disease (Corbi, Healthcare 2022), and practice among specialists is highly variable (Lyng, Scand J Med Sci Sports 2020). The Perth Children's Hospital guideline advises reassurance, limiting jumping, running and kicking until pain settles, simple quadriceps stretching, and advises against immobilising the knee. The Royal Children's Hospital adds strengthening and gentle stretching of the lower-limb muscles, with taping or a sleeve for sport.","fit":"The mainstay of care is activity adjustment with graded leg strengthening and gentle stretching, alongside reassurance. The evidence is limited, outcomes vary, and benefit cannot be guaranteed.","reviewedOn":"2026-11-07"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Osgood-Schlatter disease is a self-limiting growth-related condition of children and adolescents. The Perth Children's Hospital guideline and the Royal Children's Hospital sheet recommend reassurance, activity modification, stretching and strengthening, with no role for procedures. A 2022 review reports only low-quality evidence for saline and dextrose injections, discourages corticosteroid injection because of tendon risk, and describes surgery as a last resort after skeletal maturity (Corbi, Healthcare 2022). The clinic does not market procedures to adolescents for self-limiting conditions.","fit":"Not offered. Care is reassurance, activity adjustment, and strengthening and stretching, with review if symptoms last beyond about 18 months.","reviewedOn":"2026-11-07"}}},{"slug":"elbow-osteoarthritis","title":"Osteoarthritis of the Elbow","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/elbow-osteoarthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested any needling technique in elbow osteoarthritis. A search pairing dry needling, trigger point needling and trigger point injection with arthritis of the shoulder, elbow, wrist, thumb base and big toe returned 19 records, and none tested needling in an arthritic elbow. The elbow needling literature is about tennis elbow instead, and a randomised trial comparing ultrasound-guided dry needling with platelet-rich plasma there specifically excluded people with elbow osteoarthritis (Sharma, J Ultrasound 2024). A second pass restricted to clinical trials returned nothing at this joint.","fit":"Only where the assessment finds a separate tender forearm or upper-arm muscle band reproducing part of the pain. It does not treat the arthritic joint.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"No steroid trial here","evidence":"The elbow is one of the few joints where an injection has been tested against a dummy injection and separated from the result at another joint in the same trial. Fifty people with elbow osteoarthritis received three injections of a diclofenac-hyaluronate conjugate or placebo over 12 weeks; the difference in pain was 0.61 points on an 11-point scale in favour of placebo (95% CI -0.41 to 1.62) (no benefit) while the hip arm of the same trial did benefit (-0.81, -1.48 to -0.13) (Kubo, BMC Musculoskelet Disord 2022). A search of 33 records found no randomised trial of corticosteroid at this joint. A review of primary elbow osteoarthritis describes occasional intra-articular corticosteroid as part of reasonable conservative care in earlier stages, which is opinion rather than trial evidence (Martinez-Catalan, J Clin Orthop Trauma 2021).","fit":"Worth discussing to settle a painful phase or to help work out how much of the pain is coming from inside the joint, with the thinness of the evidence made clear. Loss of extension that limits function is a surgical conversation, not an injection one.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies at this joint","evidence":"Searching shockwave, shock wave, ESWT and radial shockwave against elbow osteoarthritis and elbow arthrosis returns no trial of either device in this condition, and the same search restricted to randomised trials returns nothing at this joint. The elbow shockwave evidence is all tennis and golfer's elbow, which is a tendon attachment problem rather than a worn joint, and even there a systematic review of 20 randomised trials of electrophysical treatments found the evidence for shockwave limited or conflicting (Dingemanse, Br J Sports Med 2013).","fit":"Offered for tender forearm muscle and tendon attachment where examination finds those contributing, not for the joint itself. Stiffness and loose bodies in an arthritic elbow are a separate problem and shockwave does nothing for either.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested shockwave for elbow osteoarthritis: searching shockwave, shock wave and ESWT against elbow osteoarthritis and elbow arthrosis returns no human study of either device. The case for it rests on other arthritic joints. Pooled trials at the knee favour shockwave over sham for pain and function (Tang, Int J Surg 2024), and at the hip a 148-person trial found focused shockwave better than sham (Şah, J Pers Med 2022).","fit":"A reasonable option to try for arthritic elbow pain on the strength of the knee and hip trials, with the gap at this joint explained. It will not free an elbow that locks or catches: loose bodies and bony blocks are a surgical question.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of PRP in an arthritic human elbow was found. Searches on 8 October 2026 pairing platelet-rich plasma with the elbow and with osteoarthritis or arthritis returned 23 records, and a randomised-trial pass returned two; none was a trial, cohort, case series or case report of PRP injected into an arthritic elbow joint. The elbow PRP literature is about tennis elbow and the ulnar collateral ligament. The only studies at this joint are veterinary: in 19 dogs with elbow osteoarthritis a single joint injection of PRP with fat-derived cells changed one of seven gait measures at a year, and the authors could not confirm a benefit (Bergström, Vet Sci 2024). The rationale therefore rests on the knee, where pooled placebo-controlled trials favour PRP (Bensa, Am J Sports Med 2025), and that result has not carried over reliably to other joints - at the ankle PRP was no better than saline in a trial of 100 people (Paget, JAMA 2021).","fit":"Can be discussed on the knee-based rationale for a painful arthritic elbow that has not responded to simpler care, with the complete absence of human studies at this joint, the cost and the uncertainty all stated beforehand. Not a first-line option.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No human study of prolotherapy in elbow arthritis. A search on 12 October 2026 for dextrose or prolotherapy in arthritis of the elbow, wrist or big toe returned four records. The only elbow trial was in dogs, a small placebo-controlled pilot in elbow and knee arthritis that found no benefit (Sherwood, J Am Anim Hosp Assoc 2017), which says nothing either way about people. The human trials of dextrose injection into an arthritic joint are in the knee and the fingers (Chen, Clin Rehabil 2022; Reeves, J Altern Complement Med 2000).","fit":"Prolotherapy is offered here and can be discussed for elbow arthritis pain that persists despite activity changes and exercise, with the absence of studies at the elbow explained. It is not expected to restore lost movement from bone spurs or loose bodies.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No benefit shown in small studies","evidence":"Searched PubMed for the same hyaluronic acid terms with elbow and osteoarthritis, arthritis or arthrosis (20 records; 4 trials, no systematic review; 4 animal studies excluded). The only placebo-controlled data come from a diclofenac-hyaluronate conjugate rather than plain hyaluronic acid: in 50 people with elbow arthritis, three injections were no better than placebo at 12 weeks (Kubo, BMC Musculoskelet Disord 2022). With plain hyaluronic acid, a series of 19 elbows with arthritis after injury had slight short-term pain relief at three months and no benefit in any elbow at six (van Brakel, Arthroscopy 2006). No trial of plain hyaluronic acid against placebo or cortisone at the elbow was found. The evidence is small, but what there is points to no benefit.","fit":"Not a first-line option for elbow arthritis: the small studies that exist found no lasting benefit. Activity modification and strengthening come first, with a guided cortisone or other injection considered if needed.","reviewedOn":"2026-10-26"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"hip-osteonecrosis","title":"Osteonecrosis of the Hip (Avascular Necrosis)","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/hip-osteonecrosis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Load is what builds bone; nothing else offered here does. A meta-analysis of 80 studies and 5,581 postmenopausal women found exercise improved bone mineral density at the lumbar spine, femoral neck and total hip, and that supervision was not required for the effect (Mohebbi, Osteoporos Int 2023). A network meta-analysis of 97 trials found every exercise type beat no exercise at the femoral neck, with resistance training ranking best for total hip (Zhang, J Clin Nurs 2021). Moderate-to-high impact loading also improves bone structure, not just density, and the effect is site-specific. It accrues where the load is applied (Ng, J Bone Miner Res 2023).","fit":"For a bone stress injury the sequence is relative rest until it settles, then a graded return to load that is progressed slowly enough for the bone to keep up. For bone density, the loading is the treatment and it has to continue. The gains reverse when it stops. Energy availability, vitamin D and medical contributors are assessed alongside it.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Every randomised trial in osteonecrosis of the hip that names its device used a focused one. The only radial report is a single case: one person with advanced, collapsed disease, treated for two years, whose hip score rose from 33 to 92 (Ma, Am J Phys Med Rehabil 2016). One 60-person trial used a device the paper does not classify and found it inferior to PRP injections (Luan, J Pain Res 2022). A radial pulse is strongest at the skin and does not deliver useful energy at the depth of the femoral head.","fit":"Not offered for the bone problem. Where shockwave is appropriate here, the focused form is the one with the trials.","reviewedOn":"2026-10-24"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Short-term relief in small trials","evidence":"Shockwave has been tested in randomised trials in early osteonecrosis of the femoral head, and every trial that names its device used a focused one. The benefit is on pain and function in the short term rather than on the bone. In 143 people with early steroid-related disease, two focused sessions added to medication gave lower pain and better hip scores than medication alone at three and six months, but no difference at twelve, and the size of the dead area did not differ (Shi, Int J Clin Pract 2022). In 72 people, focused treatment was not inferior to an anti-inflammatory with a sham treatment at eight weeks, with response rates of 69% against 51%, although the published table shows no difference in pain or WOMAC score at eight weeks (Zhu, World J Clin Cases 2023). In an older trial of 48 people, 79% of hips treated with shockwave had improved at about two years against 29% after core decompression and bone grafting (Wang, J Bone Joint Surg Am 2005). Against platelet-rich plasma injections in 60 people, shockwave did worse at twelve months: pain fell from 6.0 to 3.8 with shockwave, and PRP was about 0.8 points better again (Luan, J Pain Res 2022; the paper does not say whether its device was focused or radial). Pooled analyses agree on short-term pain and function, but find no reduction in progression or in later hip replacement and rate most studies at moderate to serious risk of bias (Gouravani, Eur J Orthop Surg Traumatol 2026, 26 studies; Niu, Front Cell Dev Biol 2026, 29 studies; Zhang, Medicine 2017). No trial has compared shockwave with a sham treatment alone.","fit":"Discussed in early-stage disease, before collapse, as a way to settle pain alongside protected loading, the rehabilitation program and orthopaedic management, not instead of them. It has not been shown to stop the femoral head collapsing. Focused is the only form that reaches bone at this depth.","reviewedOn":"2026-10-24"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered; one small trial","evidence":"Trialled once as an injection on its own in this condition, with a result that favours PRP on pain, and not offered here. Sixty people aged 40 to 79 with osteonecrosis of the femoral head that was not caused by an injury, from the earliest stage through to the stage where the bone surface has begun to give way, were randomised to four weekly ultrasound-guided PRP injections into the hip joint or four weekly sessions of shockwave. Both groups improved and PRP was ahead from three months to twelve: pain fell from 6.1 to 3.1 out of 10 with PRP and from 6.0 to 3.8 with shockwave. The difference between the groups, 0.8 of a point, is smaller than the one-point change the trial itself took as the smallest that matters, and the hip scores were better by about 4 points out of 96 on the WOMAC and 5 out of 100 on the Harris Hip Score. No treatment-related adverse events were reported (Luan, J Pain Res 2022). The limits are real. There was no placebo or untreated group, the patients knew which treatment they had, and it was a single hospital. The bone itself did not change: on MRI at twelve months one hip in each group had improved by a stage, one in each group had gone on to collapse and the rest were unchanged, and two people in each group had a hip replacement within the year. A look back at 146 people with steroid-related osteonecrosis found more good or excellent hip scores when the same course of injections was added to simvastatin than with simvastatin alone (85.7% against 71.3% of hips), but the treating doctor chose who received PRP and the paper does not say when the hips were scored (Chu, Pak J Med Sci 2025). Beyond that there is a single case report (Luan, Regen Med 2020). Most of the PRP research in this condition is a different procedure, PRP placed into the bone during core decompression surgery with a bone graft. Pooling 16 randomised trials and 999 people, adding PRP to that operation gave a Harris Hip Score 5.3 points better and fewer hip replacements (risk ratio 0.29), and its authors still ask for better trials (Cao, J Orthop Surg Res 2025). That is an operation performed by an orthopaedic surgeon, not this injection.","fit":"Not offered here for osteonecrosis of the hip. Protected loading, the rehabilitation program and review by an orthopaedic surgeon come first, because joint-preserving surgery depends on timing. The single trial of the injection showed a small gain in pain over shockwave and no change to the bone.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report only","evidence":"No trial or case series has tested prolotherapy for osteonecrosis of the hip. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose or hypertonic glucose with osteonecrosis, avascular necrosis, femoral head, subchondral insufficiency or bone marrow lesion, then randomised-trial and systematic-review passes) returned one case report: a person with steroid-related osteonecrosis of the femoral head who had six sessions of prolotherapy, with the WOMAC score falling from 92 to 12 and pain from 5 to 1 on a Likert scale (Ozen, Altern Ther Health Med 2019). A single case cannot show the injection caused the improvement, the abstract does not say where in the hip it was given, and there is no evidence it changes the bone.","fit":"Protected loading, the rehabilitation program and review by an orthopaedic surgeon come first, because joint-preserving surgery depends on timing. One case report is the whole of the prolotherapy evidence here; whether it has any place is discussed at consultation with that stated, and never in place of orthopaedic review.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hyaluronic acid in osteonecrosis of the hip. The published reports are small and uncontrolled: seven cancer patients with radiographically confirmed avascular necrosis, six of them at the hip, were given ultrasound-guided hyaluronic acid and five improved (Chang, Pain Med Case Rep 2022), alongside a single paediatric case report in sickle cell disease at the shoulder (Wong, Reg Anesth Pain Med 2021). Where a hip has gone on to osteoarthritis, ultrasound-guided hyaluronic acid did reduce pain and WOMAC scores out to six months in 15 people with 28 injected hips: a study that also notes scanning before injecting can reveal early osteonecrosis (Micu, Clin Rheumatol 2022). None of it acts on the dying bone.","fit":"Not a treatment for the bone problem, and it does not change whether the femoral head collapses. Discussed only for pain from established joint-surface damage, alongside load management and orthopaedic review.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"knee-osteonecrosis","title":"Osteonecrosis of the Knee (Avascular Necrosis)","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/knee-osteonecrosis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Load is what builds bone; nothing else offered here does. A meta-analysis of 80 studies and 5,581 postmenopausal women found exercise improved bone mineral density at the lumbar spine, femoral neck and total hip, and that supervision was not required for the effect (Mohebbi, Osteoporos Int 2023). A network meta-analysis of 97 trials found every exercise type beat no exercise at the femoral neck, with resistance training ranking best for total hip (Zhang, J Clin Nurs 2021). Moderate-to-high impact loading also improves bone structure, not just density, and the effect is site-specific. It accrues where the load is applied (Ng, J Bone Miner Res 2023).","fit":"For a bone stress injury the sequence is relative rest until it settles, then a graded return to load that is progressed slowly enough for the bone to keep up. For bone density, the loading is the treatment and it has to continue. The gains reverse when it stops. Energy availability, vitamin D and medical contributors are assessed alongside it.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials in this condition","evidence":"Searching osteonecrosis, avascular necrosis and bone marrow lesion against dry needling and trigger point injection returned three records, and all three are matches at other sites or on other treatments: jaw osteonecrosis after bisphosphonates (Almăşan, Rom J Morphol Embryol 2011), massage and acupressure for pain in sickle cell disease (Bodhise, Hematology 2004), and a facial pain case report (Adams, J Oral Pathol Med 1999). Nothing has tested needling in osteonecrosis of the knee.","fit":"Not directed at the bone, which is where the problem is. Considered only where a separate tender muscle band is adding to your pain.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"No study has tested radial shockwave in osteonecrosis of the knee: PubMed searches for shockwave in this condition, and for radial devices in osteonecrosis or bone oedema at any site, returned no knee study. The bone studies nearest to this condition used focused devices (Gao, BMC Musculoskelet Disord 2015). A radial pulse is strongest at the skin and does not deliver useful energy at bone depth.","fit":"Not offered for the bone problem. Where shockwave is considered here, the focused form is the one that reaches bone.","reviewedOn":"2026-10-24"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No knee osteonecrosis studies","evidence":"A search of PubMed for shockwave in osteonecrosis of the knee, including spontaneous osteonecrosis and subchondral insufficiency fracture, returned 15 records and no study in this condition. The nearest evidence is in painful bone marrow oedema of the knee without osteonecrosis, which those studies excluded: in a 40-person randomised trial, focused shockwave relieved pain faster than bone medication over the first six months, with no difference at a year (Gao, BMC Musculoskelet Disord 2015), and a non-randomised comparison of 86 people favoured it over rest and pain relief (Sansone, Med Princ Pract 2016). The femoral-head trials on the hip osteonecrosis page are a different bone and are not counted here.","fit":"Plausible for pain from an early lesion, since a focused device reaches the bone, but untested in this condition. If discussed, it sits alongside protected weight-bearing, a brace, the strengthening program and orthopaedic review, with the gap stated.","reviewedOn":"2026-10-24"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study has tested a PRP injection into the knee for osteonecrosis, whether the spontaneous form, a subchondral insufficiency fracture or the steroid-related form. A PubMed search in October 2026 pairing platelet-rich plasma, platelet concentrate and platelet lysate with osteonecrosis, avascular necrosis, subchondral insufficiency and bone marrow lesions at the knee returned 42 records, and none is a trial or a case series in this diagnosis. The one report is a single person with steroid-related osteonecrosis who was given a mixture of bone marrow concentrate, bone matrix and PRP injected into the bone itself and was better at eleven months (Street, Cureus 2021). That is neither an injection into the joint nor PRP on its own. The randomised trials near this topic are all in knee osteoarthritis, a different diagnosis, and the one that tested injections into the bone found they added nothing: in 50 people, PRP into the bone under X-ray guidance as well as into the joint was no better at six months than PRP into the joint alone, and caused more injection-related side effects (Barman, Injury 2022).","fit":"Not a treatment for the bone lesion, which is managed with protected weight-bearing, time and orthopaedic review where the joint surface is at risk. PRP is considered only where knee osteoarthritis is a separate, established source of pain, on the evidence set out on that page.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in this condition","evidence":"No study has tested prolotherapy for osteonecrosis of the knee. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hyperosmolar dextrose or regenerative injection with knee and osteonecrosis, insufficiency fracture, SONK, bone marrow, subchondral or intraosseous; prolotherapy or hypertonic dextrose with osteonecrosis or avascular necrosis; randomised-trial and systematic-review passes) returned eleven knee records, all in knee osteoarthritis or in rats, and none in spontaneous osteonecrosis, a subchondral insufficiency fracture or the steroid-related form. The knee osteoarthritis trials are a different condition and do not carry over.","fit":"Protected loading, the rehabilitation program and orthopaedic review come first, because the outlook depends on the size and stage of the lesion. Prolotherapy is considered only for a separate ligament or tendon problem around the knee, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hyaluronic acid in spontaneous osteonecrosis of the knee. Across the records it appears only as treatment for coexisting osteoarthritis or as salvage after something else failed: 11 of 74 people went on to viscosupplementation after percutaneous fixation for painful subchondral bone marrow oedema (DeBernardis, Arthrosc Sports Med Rehabil 2020), and a case report used it at four months for the osteoarthritis accompanying a subchondral insufficiency fracture (Gourlay, BMJ Case Rep 2015). The one randomised trial to measure bone marrow oedema after hyaluronic acid found it did not fall in the hyaluronic acid arm over twelve months, while it did where platelet-rich plasma was added (Zhang, J Clin Med 2025).","fit":"Not a treatment for the bone lesion itself. Discussed only where the knee also has established osteoarthritis, and alongside load reduction and orthopaedic review.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"osteoporosis","title":"Osteoporosis","region":"General","url":"https://www.backpaindoctor.com.au/conditions/osteoporosis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Load is what builds bone; nothing else offered here does. A meta-analysis of 80 studies and 5,581 postmenopausal women found exercise improved bone mineral density at the lumbar spine, femoral neck and total hip, and that supervision was not required for the effect (Mohebbi, Osteoporos Int 2023). A network meta-analysis of 97 trials found every exercise type beat no exercise at the femoral neck, with resistance training ranking best for total hip (Zhang, J Clin Nurs 2021). Moderate-to-high impact loading also improves bone structure, not just density, and the effect is site-specific. It accrues where the load is applied (Ng, J Bone Miner Res 2023).","fit":"For a bone stress injury the sequence is relative rest until it settles, then a graded return to load that is progressed slowly enough for the bone to keep up. For bone density, the loading is the treatment and it has to continue. The gains reverse when it stops. Energy availability, vitamin D and medical contributors are assessed alongside it.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Laboratory studies only","evidence":"Radial shockwave has not been tested as a treatment for osteoporosis in people. A search on 11 November 2026 for radial shockwave with osteoporosis or bone mineral density returned 19 records, all read: cell, animal and modelling studies, such as improved bone structure in rats after removal of the ovaries (Inoue, Calcif Tissue Int 2021), plus reports in other bone conditions, and no human study of bone density. A wider search for human trials of any shockwave device (16 records) found two that measured bone density, neither stating a radial device. In 64 postmenopausal women all taking alendronate, a single higher-energy session to one hip was followed by a larger gain in hip bone density at twelve months than in controls (Shi, Osteoporos Int 2017). A pilot using an unfocused device on one forearm in twelve women without bone disease found no change (Koolen, Arch Osteoporos 2019). Neither measured fractures.","fit":"Not a treatment for bone density or fracture risk. Considered only for a separate muscle or tendon problem.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Not a treatment for bone density. Two human trials have measured bone density after shockwave, and neither measured fractures. In 64 postmenopausal women with osteoporosis, all taking alendronate, a single higher-energy session to one hip was followed by a larger gain in hip bone density at twelve months than in untreated controls or in a lower-energy group; the abstract does not state the type of device (Shi, Osteoporos Int 2017). A pilot applying an unfocused device to one forearm in twelve women without bone disease found no change in bone density or bone mineral content at six and twelve weeks (Koolen, Arch Osteoporos 2019). That is one small positive trial with a single treated site and one negative pilot. The established bone evidence for shockwave is in nonunion, resistant stress fracture and osteonecrosis.","fit":"Considered only where one of those specific problems is present.","reviewedOn":"2026-11-11"},"emtt":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.","fit":"Not part of the plan here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study in people has tested PRP as a treatment for osteoporosis or low bone density. A PubMed search in October 2026 pairing platelet-rich plasma with osteoporosis, osteopenia and bone mineral density returned 31 records once animal and laboratory work was excluded, and none measures bone density in people after PRP. What has been tested is PRP added to surgery for the fractures osteoporosis causes, and it did not help. In 200 people aged 65 and over having a broken hip fixed with screws, PRP injected into the fracture did not reduce the need for repeat surgery within a year (an absolute difference of 5.6%, 95% CI -10.6% to 21.8%) (Griffin, BMJ Open 2013). In 84 people aged 60 and over having a hip fracture fixed with a nail, PRP gave a better X-ray healing score at two weeks only, with no difference in healing or function from six weeks to six months (Tantavisut, Orthop Traumatol Surg Res 2026).","fit":"Not a treatment for bone density. Loading exercise, nutrition, falls prevention and, where indicated, bone-protective medication are what reduce fracture risk. PRP is considered only for a separate tendon or joint problem, on that problem's own evidence.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not a bone-density treatment","evidence":"No study has tested prolotherapy as a treatment for osteoporosis or bone density. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose or hypertonic glucose with osteoporosis, osteoporotic, bone mineral density or fragility fracture, then randomised-trial and systematic-review passes) returned two case reports in which the patient happened to have osteoporosis and was treated for something else (a knee arthritis case, Yoon, Cureus 2026; a nerve entrapment case managed with exercise, Ozuberk, J Med Case Rep 2024).","fit":"Not a treatment for osteoporosis, which is managed with bone-protective medicines, strength and impact training, calcium, vitamin D and falls prevention. Prolotherapy is considered only for a separate ligament or tendon problem, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"patellar-instability","title":"Patellar Instability (Unstable Kneecap)","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/patellar-instability","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials in this condition","evidence":"Searching patellar dislocation and patellar instability against dry needling, trigger point work and trigger point injection returned no study of needling in this condition. The records that matched sit at other knee structures - needling after cruciate reconstruction (Velázquez-Saornil, Medicine 2017) and a massage case report for kneecap pain after the same operation (Zalta, Int J Ther Massage Bodywork 2008). Needling has not been tested for an unstable kneecap.","fit":"Does not address the tracking problem that drives the instability. Considered only where a tender band in the quadriceps or lateral thigh is adding to your pain.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Radial shockwave has not been studied in patellar instability. PubMed searches on 25 October 2026 for shockwave terms with patellar instability or dislocation (within 30 records on tendon tears and repairs, all read) and for radial device terms with patella, patellar, dislocation or instability (12 records) found no study in this condition.","fit":"May ease tender thigh and hip muscles during the strengthening program. It does nothing to stabilise the kneecap.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in patellar instability or after a kneecap dislocation. A PubMed search on 25 October 2026 for shockwave, shock wave, ESWT or pressure wave with patellar instability or patellar dislocation, within a wider search over tendon tears and repairs (30 records, all read), and a trial pass over instability and dislocation (12 records) found none. The nearest shockwave evidence at the front of the knee is in patellar tendinopathy, a different condition.","fit":"Not a treatment for an unstable kneecap, which is managed with strengthening, taping or bracing and sometimes surgery. Considered only for a coexisting tendon problem.","reviewedOn":"2026-10-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study of platelet-rich plasma for patellar instability, a dislocated kneecap or an injury to the medial patellofemoral ligament was found. A PubMed search in October 2026 pairing platelet-rich plasma and platelet concentrate with those terms returned no records, and a wider pass on the bare terms PRP, platelet, orthobiologic and prolotherapy returned five, none of them a study of PRP for an unstable kneecap. The nearest statement is expert opinion: 60 surgeons from 11 countries could not reach agreement on whether biologic injections have any place in the non-operative care of patellar instability (Hurley, Bone Joint J 2023).","fit":"Not offered for the instability. That is a matter of ligament competence, the shape of the groove and quadriceps control, which rehabilitation and, where warranted, surgical reconstruction address. Considered only for a separate problem in the same knee, such as arthritis behind the kneecap, on that problem's own evidence.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for prolotherapy or dextrose injection in patellar instability, patellar dislocation or the medial patellofemoral ligament returns no study of any design.","fit":"Does not replace rehabilitation or, where it is warranted, surgical reconstruction: instability after a dislocation is a matter of ligament competence, trochlear shape and quadriceps control. Prolotherapy is offered here and can be discussed alongside the rehabilitation program, on the understanding that no study has tested it for this condition.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"patellar-tendinopathy","title":"Patellar Tendinopathy","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/patellar-tendinopathy","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Tendon needling, not trigger point","evidence":"Needling has been trialled at this tendon, but the needle goes into the tendon itself rather than into a tender muscle band, which is a different procedure from the one this row describes. In a double-blind randomised trial of 23 people, ultrasound-guided needling of the tendon with eccentric exercise improved the VISA-P score by 33.2 points by six months on its own; adding leukocyte-rich platelet-rich plasma was ahead at twelve weeks but no longer at six months (Dragoo, Am J Sports Med 2014). A later multicentre randomised trial of 31 people repeated that comparison and found both arms improved with no difference between them (Herrero, Bull Hosp Jt Dis 2024). A systematic review of nine trials rated the two tendon-needling trials its highest-quality evidence and concluded that needling and eccentric exercise both help pain and function in the longer term (Sharif, Front Rehabil Sci 2025). No trial has tested trigger point needling or injection of the surrounding muscle in this condition.","fit":"Considered where examination finds a tender band in the quadriceps reproducing part of your pain. Needling of the tendon itself, which is what the trials above tested, is a different procedure from this one.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Short-term relief, later relapse","evidence":"This row's injection has been tested in patellar tendinopathy, and the trials point in different directions over time. In 48 athletes with patellar or Achilles tendinopathy, three ultrasound-guided steroid injections beside the tendon reduced pain and tendon thickening more than a placebo injection, but many relapsed within six months once running resumed (Fredberg, Scand J Rheumatol 2004). In 39 men, injections of corticosteroid beside the tendon improved symptoms at 12 weeks as much as exercise did, but the gains were lost by six months, while those of heavy slow resistance training were kept (Kongsgaard, Scand J Med Sci Sports 2009). A network meta-analysis of 11 randomised trials found function scores worse after corticosteroid than in control groups (VISA-P mean difference -23 points, 95% CI -36.7 to -9.3) and no pain benefit (Chen, Arthroscopy 2019). A high-volume ultrasound-guided injection, with or without hydrocortisone, added nothing to six months of progressive loading in 62 military patients with patellar or Achilles tendinopathy (Barker-Davies, Orthop J Sports Med 2022). Ultrasound-guided polidocanol injections into new blood vessels beat lignocaine with adrenaline in one small trial of 33 athletes (Hoksrud, Am J Sports Med 2006) and did worse than arthroscopic shaving in another (Willberg, Br J Sports Med 2011); that is a different injection and is named here only as the nearest evidence.","fit":"Not a first choice: heavy slow loading has the better long-term results. Where pain is blocking that programme, a guided injection beside the tendon may be discussed, with the short benefit and the relapse risk explained and the loading programme continuing. See the note on cortisone.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Radial shockwave was null for both function and pain in a Level I network meta-analysis of patellar tendinopathy (Chen, Arthroscopy 2019).","fit":"Eccentric and slow heavy loading is first-line here and shockwave has not been shown to add to it.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Three independent syntheses agree it does not add to loading. A Level I network meta-analysis found focused shockwave null for both function (VISA change -1.28, 95% CI -6.25 to 3.68) and pain, with radial no better (Chen, Arthroscopy 2019). A living network meta-analysis found moderate-strength evidence that adding shockwave to eccentric exercise gives no short-term benefit (Challoumas, Sports Med Open 2023).","fit":"Eccentric and slow heavy loading is first-line and shockwave has not been shown to add to it. Discussed only where a proper loading programme has been done and has stalled.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Leukocyte-rich PRP ranked best of nine non-surgical options for both functional improvement and pain reduction in a Level I network meta-analysis (Chen, Arthroscopy 2019). A separate meta-analysis of 70 studies found eccentric exercise best in the short term but MULTIPLE PRP injections best at long-term follow-up, ahead of both shockwave and eccentric exercise (Andriolo, Am J Sports Med 2019).","fit":"Where a proper loading programme has stalled, this has better evidence than shockwave for this particular tendon. Multiple injections rather than one.","reviewedOn":"2026-08-30"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled series of 47","evidence":"No randomised trial of prolotherapy in adults with patellar tendinopathy was found. A PubMed search on 13 October 2026 (prolotherapy, dextrose or hypertonic glucose with patellar tendinopathy, tendinosis, tendinitis or jumper's knee) returned 11 records, and a pass restricted to randomised trials found none in this condition. The best direct evidence is an uncontrolled series: 47 people whose tendon pain had not settled with standard care had ultrasound-guided 25% dextrose into the abnormal part of the tendon, about four sessions on average, and at an average of 45 weeks pain during sport had fallen from 78 to 39 out of 100 and pain in daily activity from 51 to 26. Three people reported more pain after treatment, and there was no comparison group, so the injection cannot be separated from time and rehabilitation (Ryan, Br J Sports Med 2011). A systematic review found that series was the only prolotherapy study in adult patellar tendinopathy and called the evidence very weak (Morath, J Exp Orthop 2020); an earlier review called dextrose injection here unproven (Gaida, Curr Sports Med Rep 2011). The randomised trials closest to this tendon are in Osgood-Schlatter disease in adolescents, a different condition, and they disagree: dextrose beat lidocaine alone and usual care in one (Topol, Pediatrics 2011) and was no better than saline in another (Nakase, Arch Orthop Trauma Surg 2019).","fit":"Can be discussed where tendon pain persists despite a well-run progressive loading program, as a way to settle pain enough to keep loading, with the lack of a controlled trial stated. The loading program remains the treatment.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here. A meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems, 1,629 patients in all, reported less pain than the comparison treatments overall, but it contained only one patellar tendinopathy trial, so that result has not been repeated (Khan, Sports Health 2022). These are injections around a tendon, which is a different procedure from the joint injection in this row.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for perineural injection, neural prolotherapy or perineural dextrose combined with tendinopathy returns no study in patellar tendinopathy.","fit":"Not offered. Patellar tendinopathy responds to progressive tendon loading, and that is where the effort belongs. An injection around a nerve does not address a tendon that is intolerant of load.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hydrodissection as a treatment for patellar tendinopathy. The one controlled study at this tendon did something different: during anterior cruciate ligament reconstruction using a patellar tendon graft, 22 patients had the paratendon hydrodissected during the operation and 23 did not, and the hydrodissected group had less pain at ten days and four weeks and better knee scores and flexion (Luna-Pizarro, Cir Cir 2006). That is fluid separating a healthy tendon from its sheath during surgery, not treatment of a painful degenerate tendon.","fit":"Only where the assessment finds a nerve, or a tendon stuck to the tissue around it after surgery or injury, contributing alongside the tendon pain. Graded loading remains the treatment with the evidence behind it at this tendon.","reviewedOn":"2026-09-15"}}},{"slug":"patellar-tendon-tear","title":"Patellar Tendon Tear","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/patellar-tendon-tear","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials in this condition","evidence":"A search pairing patellar tendon rupture, quadriceps tendon rupture, quadriceps tendon tear and extensor mechanism injury with dry needling, trigger point work and needling returned no records at all. Needling has never been tested in a torn extensor tendon at the knee, and a ruptured tendon is a surgical problem rather than one a needle addresses.","fit":"Not a treatment for the tear. Considered only during rehabilitation, and only where a separate tender muscle band is reproducing part of your pain.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Radial shockwave has not been studied in a patellar tendon tear or after its repair. PubMed searches on 25 October 2026 for shockwave terms with tendon ruptures, tears and repairs (30 records, all read) and for radial device terms with knee tears and repairs (12 records) found no human study in this injury; the radial evidence at the front of the knee is in patellar tendinopathy. Achilles ruptures have been reported after radial and other shockwave in case reports (Briffa, Cureus 2026; Lin, Phys Ther Sport 2012), without proof that the treatment caused them.","fit":"May ease the tight, tender thigh muscle during rehabilitation after a repair. Not applied over the healing tendon.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a torn patellar tendon or after its repair. A PubMed search on 25 October 2026 for shockwave, shock wave, ESWT or pressure wave with tendon rupture, tear or repair, the quadriceps tendon, patellar tendon rupture or patellar dislocation (30 records, all read), a trial pass (12 records) and a systematic-review pass (8 records) found none. The shockwave evidence at this tendon is in patellar tendinopathy, where the tendon is intact. Tendon ruptures have been reported after shockwave at the Achilles - in two people aged 62 and 65 within one sham-controlled trial (Costa, Clin Orthop Relat Res 2005) and in single case reports (Lin, Phys Ther Sport 2012; Briffa, Cureus 2026) - though none was shown to be caused by it.","fit":"Not used over a torn or recently repaired patellar tendon. Considered only later, for a coexisting tendinopathy, once the repair has healed and the strengthening program is under way.","reviewedOn":"2026-10-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A PubMed search for platelet-rich plasma in patellar and quadriceps tendon rupture and repair returned seven records, none of them a comparative trial. What exists is case reports of platelet-rich plasma used as an adjunct at the time of surgical repair (Jarjess, Cureus 2025). Pulling the other way, there is a published case of a complete patellar tendon rupture occurring after a course of four platelet-rich plasma injections into a severely degenerate tendon, with the authors questioning both its efficacy and its safety in that setting (Redler, Clin J Sport Med 2020).","fit":"Not offered. A ruptured patellar tendon leaves you unable to straighten the knee against gravity, and it is repaired surgically. An injection does not restore a torn extensor mechanism, and the sooner the tear is recognised the better the result. Patellar tendinopathy without a tear is a separate problem with a separate answer.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"The prolotherapy evidence in the patellar tendon is in tendinopathy, not in a tear: a systematic review of sclerotherapy and prolotherapy for chronic patellar tendinopathy found ten studies including three positive randomised trials, but rated the overall level of evidence IV (Morath, J Exp Orthop 2020). A search for prolotherapy or dextrose injection combined with patellar tendon, tendon tear or tendon rupture returns twelve records and no trial in a torn tendon. Complete extensor mechanism disruption should be repaired surgically, with high rates of return to work and sport and re-rupture under 5% (Tandogan, EFORT Open Rev 2022), and the largest recent prolotherapy randomised trial excluded complete tendon rupture at entry (Lhee, Am J Sports Med 2025).","fit":"Not offered for a torn patellar tendon. The job here is confirming the tear and getting you to a surgeon quickly. If what you have is patellar tendinopathy rather than a tear, that is a different diagnosis with a different answer.","reviewedOn":"2026-09-02"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with tendon rupture, patellar tendon, quadriceps tendon or tendon repair, 23 records; the same terms with quadriceps, thigh, rectus femoris, vastus or infrapatellar, 24 records; a randomised-trial and systematic-review pass returned none). No study has tested hydrodissection for a torn patellar tendon, and it cannot repair one. The only patellar tendon record concerns a different situation: saline injected around the tendon sheath during open surgery when part of the tendon was harvested as an ACL graft, with less pain at four weeks than without it in 45 people (Luna-Pizarro, Cir Cir 2006). The nearest ultrasound-guided reports are at the nerve branch that crosses below the kneecap, after knee replacement or ACL reconstruction (Clendenen, Clin Orthop Relat Res 2015: 16 people, 9 with pain brought to 0 or 1 out of 10, no comparison group; Rao, J Back Musculoskelet Rehabil 2022, one case).","fit":"Not a treatment for a torn patellar tendon, which usually needs surgical repair followed by a staged rehabilitation program. Considered only if burning or numbness below the kneecap persists after healing, in the pattern of the saphenous nerve branch there.","reviewedOn":"2026-11-10"}}},{"slug":"patellofemoral-arthritis","title":"Patellofemoral Arthritis","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/patellofemoral-arthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials in this diagnosis","evidence":"Searching trigger point and myofascial needling against patellofemoral osteoarthritis, patellofemoral arthritis, retropatellar pain and chondromalacia patellae returned two records, and neither is a trial: a single case of trigger point acupuncture at this joint (Ye, Acupunct Med 2024) and a massage case report after cruciate reconstruction (Zalta, Int J Ther Massage Bodywork 2008). The large needling meta-analysis that covers the patellofemoral joint studied patellofemoral pain syndrome, which is a different diagnosis from arthritis behind the kneecap, and reported its result on the Kujala score for that condition (Hu, PLoS One 2026).","fit":"Considered only where examination finds a tender band in the quadriceps or lateral thigh reproducing part of your pain. It does not treat the joint surface.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One trial, no placebo arm","evidence":"Almost all knee injection trials enrol people with arthritis of the main knee compartment, so the kneecap joint has little evidence of its own; a search in November 2026 found no placebo-controlled injection trial in established patellofemoral osteoarthritis. The one trial of corticosteroid there randomised 60 people, double-blind, to a single injection of triamcinolone or of hyaluronic acid: both groups improved from 48 hours through to six months, the corticosteroid group had better pain relief in the first week, and by six months there was no difference in pain or in the Kujala knee score (Mekariya, J ISAKOS 2025). There was no placebo arm, so how much of that improvement was due to the injection is not known. The injection goes into the same joint cavity as any other knee injection, where placebo-controlled trials show a benefit that fades within three to six months (Jüni, Cochrane Database Syst Rev 2015) and where corticosteroid repeated every three months for two years cost cartilage without helping pain (McAlindon, JAMA 2017). That cartilage concern is why the authors of the patellofemoral trial suggest hyaluronic acid as an alternative when the rest of the knee is still well preserved; the hyaluronic acid trials at this joint are set out in the viscosupplementation row.","fit":"Reasonable to discuss for a flare that is blocking the quadriceps and hip strengthening that carries the evidence in this condition. Expect weeks rather than months of help, and not something to repeat routinely: see the note on cortisone.","reviewedOn":"2026-11-05"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Knee trials, not this compartment","evidence":"The randomised shockwave evidence at the knee sits in the main weight-bearing joint, not the joint behind the kneecap. Searching shockwave, shock wave, ESWT and radial shockwave against patellofemoral osteoarthritis returns no randomised trial of either device in this compartment. The reviews that mention shockwave list it among the non-surgical options without evidence specific to this joint, and one states that research into patellofemoral osteoarthritis is limited (Katz, Curr Rev Musculoskelet Med 2024; Kuwabara, Curr Rev Musculoskelet Med 2022; Runer, Orthopadie 2025). What does have trial evidence nearby is knee osteoarthritis generally, where 89 people randomised across four radial doses and a placebo device all did better than placebo at four weeks (Zhang, J Rehabil Med 2021).","fit":"Offered for the tender quadriceps and lateral thigh muscle that commonly comes with kneecap arthritis, not for the joint surface. The strength work is what changes how the kneecap is loaded, and that is where the effort belongs.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Trials are in the main knee joint","evidence":"The shockwave trials at the knee are in osteoarthritis of the main weight-bearing joint, where pooled results favour it over sham for pain and function (Tang, Int J Surg 2024; Silva, Clin Rehabil 2022). No human trial has tested it specifically for arthritis behind the kneecap; reviews list it among the non-surgical options there while noting that the research is limited (Katz, Curr Rev Musculoskelet Med 2024; Kuwabara, Curr Rev Musculoskelet Med 2022). In a rat model of patellofemoral osteoarthritis, shockwave reduced cartilage breakdown, inflammation and bony change (Jhan, Int J Med Sci 2026), which supports the rationale but is not evidence that it helps people.","fit":"A reasonable option to try on the strength of the trials in the rest of the knee, with the gap for this compartment explained. Used alongside the quadriceps and hip strength work that changes how the kneecap is loaded.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled studies only","evidence":"Studied at the kneecap joint, in uncontrolled and retrospective studies rather than trials. A systematic review found five studies in 146 people with patellofemoral arthritis, chondromalacia or anterior knee pain: pooled pain fell from 6.7 to 2.1 out of 10 and the Kujala knee score rose from 71 to 83, with evidence of cartilage repair on imaging limited and uncertain, and the authors calling for randomised trials (Chalidis, Int J Mol Sci 2025). The largest single report followed 103 people with patellofemoral chondromalacia for six months: pain fell from 6.4 to 1.2 out of 10 and the anterior knee pain score rose from 81 to 90, while the cartilage grade did not change in anyone (Alhamam, Cureus 2025). In 34 people given PRP and 34 managed without an injection, both groups improved clinically and only the PRP group showed a change on cartilage MRI mapping (Cobianchi Bellisari, Radiol Med 2021). None of these was randomised and none had a dummy-injection group; a second systematic review reached the same verdict of consistent improvement on generally poor-quality evidence (Franceschi, Front Bioeng Biotechnol 2026). The injection enters the same joint cavity as any other knee injection, where pooled placebo-controlled trials favour PRP (Bensa, Am J Sports Med 2025) and the largest Australian trial found no benefit over saline at twelve months (Bennell, JAMA 2021).","fit":"Worth discussing where kneecap-joint arthritis has not settled with quadriceps and hip strengthening, taping or bracing and load changes, which carry the evidence here. The published results at this joint are encouraging but uncontrolled, and that is explained beforehand, along with the mixed picture from the main knee trials. Reviewed at about three months, and not expected to regrow cartilage.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One trial, in early kneecap wear","evidence":"No trial in established kneecap-joint arthritis. The closest is in chondromalacia patella, softening and wear of the cartilage under the kneecap: 54 people were randomised to injections around the kneecap of 5% dextrose, which the authors call prolotherapy, or saline, three times over six weeks, and at 24 weeks the dextrose group was 1.67 points lower for pain out of 10 and 9.3 points better on the Kujala knee score (Bayır, PM R 2026). That concentration is the one used for perineural injection, and the same trial is counted in that row. A retrospective report of 61 people with chondromalacia given 15% dextrose injections at one clinic described lasting improvement, by self-report and without a comparison group (Hauser, Clin Med Insights Arthritis Musculoskelet Disord 2014). A 2026 review of randomised trials in chondromalacia, which did not include the saline-controlled trial, found no prolotherapy trial against placebo or no treatment and could draw no conclusion (De la Cerna-Luna, Am J Phys Med Rehabil 2026).","fit":"Prolotherapy is offered here and can be discussed where kneecap pain persists despite quadriceps and hip strengthening, taping or bracing and load changes, which carry the evidence. The one controlled trial is in earlier cartilage wear rather than established arthritis, and that is explained. Not expected to regrow cartilage.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Equal to cortisone, no placebo trial","evidence":"Trialled at the kneecap joint several times, never against a dummy injection in established arthritis, and the results do not agree. In 60 people with isolated patellofemoral osteoarthritis randomised, double-blind, to a single injection of hyaluronic acid or triamcinolone, both groups improved and there was no difference in pain or the Kujala knee score at six months, with the corticosteroid ahead in the first week (Mekariya, J ISAKOS 2025). In 126 people randomised to five weekly hyaluronic acid injections or four weeks of tui na massage, pain improved equally and the massage group did better on the WOMAC score a week after treatment (Gu, Complement Ther Med 2025). In 70 younger adults with grade II to III kneecap cartilage damage, hyaluronic acid added to physiotherapy gave less pain and better Kujala and Lysholm scores at three and six months than physiotherapy alone, with no difference on MRI and no dummy injection (Astur, Rev Bras Ortop 2019). The one sham-controlled trial enrolled 86 younger people with patellofemoral pain rather than arthritis, and found a single injection no better than sham at six months (Hart, Orthop J Sports Med 2019). In the main knee joint, the largest placebo-controlled analysis found an average effect too small for patients to feel (Pereira, BMJ 2022).","fit":"May be discussed as a non-steroid option when kneecap-joint pain is blocking the strengthening work and cortisone is unsuitable or has already been used, with it stated that it matched cortisone at six months in one trial but has never been shown to beat a dummy injection in this condition. Any benefit should be expected to be modest.","reviewedOn":"2026-10-08"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Trials in chondromalacia, not arthritis","evidence":"No trial has been run in established patellofemoral osteoarthritis: PubMed searches for perineural, subcutaneous and low-concentration dextrose injection at the knee (12 records, with two wider passes of 18 and 7) found none. The closest direct trial is in chondromalacia patella: 54 people randomised to periarticular 5% dextrose or saline were 1.67 points lower on pain and 9.3 points better on the Kujala score at 24 weeks (Bayır, PM R 2026). A second randomised trial, in 50 people with grade II to III chondromalacia, found perineural dextrose plus a home physiotherapy program better than physiotherapy alone at six months on WOMAC pain, stiffness and function, without a dummy injection (García-Triana, J Altern Complement Med 2021). In whole-knee osteoarthritis, a trial of 60 people compared perineural 5% dextrose around the knee with an injection into the joint and with both, found the combination best at four and eight weeks, and had no placebo arm (Fu, J Orthop Surg Res 2024); a systematic review of eight studies and 599 people found less pain and better function in every study but rated them low quality and drew no firm conclusion (Arias-Vázquez, J Integr Complement Med 2026). None of the knee osteoarthritis studies separates the kneecap joint from the rest of the knee.","fit":"Worth discussing where the pain is anterior and load management, quadriceps and hip work have been given a fair run. Presented as a pain treatment that helps the person keep loading, with short to medium-term evidence, not as something that changes the cartilage.","reviewedOn":"2026-11-09"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Nothing has been published on hydrodissection for patellofemoral arthritis specifically. Knee osteoarthritis appears in this literature, but as fluid spread around or into the joint rather than as nerve treatment: a scoping review of 21 included studies pools hydrodissection with hydrodilatation and calls the evidence early and heterogeneous (Leahy, Front Pain Res 2026), and the only prospective knee work is an uncontrolled series of ten people given three monthly posteromedial fascial injections of 5% dextrose, with WOMAC scores roughly halved at twelve months and the authors themselves noting that placebo and natural fluctuation cannot be excluded (Lam, Diagnostics 2026).","fit":"Only where the assessment finds a nerve contributing separately to the front-of-knee pain, most often the infrapatellar branch of the saphenous nerve. The arthritis itself is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"patellofemoral-pain","title":"Patellofemoral Pain","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/patellofemoral-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Dry needling studied, not injection","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, dry needling or intramuscular injection with patellofemoral, anterior knee pain or chondromalacia, 35 records, all read). No study has injected anything into a muscle trigger point in this condition, with glucose or any other solution. The only muscle injections in anterior knee pain were botulinum toxin into the outer thigh muscle to rebalance the quadriceps, which is a different treatment (Singer, Disabil Rehabil 2006, eight people, uncontrolled). The nearest evidence is dry needling, which uses the same needle with nothing injected and is not offered here, and its trials disagree. Against sham needling, one 50-person trial found less pain and better function at six weeks and three months (Ma, J Pain Res 2020), while a 60-person trial found no difference at 72 hours (Sutlive, Int J Sports Phys Ther 2018). Added to manual therapy and exercise in 60 people, needling the thigh muscles made no difference at three months (Espi-Lopez, J Orthop Sports Phys Ther 2017), and it matched pressure on the trigger point in 54 (Behrangrad, Acupunct Med 2020). Meta-analyses found a modest short-term benefit on pain, larger when needling was added to exercise and absent when it was added to shockwave or combined care (Sun, Complement Ther Clin Pract 2025, 12 studies, 624 people; Rahou-El-Bachiri, J Clin Med 2020, no effect at medium or long term), and higher-quality guidelines do not recommend dry needling for this condition (Wallis, Phys Ther 2021).","fit":"Considered only where examination finds a tender thigh or hip muscle band contributing to the pain, as an adjunct to the loading program, which remains the main treatment.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No trial in this condition","evidence":"Searched 3 November 2026 (PubMed: patellofemoral pain, anterior knee pain or chondromalacia with corticosteroid, steroid, triamcinolone, methylprednisolone or betamethasone injection, 12 records; and a randomised-trial and systematic-review pass across this and three neighbouring conditions, 24 records). No study has tested a corticosteroid or local anaesthetic injection in patellofemoral pain itself, and a Cochrane review of drug treatments for patellofemoral pain found no corticosteroid injection trial (Heintjes, Cochrane Database Syst Rev 2004). The nearest evidence is in neighbouring problems. In 58 people with cartilage softening found at knee arthroscopy for a meniscus problem, a joint injection of methylprednisolone and lignocaine scored better than saline and lignocaine at six weeks but not at six or twelve months (Koyonos, Am J Sports Med 2009). In 60 people with arthritis confined to the kneecap joint, triamcinolone and lignocaine relieved pain faster than hyaluronic acid in the first week, with no difference at six months (Mekariya, J ISAKOS 2025). Five weekly joint injections of a different drug, or of saline, added nothing at six months to a quadriceps exercise program in 53 people with patellofemoral pain (Kannus, Arthritis Rheum 1992). Steroid injection into a specific painful structure at the front of the knee, such as a fat-pad cyst or an inflamed bursa, appears only in case reports.","fit":"Hip and knee exercise is the treatment with the evidence. An injection is considered only where examination or ultrasound finds a specific painful structure at the front of the knee, such as an inflamed bursa or a fat-pad cyst, and then under guidance alongside the exercise program.","reviewedOn":"2026-11-03"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One non-randomised study","evidence":"Searched 20 October 2026: shockwave, shock wave, ESWT, rESWT or radial shock with patellofemoral pain, anterior knee pain, chondromalacia or patellofemoral syndrome (12 records) and with patellofemoral, retropatellar or patellar pain (10), each with a randomised-trial pass (no records) and a systematic-review pass (none on shockwave), plus one Consensus search; patellar tendon studies were set aside as a different condition. The old line here said the trials used focused devices; the only study with a comparison group used radial. Sixty-four adults aged 20 to 39 were divided into two groups for about three weeks, one given radial shockwave with specific exercises and the other electrotherapy, ultrasound and laser with exercises, and the shockwave group had less pain and better knee function after the program (Neculăeș, J Clin Med 2024). The abstract does not say the groups were randomised, there is no follow-up beyond the program, and there was no sham or exercise-only group. One case report describes a possible noise-related migraine during shockwave for patellofemoral joint pain (Lo, J Bodyw Mov Ther 2025).","fit":"Can be discussed as an add-on to a hip and quadriceps strengthening program when front-of-knee pain has not settled, on the understanding that the one study is small, short and not randomised. Exercise remains the treatment with the strongest evidence here.","reviewedOn":"2026-10-20"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One small study; exercise did better","evidence":"Searched 20 October 2026 (the searches named in the radial row, and one Consensus search). The one study of a focused device in this condition is not indexed on PubMed: 39 people with patellofemoral pain were divided between focused shockwave and resistance exercise with elastic bands for six weeks; both groups improved, the exercise group had significantly less pain, and knee function scores did not differ (Kim, Phys Ther Rehabil Sci 2025; randomisation not stated in the abstract). No trial against a sham exists, so this is not evidence that shockwave fails, but the only comparison made favoured exercise.","fit":"Not a first choice: in the one study a strengthening program did better than focused shockwave on its own. Considered only alongside that program, where a clearly tender structure around the kneecap is part of the picture.","reviewedOn":"2026-10-20"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"No trial; small studies disagree","evidence":"No randomised trial of PRP in patellofemoral pain: a trial-type search on 8 October 2026 returned five records and none enrolled people with this condition. Two small non-randomised comparisons in neighbouring groups point in different directions. In 43 adults aged 18 to 50 with anterior knee pain, a positive kneecap grind test and no structural abnormality, the 28 who chose three PRP injections plus one of hyaluronic acid did better on pain and the Kujala knee score at three and six months than the 15 who chose physiotherapy alone - not randomised, and not PRP on its own (Ostojic, Arch Orthop Trauma Surg 2024). In 55 adults under 40 with anterior knee pain attributed to the fat pad and normal imaging, the 27 given PRP into the joint finished with more pain than the 28 given anti-inflammatories and ice (3.0 against 1.5 out of 10), having also started with more (Gürsoy, Medicine 2025). A systematic review covering anterior knee pain found five studies in all and concluded that randomised trials are needed before PRP can be accepted for it (Chalidis, Int J Mol Sci 2025).","fit":"Rarely the right tool for patellofemoral pain, where there is usually no cartilage or tendon lesion to target and exercise for the hip and thigh carries the evidence. It may be discussed where imaging shows early kneecap cartilage change and a full course of rehabilitation has not been enough, with the lack of trials and the cost stated.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat saline in one 54-person trial","evidence":"One double-blind trial, in chondromalacia patella: 54 people with kneecap pain for at least three months were randomised to injections around the kneecap of 5% dextrose, which the authors call prolotherapy, or saline, at 0, 3 and 6 weeks. At 24 weeks the dextrose group was 1.67 points lower for pain out of 10, 15.4 points better on the Patellofemoral Pain Severity Scale and 9.3 points better on the Kujala knee score (Bayır, PM R 2026). That concentration is the one used for perineural injection, and the same trial is counted in that row. Beyond it there is a retrospective single-clinic report of 61 people with chondromalacia given 15% dextrose, without a comparison group (Hauser, Clin Med Insights Arthritis Musculoskelet Disord 2014), and one case report of ultrasound-guided 25% dextrose with an exercise program in a 27-year-old man (Furigay, Pain Manag 2026). A search on 12 October 2026 for dextrose or prolotherapy in patellofemoral pain, anterior knee pain or chondromalacia returned ten records. No trial has followed anyone beyond six months.","fit":"Prolotherapy is offered here and can be discussed where hip and knee strengthening has been done properly and kneecap pain is still limiting. It is used to make the loading program tolerable, not instead of it, and the single trial behind it is stated beforehand.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No better than sham injection","evidence":"Tested against a sham injection and found no better. Eighty-six people with patellofemoral pain that had not responded to conservative care, average age 27, were randomised, double-blind, to a single 6 mL hyaluronic acid injection or a sham injection, all with a home exercise programme. Pain on a single-leg squat, the KOOS and the Kujala knee score improved in both groups at six months with no difference between them, and the authors concluded the injection had no clinically meaningful effect (Hart, Orthop J Sports Med 2019). A single-arm study of 60 athletes given a hyaluronic acid and sorbitol injection reported better knee scores at six months, but it had no comparison group, one author worked for the manufacturer, and it calls for controlled trials itself (Vélez de Lachica, PLoS One 2026).","fit":"Not offered for patellofemoral pain. There is no arthritic joint surface to treat, the one sham-controlled trial found no benefit, and exercise for the hip and thigh carries the evidence here.","reviewedOn":"2026-10-08"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small trials, to six months","evidence":"One small randomised trial of this procedure, plus a saline-controlled trial of a closely related injection, both in chondromalacia patella (softened cartilage behind the kneecap). In 50 people (median age 55) given a home physiotherapy program, adding perineural dextrose injections gave more improvement at six months than physiotherapy alone on WOMAC pain (7.3 against 3.2 points), stiffness and function (23.2 against 11.1), with no dummy injection (García-Triana, J Altern Complement Med 2021). That appears to be the single trial behind the perineural result in a meta-analysis of 65 high-quality patellofemoral pain trials, where exercise plus perineural dextrose beat exercise alone at three months for pain (SMD 1.34, 95% CI 0.72 to 1.95) and function (1.21, 0.60 to 1.82) (Neal, J Orthop Sports Phys Ther 2022): the trial's own figures reproduce those effect sizes, and no other qualifying trial was found, so the meta-analysis does not add a second trial. A double-blind trial of 54 people with at least three months of knee pain compared periarticular 5% dextrose with saline at 0, 3 and 6 weeks: at 24 weeks dextrose was 1.67 points lower on a 10-point pain scale, 15.4 points better on the Patellofemoral Pain Severity Scale and 9.3 points better on the Kujala score (Bayır, PM R 2026); the abstract describes the injections as periarticular prolotherapy at tender points, and whether they were placed under the skin as in this treatment is not stated. Limits: both trials are single-centre and in chondromalacia rather than in younger people with patellofemoral pain and healthy cartilage, neither followed anyone past six months, and the meta-analysis notes that no treatment for this condition has been adequately tested beyond three months. Searched 29 October 2026: patellofemoral, anterior knee pain or chondromalacia with dextrose, perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture, Lyftogt, neurofascial or prolotherapy (10 records, all read).","fit":"An option alongside the loading programme rather than instead of it: both trials injected in addition to exercise, or in people who had already had months of knee pain. Discussed where hip and knee strengthening has been done properly and anterior knee pain is still limiting.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Hydrodissection has not been tested in patellofemoral pain. Searching hydrodissection and hydrorelease against the patellofemoral joint, the anterior knee and the infrapatellar region returns no trial in this condition, only reports of a nerve or a stuck tissue plane being treated near the front of the knee: three case reports of releasing scar or fat-pad adhesions after knee surgery (Machida, Cureus 2020; Machida, Cureus 2022; Obara, JA Clin Rep 2022); a series of 29 people with medial knee pain after knee replacement whose infrapatellar saphenous nerve was hydrodissected, median pain falling from 9 to 5 and holding at nearly five years (Shi, Cureus 2020); and a man whose pain around the patellar tendon proved to be common peroneal nerve compression at the fibular head, identified and partly relieved by hydrodissection (Song, Proc Bayl Univ Med Cent 2020).","fit":"Only where the examination points to a nerve rather than to the way the kneecap is loaded. The two patterns that fit are the infrapatellar branch of the saphenous nerve, usually after surgery or a blow to the inner knee, and the common peroneal nerve at the outer side of the knee. Patellofemoral pain itself is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"peroneal-tendinopathy","title":"Peroneal Tendinopathy","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/peroneal-tendinopathy","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line, on case-series evidence","evidence":"Non-operative care is the recognised starting point: relative rest and activity modification, anti-inflammatory medicines, orthoses with lateral posting, and a walking boot or cast for around six weeks in refractory cases, persisted with for four to six months before surgery is considered (StatPearls, Peroneal Tendon Syndromes 2023; Davda, EFORT Open Rev 2017). A specialist review notes that treatment recommendations for these disorders rest mainly on case series and expert opinion, and no randomised trial of a rehabilitation programme for peroneal tendinopathy was identified.","fit":"The starting point: unloading the outer ankle, progressive peroneal and ankle strengthening, balance work, and footwear or orthotic changes. A high-arched, inward-tilted heel and lateral ankle instability are looked for at the first visit, because they are often the reason the tendons are overloaded.","reviewedOn":"2026-09-28"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search pairing peroneal or fibularis tendinopathy with dry needling and trigger point treatment returned no study treating this condition with needling.","fit":"Only where a separate tender band in the peroneal or calf muscle belly is reproducing part of the pain. It does nothing for the tendon itself.","reviewedOn":"2026-09-28"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Short relief for many","evidence":"The largest series is 96 patients given an ultrasound-guided corticosteroid injection into the peroneal tendon sheath: 37 per cent reported more than 12 weeks of relief, 44 per cent a week or less, and a quarter went on to tendon surgery; shorter symptom duration predicted a longer response, and complications were sural nerve irritation and progression of one tear (Fram, Foot Ankle Int 2019). There is no controlled trial, and one specialist unit does not use steroid here at all because of the risk of tendon rupture (Davda, EFORT Open Rev 2017).","fit":"Considered for sheath inflammation that has not settled with a proper rehabilitation trial, placed in the sheath under ultrasound rather than into the tendon, and with the rupture risk explained. It also helps confirm that the tendons are the source.","reviewedOn":"2026-09-28"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A combined search for vibration therapy with peroneal tendon terms returned no study treating this condition.","fit":"A comfort adjunct at most where calf or peroneal muscle guarding is limiting the exercise programme. Not a treatment for the tendon.","reviewedOn":"2026-09-28"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search for shockwave with peroneal or fibularis tendon terms returned two records: a single case report of a peroneus longus tear treated with focused shockwave alongside physiotherapy and orthotics (Culebras Almeida, Life 2026), and a case report of ankle ligament adhesions. No trial has tested radial shockwave in peroneal tendinopathy, and evidence from the Achilles or plantar fascia cannot be assumed to transfer.","fit":"May be discussed for persistent tendinopathy after a full rehabilitation trial, on mechanism only and with the absence of evidence explained. Not used for a significant tear or for tendons slipping out of their groove, which are structural problems.","reviewedOn":"2026-09-28"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"The only published use is a single case report: a professional footballer with an isolated peroneus longus tear treated with eight sessions of ultrasound-guided focused shockwave plus physiotherapy and orthotics, who returned to play at 12 weeks (Culebras Almeida, Life 2026). A case report cannot separate the effect of shockwave from the rest of the programme.","fit":"Same position as radial shockwave: discussed only after rehabilitation, as untested, and never in place of a surgical opinion for a tear or dislocation.","reviewedOn":"2026-09-28"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A combined search for electromagnetic and magnetotransduction therapy with peroneal tendon terms returned no study.","fit":"Not part of managing this condition.","reviewedOn":"2026-09-28"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"The only data specific to these tendons are a subgroup of 23 peroneal patients within an uncontrolled pilot series of ultrasound-guided PRP for tendinopathy in general (Dallaudiere, J Vasc Interv Radiol 2014, cited in StatPearls). A 2023 review of non-operative management concludes that PRP is not currently supported by the evidence for peroneal tendon disorders (Curr Phys Med Rehabil Rep 2023).","fit":"Not offered as a treatment for this condition on current evidence.","reviewedOn":"2026-09-28"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search pairing peroneal tendon terms with prolotherapy and dextrose returned no study treating this condition.","fit":"Not offered for this condition.","reviewedOn":"2026-09-28"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"The only hyaluronic acid records with peroneal terms are laboratory and animal studies of a hyaluronic acid-gelatin coating to reduce adhesions on tendon grafts, not injection treatment of tendinopathy. There is no joint to inject.","fit":"Not offered for this problem.","reviewedOn":"2026-09-28"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial of perineural dextrose in peroneal tendinopathy was identified. The sural nerve runs close to the tendons, and sural nerve irritation is a recognised complication of injections here (Fram, Foot Ankle Int 2019).","fit":"Considered only if examination finds a separate superficial nerve pain pattern, such as sural nerve irritation. It is not treatment of the tendon.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not a nerve problem","evidence":"The hydrodissection record that matches peroneal terms concerns the common peroneal nerve at the fibular head, a different structure at the knee (Song, Proc Bayl Univ Med Cent 2020). No study addresses the peroneal tendons, which are not a nerve entrapment.","fit":"Only relevant if ultrasound and examination identify a separately compressed nerve, such as the sural or superficial peroneal nerve. Not a treatment for the tendons.","reviewedOn":"2026-09-28"}}},{"slug":"pes-anserine-bursitis","title":"Pes Anserine Bursitis","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/pes-anserine-bursitis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"The strongest evidence here is what does not work. In a placebo-surgery controlled trial, arthroscopic subacromial decompression gave no benefit over a sham operation or over exercise therapy, at two years, at five, and at ten (Paavola, BMJ 2018; Paavola, Br J Sports Med 2020; Kanto, BMJ 2025). A network meta-analysis of 54 trials and 3,893 patients found shoulder-specific exercise reduced pain out to 52 weeks, and that adding injections, manual therapy or electrotherapy to it added little (Silveira, PLoS One 2024).","fit":"Loading the shoulder properly is the treatment. An injection is occasionally used to settle pain enough to start, which is a different claim from treating the problem.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials at this bursa","evidence":"Searching dry needling, trigger point work, needling and lignocaine against the pes anserine returned a single record, and it is a survey of what sports physicians choose to inject rather than a trial (Cushman, PM R 2021). Nothing has tested needling or trigger point injection at this bursa. What has been mapped is that the medial knee is a common site for tender points: across 483 people with knee pain at four centres, 76 with medial-side diagnoses including pes anserine bursitis had tender points clustered on the medial knee with referred pain into the adductor group and medial calf (Qin, Zhen Ci Yan Jiu 2020) - an observational mapping study, not a treatment trial. The injection literature at this bursa tests corticosteroid, dextrose and ozone placed into the bursa itself, which belongs to the guided injection and prolotherapy rows rather than to this one.","fit":"Considered where examination finds a tender band in the medial thigh or calf reproducing part of your pain, rather than tenderness over the bursa itself.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Bursal and sheath targets are small, often deep, and poorly identified by surface landmarks; ultrasound guidance improved accuracy across shoulder girdle targets and improved efficacy where the target was a sheath rather than a large space (Aly, Br J Sports Med 2014).","fit":"Where an inflamed bursa is the identified target, this is a reasonable step, with the number of injections kept low. See the note on cortisone.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No radial-device trial","evidence":"Searched 18 October 2026 (shockwave, shock wave or ESWT with anserine, anserinus or pes anserinus; 5 records, all read): no trial of radial shockwave in this condition. The sham-controlled trial and the cortisone-comparison trial both used a focused probe (Khosrawi, Adv Biomed Res 2017; Gouda, Adv Orthop 2023), and a third trial did not state its device (Majidi, Med J Islam Repub Iran 2023). For this condition the old statement that the trials used focused devices is correct.","fit":"The pes anserine lies close to the skin, so radial is plausible here and can be discussed alongside a strengthening program, but patients are told the trials used a focused device.","reviewedOn":"2026-10-18"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat sham in one 40-person trial","evidence":"Searched 18 October 2026: shockwave, shock wave or ESWT with anserine, anserinus or pes anserinus (5 records, all read; the 180-person trial read in full). In 40 people with pes anserine bursitis of more than three months that had not settled with other care, three weekly sessions of focused shockwave lowered pain more than sham at three weeks and again eight weeks after treatment (Khosrawi, Adv Biomed Res 2017; the abstract gives p-values, not effect sizes). Against a cortisone injection it did worse in the short term: in 180 people randomised to cortisone, PRP or four sessions of focused shockwave, cortisone gave the most relief at one and eight weeks (pain at eight weeks 2.2 out of 10 with cortisone, 4.4 with shockwave), though the paper's tables contain inconsistencies (Gouda, Adv Orthop 2023). In 53 people a guided cortisone injection did better at one month and shockwave better at three months, the device type not stated (Majidi, Med J Islam Repub Iran 2023). All three are single-centre, with follow-up of three months or less, and none reports harms in figures.","fit":"Worth discussing alongside strengthening and load management for inner-knee pain over the pes anserine that has not settled. A cortisone injection works faster; in one trial shockwave held up better by three months.","reviewedOn":"2026-10-18"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Case series; cortisone better early","evidence":"Studied here, mostly without a comparison group. In 33 people with long-standing pain at the pes anserinus given one injection of PRP into the painful area, 28 (85%) had complete or near-complete relief within six months, with a poorer response where knee arthritis was advanced (Rowicki, Ortop Traumatol Rehabil 2014). In a randomised trial of 60 people comparing one ultrasound-guided PRP injection with two a week apart, both groups improved in pain, function and walking distance at four and twelve weeks with nothing between them. At twelve weeks 78% reported complete or significant relief and 7% were worse, but there was no group without PRP (Karabaş, Transfus Apher Sci 2021). The one comparison with another treatment went against it in the short term: in 180 people randomised to cortisone, PRP or shockwave, cortisone gave better pain and function scores than PRP at one and eight weeks. The groups were not well matched for pain at the start, and nobody was followed beyond eight weeks (Gouda, Adv Orthop 2023). There is no placebo-controlled trial. A systematic review of the bursae around the knee describes PRP as a promising alternative for cases that have not settled, while calling for better trials (Hasan, Cartilage 2025).","fit":"Can be discussed for pain at the inner knee that has not settled with load management and strengthening, particularly where a cortisone injection has worn off or is best avoided. Cortisone works faster, and Patients are told so. If used, PRP is placed at the tender area under ultrasound guidance to make the strengthening program more tolerable, and the knee joint itself is assessed, because arthritis there predicts a poorer response.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Outlasted cortisone in one trial","evidence":"Tested in one randomised trial. Seventy-two people with pes anserine bursitis, most of them women and with an average age of 61, were randomised at several centres to an ultrasound-guided injection into the bursa of cortisone, oxygen-ozone or 20% dextrose. All three groups improved. Cortisone and ozone were ahead on pain and function at one week, and by eight weeks ozone and dextrose were ahead of cortisone (Babaei-Ghazani, Am J Phys Med Rehabil 2024). The limits: 72 people split across three groups, eight weeks of follow-up, and no placebo group, so it shows dextrose lasting longer than cortisone rather than dextrose beating no treatment. A search for dextrose or prolotherapy at the pes anserine returned four records and no other trial. The one other clinical report is a single badminton player treated with weaker 5% dextrose at the tendon attachments (Yang, Int Med Case Rep J 2026).","fit":"Can be discussed for pain at the inner knee that has not settled with load management and strengthening, particularly where a cortisone injection has given only short relief. It rests on one small trial, and Patients are told so. If used, it sits alongside the strengthening program and does not replace it.","reviewedOn":"2026-10-10"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Not offered here, and not studied. PubMed searches pairing hyaluronic acid with pes anserine terms found no study of any kind; the only record describing injection at this site uses cortisone (Cardone, Am Fam Physician 2003). In the one randomised trial of hyaluronic acid into a bursa, at the shoulder rather than the knee, it was only marginally better than saline (Hsieh, Clin Rehabil 2021). This is an absence of evidence at this site, not evidence that it fails.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this bursa and its tendons sit outside the knee joint. Where knee osteoarthritis coexists, the joint itself is assessed separately.","reviewedOn":"2026-11-09"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial of perineural injection at this site. The randomised evidence here tested a different injection: 72 people had ultrasound-guided 20% dextrose, corticosteroid or oxygen-ozone placed into the bursa itself, with dextrose and ozone still ahead of corticosteroid at eight weeks (Babaei-Ghazani, Am J Phys Med Rehabil 2023). That is prolotherapy into the bursa, not dilute dextrose around a nerve. The only report using the perineural technique nearby is a single case, in which 5% dextrose at the sartorius, gracilis and semitendinosus tendon traction points settled medial knee pain from 8 to 1 out of 10 (Yang, Int Med Case Rep J 2026).","fit":"Considered only where the medial knee is tender over the skin and superficial nerve territory rather than over the bursa. If the bursa is the problem, the injection that has been tested is the one placed into it.","reviewedOn":"2026-09-09"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searching hydrodissection and hydrorelease against pes anserine and pes anserinus returns no records at all, so this technique has not been reported at this bursa. What has been reported nearby is treatment of the infrapatellar branch of the saphenous nerve, which crosses exactly this part of the inner knee and can cause pain here: 16 people with persistent medial knee pain after knee replacement had the nerve hydrodissected and freed from the surrounding tissue planes, nine of them dropping to a pain score of 0 or 1 (Clendenen, Clin Orthop Relat Res 2015), with a later series of 29 holding its gain at nearly five years (Shi, Cureus 2020). Both authors call for a placebo-controlled trial, which has not been done.","fit":"Only where the inner knee pain has a nerve quality (burning, numbness or an area that feels oversensitive to touch) and the examination points to the infrapatellar branch of the saphenous nerve rather than to the bursa. The bursitis itself is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"plantar-fasciitis","title":"Plantar Fasciitis","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/plantar-fasciitis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Short-term only","evidence":"Trials exist here and they disagree. In a participant-blinded trial, 84 people with plantar heel pain were randomised to real or sham trigger point dry needling weekly for six weeks: first-step pain improved by 14.4 mm on a 100 mm scale (95% CI 5.2 to 23.5) and foot pain by 10.0 points (1.0 to 19.1) in favour of real needling, but both differences were smaller than the change patients report as important, and minor short-lived side effects followed 32 per cent of real appointments against under 1 per cent of sham ones (Cotchett, Phys Ther 2014). A meta-analysis covering 236 trials and 15,401 patients found dry needling effective for pain in the short term (mean difference -2.34, 95% CI -4.64 to -0.04) but found only shockwave still effective at medium and long term (Guimarães, Clin Rehabil 2022), and a separate systematic review concluded that trigger point therapy adds limited or no benefit to self-stretching (Piper, Man Ther 2015). For the injected form specifically the base is thin: three poor-quality trials, one of which used 1% lignocaine alongside physiotherapy (Cotchett, J Foot Ankle Res 2010).","fit":"Directed at tender bands in the calf and the foot rather than at the fascia itself. Reasonable to try alongside the loading and shockwave work, with the expectation that any benefit is short-lived.","reviewedOn":"2026-09-11"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Brief relief, rupture risk","evidence":"This row's exact procedure has been tested here. The trials agree that any effect is short-lived and disagree on whether it is worth having. In 82 people, an ultrasound-guided dexamethasone injection beat a saline injection on pain at four weeks by 10.9 points out of 100 (95% CI 1.4 to 20.4), with no difference at eight or twelve weeks (McMillan, BMJ 2012). A Cochrane review of 39 trials in 2,492 adults found corticosteroid may slightly reduce heel pain for up to one month (MD -6.38 out of 100, 95% CI -11.13 to -1.64) and not afterwards, at low quality (David, Cochrane Database Syst Rev 2017). In 180 people, adding an ultrasound-guided triamcinolone injection to heel-raise exercise, advice and a heel cup was no better than the same programme without it at any point up to one year (Riel, Br J Sports Med 2023). Guidance does help: five trials in 149 people found ultrasound-guided injection better than injection placed by feel for pain and response rate (Li, PLoS One 2014). The risk is rupture of the plantar fascia. Of 35 ruptures among 286 people with plantar fasciitis, 33 had received a corticosteroid injection (Lee, Foot Ankle Int 2014), and a rupture can leave lasting arch and midfoot problems (Acevedo, Foot Ankle Int 1998).","fit":"Not a first choice here: shockwave and a loading programme have the longer-lasting evidence. Considered for severe pain that is blocking that work, as a single guided injection with the rupture risk explained beforehand: see the note on cortisone.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"A network meta-analysis of 19 trials and 1,676 patients found radial shockwave the ONLY modality producing significant pain reduction versus placebo at 0 to 6 weeks, and concluded with a recommendation to treat plantar fasciitis with radial rather than focused (Li, Medicine 2018). An earlier network meta-analysis also ranked radial highest for probability of being the best option (Chang, Arch Phys Med Rehabil 2012).","fit":"The form of shockwave the network evidence favours for heel pain, and the cheaper of the two. Focused remains a reasonable alternative.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Level I evidence that focused shockwave is effective as a stand-alone treatment in athletes and physically active people (Rhim, Br J Sports Med 2024), and a 16-trial meta-analysis found it more effective than corticosteroid injection for pain, fascia thickness and foot function at three and six months (Cortés-Pérez, Clin Rehabil 2024).","fit":"One of the better-supported uses. Offered where heel pain has not settled with load management and calf and plantar loading work.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Two randomised trials of PRP in chronic plantar fasciitis reported positive results for pain and function (O'Dowd, Orthop J Sports Med 2022), and a 236-study meta-analysis found PRP effective for short-term pain (MD -2.40), though only shockwave remained effective at medium and long term (Guimarães, Clin Rehabil 2022).","fit":"Worth discussing in stubborn heel pain. Shockwave has the better durable data.","reviewedOn":"2026-08-30"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"A meta-analysis of 6 randomised trials found dextrose prolotherapy superior to placebo or exercise for pain in the short and medium term, and better than corticosteroid for pain in the long term, but INFERIOR to corticosteroid in the short term and inferior to shockwave for short-term function (Lai, Medicine 2021). A second review of 8 trials reached the same shape of conclusion at low to moderate certainty (Fong, Arch Phys Med Rehabil 2023).","fit":"Worth discussing where the aim is longer-term change rather than fast relief. Shockwave has the better short-term data here.","reviewedOn":"2026-08-30"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Trialled in the plantar fascia itself, but not offered here. A multicentre double-blind randomised trial of 168 people with heel pain lasting more than twelve weeks found five weekly injections of high-molecular-weight hyaluronic acid reduced pain more than a dilute control injection (a 3.3 cm fall on a 10 cm pain scale against 2.4 cm, p = 0.029) (Kumai, Knee Surg Sports Traumatol Arthrosc 2018). A separate randomised trial of 75 people found a single hyaluronic acid injection matched cortisone at 24 weeks, with cortisone working faster over the first six (Raeissadat, J Pain Res 2020).","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and plantar fasciitis is a problem of the fascia under the heel.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested perineural injection in plantar fasciitis. Two reports from the same group describe 5% dextrose placed around the tibial nerve with pain falling over one or two sessions, and the earlier of them states that no study yet compares this with the conventional corticosteroid injection (Darmawan, Acta Med Indones 2024; Darmawan, Folia Medica 2026).","fit":"Not a first-line option for heel pain. Calf and plantar loading, footwear and load management carry the evidence. An injection aimed at the tibial nerve would only make sense where the pain has a burning or numb quality suggesting nerve involvement.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"The heel evidence is for the nerve rather than the fascia, and it sits at case level. A case series describes ultrasound-guided 5% dextrose hydrodissection around the tibial nerve for plantar fasciitis (Darmawan, Folia Med 2026). Two case reports cover entrapments that produce heel pain: Baxter's neuropathy accompanying plantar fasciitis, where hydrodissection or surgical release is proposed for cases that do not respond (Kaur, J Orthop Case Rep 2024), and a gastrocnemius nerve branch caught in scar after surgery for recalcitrant plantar fasciitis, which settled after hydrodissection (Toral Guisasola, Rehabilitacion 2020). No randomised trial was found in plantar fasciitis.","fit":"Considered where the pain pattern is neuropathic rather than the usual first-step morning heel pain: a Baxter's nerve pattern, or nerve pain persisting after previous heel surgery.","reviewedOn":"2026-09-08"}}},{"slug":"polymyalgia-rheumatica","title":"Polymyalgia Rheumatica","region":"General","url":"https://www.backpaindoctor.com.au/conditions/polymyalgia-rheumatica","pairings":{"rehab":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Adjunct to medical treatment","evidence":"Treatment is medical: glucocorticoid with a planned taper, reviewed against the European and American recommendations (Dejaco, Ann Rheum Dis 2024 treat-to-target). Exercise evidence is thin. One randomised crossover trial of home exercise was found, and it compared two protein supplements, not exercise against none (Bjorkman, J Nutr Health Aging 2011). An Australian cohort of 36 people showed greater disability, slower gait and more pre-frailty than matched controls up to 18 months after starting treatment, and the authors recommended routine functional assessment and muscle conditioning (Leung, Rheumatology 2025). An Australian survey of 149 people found many wanted specific exercise guidance (Osmotherly, Musculoskelet Care 2026).","fit":"A reasonable adjunct once the diagnosis is made and treatment is under way, aimed at strength, walking and chair-rise ability, with the thin evidence stated. It sits alongside medical treatment and bone protection, never instead of it.","reviewedOn":"2026-10-11"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A PubMed search pairing polymyalgia rheumatica with dry needling, wet needling or acupuncture found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial located of image-guided injection as treatment for polymyalgia rheumatica itself; the established treatment is systemic prednisolone with a planned taper (Dejaco, Ann Rheum Dis 2024; Lancet 2023 review).","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A PubMed search pairing polymyalgia rheumatica with vibration or percussive devices found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing polymyalgia rheumatica with radial shockwave found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing polymyalgia rheumatica with focused shockwave found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing polymyalgia rheumatica with electromagnetic transduction or pulsed electromagnetic therapy found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing polymyalgia rheumatica with platelet-rich plasma found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search pairing polymyalgia rheumatica with prolotherapy or dextrose injection found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Hyaluronic acid is for intra-articular problems. Polymyalgia rheumatica is a systemic inflammatory condition, and no trial of hyaluronic acid in it was found.","fit":"Not offered. Treatment is systemic and medical.","reviewedOn":"2026-10-11"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A PubMed search pairing polymyalgia rheumatica with perineural injection or nerve block found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A PubMed search pairing polymyalgia rheumatica with hydrodissection found no randomised or controlled treatment trial.","fit":"Not part of managing polymyalgia rheumatica, which is an inflammatory condition treated with prednisolone under medical supervision. Only considered if a separate, localised problem is found on examination.","reviewedOn":"2026-10-11"}}},{"slug":"posterior-tibial-tendon-dysfunction","title":"Posterior Tibial Tendon Dysfunction (Adult Acquired Flatfoot)","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/posterior-tibial-tendon-dysfunction","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in this condition","evidence":"Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection, myofascial or intramuscular stimulation with tibialis posterior or posterior tibial, 14 records, three of them stroke-spasticity studies and two cadaver studies; and a randomised-trial and systematic-review pass). No study has injected or needled a trigger point in people with tibialis posterior tendon dysfunction. The nearest work is in other groups: an 82-person sham-controlled trial of a single dry needling session to tibialis posterior trigger points in people without a stated tendon diagnosis measured only foot pressure, which changed for 24 hours and not at 72 hours (Martínez-González, PLoS One 2026); a cadaver study and a healthy-volunteer ultrasound study of needle safety near the tibial nerve and artery (Albin, Int J Sports Phys Ther 2021); and a retrospective study of needle-knife release of tibialis posterior in painful accessory navicular, a different procedure (Cheng, Quant Imaging Med Surg 2026).","fit":"Bracing or an orthosis and a tibialis posterior loading program treat the tendon. A trigger point injection would be considered only where a tender calf-muscle band is found adding to the pain.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled series only","evidence":"Searched 3 November 2026 (PubMed: tibialis posterior or posterior tibial with tendinopathy, tenosynovitis, dysfunction or tendinitis and corticosteroid, steroid, triamcinolone or injection, 26 records; and a randomised-trial and systematic-review pass, which found no trial in this condition). No randomised trial of a steroid injection in this condition was found; the evidence is uncontrolled. In 33 patients given 38 ultrasound-guided corticosteroid injections into the tendon sheath, 47% of injections gave good or better pain relief, 21% of patients went on to surgery, and no complications were recorded; the review was retrospective and had no comparison group (Spencer, Australas J Ultrasound Med 2023). In 65 people given local anaesthetic and steroid into the sheath under X-ray, 48% had complete or near-complete relief at six months or more, 26% had relief that wore off and 26% had none; across all 144 tendon-sheath procedures in that series, one posterior tibial tendon ruptured (Jaffee, AJR Am J Roentgenol 2001). In 166 patients, an earlier cortisone injection was one of the factors that distinguished those who later had surgery (O'Connor, Foot Ankle Int 2010); that study does not show the injection caused it. Rupture after repeated steroid injection is a recognised concern for this tendon (Simpson, J Foot Surg 1983). Local anaesthetic into the sheath is also used to confirm the diagnosis, and gave complete relief in all 17 ankles with early disease in one series (Cooper, Foot Ankle Int 2007).","fit":"Bracing or an orthosis and a progressive loading program are the main treatment. Where tendon-sheath pain is blocking that program, a guided injection into the sheath may be discussed, with the variable benefit and the small risk of rupture explained, and the loading program continuing. See the note on cortisone.","reviewedOn":"2026-11-03"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One 10-person case series","evidence":"Searched 20 October 2026: shockwave, shock wave, ESWT, rESWT or radial shock with tibialis posterior, posterior tibial, flatfoot, accessory navicular or navicular (25 records), and with progressive collapsing foot, PTTD, os tibiale, pes planus, planovalgus or acquired flatfoot (4), with randomised-trial and systematic-review passes that found nothing in this condition; racehorse navicular studies were set aside. No randomised trial exists. In a case series of 10 people with tibialis posterior tendinopathy who had not improved with standard care, radial shockwave combined with a progressive foot-strengthening program gave a clinically important improvement in daily-activity function in 9 and in sport function in 8 at a median of four months, with no side effects; there was no comparison group (Robinson, J Foot Ankle Surg 2020). Two single case reports at the tendon's attachment to the navicular, device not stated, describe lasting relief and, in a teenager with a calcified tendon, the calcium clearing by six months (Andresen, J Surg Case Rep 2024; Ikoma, Prog Rehabil Med 2018). A retrospective study added shockwave after flatfoot surgery, aimed at the calf rather than this tendon (Zeng, Indian J Orthop 2026).","fit":"Can be discussed alongside a foot and calf strengthening program and, where needed, footwear or orthotic support, for tendon pain on the inside of the ankle that has not settled. The evidence is one small series without a comparison group. A tendon that is failing, with the arch progressively collapsing, needs a surgical opinion rather than more shockwave.","reviewedOn":"2026-10-20"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No focused-device study","evidence":"Searched 20 October 2026 (the searches named in the radial row: 25 and 4 records, with randomised-trial and systematic-review passes that found nothing in this condition). No study used a focused device at the tibialis posterior tendon. The one case series used radial shockwave (Robinson, J Foot Ankle Surg 2020); two case reports at the navicular attachment do not name the device (Andresen, J Surg Case Rep 2024; Ikoma, Prog Rehabil Med 2018), and a retrospective flatfoot-surgery study aimed shockwave at the calf, device not stated (Zeng, Indian J Orthop 2026).","fit":"Plausible on the same mechanism as other tendon problems and can be discussed on that basis alongside the strengthening program, but patients are told the only series in this condition used the radial device.","reviewedOn":"2026-10-20"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Only a few unseparated cases","evidence":"Searched for PRP at the posterior tibial tendon and in adult acquired flatfoot. Fourteen records, and no trial or controlled study of an injection for this tendon. The only report of PRP injected on its own is five posterior tibial tendons within a series of 19 elite dancers treated at different sites under ultrasound guidance. Eighteen of the 19 returned to dance, most within six months, but the tendon cases were not reported separately and the foot and ankle sites were the slowest to recover (Jain, J Dance Med Sci 2018). Otherwise PRP has only been used as an addition to surgery: 13 people with an early flatfoot had a supporting screw placed, the tendon inspected through a small scope and PRP delivered at the same operation, and their pain and function scores improved at about two and a half years, with no way of telling what the PRP contributed (Yasui, Int Orthop 2017).","fit":"Not something to choose ahead of the established treatment, which is an orthotic or brace to support the arch and a progressive strengthening program for the tendon. PRP can be discussed only on the understanding that no study has tested it for this tendon on its own.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study of dextrose prolotherapy in posterior tibial tendon dysfunction was found. A PubMed search on 13 October 2026 (prolotherapy, dextrose, hypertonic glucose or hyperosmolar with posterior tibial, tibialis posterior, adult acquired flatfoot or flatfoot) returned two records, and passes restricted to randomised trials and to systematic reviews or meta-analyses found nothing in this condition. The one clinical record is a single case treated after ankle surgery with ultrasound-guided injections of polydeoxyribonucleotide, a different injectate that its authors called prolotherapy (Lim, Medicine 2016); it says nothing about dextrose. The other record is an anatomy paper on the nerves of the inner ankle.","fit":"Can be discussed for a painful but intact tendon where pain persists despite orthoses or bracing and a loading program, with the absence of studies stated. It cannot rebuild a collapsed arch or repair a torn tendon.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here, and not studied. PubMed searches pairing hyaluronic acid, hyaluronate or hylan with posterior tibial or tibialis posterior tendon terms returned no treatment study of any kind, and a meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems contains none at this tendon (Khan, Sports Health 2022). This is an absence of evidence, not evidence that it fails.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem. Tendon loading, footwear and orthotic support remain the centre of treatment.","reviewedOn":"2026-11-09"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested dextrose injections of any kind for posterior tibial tendon dysfunction. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against the posterior tibial tendon and flatfoot returns no treatment study, and a randomised-trial search on 6 October 2026 returned no record. Widening to any dextrose or prolotherapy injection adds one case report, and it used a different injectate altogether: ultrasound-guided polydeoxyribonucleotide in a 67-year-old whose tendon failed three years after ankle surgery, with less pain and a better arch described but no measurements and no comparison (Lim, Medicine 2016). Injections around the nerves of the foot and ankle have been reported for nerve pain in this region. Across 59 ultrasound-guided procedures in 46 people, the saphenous and posterior tibial nerves among them, 43 of 45 gave immediate relief and 23 of the 38 with follow-up gave relief that lasted beyond the injection (Walter, Skeletal Radiol 2017). Those were placed around the nerve under ultrasound for a nerve problem, not under the skin for a tendon problem.","fit":"Not a treatment for the tendon, which is managed with the options higher up this page. Considered only where tender, hypersensitive skin or nerve-type pain over the inner ankle sits alongside the tendon problem.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of hydrodissection in posterior tibial tendon dysfunction. What exists is mechanism at exactly this tendon: in twelve cadaver legs, hydrorelease between the epimysial fasciae of tibialis posterior and flexor digitorum longus lowered the gliding resistance measured during tendon pull by 4.3% (Shiwaku, BMC Musculoskelet Disord 2025). That shows the injection does what it is said to do to gliding. It says nothing about whether people with a failing tendon feel better.","fit":"Not a treatment for the tendon. Relevant only where assessment finds a nerve involved as well, most often a tarsal tunnel pattern at this part of the ankle.","reviewedOn":"2026-09-08"}}},{"slug":"hamstring-tendinopathy","title":"Proximal Hamstring Tendinopathy","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/hamstring-tendinopathy","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, dry needling or trigger point with adductor, groin, pubic, hamstring, posterior thigh or ischial, 54 records, all read). No study has injected a muscle trigger point in proximal hamstring tendinopathy, with glucose or anything else. The nearest are two case reports of runners treated with dry needling (nothing injected, not offered here) alongside eccentric hamstring loading and pelvic stability work, both returning to running and sitting without pain (Jayaseelan, J Orthop Sports Phys Ther 2014). The one controlled trial nearby went the other way: in 59 Australian Rules footballers with back-of-thigh pain referred from buttock trigger points, dry needling of the buttock muscles did no better than placebo needling, both groups improving equally (Huguenin, Br J Sports Med 2005). A systematic review of 13 studies in this condition recommends a loading program and notes needling only as part of combined care, with no separate result (Dizon, Sports 2023).","fit":"Considered only where examination finds a tender hamstring or buttock muscle band contributing to the pain, as an adjunct to the tendon loading program, which treats the tendon itself.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Case series only, no trial","evidence":"No randomised trial of a corticosteroid or anaesthetic injection in proximal hamstring tendinopathy was found; the evidence is uncontrolled. After ultrasound-guided corticosteroid injection, 50% of patients improved for more than a month and 24% for more than six months (Zissen, AJR Am J Roentgenol 2010). In 18 athletes (22 cases), a fluoroscopically guided injection beside the tendon was followed by pain falling from 7.2 to 3.9 out of 10 at a mean of 21 months, with 39% fully resolved, but there was no comparison group and outcomes were collected by questionnaire (Nicholson, Orthop J Sports Med 2014). A 2021 systematic review of 12 studies found insufficient evidence to favour any one treatment (Nasser, Int J Sports Phys Ther 2021).","fit":"A loading programme is the main treatment. Where pain at the sitting bone is blocking it, a guided injection beside the tendon may be discussed, with the limited and often short-lived benefit explained. See the note on cortisone.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Radial shockwave was superior to conservative treatment at short, mid and long term in proximal hamstring tendinopathy (Korakakis, Br J Sports Med 2017), and Level I evidence supports shockwave as a stand-alone treatment here (Rhim, Br J Sports Med 2024).","fit":"The form used in the trials for this diagnosis, alongside loading.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Level I evidence for effectiveness as a stand-alone treatment in proximal hamstring tendinopathy (Rhim, Br J Sports Med 2024). The trial evidence used RADIAL shockwave, which was superior to conservative treatment at short, mid and long term (Korakakis, Br J Sports Med 2017).","fit":"Offered alongside loading. Note the trials used radial rather than focused, and that is what would be used here.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small case series; results vary","evidence":"Studied at the hamstring origin only in small groups, and never against a dummy injection. In 18 people with pain for an average of nearly three years, one ultrasound-guided injection was followed by an average 63% fall in pain at six months, with 10 of the 18 improving by 80% or more (Fader, Muscles Ligaments Tendons J 2014). In 22 people, 68% had at least halved their pain at an average of eight months (Auriemma, Regen Med 2020). An Australian study of 29 people with MRI-confirmed tendinopathy found the opposite: no significant change in the hamstring score eight weeks after a single injection, and 69% reporting no change in what they could do (Levy, J Sci Med Sport 2019). The one randomised trial compared PRP with an injection of the person's own whole blood, double-blind, and found no significant difference between them over six months (Davenport, J Ultrasound Med 2015). A systematic review of 12 studies rated that evidence very low and found too little to recommend any one treatment over another (Nasser, Int J Sports Phys Ther 2021). One serious complication has been reported, an infection of the sitting bone after a third injection, which settled with eleven weeks of antibiotics (Epshtein, JBJS Case Connect 2026).","fit":"Discussed where a hamstring loading program has been done properly and has not been enough, usually after shockwave, which has the stronger trials at this tendon. If used, PRP is placed under ultrasound guidance with the sciatic nerve identified and avoided, and the modest and inconsistent evidence, the cost and the small infection risk are stated beforehand.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report only","evidence":"No trial or case series of prolotherapy in hamstring tendinopathy was found. A PubMed search on 13 October 2026 (prolotherapy, dextrose or hypertonic glucose with hamstring, ischial tuberosity or ischial bursitis) returned five records, and passes restricted to randomised trials and to systematic reviews or meta-analyses found nothing in this condition. The only clinical record is a single case of tendinopathy at the lower end of the semimembranosus, behind the knee rather than at the sitting bone, in which three 12.5% dextrose injections gave no lasting relief before PRP was used (Senchyshak, Pain Med Case Rep 2026). The other records were a laboratory study of tendon cells, a nerve block, a different hip condition and an unrelated nutrition study. The prolotherapy trials sit at other tendons, chiefly the elbow, the shoulder and the plantar fascia (Capotosto, Orthop J Sports Med 2024: 20 trials, 1,136 people).","fit":"Can be discussed for pain at the hamstring origin that persists despite a progressive loading program, with the absence of studies stated. It supports the loading program and does not replace it.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here, and not studied. PubMed searches for hyaluronic acid with hamstring or ischial tuberosity terms (seven records once graft and ligament-reconstruction papers were excluded) and a randomised-trial pass across tendinopathy and bursitis (13 records) found no study of hyaluronic acid in proximal hamstring tendinopathy; it appears only as a passing mention in a review of hip injection treatments (Sullivan, J Hip Preserv Surg 2021). A meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems contains no hamstring trial (Khan, Sports Health 2022). This is an absence of evidence, not evidence that it fails.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem. Progressive hamstring loading remains the centre of treatment.","reviewedOn":"2026-11-09"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested small dextrose injections under the skin for hamstring tendinopathy. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against the proximal hamstring and ischial terms returns no treatment study at this tendon, and a randomised-trial search across the dextrose and perineural terms on 6 October 2026 returned no record. The one dextrose report here is of the other procedure, and it did not work: a three-injection course of 12.5% dextrose prolotherapy gave no lasting relief or functional gain in a 61-year-old with chronic semimembranosus tendinopathy, who later improved with other treatment (Senchyshak, Pain Med Case Rep 2026). Where this row could matter is the skin nerve that runs beside the tendon origin. The posterior femoral cutaneous nerve can cause pain over the buttock and back of the thigh, has been reported trapped through overuse (Hu, Clin J Sport Med 2024), and has been injected under ultrasound with local anaesthetic with immediate partial relief and no adverse events reported, in a technique paper that gives no patient numbers and no follow-up (Vita, J Ultrasound 2025). Both are injections placed around the nerve under ultrasound, not a series just beneath the skin.","fit":"Not a treatment for the tendon, which is managed with the options higher up this page. Considered only where sitting pain comes with tender, hypersensitive skin or altered sensation over the lower buttock and back of the thigh, suggesting a skin nerve is contributing.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hydrodissection for hamstring tendinopathy. The technique does appear at this site, but for a different problem: sciatic pain years after a complete tear of the hamstring origin, where dynamic ultrasound and MRI showed the retracted tendon scarred onto the sciatic nerve, treated by freeing the nerve under ultrasound guidance (Bohyn, Skeletal Radiol 2022). A radioanatomical study of 192 hips is a useful caution about how close these structures run: at the top of the femoral head the sciatic nerve sits within about 1.5 mm of bone, with nothing in between in over half of cases (Ollivier, Surg Radiol Anat 2026).","fit":"Only where sitting pain at the hamstring origin comes with nerve symptoms down the back of the leg and the assessment suggests the sciatic nerve is tethered near the tendon, which is most likely after a significant tear. The tendinopathy itself is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"psoriatic-arthritis","title":"Psoriatic Arthritis","region":"General","url":"https://www.backpaindoctor.com.au/conditions/psoriatic-arthritis","pairings":{"rehab":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Supportive, not disease-modifying","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. EULAR describes PsA as sometimes needing multidisciplinary care and asks that comorbidities such as obesity, cardiovascular disease, depression and bone health be addressed; Arthritis Australia lists physical activity and pain management as supporting measures. Trial evidence for specific exercise programs in PsA was not reviewed.","fit":"A supportive part of care alongside, never instead of, rheumatology-directed disease control: activity, weight, joint protection and a plan for any mechanical problem.","reviewedOn":"2026-10-17"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Needling is not among EULAR 2023 recommendations and does not treat the inflammation that drives PsA.","fit":"Not offered for psoriatic arthritis. A separate mechanical problem would be assessed on its own page.","reviewedOn":"2026-10-17"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Adjunct per EULAR","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. EULAR 2023 states that local glucocorticoid injections may be used as an adjunct for musculoskeletal symptoms, and mentions them for enthesitis before escalating to a biologic. They ease a joint or attachment but do not control the disease.","fit":"Considered for a persistently inflamed joint, tendon sheath or enthesis alongside rheumatology care, not instead of disease-modifying treatment.","reviewedOn":"2026-10-17"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Vibration-based devices are not part of the PsA recommendations and do not treat the inflammation.","fit":"Not offered for psoriatic arthritis.","reviewedOn":"2026-10-17"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Shockwave is not part of the EULAR 2023 recommendations and does not treat the underlying inflammation.","fit":"Not offered for psoriatic arthritis. A separate mechanical heel or tendon problem is assessed on its own page.","reviewedOn":"2026-10-17"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Shockwave is not part of the EULAR 2023 recommendations and does not treat the underlying inflammation.","fit":"Not offered for psoriatic arthritis.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Magnetotransduction therapy is not part of any PsA recommendation reviewed.","fit":"Not offered for psoriatic arthritis.","reviewedOn":"2026-10-17"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Platelet-rich plasma is not part of the PsA recommendations reviewed, and the condition is driven by systemic inflammation.","fit":"Not offered for psoriatic arthritis.","reviewedOn":"2026-10-17"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Dextrose prolotherapy is not part of the PsA recommendations reviewed.","fit":"Not offered for psoriatic arthritis.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong problem","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Hyaluronic acid injection is a treatment for osteoarthritis and is not part of the PsA recommendations reviewed.","fit":"Not offered for psoriatic arthritis. Coexisting osteoarthritis would be assessed separately.","reviewedOn":"2026-10-17"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Perineural injection is not part of the PsA recommendations reviewed.","fit":"Not offered for psoriatic arthritis.","reviewedOn":"2026-10-17"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Does not treat the disease","evidence":"The sources reviewed for this page were EULAR 2023 (Gossec, Ann Rheum Dis 2024), the Australian 2024 recommendations (Nash, Intern Med J; abstract and headings only), the Arthritis Australia information sheet and the Alinaghi 2019 prevalence meta-analysis. Hydrodissection addresses nerve entrapment and is not part of the PsA recommendations reviewed.","fit":"Not offered for psoriatic arthritis.","reviewedOn":"2026-10-17"}}},{"slug":"pubic-related-groin-pain","title":"Pubic-Related Groin Pain (Osteitis Pubis)","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/pubic-related-groin-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line, much of it indirect","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Supervised active rehabilitation is first-line, but much of the support is indirect, drawn from adductor-related groin pain. In 14 academy footballers with longstanding pubic-related pain, a six-level criteria-based program had a high return-to-play rate and one recurrence at a mean of about 135 days, in a small uncontrolled cohort. A 2024 adolescent randomised trial found a modified active program and traditional physiotherapy both improved outcomes over 12 weeks, with greater strength and function gains in the modified program and a larger pain reduction in the traditional group. Reported nonoperative failure thresholds range from 3 to 6 months and none is validated.","fit":"Where care starts: assessment of the pubic symphysis, adductors, hip and abdominal wall, then a graded program with criteria-based return to sprinting and kicking. The evidence is small and partly borrowed from adductor-related groin pain, and recovery usually takes months.","reviewedOn":"2026-10-17"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only a separate muscle target","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Neither source evaluates needling for pubic-related groin pain. It would only apply to a separately confirmed tender adductor or abdominal muscle target.","fit":"Not a treatment for pubic-related pain. Considered only for a separate, examined muscle problem, with the evidence gap stated.","reviewedOn":"2026-10-17"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Low-level evidence","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). A 2011 systematic review reported that about 59 per cent of injected athletes returned to sport and roughly a fifth did not respond; all included treatment studies were low level. A 2025 retrospective, non-randomised cohort found no significant difference in return to sport between corticosteroid, platelet-rich plasma and no-injection groups for chronic adductor longus lesions. The 2026 review proposes injection as an intermediate step only after a documented failed rehabilitation program.","fit":"Worth a careful discussion only after a proper rehabilitation course has not settled the problem, alongside continued rehabilitation. The evidence is low level and the uncertainty is explained before any treatment.","reviewedOn":"2026-10-17"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only a separate muscle target","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Neither source evaluates vibration devices for pubic-related groin pain. The rationale would be short-term modulation of a separate tender adductor or abdominal muscle.","fit":"Not a treatment for pubic-related pain. Considered only as a short-term adjunct to rehabilitation where a tight muscle limits it.","reviewedOn":"2026-10-17"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No radial trial identified","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). The randomised trial described in the 2026 review used focused shockwave. A 2024 systematic review found promising results when shockwave was combined with exercise but noted heterogeneous protocols and limited study quality. No radial-shockwave trial for pubic-related groin pain was identified in those sources.","fit":"Not a first-line option. Could be discussed alongside rehabilitation, with the thin evidence stated, and never implied to improve on exercise alone.","reviewedOn":"2026-10-17"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One trial with rehab, no sham","evidence":"Searched 21 October 2026: shockwave terms with groin, adductor, pubalgia, osteitis pubis or pubic (21 records) and a trial and review pass (4); the trial's abstract was also checked through Consensus. One randomised trial: 44 amateur footballers with pubic overload and osteitis pubis did the same intensive rehabilitation programme with shockwave (26) or without it (18). The shockwave group had pain relief sooner (p < 0.001) and returned to football sooner (p = 0.048); 42 of the 44 were back within four months with no recurrence at a year, against 240 days and recurrent pain in 51% of 51 players who only stopped sport. Follow-up MRI showed no effect of shockwave (Schöberl, Knee Surg Sports Traumatol Arthrosc 2017). The abstract calls the study double-blinded but describes no sham treatment and does not name the device; a later paper describes it as focused. A single-arm series of 31 footballers given focused shockwave within a 16-week rehabilitation programme, just over half with osteitis pubis, improved from a groin-function score of 47 to 90 and from pain of 6.8 to 1.9 out of 10 at four months, with no comparison group (Santilli, Life 2026). A 2024 systematic review rated shockwave a possible addition to exercise here (Rhim, Br J Sports Med 2024). The earlier line on this page described the trial as sham-controlled, which its abstract does not support.","fit":"Could be discussed as an addition to rehabilitation, never a replacement for it. In the one trial it brought pain relief and return to football forward; it did not change the MRI, and nearly everyone who completed the rehabilitation recovered either way.","reviewedOn":"2026-10-21"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No studies identified","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Neither source describes magnetotransduction therapy for pubic-related groin pain.","fit":"Not a first-line option. Any use would be described as emerging and unproven.","reviewedOn":"2026-10-17"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Minimal evidence","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Evidence for platelet-rich plasma is minimal: a 2022 case report described improvement, and a 2025 retrospective cohort found no significant difference in return to sport between steroid, PRP and no-injection groups, with non-random allocation.","fit":"Not a first-line option. If discussed, the absence of controlled evidence is explained.","reviewedOn":"2026-10-17"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Uncontrolled series only","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Dextrose prolotherapy has only uncontrolled elite-athlete case series support, per the 2026 review.","fit":"Not a first-line option. If discussed, it is described as unproven and used alongside rehabilitation.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong problem","evidence":"Hyaluronic acid injection is studied in synovial joint osteoarthritis. The pubic symphysis is a fibrocartilaginous joint and the sources reviewed describe no such use.","fit":"Not offered for pubic-related groin pain.","reviewedOn":"2026-10-17"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Different diagnosis","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Nerve-related groin pain is a separate diagnosis within the Doha framework and the sources describe no perineural treatment for pubic-related pain. Pulsed radiofrequency and botulinum toxin appear in the 2026 review only as isolated reports or extrapolation.","fit":"Not offered for pubic-related groin pain.","reviewedOn":"2026-10-17"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Different diagnosis","evidence":"The sources reviewed for this page were the 2015 Doha agreement (Weir, Br J Sports Med) and a 2026 narrative review of osteitis pubis and pubic-related groin pain (J Clin Med 2026). Hydrodissection addresses nerve entrapment, which is not what pubic-related groin pain describes.","fit":"Not offered for pubic-related groin pain.","reviewedOn":"2026-10-17"}}},{"slug":"quadriceps-tendon-tear","title":"Quadriceps Tendon Tear","region":"Knee","url":"https://www.backpaindoctor.com.au/conditions/quadriceps-tendon-tear","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials in this condition","evidence":"A search pairing quadriceps tendon rupture, quadriceps tendon tear, patellar tendon rupture and extensor mechanism injury with dry needling, trigger point work and needling returned no records at all. Needling has never been tested in a torn quadriceps tendon, and a complete tear is a surgical problem rather than one a needle addresses.","fit":"Not a treatment for the tear. Considered only during rehabilitation, and only where a separate tender muscle band is reproducing part of your pain.","reviewedOn":"2026-09-19"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Radial shockwave has not been studied in a quadriceps tendon tear or after its repair. PubMed searches on 25 October 2026 for shockwave terms with the quadriceps tendon and with tendon ruptures, tears and repairs (30 records, all read) and for radial device terms with knee tears and repairs (12 records) found no human study in this injury. A small retrospective series of runners with quadriceps or patellar TENDINOPATHY, an intact tendon, treated with radial or combined shockwave is the nearest evidence (Katz, Arthrosc Sports Med Rehabil 2024).","fit":"May ease the tender thigh muscle during rehabilitation after a repair. Not applied over the healing tendon.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a torn quadriceps tendon or after its repair. A PubMed search on 25 October 2026 for shockwave, shock wave, ESWT or pressure wave with the quadriceps tendon or with tendon rupture, tear or repair (30 records, all read), plus trial and systematic-review passes (12 and 8 records), found none; the one quadriceps-tendon record was a review of tendinopathy. Achilles ruptures have been reported after shockwave, including two in older people in one sham-controlled trial (Costa, Clin Orthop Relat Res 2005), which is a reason for caution over a weakened tendon.","fit":"Not used over a torn or recently repaired quadriceps tendon. Considered only for a coexisting tendinopathy once the repair has healed and the rehabilitation program is progressing.","reviewedOn":"2026-10-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"The same PubMed search returned seven records for platelet-rich plasma in quadriceps or patellar tendon rupture, with no comparative trial in either. Platelet-rich plasma appears only inside descriptions of surgical technique (a platelet-rich plasma-soaked biocomposite patch laid over a revision repair construct; Meixner, Video J Sports Med 2026), and in a ten-patient case series listing it among methods used alongside graft repair (Dhariwal, J Orthop Case Rep 2025). None of this tests platelet-rich plasma against anything.","fit":"Not offered. A complete quadriceps tendon rupture is repaired surgically and the results are best when that happens within about three weeks, so the job here is to recognise it and refer promptly rather than to inject it.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"No trial of prolotherapy in quadriceps tendon tear. A search for prolotherapy or dextrose injection combined with quadriceps tendon, tendon tear or tendon rupture returns twelve records, none of them a trial in a torn tendon; the studied indications are tendinopathy, osteoarthritis and enthesopathy (Hsu, Phys Med Rehabil Clin N Am 2023). Complete extensor mechanism disruption should be repaired surgically, with high rates of return to work and sport and re-rupture under 5% (Tandogan, EFORT Open Rev 2022), and the largest recent prolotherapy randomised trial excluded complete tendon rupture at entry (Lhee, Am J Sports Med 2025).","fit":"Not offered for a torn quadriceps tendon. Prompt diagnosis and surgical referral is the treatment. An injection at the attachment does not address a tendon that is no longer continuous.","reviewedOn":"2026-09-02"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with tendon rupture, quadriceps tendon or tendon repair, 23 records; the same terms with quadriceps, thigh, rectus femoris or vastus, 24 records; a randomised-trial and systematic-review pass returned none). No study has tested hydrodissection for a torn quadriceps tendon, and it cannot repair one. None of the 47 records concerns a quadriceps tendon injury or a nerve problem after one; the thigh records are about nerves trapped for other reasons, such as the saphenous nerve in the canal on the inner thigh (Eliot Hu, Clin J Sport Med 2022) and the nerve on the outer thigh in meralgia paraesthetica.","fit":"Not a treatment for a torn quadriceps tendon, which usually needs surgical repair followed by a staged rehabilitation program. Considered only if a separate trapped nerve is found on assessment.","reviewedOn":"2026-11-10"}}},{"slug":"radial-tunnel-syndrome","title":"Radial Tunnel Syndrome","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/radial-tunnel-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line, with the caveat below","evidence":"Activity modification, a removable splint and anti-inflammatory medication are the described first-line treatment. A 2017 systematic review found no published studies of conservative treatment at all, so the natural history and the right duration of non-operative care are both unknown.","fit":"Avoiding sustained elbow extension with forearm pronation is the practical starting point. The evidence behind it is weak, and patients are told so.","reviewedOn":"2026-09-13"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial of any needling technique in radial tunnel syndrome. What exists is one case report of a man with six months of failed treatment whose pain resolved completely after dry needling and stayed resolved at six months (Anandkumar, Physiother Theory Pract 2018), a cadaveric study in ten forearms showing the supinator muscle can be needled accurately without piercing the radial nerve, the needle tip sitting about 8 mm away from it (Fernandez-de-las-Penas, Int J Environ Res Public Health 2021), and a review listing dry needling among emerging non-surgical options (Levina, Curr Rev Musculoskelet Med 2021). All of that is dry needling, not injection.","fit":"The supinator muscle is the target, and it is the muscle the nerve passes through. Considered where that muscle is tender and reproducing the pain, with the thin evidence stated.","reviewedOn":"2026-09-14"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small series","evidence":"A series of 25 patients reported complete resolution of forearm pain in 72% at 6 weeks and 60% still pain-free at 2 years after corticosteroid injection into the radial tunnel, and a review of the condition lists ultrasound-guided corticosteroid injection around the nerve among the emerging non-surgical options (Levina, Curr Rev Musculoskelet Med 2021). That is a single uncontrolled series. Anaesthetic tracking toward the lateral epicondyle also confounds the diagnostic reading of a positive response.","fit":"Reasonable to discuss for persistent symptoms, with both the weak evidence and the diagnostic limitation stated.","reviewedOn":"2026-09-14"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search for vibration therapy in radial tunnel syndrome returned no records at all. Vibration has not been tested in this condition.","fit":"Not a treatment for the compressed nerve. Considered only where tight forearm muscle is a separate contributor, and kept away from the nerve itself.","reviewedOn":"2026-09-14"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of shockwave in radial tunnel syndrome. The nerve entrapment trials are in carpal tunnel syndrome.","fit":"Not offered as a treatment for this condition. Where lateral elbow tendinopathy is the actual problem, that is a different page and a different answer.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial in radial tunnel syndrome or posterior interosseous nerve compression.","fit":"Not offered as a treatment for this condition.","reviewedOn":"2026-09-13"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of EMTT in this condition.","fit":"Not part of managing this condition.","reviewedOn":"2026-09-13"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of PRP in radial tunnel syndrome.","fit":"Not offered for this condition.","reviewedOn":"2026-09-13"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of prolotherapy in radial tunnel syndrome. Dextrose appears at this nerve only as an injectate for hydrodissection, which is a different procedure at a different target (Colorado, Muscle Nerve 2025).","fit":"Not relevant to this diagnosis. There is no painful attachment to treat.","reviewedOn":"2026-09-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for hyaluronic acid, hyaluronate or viscosupplementation at the radial tunnel or the posterior interosseous nerve returned no study of this treatment in this condition. Hyaluronic acid is named at peripheral nerves only as one of several fluids used to hydrodissect them (Colorado, Muscle Nerve 2025), which is a different procedure, and there is no joint here to inject.","fit":"Not offered for this problem.","reviewedOn":"2026-09-14"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"The posterior interosseous nerve supplies no skin, so the cutaneous hypersensitivity that perineural injection targets is not a feature of this condition.","fit":"Not relevant to this diagnosis.","reviewedOn":"2026-09-13"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of hydrodissection of the posterior interosseous nerve in the radial tunnel. The randomised hydrodissection evidence is in carpal tunnel syndrome.","fit":"Not offered for this condition. Persistent symptoms go to an upper limb surgical opinion rather than to a further injectate.","reviewedOn":"2026-09-13"}}},{"slug":"relative-energy-deficiency-in-sport","title":"Relative Energy Deficiency in Sport (REDs)","region":"General","url":"https://www.backpaindoctor.com.au/conditions/relative-energy-deficiency-in-sport","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"The 2023 International Olympic Committee consensus on relative energy deficiency in sport sets out updated health and performance models, a clinical assessment tool that grades severity with linked training and competition recommendations, and prevention and treatment principles centred on restoring energy availability (Mountjoy, Br J Sports Med 2023). A companion paper describes how the size, duration and cause of low energy availability, and individual factors, shape who is harmed and how (Burke, Br J Sports Med 2023).","fit":"This is the plan: restoring energy availability with a sports dietitian, adjusting training with your coach, medical review of bone and hormonal health, and psychological support where eating or body image are involved.","reviewedOn":"2026-10-30"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Relative energy deficiency in sport is a problem of energy availability. The 2023 International Olympic Committee consensus presents prevention and treatment principles built around restoring it, with a clinical assessment tool that grades severity and guides training and competition decisions (Mountjoy, Br J Sports Med 2023). Device and injection treatments are not part of that framework.","fit":"Not offered for REDs. A bone stress injury or other problem that comes with it is managed on its own guide and its own evidence.","reviewedOn":"2026-10-30"}}},{"slug":"rheumatoid-arthritis","title":"Rheumatoid Arthritis","region":"General","url":"https://www.backpaindoctor.com.au/conditions/rheumatoid-arthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise and education sit alongside disease-modifying medication, not instead of it. The American College of Rheumatology's guideline for rheumatoid arthritis gives consistent exercise its one strong recommendation, alongside conditional recommendations for rehabilitation such as hand therapy, splinting and foot orthoses (England, Arthritis Care Res 2023), and the EULAR recommendations, updated in 2025, make physical activity part of standard care throughout the course of inflammatory arthritis (Rausch Osthoff, Ann Rheum Dis 2026). Across 13 randomised trials (967 people) aerobic exercise improved function and reduced pain by a moderate amount (pain standardised mean difference -0.46; Ye, BMC Sports Sci Med Rehabil 2022), and a 2026 analysis of 44 trials (3,132 people) found resistance training reduced pain by about 14 points out of 100 at the best-performing dose, with confidence in the evidence rated very low to moderate (Huo, Semin Arthritis Rheum 2026). The largest single trial randomised 490 people with painful rheumatoid hands to a tailored hand exercise program or usual care: hand function was better at 12 months (4.3 points on the Michigan Hand Outcomes Questionnaire, 95% CI 1.5 to 7.1), but pain did not differ, and there were no serious adverse events (Lamb, Lancet 2015). What exercise does not reliably do is lower disease activity: the pooled effect on inflammation measures is small or absent (Brady, BMC Rheumatol 2023; Courel-Ibáñez, Ann Phys Rehabil Med 2026), which is why it is paired with medical treatment rather than offered as a substitute.","fit":"The critical point is sequencing: this does not replace rheumatological treatment, and a delay in getting disease control is the thing that causes lasting damage. Assessment here is aimed at recognising the pattern early and getting you to the right treatment, with exercise supporting it throughout.","reviewedOn":"2026-11-05"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Injecting an inflamed rheumatoid joint has trial evidence behind it. In a double-blind trial of 60 people with rheumatoid arthritis and an inflamed knee, triamcinolone injected into the joint relieved pain, swelling and morning stiffness better than the same dose given into muscle (Konai, Clin Exp Rheumatol 2009). In 160 people with early rheumatoid arthritis treated to target with methotrexate, 1,373 joints were injected with betamethasone: about six in ten people had a good overall response by six weeks, and 62.3% of the joints injected at the start had not flared again at one year and 55.5% at two years, with second and third injections into the same joint lasting less well than the first (Hetland, Ann Rheum Dis 2012). Ultrasound earns its place mainly in choosing the joint. In a randomised trial of ultrasound-informed care, injecting a swollen joint that showed no Doppler signal of active inflammation was no better than leaving it alone, while joints with moderate Doppler activity responded best (Nordberg, Arthritis Rheumatol 2018). Whether it also helps place the needle is disputed: that same analysis found guided injection no more successful than injection by feel, while a randomised trial of 244 inflamed joints, three-quarters of them rheumatoid, found guidance gave 81% less injection pain, 38% more responders and a 32% longer-lasting effect (Sibbitt, J Rheumatol 2011).","fit":"For one or two joints that stay inflamed despite your regular treatment, or during a flare. Coordinated with your rheumatologist and your systemic treatment, not instead of it. A joint that keeps needing injections is a signal to review that treatment.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One case series of 15","evidence":"Searched 27 October 2026 (the rheumatoid searches named in the focused row, plus radial device terms with arthralgia, inflammatory joint disease and spondyloarthritis: 1 record). In a series of 15 people with persisting joint pain after more than three months of disease-modifying drugs, three months of radial shockwave lowered pain on movement from 5.7 to 2.2 out of 10 and shortened morning stiffness, and 11 stopped their pain-relief medicine; there was no comparison group, and blood markers of inflammation did not change (Liu, Pain Pract 2018). No randomised trial of a radial device in rheumatoid arthritis was found; the one trial used a focused device (Zhang, Pain Res Manag 2024).","fit":"Never a substitute for your rheumatologist's treatment. Discussed for joint or soft-tissue pain that persists once the disease is controlled, alongside the exercise program.","reviewedOn":"2026-10-27"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial, two weeks","evidence":"Searched 27 October 2026: shockwave, shock wave, ESWT or pressure wave with rheumatoid or inflammatory arthritis (8 records, all read), with a trial and review pass (3). The old line here said shockwave has no role; that does not survive the search. In one randomised trial of 40 people with rheumatoid arthritis and painful wrists or knees, all already treated with disease-modifying drugs, focused (piezoelectric) shockwave around the painful joint lowered pain from 4.9 to 1.2 out of 10 over 14 days, against 4.8 to 2.6 in a group given diclofenac and methotrexate; no adverse events were reported (Zhang, Pain Res Manag 2024). That trial was small, allocated by alternating numbers, used an unusual comparison and stopped at two weeks. A meta-analysis of pain treatments in rheumatoid arthritis found shockwave reduced pain by about 3.4 points out of 10, but pooled change from baseline in small studies with high heterogeneity and publication bias (Lautenschlager, Adv Rheumatol 2025). Nothing shows that shockwave changes the disease.","fit":"Never a substitute for your rheumatologist's treatment. Discussed for a joint or tendon that stays painful once the disease is controlled, as a way to make the exercise and hand or knee strengthening program easier to do.","reviewedOn":"2026-10-27"},"emtt":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.","fit":"Not part of the plan here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered; one open-label trial","evidence":"Trialled once in rheumatoid arthritis, with a result that favours PRP over a single cortisone injection at six months, and not offered here. Sixty people whose rheumatoid arthritis was otherwise settled on disease-modifying medication, but who had one or two joints that stayed painful and inflamed, were given three monthly PRP injections into the joint or a single cortisone injection. Both groups had improved at three months, and the improvement was still present at six months only in the PRP group (Saif, Curr Rheumatol Rev 2021). The trial was open-label, so everyone knew which injection they had, and it came from one centre. Its published summary gives no figures for the size of the difference and the full paper could not be obtained; a later review reports that the joints were wrists, elbows and ankles and that no adverse effects were recorded over the six months (Moeda, Cureus 2022). Beyond the trial there are only handfuls of cases: four people whose joints had not settled with cortisone injections, reported as improved at four and eight weeks (Badsha, Case Rep Rheumatol 2020), and three with rheumatoid finger joints who reported 20% to 50% less pain over six months (Shively, Cureus 2021). There is also a report of the opposite: a man with rheumatoid arthritis whose knees became more swollen and painful two weeks after PRP into both, and who needed his medication increased (described in Moeda, Cureus 2022). A systematic review found a single study in people among the eight it included and called the evidence limited (Chellamuthu, Rheumatol Int 2021), and the review behind the European rheumatology recommendations on joint injections concluded that no firm conclusion can be drawn in inflammatory arthritis because the data are so limited (Rodriguez-García, RMD Open 2021). None of it alters the disease itself.","fit":"Not offered here for a rheumatoid joint. Rheumatoid arthritis is controlled with disease-modifying medication under a rheumatologist, and a cortisone injection is the established choice for a joint that stays inflamed. The single PRP trial is open-label and has not been repeated. A separate tendon or joint problem in someone who has rheumatoid arthritis is assessed on that problem's own evidence.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in a rheumatoid joint","evidence":"No study has tested prolotherapy as a treatment for rheumatoid arthritis or a rheumatoid joint. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose, hyperosmolar dextrose or regenerative injection therapy with rheumatoid arthritis, synovitis or inflammatory arthritis, then randomised-trial and systematic-review passes) returned no trial or series. The nearest records are one case report of dextrose and PRP injections for neck ligament instability in a woman who also had rheumatoid arthritis, which treated the ligaments and not the disease (Jones, Cureus 2026), and a review of jaw-joint treatments in rheumatic disease that includes dextrose injected under the skin beside the nerves, a different procedure (Aiello, BMC Musculoskelet Disord 2025).","fit":"Not a treatment for the inflammatory disease, which is controlled by your rheumatologist. Prolotherapy is considered only for a separate ligament or tendon problem in someone whose disease is well controlled, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"The overview of systematic reviews behind the 2020 EULAR recommendations on intra-articular therapy covered 29 reviews and found hyaluronic acid gives a small benefit in knee osteoarthritis but not in hip osteoarthritis or frozen shoulder, and concluded that no firm conclusion can be drawn for inflammatory arthritis because the data are so limited (Rodriguez-García, RMD Open 2021). What direct rheumatoid evidence exists sits at particular joints: in an open comparison of 70 people with a painful wrist or elbow, betamethasone alone was the most cost-effective injection while betamethasone combined with hyaluronic acid gave the best range of movement at one month (Li, J Clin Rheumatol 2018). None of this alters the disease itself.","fit":"Considered only where a single joint stays painful from established joint-surface damage while the rheumatoid disease is otherwise well controlled. It is not a substitute for disease-modifying treatment, and delaying that treatment is what causes lasting damage.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"rheumatoid-arthritis-foot-ankle","title":"Rheumatoid Arthritis of the Foot & Ankle","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/rheumatoid-arthritis-foot-ankle","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Foot care in rheumatoid arthritis rests on education, exercise and foot orthoses alongside disease-modifying medication. A 2024 multidisciplinary guideline supports self-care education, orthoses for pain, function and quality of life, and therapeutic footwear where needed (Ramos-Petersen, Rheumatol Int 2024), as does a Dutch consensus of 41 recommendations covering shoes, orthoses and exercise therapy (Tenten-Diepenmaat, J Foot Ankle Res 2018). For exercise, a 2026 meta-analysis of 13 studies (548 people) found supervised programs reduced foot pain (standardised mean difference -0.68) and improved walking distance by about 48 metres, though some of the studies were not randomised (Cruz-López, Clin Rheumatol 2026). For orthoses, a randomised trial of 98 people with painful rearfoot deformity found custom rigid orthoses reduced foot pain by 19% and disability by 31% over 30 months against usual care, with minor blisters or tender spots in 30% early on (Woodburn, J Rheumatol 2002), and two double-blind trials against flat insoles found less pain but no difference in disability (Moreira, Scand J Rheumatol 2016; Reina-Bueno, Clin Rehabil 2019). Not every analysis agrees: one meta-analysis of five trials found no significant difference from control (Gijon-Nogueron, Qual Life Res 2018), and custom orthoses have not clearly beaten simpler insoles (Novak, Disabil Rehabil 2009; Rome, Scand J Rheumatol 2016).","fit":"This does not replace rheumatological treatment, and getting the disease under control is what protects the joints of the foot. Assessment here is aimed at recognising the pattern early, making sure that treatment is in place, and then building foot and lower-limb strength, with orthoses or footwear advice where the foot shape calls for it.","reviewedOn":"2026-11-05"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"No foot-specific trial","evidence":"The randomised evidence for corticosteroid injection in rheumatoid arthritis comes mainly from the knee; at the foot and ankle it is observational. Ankles and the joints at the base of the toes were among 1,373 joints injected with betamethasone in a treat-to-target trial of 160 people with early disease, and every joint region showed good two-year survival without a further flare (Hetland, Ann Rheum Dis 2012). In a comparison that was not randomised, 44 people had triamcinolone injected into 70 inflamed ankles, wrists and elbows: the joints were better at two months and back to where they started at five (Mortada, Clin Rheumatol 2018). A review of the field found few studies of corticosteroid injection in the foot and ankle at all (Pekarek, Foot 2011). Ultrasound matters in the forefoot for a different reason: it finds inflamed joints that examination misses. In a randomised trial of ultrasound-informed care in early rheumatoid arthritis, the ultrasound group had nearly twice as many toe-base joints injected (200 against 104), and injections worked best where Doppler showed active inflammation; guiding the needle with ultrasound was no more successful than injecting by feel (Nordberg, Arthritis Rheumatol 2018).","fit":"Considered for an ankle, hindfoot or toe-base joint that stays inflamed despite your regular treatment. Coordinated with your rheumatologist and your systemic treatment, not instead of it. A joint that keeps flaring is a reason to review that treatment rather than to keep injecting.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Tested in RA, not in the feet","evidence":"Searched 27 October 2026 (the rheumatoid searches named on the main rheumatoid arthritis page, plus radial device terms with arthralgia and inflammatory joint disease: 1 record). No study has tested radial shockwave in the rheumatoid foot or ankle. The nearest evidence is an uncontrolled series of 15 people with rheumatoid joint pain on disease-modifying drugs, whose pain on movement fell from 5.7 to 2.2 out of 10 after three months of radial shockwave; the joints treated are not named in the abstract and there was no comparison group (Liu, Pain Pract 2018).","fit":"Never a substitute for your rheumatologist's treatment. Discussed only for tender muscle, fascia or a separate mechanical problem in the foot once the disease is controlled, alongside footwear, orthoses and the exercise program.","reviewedOn":"2026-10-27"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Tested in RA, not in the feet","evidence":"Searched 27 October 2026 (the rheumatoid searches named on the main rheumatoid arthritis page: 8 records, all read). No study has tested shockwave in the rheumatoid foot or ankle. The nearest evidence is one small randomised trial in rheumatoid wrists and knees, where focused shockwave lowered pain more than diclofenac and methotrexate over 14 days (40 people, 4.9 to 1.2 against 4.8 to 2.6 out of 10; Zhang, Pain Res Manag 2024), a trial that was short, allocated by alternating numbers and used an unusual comparison. Nothing shows that shockwave changes the disease.","fit":"Never a substitute for your rheumatologist's treatment. Discussed only for a separate, persisting mechanical problem in the foot, such as plantar heel or Achilles pain, once the disease is controlled, alongside footwear, orthoses and the exercise program.","reviewedOn":"2026-10-27"},"emtt":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No evidence in this condition, and the rationale offered for EMTT (an effect on tendon and soft-tissue cell behaviour) does not apply to a systemic, bone or complete structural problem.","fit":"Not part of the plan here.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for a rheumatoid joint","evidence":"No study reports the result of a PRP injection on its own at a rheumatoid foot or ankle. The one randomised trial in rheumatoid arthritis compared three monthly PRP injections with a single cortisone injection in 60 people with one or two persistently painful joints, and found the improvement lasted to six months only with PRP (Saif, Curr Rheumatol Rev 2021). A later review says ankles were among the joints treated, but the trial's published summary does not report them separately and gives no figures (Moeda, Cureus 2022). The only study specific to the ankle is of PRP added after an operation. In 138 people followed for five years after keyhole removal of the inflamed lining of the ankle, those who also had three or more PRP injections into the ankle showed less decline in ankle scores and less X-ray change than those who had fewer or none. PRP was not allocated at random, so the groups are not a fair comparison, and the authors say a randomised trial is needed (Zhang, J Orthop Traumatol 2025). A PubMed search in October 2026 pairing platelet-rich plasma with rheumatoid arthritis and the foot, forefoot or ankle returned three records, and the other two are general reviews of foot and ankle injections.","fit":"Not offered here for a rheumatoid joint in the foot or ankle. Rheumatoid disease in the foot depends on disease-modifying medication, footwear and orthoses, with a cortisone injection for a joint that flares, coordinated with your rheumatologist. A separate, clearly identified tendon or soft-tissue problem in the same foot is assessed on that problem's own evidence.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in a rheumatoid joint","evidence":"No study has tested prolotherapy in rheumatoid arthritis of the foot or ankle, or in rheumatoid arthritis anywhere. PubMed searches on 17 October 2026 (prolotherapy, dextrose injection, hypertonic dextrose, hyperosmolar dextrose or regenerative injection therapy with rheumatoid arthritis, rheumatoid foot, synovitis or inflammatory arthritis, then randomised-trial and systematic-review passes) returned no trial or series. A review of foot injection techniques discusses cortisone and hyaluronic acid for rheumatoid feet and does not report prolotherapy there (Urits, Pain Ther 2020).","fit":"Not a treatment for the inflammatory disease, which is controlled by your rheumatologist, with footwear, orthoses and podiatry for the foot. Prolotherapy is considered only for a separate ligament or tendon problem in someone whose disease is well controlled, assessed on its own evidence.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small pilot trial","evidence":"This is the one rheumatoid site with a randomised trial of hyaluronic acid. Forty-four people with 75 painful rheumatoid ankle and foot joints were randomised to ultrasound-guided low-molecular-weight hyaluronic acid or lignocaine at fortnightly intervals. At four weeks the hyaluronic acid group had better pain scores (p = 0.009) and better foot function index scores on two subscales, and Doppler signal fell in 54% of injected joints against 20% of controls, though hyaluronic acid was no better than lignocaine at reducing that signal, and synovial thickening did not change in either group (Wang, Mod Rheumatol 2017). The gains were short-term and the trial was an explicitly labelled pilot. The wider overview behind the EULAR intra-articular recommendations still finds the inflammatory-arthritis data too limited to draw a firm conclusion (Rodriguez-García, RMD Open 2021).","fit":"Worth discussing for a single ankle or forefoot joint that stays painful despite good rheumatoid disease control. Expect a few weeks to a few months of benefit rather than a lasting change, and keep it alongside rheumatological treatment rather than instead of it.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"rotator-cuff-shoulder-pain","title":"Rotator Cuff & Shoulder Pain","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/rotator-cuff-shoulder-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small trials only","evidence":"Trigger point injection has been tested in this condition, in small trials. Twenty-one people with rotator cuff disease and upper arm pain were randomised to ultrasound-guided trigger point injection of the brachialis or to an oral anti-inflammatory: pain fell from 7.3 to 4.5 out of 10 with the injection against 7.4 to 5.9 with the tablets, a difference of 2.8 points against 1.5 that favoured the injection (Suh, Ann Rehabil Med 2014). In a larger randomised trial, 50 people with subacromial pain syndrome were given a rotator cuff exercise programme with or without two sessions of trigger point needling; the needling group had better arm and shoulder disability scores at every follow-up out to twelve months, but the two groups improved equally on pain (Arias-Buría, J Pain 2016). The Dutch Orthopaedic Association guideline for subacromial pain syndrome lists treatment of myofascial trigger points as something that may be considered within exercise therapy (Diercks, Acta Orthop 2014).","fit":"Directed at a tender muscle band in the shoulder girdle or upper arm that reproduces part of your pain, alongside the loading programme. It does not treat the tendon itself.","reviewedOn":"2026-09-11"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Ultrasound guidance improves needle placement but not, at this target, the result. A meta-analysis of 15 trials found no advantage over blind injection at the subacromial bursa for pain or function (Fan, Arthroscopy 2021), and a randomised trial found no difference at 6 weeks (Cole, Am J Sports Med 2016). One trial did find better passive abduction with guidance (Hsieh, Med Sci Sports Exerc 2013).","fit":"Used where the anatomy or a previous failed injection makes placement the question. See the note on cortisone for why the number is kept low.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Tested: no benefit","evidence":"Searched 18 October 2026: radial shockwave with rotator cuff, supraspinatus, subacromial, impingement or shoulder pain (48 shockwave records screened, 20 randomised trials), plus a pass for non-calcific disease (24 records). This is evidence of absence, not absence of evidence. In a double-blind multicentre trial of 82 people with chronic rotator cuff tendinitis, low-dose radial shockwave was no better than placebo for pain or function at three and six months (Kolk, Bone Joint J 2013). In a sham-controlled trial of 143 people with subacromial pain, all doing supervised exercise, radial shockwave added nothing at 24 weeks (difference 0.7 points on the SPADI, 95% CI -6.9 to 8.3) or at one year, and the authors advise against it (Kvalvaag, Am J Sports Med 2017; Eur J Phys Rehabil Med 2018). In 104 people, supervised exercise did better than radial shockwave to 18 weeks (8.4 SPADI points) and fewer needed further treatment (Engebretsen, BMJ 2009). In 46 people with non-calcific cuff tendinopathy, radial did worse than focused shockwave at 24 and 48 weeks (Li, Biomed Res Int 2021). A pooled analysis of nine sham-controlled trials of any shockwave device in non-calcific disease found only a small, short-term effect on pain (Kamonseki, Am J Phys Med Rehabil 2024). The one positive radial trial compared it with passive heat and electrical treatments, not sham, in 60 people with partial tears (Wang, J Clin Med 2026). The only benefit in the sham-controlled trial was in people with a calcific deposit, and it did not last.","fit":"Not offered for rotator cuff pain without calcification, because the controlled trials found it adds nothing to exercise. The loading program is the treatment that changes the course. Where a calcific deposit is present the evidence is different; see the calcific tendinopathy guide.","reviewedOn":"2026-10-18"},"focusedShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"For rotator cuff pain WITHOUT calcification the Cochrane review of 32 trials found improvements that favour shockwave but fall below the clinically important threshold. Pain 0.78 points where 1.5 matters, function 7.9 points where 10 matters, both moderate-quality evidence (Surace, Cochrane 2020). High-energy shockwave was no better than placebo in non-calcific disease specifically (Bannuru, Ann Intern Med 2014).","fit":"Where a calcific deposit is present the picture is quite different and much stronger: see the calcific tendinopathy guide. For non-calcific cuff pain, loading remains the treatment that changes the course.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Modest edge over cortisone, not saline","evidence":"Searched 20 October 2026: platelet-rich plasma with rotator cuff tendinopathy or tendinitis, supraspinatus tendinopathy, subacromial impingement or pain, or rotator cuff disease, restricted to randomised trials and systematic reviews (41 records, all read; one retracted trial excluded). Against a dummy injection the results are weak. In the one adequately sized saline-controlled trial, 40 people all doing a six-week exercise program, an ultrasound-guided PRP injection under the acromion was no better than saline on pain or function at any point to one year (Kesikburun, Am J Sports Med 2013). A review of five trials found no difference from saline when both groups exercised, and worse results with PRP alone than with a formal exercise program (Hurley, Arthroscopy 2019). Pooling five trials against sham, no injection or physiotherapy, the two were indistinguishable to six months, with a small pain advantage for PRP later (standardised difference 0.42) (Lin, Diagnostics 2020), and a review of ultrasound-guided PRP found no clear difference in the cuff at low or very low certainty (Masiello, Blood Transfus 2022). Against cortisone, PRP is slower and modestly better later. Pooling ten trials and 591 people, there was no difference to three months, and at six months PRP gave 0.8 points less pain on the 0 to 10 scale and about 11 points better on shoulder function scores, with fewer side effects (Yuwarungsikul, Knee Surg Sports Traumatol Arthrosc 2026); two other pooled analyses found that none of the differences reached the size patients notice (Pang, Arthroscopy 2022; Peng, J Shoulder Elbow Surg 2023). The best single trial, double-blind in 100 people aged 18 to 50, found less pain and fewer treatment failures at one year with one PRP injection than with cortisone (12% against 30%) (Rossi, J Shoulder Elbow Surg 2024). Added to an operation, PRP did no better than the operation alone (Carr, Am J Sports Med 2015; O'Dowd, Orthop J Sports Med 2022). Short-lived pain after the injection is more common with PRP (Masiello 2022).","fit":"An option that can be discussed for cuff-related shoulder pain that has not settled with a proper course of cuff strengthening, usually where a cortisone injection is being considered: on these trials PRP is slower than cortisone and modestly better at six months, but it has not been shown to beat a saline injection. If used, it is placed under ultrasound guidance and the rehabilitation program continues. It is not added to a surgical repair.","reviewedOn":"2026-10-20"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Trials disagree; newest review null","evidence":"Trials exist and disagree. The newest pooled analysis, of 14 studies (13 randomised) in rotator cuff tendinopathy and subacromial bursitis, found dextrose may have little to no benefit over saline (pain-related function SMD -0.3, 95% CI -1.0 to 0.4; three trials, 149 people; very low certainty) and probably worse physical performance than a cortisone injection; ten of the fourteen studies were at high risk of bias (Zerzan, PM R 2026). Against saline, the results split: three monthly dextrose injections onto the painful tendon attachments, given with physiotherapy, left 59% with a meaningful pain improvement at nine months against 27% given saline above the tendon (p=0.017), though the gap from saline injected onto the attachments (37%) did not reach significance (Bertrand, Arch Phys Med Rehabil 2016, 73 people); one 20% dextrose injection at the supraspinatus beat saline on pain and disability at two weeks but not at six (Lin, Eur J Phys Rehabil Med 2019, 31 people); and three bursal injections of 15% dextrose did no better than saline at three months (Chang, Arch Phys Med Rehabil 2021, 50 people). Against exercise alone, 120 people with chronic cuff problems given ultrasound-guided prolotherapy did better on pain and function to at least one year, without blinding (93% against 57% rating the outcome good or excellent; Seven, Orthop Traumatol Surg Res 2017). Against cortisone, a double-blind trial of 54 people with chronic subacromial bursitis found cortisone better on pain at two and six weeks and on disability to twelve weeks (Lin, Am J Phys Med Rehabil 2023).","fit":"Can be discussed for persistent cuff-related pain that has not settled with a well-run loading program, particularly where cortisone has already been used or is unsuitable, on the understanding that the trials conflict and the newest review found little benefit over saline. It sits alongside the loading program and does not replace it.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here. A meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems, 1,629 patients in all, reported less pain than the comparison treatments overall, but its rotator cuff group was ten trials whose results scattered badly, with heterogeneity of 94% (Khan, Sports Health 2022). These are injections around a tendon, which is a different procedure from the joint injection in this row.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"One randomised sham-controlled trial has tested it here. Thirty-nine people with rotator cuff tendinopathy received 5% dextrose around either the upper or the lower part of the axillary nerve, or a sham injection, all alongside home exercise. The lower injection site reduced pain more than sham at two and four weeks (about 2.5 points on a 10-point scale, falling to 1.5 by four weeks); the upper site did no better than sham, and neither site improved shoulder function scores or range of motion (Vitoonpong, Asian Biomedicine 2026).","fit":"A short-term pain option, not a tendon treatment. The trial that found a benefit still had everyone doing exercises, and function did not shift. Considered where pain is blocking progress with loading work, and only where the examination points to nerve-related pain around the shoulder.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hydrodissection in rotator cuff tendinopathy itself. The nearest tissue-plane work is elsewhere around the shoulder: in a double-blind trial of 35 people with chronic myofascial shoulder pain, 10 mL of 10% dextrose injected between fascial layers under ultrasound reduced pain more than a sham injection at 12 weeks, with no difference in range of motion or function (Hsu, Am J Phys Med Rehabil 2024); and a small pilot in thickened, adherent subacromial bursitis found ultrasound-guided hydrodilation of the bursa relieved pain as well as a blind cortisone injection, with nobody in the hydrodilation group needing a repeat (Al Khayyat, J Ultrasound 2024). The axillary nerve dextrose trial in this condition used perineural injection and is covered in that row.","fit":"Only where examination points to a nerve or fascial pain source around the shoulder alongside the tendon; the suprascapular and axillary nerves are the usual candidates. Loading-based rehabilitation remains the treatment for the tendon.","reviewedOn":"2026-09-29"}}},{"slug":"rotator-cuff-partial-tear","title":"Rotator Cuff Partial Tear","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/rotator-cuff-partial-tear","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Needling has been tested in partial-thickness rotator cuff tears, but as the comparison arm rather than the treatment. In a systematic review of eight randomised trials of platelet-rich plasma in partial-thickness tears, the one trial that used dry needling as its comparator found PRP ahead of it, with shoulder pain and disability scores improving 66 per cent at three months and 72 per cent at six months (Dakkak, JSES Int 2024). After rotator cuff repair surgery, adding four sessions of trigger point dry needling to rehabilitation was no better than sham needling in 46 people (difference 0.32 points of pain, 95% CI -0.41 to 1.05) (Naseri, Chiropr Man Therap 2024). No trial has tested trigger point injection as a treatment for the tear itself.","fit":"Not a treatment for the tear. Considered only where examination finds a separate tender muscle contributing to the pain, as an adjunct to the loading programme.","reviewedOn":"2026-09-11"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat physiotherapy in one trial","evidence":"In 60 adults with an MRI-confirmed degenerative partial supraspinatus tear, all doing home exercises, six weekly radial sessions beat a program of physiotherapy machines (interferential, shortwave and magnetic therapy): the shoulder score rose 31 points against 26, and pain fell from 5.2 to 1.0 out of 10 against 1.7, at twelve weeks, with no serious adverse events (Wang, J Clin Med 2026). It was single-centre, had no sham group and followed people for twelve weeks only. After surgical repair of a FULL-thickness tear, a different situation, radial shockwave added to rehabilitation gave less pain than sham at one to six months in 72 people (Wang, Am J Phys Med Rehabil 2026) and less pain and better shoulder scores at six months in 38 (Shao, Ann Phys Rehabil Med 2023), but at three years pain and function were no different and two of the shockwave group had a failed repair against one (Wu, Asia Pac J Sports Med Arthrosc Rehabil Technol 2024). A 71-person trial of shockwave six weeks after repair found no effect on healing or scores (Kim, Knee Surg Sports Traumatol Arthrosc 2012). Searched on PubMed 25 October 2026.","fit":"Worth discussing where a partial-thickness tear is being managed without surgery and the strengthening program alone has not been enough. It is added to that program, not used instead of it.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Sham trial: movement, not pain","evidence":"In the only sham-controlled trial in partial-thickness rotator cuff tears, 55 people with an MRI-confirmed partial tear all had a PRP injection and then one session of shockwave (Orthospec electrohydraulic device, 0.32 mJ/mm2) or sham: the shockwave group gained more forward flexion and abduction at one month and more range of movement at six months, but pain, abduction strength and the Constant shoulder score were no better than with PRP alone (Kuo, J Pers Med 2024). The paper does not itself call the device focused. After arthroscopic repair, a 71-person randomised trial found shockwave at six weeks did not improve the Constant or UCLA scores, and retears on CT were 2 against 4, the authors concluding it did not help the cuff heal (Kim, Knee Surg Sports Traumatol Arthrosc 2012; device type not stated). A retrospective study of 86 repaired tears found earlier shockwave far more common before posterior than anterior tears (75% against 24%), which the authors raised as a possible risk factor (Han, Clin Orthop Surg 2022; device type not recorded). No trial tests shockwave on its own for a partial tear. Search: PubMed, shockwave terms with partial tear, partial-thickness, rotator cuff tear or rotator cuff repair, animal work excluded (33 records).","fit":"Discussed only as an add-on where shoulder stiffness is holding back the rehabilitation program after a partial tear. The one sham-controlled trial found gains in movement, not in pain, and the treatment does not replace the loading program.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small positive trials; reviews split","evidence":"One of the most-studied injections for a partial-thickness rotator cuff tear, and the results do not all agree. Three randomised trials against a dummy injection or physiotherapy alone favoured PRP. In a double-blind four-arm trial, four weekly injections into the space above the cuff gave better shoulder scores than saline at three, six and twelve months and smaller tears on MRI at a year (Cai, Med Sci Sports Exerc 2019; Dakkak, JSES Int 2024). In a double-blind trial of needling with PRP or with saline, the two were level at six weeks and PRP was ahead at six months (de Castro, Biomedicines 2023). In 63 people, two ultrasound-guided injections added to physiotherapy gave a larger fall in tear volume and a better Constant score than physiotherapy alone (Demiral, Knee Surg Sports Traumatol Arthrosc 2026). A European consensus of shoulder surgeons lists PRP injection, at grade B, among the measures to try before surgery (Kany, Knee Surg Sports Traumatol Arthrosc 2026). The pooled analyses split. One of 12 trials and 762 people found less pain at every point to a year, but with results so inconsistent between trials that its authors conclude compelling evidence remains elusive (Desouza, J ISAKOS 2024). A network meta-analysis of 16 randomised trials found that no injection, PRP included, improved pain or function significantly more than saline at any follow-up (Liu, Arthroscopy 2026). Against cortisone the trials conflict: PRP was ahead at three months and no different at twelve in 99 people with cuff tendon pain or a partial tear (Kwong, Arthroscopy 2021), and cortisone was ahead at both three and six months in 107 (Guity, JSES Int 2025). People with a partial tear also did less well after PRP than people with tendon pain and no tear, 49% against 94% reaching a substantial benefit at a year, and one in five went on to surgery (Rossi, Arthroscopy 2023). Across 19 trials of cuff injections, frozen shoulder was reported more often after PRP than after the comparison injections, with no serious events (Driscoll, Arthroscopy 2026).","fit":"An option that can be discussed for a painful partial tear that has not settled with a proper course of cuff rehabilitation. The position is that small trials favour it and the largest pooled analysis does not separate it from a saline injection. If used, it is placed under ultrasound guidance and rehabilitation continues. The response is reviewed at about three months, and a tear that keeps giving trouble is referred for a surgical opinion rather than injected repeatedly.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Trials disagree; tear trial unfavourable","evidence":"Trials disagree, and the one randomised trial confined to partial tears was unfavourable. Thirty-four people with MRI-confirmed partial-thickness supraspinatus tears were randomised to three weekly ultrasound-guided injections of hypertonic dextrose or of atelocollagen; 28 finished. Dextrose relieved pain only at two weeks, and on repeat MRI at three months 10 of 13 dextrose patients showed worse tear signs and none improved, against 2 worse and 4 improved with atelocollagen (Choi, Pain Physician 2025). A retrospective comparison of 64 people with partial supraspinatus tears found cortisone ahead at three weeks and prolotherapy ahead on pain and disability at three months (Eroglu, J Sport Rehabil 2022). The wider rotator cuff trials, some of which enrolled partial tears, are themselves divided: dextrose onto the painful tendon attachments with physiotherapy beat saline injected above the tendon at nine months (59% against 27% keeping a meaningful pain improvement; Bertrand, Arch Phys Med Rehabil 2016, 73 people with tendinosis or tear), bursal 15% dextrose did no better than saline (Chang, Arch Phys Med Rehabil 2021, 50 people), and the newest pooled analysis of 14 studies found little to no benefit over saline at very low certainty, without analysing partial tears separately (Zerzan, PM R 2026).","fit":"May be discussed for a partial-thickness tear that has not settled with a well-run loading program, on the understanding that the trials conflict and that the one trial in partial tears found worse MRI appearances after dextrose. It sits alongside the loading program, not in place of it.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Trialled around the rotator cuff with inconsistent results, and not offered here. A meta-analysis of 19 randomised trials found hyaluronic acid helped pain across several soft-tissue problems, but the rotator cuff group was its least consistent: ten trials with heterogeneity of 94%, meaning the results scatter badly (Khan, Sports Health 2022). A prospective series of 80 shoulders given five weekly injections into the subacromial space found those with a partial or full-thickness cuff tear improved, while the subgroup with acromioclavicular arthritis got worse on every measure (Jimenez, Acta Ortop Mex 2018).","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and a partial cuff tear is a tendon problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Tested in tendinopathy, not in tears","evidence":"The one randomised trial of this treatment at the shoulder recruited people with rotator cuff tendinopathy rather than a tear. Thirty-nine people received 5% dextrose around either the upper or the lower part of the axillary nerve, or a sham injection, all alongside home exercise; the lower site reduced pain more than sham at two and four weeks, the upper site did no better than sham, and neither site improved shoulder function scores or range of motion (Vitoonpong, Asian Biomedicine 2026). No study in a partial-thickness tear was found, and nothing in that trial addresses tendon healing.","fit":"Occasionally relevant where pain is out of proportion to the tear and examination finds tender, hypersensitive skin around the shoulder. It does not repair a tear.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hydrodissection for a partial-thickness rotator cuff tear. The only record in the search concerns a different procedure: in a retrospective cohort of 78 people given capsular hydrodilatation for frozen shoulder, the 10 with a partial-thickness tear gained about half as much abduction at three months as those with an intact cuff (median 40° against 80°), although pain improved in every group (Prakash, Cureus 2025).","fit":"Only where examination finds a separate nerve pain source alongside the tear; suprascapular nerve pain is the pattern that occasionally fits. Loading-based rehabilitation remains the treatment for the tendon.","reviewedOn":"2026-09-29"}}},{"slug":"sacroiliac-joint-pain","title":"Sacroiliac Joint (SIJ) Pain","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/sacroiliac-joint-pain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"This is the only treatment for sacroiliac and pelvic girdle pain with durable randomised evidence, and the trials also show why most versions of it fail. A randomised controlled trial of 81 women with pelvic girdle pain after pregnancy, with a blinded assessor and no dropouts, compared 20 weeks of physiotherapy with specific stabilising exercises against individualised physiotherapy without them: disability fell by more than half in the exercise group with negligible change in controls, and the median group difference in evening pain was 30 mm on a 100 mm scale (Stuge, Spine 2004). At two years, 85% of the exercise group had minimal disability against 47% of controls, though the authors note the between-group differences disappeared after adjusting for one-year score level (Stuge, Spine 2004). A published comparison against the negative trial of the same era identifies the design features that separate them: local muscles first with global added gradually, supervised and corrected in person, individualised in choice, order and dosage, and pain explicitly avoided (Stuge, Man Ther 2006). The counterweight is real: a 2025 narrative review found five of six eligible studies reported NO significant short-term pain change from motor control exercise in this population, and judged the exercises used generally unspecific (Zitti, Healthcare 2025). The 2025 consensus guidelines note that the non-interventional evidence in sacroiliac joint complex pain is indirect, extrapolated mostly from general low back pain studies (McCormick and Cohen, Pain Med 2025).","fit":"The whole plan starts here, and the delivery matters as much as the content. A printed sheet done unsupervised is closer to the trial that found nothing than to the one that worked. Twenty weeks is the reference duration, progression is by criteria rather than by calendar, and exercises that hurt are modified rather than pushed through. Nobody will be told their pelvis is out of alignment; the palpation tests that claim to detect that have never been shown to measure anything.","reviewedOn":"2026-09-03"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in sacroiliac pain","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, dry needling or trigger point with sacroiliac, facet joint or zygapophyseal, 43 records, plus a randomised-trial and systematic-review pass on injection of the piriformis, gluteal, quadratus lumborum and multifidus muscles, 35 records). No controlled study has injected or needled a buttock or low back muscle trigger point in people diagnosed with sacroiliac joint pain. A retrospective series of 64 workers with sacroiliac pain and back muscle strain given cortisone injections around the joint and into the lower back reported pain falling from 5.1 to 3.1 out of 10, without separating the joint injections from the muscle ones (Medani, Int J Occup Med Environ Health 2020). Nearby muscles have small trials against shockwave only: a single cortisone trigger point injection into the quadratus lumborum beat five sessions of shockwave at two weeks in 54 people with low back pain but fell behind at four weeks (Eftekharsadat, BMC Musculoskelet Disord 2020), and an ultrasound-guided cortisone injection into the piriformis matched one shockwave session in 70 people with piriformis syndrome (Fu, J Formos Med Assoc 2025). Neither used this row's dilute glucose, and neither had a placebo group.","fit":"Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Evidence is for focused","evidence":"Shockwave has been tested at this joint, but with a focused device. Ninety women with postpartum sacroiliac dysfunction were randomised to focused shockwave, manual therapy, or both: focused shockwave gave better disability scores than manual therapy at one week, was behind manual therapy on pain by two weeks, and the combination did best overall (Tan, J Orthop Surg Res 2024). A review of shockwave for low back pain identifies the sacroiliac joint, the facet joints and myofascial trigger points as where the literature has concentrated, and treats the radial and focused devices as having different properties (Schoder, Orthopadie 2025); its authors run shockwave centres, which is worth weighing. A further randomised report of shockwave for sacroiliac joint pain appeared only as a letter (Notarnicola, J Biol Regul Homeost Agents 2020).","fit":"For the tender gluteal and lumbar muscle around the joint, which is often a real part of sacroiliac pain. The joint itself sits too deep for a radial pressure wave to reach, and the injections set out above are the better-evidenced options here.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Two small trials, used with rehab","evidence":"Unlike the rest of the spine, this joint has been tested, and it now has two randomised trials that disagree about which outcome moves. A prospective randomised sham-controlled trial of 30 patients delivered 2,000 shocks at the maximum tolerated energy (flux density 0.09-0.25 mJ/mm2) with the probe perpendicular to the posterior joint line, against an active sham delivering the same shock count with the probe parallel to the line. Pain fell from 6.42 (95% CI 5.19-7.66) to 3.64 (2.29-4.99) at four weeks in the treated group and did not change in the sham group, with a significant between-group difference at four weeks (3.64 versus 6.18). Oswestry Disability Index improved in the treated group but NOT significantly, and did not separate from sham at any point (Moon, J Back Musculoskelet Rehabil 2017). A second trial randomised 90 postpartum women with sacroiliac joint dysfunction to focused shockwave, manual therapy, or both. It found the mirror image: Oswestry Disability Index lower than manual therapy at one week (p<0.001), but pain relief INFERIOR to manual therapy by two weeks. The combined arm was the strongest, with the highest cure rate at 73.3% against 66.7% improvement for shockwave alone, and no adverse events in any arm over two months (Tan, J Orthop Surg Res 2024). That trial had no sham, and an author is affiliated with a shockwave device manufacturer. Neither trial followed anyone beyond four weeks. The remaining literature is a letter in a journal of contested standing (Notarnicola, J Biol Regul Homeost Agents 2020) and a narrative review whose senior authors run private shockwave centres (Schoder, Orthopadie 2025).","fit":"Used alongside the rehabilitation programme rather than as a course of its own. The arrangement the evidence actually supports, since the strongest arm of the 2024 trial was shockwave combined with hands-on treatment. The window it suits is the one where pain is the obstacle to doing the loading work. Non-invasive and low-risk, with no serious adverse events in either trial, which is a fair reason to try it before an injection rather than after. The expectation set beforehand is a short-term effect on pain, function or both, of a size that makes the programme easier to do; the two trials disagree about which of those moves, and neither goes past four weeks, so nothing is claimed about lasting change. A short course with a defined review point, not an open-ended series. Focused rather than radial, because the joint line and its interosseous ligament sit deeper than a radial device reaches; radial has a separate myofascial role here.","reviewedOn":"2026-09-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Limited SIJ evidence","evidence":"The first two randomised trials disagree, and the better-designed of them is the negative one. A DOUBLE-BLIND randomised trial at two university spine centres enrolled 26 patients who had more than 80% relief from a fluoroscopically guided diagnostic block, then randomised them to intra-articular PRP or corticosteroid: both groups improved, but the steroid group reported lower pain at one, three and six months and had significantly more responders at one and three months (Chen, Pain Med 2022). Against that, an open-label prospective randomised trial of 40 patients found PRP clearly better, with median pain at three months of 1 (IQR 1-3) versus 5 (IQR 3-5) for steroid, p=0.0002 (Singla, Pain Pract 2017) - but participants and the injector were unblinded and entry criteria were looser. A third, single-blind trial of 44 people whose pain was confirmed by a test block, injected under CT guidance, found no significant difference from a cortisone and anaesthetic injection at three months: pain fell by 3.0 points against 1.8 (p = 0.24) and 60% against 35% had their pain halved (p = 0.11), with cortisone giving more relief early (Peckham, AJNR Am J Neuroradiol 2026). Four systematic reviews reach the same place from different starting points: evidence rated VERY LOW quality by GRADE from three eligible studies, with the single RCT's odds ratio spanning 4.65 to 298.69 (Burnham, Pain Med 2020); level IV, weak recommendation (Manchikanti, Curr Pain Headache Rep 2025); not enough to support PRP over the corticosteroid standard of care (Goodwin, Regen Med 2023); inconsistent and insufficient evidence for or against, with only five of seven studies reaching 50% efficacy (Rothenberg, Regen Med 2021). The newest pooled analysis reads the cortisone comparisons more favourably: across ten randomised and quasi-randomised trials at the facet and sacroiliac joints, four of them sacroiliac, 392 people in all, pain was lower with PRP than with cortisone by 1.3 points out of 10 at three months and 1.7 at six, with no significant difference in disability, and its authors still call the evidence inconclusive (Alatefi, Pain Med 2026). The 2025 multispecialty consensus guidelines, endorsed by 21 organisations, state there is WEAK evidence supporting PRP for at least three months of relief (McCormick and Cohen, Pain Med 2025). Note also that the first two randomised trials injected inside the joint; PRP into the posterior ligaments has never been tested against a control, even though the guidelines find intra-articular and extra-articular pathology about equally common.","fit":"Used here for sacroiliac pain that has not settled with an adequately delivered rehabilitation programme, not as a first step, and only once the diagnosis has been characterised, including which part of the complex is suspected, because that determines the target. Injections are given under ultrasound guidance, which suits the posterior ligamentous structures well but does not on its own confirm placement inside the joint cavity. The Chen trial is stated explicitly at consent rather than omitted: for most people the comparison that matters is against repeated cortisone, and one good trial found cortisone did better.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Best studied injectable here","evidence":"This has the longest trial record of any injectable at this joint, and the record runs from striking to sobering. A randomised controlled trial of 48 patients, all with block-confirmed sacroiliac pain of at least three months that had failed medical treatment, compared fluoroscopically guided intra-articular dextrose prolotherapy with triamcinolone, fortnightly to a maximum of three injections. Both were indistinguishable at two weeks; by 15 months the cumulative incidence of at least 50% pain relief was 58.7% (95% CI 37.9-79.5) with prolotherapy against 10.2% (95% CI 6.7-27.1) with steroid, log-rank p<0.005 (Kim, J Altern Complement Med 2010). It is a single centre, has not been replicated in sixteen years, and the authors themselves called for confirmation of safety and validation of the protocol. The ligamentous evidence is weaker: a prospective UNCONTROLLED series of 25 patients given CT-guided hypertonic dextrose into the dorsal interosseous ligament, three injections six weeks apart, reported positive outcomes in 76% at three and twelve months but only 32% at 24 months, with attendance falling at later follow-up (Cusi, Br J Sports Med 2010). The most realistic figure comes from a retrospective cohort of 103 patients given 15% dextrose in lidocaine in a Veterans Affairs clinic: only 24 (23%) reached a minimum clinically important improvement at a median 117 days (Hoffman, Complement Ther Med 2018). The 2025 multispecialty consensus guidelines rate the evidence WEAK, supporting at least three months of relief (McCormick and Cohen, Pain Med 2025).","fit":"Considered where the diagnosis is characterised and a three-month stability programme has not held: the prerequisite built into the original Sydney protocol, and the defensible sequence. Delivered under ultrasound guidance, which suits the posterior ligamentous target; note that the Sydney ligament protocol used CT and the randomised intra-articular trial used fluoroscopy, so neither studied protocol is reproduced exactly, and where the target requires CT the injection is referred to a radiologist rather than approximated here. One injection first, not a pre-booked course: in the largest cohort a 15-point Oswestry improvement before the second injection predicted eventual responder status with 92% sensitivity and 80% specificity, so a first injection that does little is a reason to stop rather than to continue. Both the Kim figures and the Hoffman figures are given, not just the flattering one. The treatment works by provoking inflammation, so several days of increased soreness is expected rather than a complication.","reviewedOn":"2026-09-03"},"viscosupplementation":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"No randomised SIJ trials","evidence":"There is no randomised trial of hyaluronic acid in the sacroiliac joint; a search in November 2026 of PubMed for any trial or systematic review found none beyond a 2012 review. What exists is small and non-randomised but positive: a retrospective comparison of 60 people found viscosupplementation held its pain and disability gains out to six months (pain 4.3 out of 10, against 3.8 with PRP and 5.1 with cortisone), with cortisone ahead in the first week and no major complications (Yadav, Cureus 2026), and an early series of four people given three injections two weeks apart reported 40 to 67% less pain at twelve to sixteen weeks (Srejic, Reg Anesth Pain Med 1999). A systematic review of hyaluronic acid in every joint except the knee, which covered the sacroiliac joint, found improvement from baseline but limited evidence of superiority over placebo and none over cortisone (Colen, BioDrugs 2012). Without a control group, how much of the improvement is due to the injection is not known.","fit":"Occasionally raised where cortisone has been used repeatedly. PRP is the better-studied injection at this joint and is discussed first.","reviewedOn":"2026-11-05"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Aimed at the cluneal nerves","evidence":"No trial has tested this treatment at the sacroiliac joint, and it is not aimed at the joint. What makes it relevant here is that the superior cluneal nerves cross the iliac crest a few centimetres above the joint, run close to the skin, and cause pain in the same area: in 36 people with superior cluneal nerve entrapment treated with ultrasound-guided dextrose around the nerve, 77.7% improved initially, with about a quarter relapsing (Wu, Insights Imaging 2023). A narrative review agrees the injection helps, while noting that no trial has compared techniques or injectates (Wu, Pain Physician 2022). Both used ultrasound-guided hydrodissection around the nerve rather than the series of small injections under the skin described here.","fit":"Considered where examination finds tender, hypersensitive skin over the iliac crest or upper buttock, which points to a cluneal nerve rather than to the joint. Not offered for sacroiliac pain in general.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hydrodissection of the sacroiliac joint itself, and a scoping review of the technique for joint pain that searched the sacroiliac joint among others found its signals elsewhere (Leahy, Front Pain Res 2026). The nerves alongside the joint have been studied. The superior cluneal nerves cross the iliac crest just above the sacroiliac joint and are a recognised cause of pain in the same area: in 36 people with superior cluneal nerve entrapment, ultrasound-guided dextrose hydrodissection gave initial treatment success in about 78%, a quarter of whom later relapsed, with relapse more common in those with scoliosis (Wu, Insights Imaging 2023). A review of the nerve agrees that ultrasound-guided injection relieves symptoms but notes that no trial has compared the techniques or the fluids used (Wu, Pain Physician 2022).","fit":"Only where the examination points to a nerve over the iliac crest rather than to the joint. Tenderness a few centimetres out from the midline that reproduces your usual pain is the clue. This treats a condition that mimics sacroiliac pain, not the joint itself, and the sacroiliac joint is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"sarcopenia","title":"Sarcopenia (Age-Related Muscle Loss)","region":"General","url":"https://www.backpaindoctor.com.au/conditions/sarcopenia","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"The treatment","evidence":"A 2026 meta-analysis of 13 randomised trials (546 older adults with sarcopenia) found resistance exercise improved grip strength by 2.95 kg, walking speed by 0.15 m/s, muscle mass index by 0.25 kg/m2 and five-rise chair-stand time by 1.79 s (Li, BMC Geriatr 2026). A second 2026 meta-analysis of 12 trials (652 participants) found moderate gains in knee strength, walking speed and the Timed Up and Go test, but no clear difference in daily function or quality of life (Alsubaie, BMC Geriatr 2026). The trials were small, and for falls the Cochrane review (Sherrington 2019; 108 trials) found the benefit came from balance and functional exercise, with the effect of resistance training alone on falls uncertain.","fit":"The core of care: progressive resistance training with balance work, ideally supervised at first, alongside adequate protein and review of medicines. Benefits for any one person cannot be guaranteed.","reviewedOn":"2026-10-31"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for dry needling, wet needling or trigger point injection in sarcopenia found no clinical study. The nearest evidence is traditional acupuncture, a different procedure: a 2025 meta-analysis of 10 small trials reported gains in muscle mass and grip strength against usual care while noting the limited number and quality of the trials (Niu, Front Public Health 2025), and one small randomised study found no difference from no treatment (Soares Mendes Damasceno, J Aging Res 2019). Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for ultrasound-guided, corticosteroid, intramuscular or joint injections in sarcopenia returned 43 records and none tested an injection procedure as a treatment for sarcopenia in people. The human studies were of hormone medicines (testosterone, nandrolone) or treated sarcopenia only as a risk factor; the rest were animal work. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"No study has tested V-ACTOR or other hand-held local vibration in people with sarcopenia (PubMed, October 2026). The nearest evidence is whole-body vibration on a standing platform, a different treatment: a 2026 meta-analysis of 6 randomised trials (202 older adults with sarcopenia) found moderate gains in leg strength (SMD 0.50) and physical performance (SMD 0.50) but no gain in muscle mass (Beom, Sci Rep 2026), while a 2021 meta-analysis found no significant effect on knee strength or walking speed (Lu, BMC Geriatr 2021). Local vibration trials in older adults have been in people without sarcopenia. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for shockwave therapy in sarcopenia found no completed study. One registered trial protocol plans to add shockwave and kinesio taping to exercise in 94 older adults with sarcopenia (Lu, BMC Geriatr 2025; ChiCTR2200064269); it has no results yet, and its design will not separate the shockwave from the taping. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for shockwave therapy in sarcopenia found no completed study. One registered trial protocol plans to add shockwave and kinesio taping to exercise in 94 older adults with sarcopenia (Lu, BMC Geriatr 2025; ChiCTR2200064269); it has no results yet, does not state whether radial or focused shockwave is used, and will not separate the shockwave from the taping. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"No study has tested EMTT (magnetotransduction therapy) in sarcopenia (PubMed, October 2026). The nearest evidence is a pulsed electromagnetic field (PEMF) device, a different treatment: one non-randomised study of 41 older adults with sarcopenia reported knee-extension strength rising from 13.1 to 18.6 kgf and Timed Up and Go time improving from 23.1 to 18.7 seconds after 12 sessions, with no change in calf circumference and no significant change over time in the SARC-F+CC score (Leonardo, Life 2025). Without randomisation it cannot separate the device from other effects. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for platelet-rich plasma in sarcopenia returned 6 records and none tested it as a treatment in people: they were animal studies, reviews, or used the abbreviation PRP for something else. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for prolotherapy, dextrose, hyaluronic acid or viscosupplementation injection in sarcopenia found no clinical study of prolotherapy; dextrose appeared only as the placebo in supplement trials. Prolotherapy targets ligaments and tendons, and sarcopenia is a whole-body loss of muscle strength, so there is no tissue for it to treat. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia, because the injection has nothing to treat in a whole-body loss of muscle. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for hyaluronic acid injection in sarcopenia found no study using it as a treatment; hyaluronic acid appeared only as a drug carrier in animal work, as a cosmetic filler, or in knee osteoarthritis research where sarcopenia was a background factor. Hyaluronic acid acts inside a joint, and sarcopenia is not a joint problem. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture or neurofascial injection in sarcopenia returned no records. Sarcopenia is a loss of muscle strength and quality, not a painful nerve problem. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not a treatment for this","evidence":"A PubMed search in October 2026 for nerve hydrodissection in sarcopenia found no study. Hydrodissection frees a trapped nerve, and sarcopenia is not a nerve entrapment. Guidance (ANZSSFR consensus, Zanker, J Cachexia Sarcopenia Muscle 2023; EWGSOP2, Cruz-Jentoft, Age Ageing 2019) places treatment in resistance exercise, nutrition and falls prevention.","fit":"Not offered for sarcopenia. Care is a progressive resistance and balance programme, adequate protein, medication review and falls prevention.","reviewedOn":"2026-10-31"}}},{"slug":"scapular-dyskinesis","title":"Scapular Dyskinesis and Periscapular Pain","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/scapular-dyskinesis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care, modest evidence","evidence":"The 2013 consensus (Kibler, Br J Sports Med) recommends treating all contributing factors, restoring flexibility before strengthening, and using scapular exercise as part of a comprehensive shoulder program; two randomised trials it cites showed higher patient-rated outcomes than general shoulder rehabilitation. A 2026 systematic review of 14 studies (412 athletes) found moderate-certainty evidence that exercise likely improves shoulder function, disability and range of movement over 6 to 12 weeks, with low-certainty evidence for pain, strength and scapular kinematics (PLoS One 2026). A 2019 systematic review of 20 trials found conflicting evidence that exercise changes scapular position and motion, with debatable study quality (J Shoulder Elbow Surg 2019). Cools et al. state that the cause-and-effect link between dyskinesis and pain is unclear.","fit":"Where care starts: assessment of strength, flexibility, posture and the rest of the shoulder, then a graded program from low-load scapular control to loaded and work- or sport-specific exercise, usually physiotherapy-led. The effect on pain is less certain than the effect on function.","reviewedOn":"2026-10-17"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only a separate tender muscle","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. Needling is aimed at a confirmed painful trigger point, not at a pattern of shoulder blade movement. The consensus statement addresses tight tissue through stretching and exercise.","fit":"Not a treatment for dyskinesis. Considered only if examination finds a separate, tender muscle that fits your symptoms, and the evidence gap is stated.","reviewedOn":"2026-10-17"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Nothing to inject","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. Dyskinesis is a movement pattern, not a tissue with an injectable target. If the shoulder examination finds a separate structural problem, such as a rotator cuff, subacromial or AC joint problem, that diagnosis is assessed on its own page.","fit":"Not offered for dyskinesis itself.","reviewedOn":"2026-10-17"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only a separate tight muscle","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. No study of vibration-based devices in scapular dyskinesis was identified in those sources. The rationale would be short-term modulation of a tender, tight muscle, not retraining shoulder blade control.","fit":"Not a treatment for dyskinesis. Considered only as a short-term adjunct to exercise where a tight muscle limits it.","reviewedOn":"2026-10-17"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong target","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. Shockwave is studied in tendon and some muscle conditions, not in movement-pattern impairments.","fit":"Not offered for dyskinesis. A separate tendinopathy found on examination is assessed on its own page.","reviewedOn":"2026-10-17"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong target","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. Focused shockwave is studied in calcific and tendon disease, not in movement-pattern impairments.","fit":"Not offered for dyskinesis.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No target","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. Extracorporeal magnetotransduction therapy has no identified role in a movement-pattern impairment.","fit":"Not offered for dyskinesis.","reviewedOn":"2026-10-17"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No target","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. There is no tissue target for an injection of platelet-rich plasma.","fit":"Not offered for dyskinesis.","reviewedOn":"2026-10-17"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"No target","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. There is no ligament or tendon target for dextrose injection in a movement-pattern impairment.","fit":"Not offered for dyskinesis.","reviewedOn":"2026-10-17"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Wrong problem","evidence":"Hyaluronic acid injection is a joint treatment studied in osteoarthritis. Scapular dyskinesis is a movement pattern, and none of the sources reviewed for it describe the treatment.","fit":"Not offered for dyskinesis.","reviewedOn":"2026-10-17"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Different diagnosis","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. True winging from a nerve injury, for example to the long thoracic nerve, is a different diagnosis requiring its own assessment, not perineural injection for dyskinesis.","fit":"Not offered for dyskinesis. Sudden marked winging, new weakness or numbness is assessed promptly as a possible nerve problem.","reviewedOn":"2026-10-17"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Different diagnosis","evidence":"This review of scapular dyskinesis relied on the 2013 consensus statement (Kibler, Br J Sports Med), the Cools rehabilitation framework (Br J Sports Med 2014) and three systematic reviews of exercise; none evaluates this treatment, and it was not separately searched. Hydrodissection addresses nerve entrapment, which is not the problem in dyskinesis.","fit":"Not offered for dyskinesis.","reviewedOn":"2026-10-17"}}},{"slug":"sciatica","title":"Sciatica","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/sciatica","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"The evidence sits in the muscular mimic rather than in nerve root pain. Deep gluteal syndrome (the piriformis and its neighbours irritating the sciatic nerve) is a recognised non-discogenic cause of sciatica-like pain (Park, Bone Joint J 2020), and a double-blind randomised comparison of 84 people found ultrasound-guided lignocaine into the piriformis reduced pain and disability significantly at one month, though botulinum toxin outlasted it by six (Elsawy, Healthcare 2022). No trial of needling or injection into muscle was found for sciatica caused by a disc.","fit":"Considered where examination points to gluteal or piriformis muscle reproducing the leg pain, rather than a nerve root. If the leg pain is truly radicular, this is not the treatment for it, and patients are told so.","reviewedOn":"2026-09-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small, short-term effect","evidence":"The trials in sciatica test an epidural corticosteroid injection placed under X-ray or CT, which is a different procedure from the ultrasound-guided soft-tissue injections done here. Pooling 25 placebo-controlled randomised trials in 2,470 people, epidural corticosteroid was probably better than a placebo injection for leg pain in the short term, but the difference was small: 4.9 points on a 0 to 100 scale (95% CI -8.8 to -1.1), with a similar sized effect on disability (-4.2, -6.0 to -2.2) and moderate-quality evidence at best (Oliveira, Spine 2020). The American Academy of Neurology review of 90 randomised trials found the same shape of answer for radicular pain: probably better short-term pain, roughly one extra person helped for every four treated, and not enough evidence to say anything about pain at six months or beyond (Armon, Neurology 2025). A reanalysis of the same trial set, restricted to those done under X-ray guidance, argues the evidence is considerably stronger than that (Manchikanti, Pain Physician 2022), so the size of the benefit is genuinely disputed rather than settled.","fit":"Not a procedure performed here. An epidural injection is done under X-ray or CT by a radiologist or a pain medicine specialist, so this is a referral conversation and not something provided here. Worth raising where leg pain has not settled with loading and education and is limiting what you can do, with the expectation set at some weeks of partial relief rather than a cure. New or progressive weakness, numbness or bladder change needs assessment, not an injection. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for a disc problem","evidence":"A tested absence for the nerve-root part of this problem, and a real trial for the muscular part. A search pairing lumbar disc herniation, disc herniation, sciatica and radiculopathy with shockwave, shock wave and ESWT returned nine records and not one trial of shockwave for disc-related nerve-root pain. Where sciatic-type pain is coming from the deep gluteal muscles it is a different story: 48 people with piriformis syndrome were randomised to ultrasound-guided shockwave or ultrasound-guided dry needling, both groups also stretching, and both improved pain, Oswestry disability and lower-limb function at one and three months with no difference between them (Dede, Turk J Phys Med Rehabil 2026). Shockwave also appears in a surgical series as part of the conservative care that had failed before piriformis release (Han, Clin Orthop Surg 2017). A two-group study of 60 people with sciatica from scarring after laminectomy found radial shockwave added to physiotherapy reduced pain more than physiotherapy alone, but randomisation is not stated (Rashad, Ann Rehabil Med 2025; added 19 October 2026).","fit":"Considered where the leg pain is being driven by tender gluteal muscle rather than by a disc pressing on a nerve root. It does nothing for a disc or a nerve root, and new or progressive weakness or numbness needs assessment rather than treatment.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for a disc problem","evidence":"A tested absence for nerve-root pain: shockwave, shock wave and ESWT crossed with disc herniation, herniated, radiculopathy, sciatica, spinal stenosis and spondylolisthesis returned ten records on 19 October 2026, and none is a trial of shockwave for disc-related sciatica. A two-group study of 60 people with sciatica from scarring after laminectomy found radial shockwave added to physiotherapy reduced pain more, but randomisation is not stated (Rashad, Ann Rehabil Med 2025). For sciatic-type pain from the deep gluteal muscles, shockwave was level with dry needling in 48 people with piriformis syndrome (Dede, Turk J Phys Med Rehabil 2026) and was compared with guided cortisone in 70 (Fu, J Formos Med Assoc 2025); neither names a focused device.","fit":"Considered only where the leg pain is being driven by a tender gluteal muscle rather than by a disc pressing on a nerve root. New or progressive weakness or numbness needs assessment rather than treatment.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Searched 20 October 2026: platelet-rich plasma with sciatica, radiculopathy or radicular pain and an epidural, transforaminal, nerve-root or perineural route (26 records), and a pass restricted to randomised trials and systematic reviews that added disc herniation (13 records). Every trial is of an injection beside the affected nerve root, always against cortisone and never against a dummy injection or rehabilitation alone. The largest gave 124 people an ultrasound-guided injection of PRP or cortisone and found no difference in pain, disability or nerve testing at any point over twelve months, with no complications in either group (Xu, Neural Plast 2021). The smaller trials show cortisone ahead in the first weeks and PRP ahead later: at six and twelve weeks in a trial of 107 (Sonkar, J Clin Orthop Trauma 2026), and at six weeks and six months in a double-blind trial of 46 that found no difference at one year (Gupta, Asian Spine J 2024). The pooled analyses agree on that shape but not on its size. In five trials and 310 people the two were level for pain (Muthu, Exp Biol Med 2025); in seven studies and 416 people cortisone gave better function at four weeks and nothing separated them later (Wang, J Orthop Surg Res 2025); in three trials and 132 people cortisone was better at one month and PRP 1.5 points better on the 0 to 10 pain scale at six months (Ermawan, Spine Surg Relat Res 2025); and a review of 13 spinal trials found PRP ahead at three to six months in the four nerve-root trials (Zhang, Eur Spine J 2026). A systematic review graded the certainty of the whole body of work very low (Kubrova, Biomedicines 2022).","fit":"Not offered here: PRP is not injected into a disc or beside a nerve root in this clinic. Where sciatica has not settled, an image-guided injection beside the nerve root is a referral conversation with a radiologist or pain medicine specialist, and on these trials PRP is an alternative to cortisone there rather than a clear improvement on it. Most sciatica eases over weeks to months, and the rehabilitation program is what carries people through that time.","reviewedOn":"2026-10-20"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"The evidence in nerve-related leg pain conflicts. A systematic review of dextrose prolotherapy in chronic spinal pain reported rapid relief from low-concentration epidural dextrose in radicular pain (Nazwar, J Anaesthesiol Clin Pharmacol 2026), but the single randomised trial of epidural prolotherapy showed no benefit past forty-eight hours (Desai, Pain Practice 2020) and an American Pain Society review found prolotherapy not effective for low back and radicular pain (Chou, Spine 2009). Reports of sciatic pain arising outside the spine and settling with prolotherapy are single cases (Yoon, Life 2025). A 2026 pragmatic randomised trial adds a positive result against an active treatment rather than a placebo. In 104 people with at least three months of low back pain with leg pain (referred or radiating) scoring at least 6 out of 10, up to five monthly dextrose prolotherapy treatments beat up to three epidural steroid injections at 6 months (pain 5.1 against 7.2 out of 10) and 12 months (5.2 against 6.9), with better Oswestry disability scores (34 against 42 at 12 months) and no adverse events. Nobody was blinded, there was no dummy-injection group, and the abstract does not say where the dextrose was injected (Wende, PM R 2026).","fit":"Not a treatment for a compressed nerve root. Considered only where the leg pain is being driven by an irritable ligament or attachment rather than the root itself, and after core care has had a fair trial.","reviewedOn":"2026-10-29"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Hyaluronic acid appears in the sciatica literature as an additive to a nerve root block, not as a joint injection. In 44 people with lumbar radiculopathy, adding a sodium hyaluronate and carboxymethylcellulose solution to a cortisone nerve root block reduced the flare of pain that often follows the procedure (2.4 against 4.2 out of 10 at two weeks) but made no difference by six weeks and no difference to function at six or twelve weeks (Ko, Spine J 2018). That is an injection around a nerve, which belongs to the guided-injection row. Nothing has tested a spinal joint injection of hyaluronic acid for sciatica.","fit":"Not offered for this problem. Sciatica comes from an irritated nerve root rather than from a dry joint.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. No study has tested dextrose injected just under the skin for sciatica. The dextrose trial in back pain spreading to the leg used a different route, the epidural space: in 35 people with back pain radiating to the buttock or leg, a single caudal epidural of 10 mL of 5% dextrose gave more relief than saline at four hours (84% against 19% with at least half their pain gone) and at 48 hours, but not at two weeks (Maniquis-Smigel, Anesth Pain Med 2016), and an uncontrolled follow-up of repeated epidurals reported pain 52% lower at a year (Maniquis-Smigel, J Altern Complement Med 2018). Neither is the under-the-skin technique this row describes.","fit":"Not a treatment for an irritated lumbar nerve root. Considered only where a separate tender superficial nerve, such as a cluneal nerve over the buttock, is also part of the picture.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One uncontrolled series","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. One uncontrolled series of the procedure at the lumbar nerve root: in 46 people with lumbar radiculopathy, ultrasound-guided hydrodissection of the nerve root with 10 mL of saline, contrast and 1% lignocaine (no cortisone) lowered leg pain from 7.1 to 5.0 out of 10 at one week, 4.2 at one month and 3.8 at three months, with 58% responding at three months and Oswestry disability falling from 42 to 28. There was no comparison group, the fluid stayed around the target root in only 30% of cases, and two people had brief radiating pain during the injection (Arima, Spine Surg Relat Res 2026). Hydrodissection of the sciatic nerve in the buttock is reported only in single cases and a four-person emergency department series (Silver, Am J Emerg Med 2023; Stenberg, J Emerg Med 2025). The randomised trials nearby tested cortisone with saline as the control, and they are a caution against reading too much into an uncontrolled result: in 160 people with sciatica, saline beside the nerve root gave less relief than cortisone at two weeks but less back pain at three and six months (Karppinen, Spine 2001), and in 116 people a caudal epidural of saline did no better than a sham injection under the skin at any point to a year (Iversen, BMJ 2011).","fit":"Discussed for leg pain from a lumbar nerve root that has not settled with a rehabilitation program and time, as an alternative to a cortisone nerve-root injection, on the understanding that the evidence is one series without a comparison group. Progressive weakness, numbness in the saddle area or any bladder or bowel change needs urgent assessment, not an injection.","reviewedOn":"2026-10-29"}}},{"slug":"scoliosis","title":"Scoliosis","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/scoliosis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial evidence in scoliosis. Asymmetric muscular loading either side of a curve commonly produces tender bands, and those are treated as muscular pain.","fit":"Occasionally used for a specific tender band that is limiting exercise. It does not change the curve.","reviewedOn":"2026-08-30"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Injection does not alter a curve. In adult degenerative scoliosis a specific facet joint or sacroiliac joint can be the pain generator, and where that is the case an image-guided injection is used diagnostically and therapeutically as it would be in anyone else.","fit":"Considered only where assessment points to one identifiable painful structure, and always alongside the exercise programme.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Myofascial pain only: one small trial","evidence":"Used here as a treatment for muscle, not for the curve. A curve loads the muscles either side of it unevenly, and the resulting myofascial pain is what people usually feel. The one trial in this population fits that reading: 48 adults with idiopathic scoliosis and back pain randomised to five sessions of radial shockwave to the back muscles, therapeutic ultrasound or control, all alongside Klapp exercises. At two weeks pain fell more with shockwave (change -6.4 against -5.4 and -4.5 out of 10), with better quality of life, no difference in disability (Oswestry change -28 against -30 and -27) and no adverse reactions (Daia, J Clin Med 2021). It was unblinded with no sham arm, follow-up ended at day 14, and the curve was not measured. The only report claiming an effect on deformity is a single case in a 13-year-old whose trunk measures returned to baseline within three to five days of each session (Weiss, J Phys Ther Sci 2017), which cannot support that claim.","fit":"Considered only where the assessment locates the pain in muscle and the exercise programme alone has not settled it, and treated on the same basis as myofascial pain anywhere else. It does not correct, halt or influence a curve, and it is not a reason to defer specialist review of a progressive one.","reviewedOn":"2026-10-22"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No focused-shockwave study in scoliosis was found. Search: PubMed, shockwave terms with spondylolysis, pars interarticularis, pars defect, spondylolisthesis or scoliosis (10 records, all read), with a trial and systematic-review pass. The studies that exist used radial devices on the back muscles, not the curve: a 48-person randomised trial in adults with scoliosis and back pain (Daia, J Clin Med 2021) and a single case in a 13-year-old (Weiss, J Phys Ther Sci 2017); see the radial row.","fit":"Not offered for the curve. Where a specific painful structure is identified on assessment, it is treated as that problem, not as scoliosis.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Not part of managing scoliosis. Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study of platelet-rich plasma as a treatment for scoliosis was found, and there is no reason to expect an injection to change a spinal curve. A PubMed search on 11 October 2026 pairing platelet-rich plasma, platelet gel, platelet concentrate, platelet lysate and platelet-rich fibrin with scoliosis, spinal deformity and kyphosis returned three records, none a treatment study: a general overview of children's orthopaedics that mentions PRP in passing (Al-Rumaih, Cureus 2026), a laboratory study of clotting in blood samples from scoliosis surgery patients (Shams Hakimi, Clin Appl Thromb Hemost 2017), and a laboratory report on a spinal implant for tuberculosis (Yahia, RSC Adv 2023).","fit":"Not a treatment for the curve. Considered only where assessment finds a separate, clearly identified problem alongside it, such as a painful sacroiliac joint, and then judged on the evidence for that problem and used to support the exercise program.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"No study of prolotherapy in scoliosis. A PubMed search on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with scoliosis and the other spinal conditions; 10 records) returned no trial, series or case report in which the curve, or pain from it, was treated with prolotherapy. The one record pairing scoliosis with a dextrose injection is a study of 36 people given dextrose with local anaesthetic around the superior cluneal nerves of the low back, in which pain coming back was more common in those with scoliosis; scoliosis was a finding there, not the condition treated (Wu, Insights Imaging 2023).","fit":"Not offered for the curve, which an injection cannot change. Back pain in someone with scoliosis is assessed on its own terms, and a separate joint or ligament problem is weighed on the evidence for that problem.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A treatment for an arthritic peripheral joint. It has no application to a spinal curve.","fit":"Not used for this condition.","reviewedOn":"2026-08-30"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study of perineural injection in scoliosis was found. Searching perineural injection, neural prolotherapy, subcutaneous and perineural dextrose, glucopuncture, Lyftogt and neurofascial terms against scoliosis and spinal deformity, with separate passes for randomised trials and systematic reviews, returned no treatment study in this condition. The only randomised trial retrieved added drugs to a nerve block for pain after scoliosis surgery (Reysner, Spine 2025), which is a different procedure for a different purpose.","fit":"Not offered for the curve.","reviewedOn":"2026-11-04"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Trapped nerve, not the curve","evidence":"No study of hydrodissection as a treatment for scoliosis was found, and the curve itself is not something it can act on. The nearest evidence concerns superior cluneal nerve entrapment at the iliac crest, a cause of low back pain that can sit alongside scoliosis. In 36 people with that entrapment, ultrasound-guided dextrose hydrodissection gave initial success in 77.7%, but symptoms returned in a quarter of those, and the people whose pain returned were more likely to have scoliosis (Wu, Insights Imaging 2023). Two case reports, one in a person with scoliosis, describe pain relief from an ultrasound-guided cluneal nerve block rather than hydrodissection (Reyes, Pain Med Case Rep 2026). None of these studies had a control group.","fit":"Not offered for the curve. Considered only where examination and ultrasound find a trapped nerve alongside it, most often the superior cluneal nerve at the iliac crest, and with the higher chance of the pain returning explained.","reviewedOn":"2026-11-04"}}},{"slug":"sesamoiditis","title":"Sesamoiditis & Sesamoid Fracture","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/sesamoiditis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in this condition","evidence":"Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection, myofascial or intramuscular stimulation with sesamoid, sesamoiditis or hallux, 4 records, none about the sesamoids; and a randomised-trial and systematic-review pass). No study has injected or needled a muscle trigger point for sesamoid pain. The nearest trials are in bunions, a different condition: dry needling of the abductor hallucis added to toe exercises reduced resting pain over four weeks in 31 people (Dede, J Am Podiatr Med Assoc 2026), while in 30 women dry needling against sham changed the toe angle but not pain or foot function (Kharazmi, J Bodyw Mov Ther 2020). Nothing was injected in either.","fit":"Offloading with padding or an orthosis and modified activity are the treatment. A trigger point injection is rarely relevant, because the pain comes from the small bones under the big toe joint rather than from a muscle.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Case series, injection not isolated","evidence":"Searched 3 November 2026 (PubMed: sesamoiditis or sesamoid pain with injection, corticosteroid, steroid or anaesthetic, 23 records, most of them horse studies; and a randomised-trial and systematic-review pass, which found no trial). No controlled study exists. A 2025 systematic review pooled 11 case reports and series (59 patients) of non-surgical treatment, including corticosteroid injection, orthotics and physiotherapy: pain scores improved in 66% of cases, the authors judged steroid injection and orthotics to appear beneficial, and pain returning after initial improvement was common (Biz, Medicina (Kaunas) 2025). In 27 athletes with medial sesamoid pain followed prospectively, a combined program of pain relief, activity restriction, insoles, local steroid injection and a walking boot helped 48%; the injection's share of that result cannot be separated (Choi, Clin Orthop Surg 2024). An ultrasound-guided injection of local anaesthetic and steroid relieved pain from an extra sesamoid at the end joint of the big toe in one case report (Shin, Korean J Pain 2013). A narrative review suggests a fluoroscopically guided injection may avoid surgery once fracture and bone death have been excluded (Sims, World J Orthop 2014).","fit":"Offloading with padding or an orthosis, and modified activity, come first. Where pain persists and imaging has excluded a fracture or bone death, a guided injection may be discussed alongside offloading, with the chance of the pain returning explained. See the note on cortisone.","reviewedOn":"2026-11-03"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Case reports only","evidence":"Searched 20 October 2026: shockwave, shock wave, ESWT, rESWT or radial shock with sesamoid, sesamoiditis or sesamoids (10 records), and with hallux or first metatarsophalangeal and sesamoid, plantar plate or turf toe (3), with randomised-trial and systematic-review passes that found nothing in people (the only review was veterinary); horse and sheep studies were set aside. No trial exists. One case report used radial shockwave, eight sessions, in a 52-year-old man with loss of blood supply to a sesamoid that had not settled with conservative care; he returned to tennis with little or no pain (Thompson, BMJ Case Rep 2017). A second report describes shockwave in the recovery of a volleyball player with stress injuries of both sesamoids, device not stated in its record (Doyle, PM R 2026). A narrative review discusses shockwave for sesamoid problems without new data (Nakajima, J Clin Med 2025).","fit":"Plausible for a sesamoid problem that has not settled with offloading, padding and footwear changes, and can be discussed on that basis, but patients are told the evidence is two single case reports.","reviewedOn":"2026-10-20"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report; device not stated","evidence":"Searched 20 October 2026 (the searches named in the radial row: 10 and 3 records, no trial and no review in people). No study names a focused device at the sesamoids. The case of sesamoid osteonecrosis used radial shockwave (Thompson, BMJ Case Rep 2017), and the case of a volleyball player with sesamoid stress injuries does not name the device in its record (Doyle, PM R 2026).","fit":"Plausible where a sesamoid problem is slow to settle, and can be discussed on that basis alongside offloading, but patients are told there is no study of a focused device at the sesamoids.","reviewedOn":"2026-10-20"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"A few case reports only","evidence":"Searched for PRP at the sesamoid bones of the big toe. Five records, one of them a trial in racehorses, and no trial in people. The human reports are three teenage athletes with long-standing sesamoid injuries who were cleared for running and jumping six to nine weeks after a single injection, their own doctors noting that other parts of their care probably contributed (Le, Phys Sportsmed 2022), and one dancer with loss of blood supply to a sesamoid whose pain improved for some months and was back where it started at two years (Callahan, J Dance Med Sci 2025). None of the reports is of sesamoiditis as such.","fit":"Not something to choose ahead of offloading the sesamoids with padding, footwear or an orthotic and a graded return to impact. PRP can be discussed only on the understanding that it rests on a handful of individual cases.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"No study of prolotherapy for sesamoiditis. PubMed searches on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with sesamoid, sesamoiditis, plantar plate, first metatarsophalangeal, hallux or metatarsalgia) returned three records: one used dextrose only to dilute a local anaesthetic for bunion surgery, one was a fungal nail study in which dextrose was the culture medium, and the third is a single case of a professional dancer whose second-toe plantar plate tear settled over a 16-week program of taping, padding, physiotherapy and a series of prolotherapy injections, so the injection's part cannot be separated (Ojofeitimi, J Orthop Sports Phys Ther 2016). Passes restricted to randomised trials and to systematic reviews found nothing in this condition.","fit":"Can be discussed where sesamoid pain persists despite offloading, footwear changes and a graded return to load, with the absence of studies stated. It sits alongside that program, not in place of it.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Nerve targets only","evidence":"No study injects dilute dextrose under the skin for a painful sesamoid. The perineural work at the forefoot targets nerves: across 59 ultrasound-guided perineural injections in 46 people, the hallux branch of the medial plantar nerve was the commonest target and lasting relief was reached in 23 of 38 followed up, with the injectate a local anaesthetic given for nerve pathology rather than bone pain (Walter, Skeletal Radiol 2017). The only dextrose report anywhere near this joint is a professional dancer with second metatarsophalangeal instability and a plantar plate tear, treated with taping, padding, physiotherapy and a series of intra-articular prolotherapy injections over 16 weeks (Ojofeitimi, J Orthop Sports Phys Ther 2016) - a different structure and a different procedure. Two of the five records the sesamoid search returned were equine nerve-block studies.","fit":"Considered only where pain under the ball of the foot comes with tender, hypersensitive skin rather than focal bone tenderness over the sesamoid. Offloading and load management are what settle a sesamoid.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Nerve beside the joint only","evidence":"Searched 6 November 2026 (PubMed: sesamoid, sesamoiditis, hallux, first metatarsophalangeal, plantar digital nerve or Joplin with hydrodissection, hydrorelease, perineural, 5% dextrose or nerve entrapment, animal studies excluded, 27 records; every abstract read). No study has tested hydrodissection for a painful sesamoid; the only sesamoiditis record was a review in horses. The nearest human work is at the small nerve running along the inner side of the big-toe joint (Joplin's nerve), which can be irritated after bunion surgery or by repeated pressure. In a retrospective review, 15 ultrasound-guided injections around that nerve were followed by average pain falling from 6.4 to 0.25 out of 10 over a mean of 26 months, with no comparison group and the injectate not stated (Burke, Acad Radiol 2019). A second review of 59 foot and ankle nerve injections, 17 of them at the same nerve, reported lasting relief in 23 of the 38 followed up, without separate results for that nerve (Walter, Skeletal Radiol 2017). Neither describes hydrodissection, and neither treated the sesamoid.","fit":"Not a treatment for the sesamoid, which settles with offloading and load management. Considered only where the pain is burning or electric along the inner edge of the big toe, pointing to the nerve there rather than the bone.","reviewedOn":"2026-11-06"}}},{"slug":"severs-disease","title":"Sever's Disease (Calcaneal Apophysitis)","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/severs-disease","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"The treatment","evidence":"A 2024 systematic review of eight randomised trials found insoles, heel cups and orthoses, physiotherapy and Kinesio taping generally reduced pain and improved function, but the trials were small and varied, no meta-analysis was possible, and sham taping reduced pain as much as real taping (Hernandez-Lucas, J Clin Med 2024). An earlier review found rest, ice and stretching were given as a bundle and never tested separately (James, J Foot Ankle Res 2013). The Perth Children's Hospital guideline advises short-term limitation of running and jumping, heel pads, well-fitting shoes and gentle Achilles stretching once the acute episode settles.","fit":"The mainstay of care is activity adjustment, footwear and heel pads, and calf stretching, alongside reassurance. The evidence is limited, from small and varied trials, and benefit cannot be guaranteed.","reviewedOn":"2026-11-07"},"wetNeedling":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered to children","evidence":"Sever's disease is a self-limiting growth-related heel problem of children. The Perth Children's Hospital guideline, the Royal Children's Hospital sheet and the Arthritis Australia sheet recommend activity modification, footwear, heel pads and calf stretching, and no procedures; the Arthritis Australia sheet states there is no evidence that complementary medicines, including acupuncture, help. A 2013 systematic review found no study of injection or shockwave among its nine included studies (James, J Foot Ankle Res 2013). The clinic does not market procedures to children for self-limiting conditions.","fit":"Not offered. Care is activity adjustment, footwear, heel pads and calf stretching, with review if symptoms are atypical or do not settle.","reviewedOn":"2026-11-07"}}},{"slug":"shin-splints","title":"Shin Splints","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/shin-splints","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Dry needling studied, not injection","evidence":"Searched 3 November 2026 (PubMed: trigger point injection, wet needling, dry needling or trigger point with medial tibial stress, shin splints, shin pain or tibial periostitis, read with a sacroiliac and facet search, 43 records). No study has injected a muscle trigger point in this condition, with glucose or anything else. The nearest evidence is one randomised trial of dry needling, which uses the same needle with nothing injected and is not offered here: in 50 university athletes, needling trigger points in the soleus (calf) muscle lowered pain from 7 to 2 out of 10 while the control group stayed at 7, with no gain in ankle movement; follow-up was short-term and what the control group received is not stated in the abstract (Singh, J Man Manip Ther 2024). A published commentary questions the methods of needling trials in this condition (Karademir, J Man Manip Ther 2025).","fit":"Considered only where examination finds a tender calf muscle band contributing to the pain, alongside load management and the rehabilitation program, which treat the bone stress itself.","reviewedOn":"2026-11-03"},"guidedInjection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Two case reports, one with harm","evidence":"Searched 3 November 2026 (PubMed: medial tibial stress syndrome, shin splints or periostitis with injection, corticosteroid or steroid, 24 records; and a randomised-trial and systematic-review pass, which found no trial of injection). No clinical study of a steroid or anaesthetic injection in medial tibial stress syndrome was found, only two case reports. Two young women given steroid injections over the front of the shin had no benefit and developed thinning and loss of colour of the skin and underlying tissue at the injection sites (Loopik, J Sport Rehabil 2016). One person with recurrent inflammation of the shin-bone lining after a direct blow, which the authors place within this syndrome, recovered after steroid injections with no adverse events; the authors called for studies of safety and benefit (Hasegawa, Hawaii J Health Soc Welf 2022). Injection of a dextrose solution under the bone lining is covered in the prolotherapy row.","fit":"Load management and a graded return to running are the treatment. Steroid injection has no established role here; if one is ever considered, it is under guidance, with the report of tissue thinning explained.","reviewedOn":"2026-11-03"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One non-randomised controlled study","evidence":"Searched 21 October 2026 (shockwave terms with medial tibial stress syndrome, shin splints or tibial stress: 20 records; randomised-trial pass: 3). The founding study of shockwave for shin splints used a RADIAL device. Ninety-four people with long-standing shin splints all did the same home training programme; the 47 who also had low-energy radial shockwave did better at every time point, with 64% against 30% much improved or recovered at four months and 76% against 37% at fifteen months, pain 2.7 against 5.3 out of 10 at fifteen months, and 40 against 22 back at their sport at their previous level (Rompe, Am J Sports Med 2010). The groups were consecutive patients rather than randomised, which is the main limit, and the study does not report side effects. Two elite athletes treated with radial shockwave among several other measures are reported as cases (Saxena, J Foot Ankle Surg 2017). The one sham-controlled trial found no difference and did not name its device (Newman, J Sci Med Sport 2017). No randomised trial of a radial device was found. The earlier line saying the trials here used focused devices was wrong.","fit":"Reasonable to discuss alongside a home strengthening programme and a graded return to running, for shin pain that has lasted months. The inner shin bone lies just under the skin, which suits the radial device; the result to expect comes from one well-reported but non-randomised study.","reviewedOn":"2026-10-21"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial; sham trial null","evidence":"Searched 21 October 2026: shockwave, shock wave or ESWT with medial tibial stress syndrome, shin splints or tibial stress (20 records), and a randomised-trial pass (3). One randomised trial used a focused device: 42 army cadets with long-standing shin splints had one session of focused shockwave plus a stretching and strengthening programme, or the programme alone. At four weeks the shockwave group could run pain-free for about 17 and a half minutes against about 5, pain after running was 2.2 against 4.3 out of 10, and 83% against 37% rated the result good or excellent, with no significant side effects (Gomez Garcia, Int J Surg 2017; single-blind, one centre, four weeks' follow-up). In a non-randomised study of 42 athletes, those given five sessions of focused shockwave with a graded running programme recovered in about 60 days against 92 with the running programme alone (Moen, Br J Sports Med 2012). Against that, the one sham-controlled trial, 28 active adults in Canberra, found five sessions no better than a sham dose on pain or running distance at ten weeks; its abstract does not say which device was used (Newman, J Sci Med Sport 2017). A 2024 systematic review rated shockwave a possible addition to exercise here (Rhim, Br J Sports Med 2024). One small positive trial against exercise alone and one null sham trial fall short of the controlled evidence needed to call a treatment supported, so this was lowered from supported on 21 October 2026.","fit":"Worth discussing as an addition to load management and a graded return to running when shin pain has not settled, never instead of them. The positive results come from runners and cadets over weeks, not months, and the one sham-controlled trial did not show a difference.","reviewedOn":"2026-10-21"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched for PRP and autologous blood injection in shin splints, medial tibial stress syndrome and exercise-induced shin pain. Two records, and neither is a study of PRP: one is a review of shockwave therapy, and the other is a series of dextrose prolotherapy, which belongs to the prolotherapy row (Padhiar, J Foot Ankle Res 2021). No trial, case series or case report of PRP for this condition was found.","fit":"Not part of the plan for shin splints. Load management, calf and foot strengthening and a graded return to running are the treatment. With no published study of any kind, PRP would be a step into the unknown, and That is made clear if it is raised.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small case series","evidence":"One published study, and it has no comparison group. Eighteen people with shin splints that had failed all other conservative treatment had ultrasound-guided 15% dextrose injected along the painful length of the shin bone, under its lining. Pain fell by a median of 4.5 points out of 10, the improvement held at an average of 18 weeks and of 52 weeks, people rated themselves much improved, and the typical result was a return to their desired level of sport though not to their level before the injury. No side effects were reported (Padhiar, J Foot Ankle Res 2021). The authors state that trials with a comparison group are needed. A search for dextrose or prolotherapy in shin splints and medial tibial stress syndrome returned this study alone, so there is no randomised trial.","fit":"Load management, calf and foot strengthening and a graded return to running are the treatment, and they settle most cases. For shin pain that has persisted despite a proper program, prolotherapy can be discussed as a way of getting back to loading, on the understanding that it rests on one uncontrolled series of 18 people.","reviewedOn":"2026-10-10"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search for perineural injection, neural prolotherapy or perineural dextrose combined with shin splints or medial tibial stress syndrome returns no study of any design.","fit":"Not offered. Medial tibial stress syndrome is a bone-loading problem, and it settles with training modification, calf strength and attention to footwear and surfaces.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 6 November 2026 (PubMed: medial tibial stress syndrome, shin splints, tibial periostitis or chronic exertional leg pain with hydrodissection, hydrorelease, high-volume injection, dextrose, nerve entrapment, saphenous or fascial injection, 5 records; a randomised-trial and systematic-review pass on any injection in shin splints returned only a shockwave review). No study has tested hydrodissection for shin splints. The nearest report is a single case in a different condition: a soldier whose leg pain persisted after surgery for exertional compartment syndrome, with the superficial peroneal nerve caught in the scar, improved after four sessions of dilute dextrose and local anaesthetic injected along the nerves of the lower leg, which is the perineural technique rather than hydrodissection (Bui, Mil Med 2023). The one injection study in shin splints itself is of 15% dextrose under the lining of the bone in 18 people, which belongs to the prolotherapy row (Padhiar, J Foot Ankle Res 2021).","fit":"Not a treatment for shin splints, which settle with load management, calf and foot strengthening and a graded return to running. Considered only if assessment finds a trapped skin nerve, for example after previous leg surgery.","reviewedOn":"2026-11-06"}}},{"slug":"shoulder-calcific-tendinopathy","title":"Shoulder Calcific Tendinopathy","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/shoulder-calcific-tendinopathy","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"The strongest evidence here is what does not work. In a placebo-surgery controlled trial, arthroscopic subacromial decompression gave no benefit over a sham operation or over exercise therapy, at two years, at five, and at ten (Paavola, BMJ 2018; Paavola, Br J Sports Med 2020; Kanto, BMJ 2025). A network meta-analysis of 54 trials and 3,893 patients found shoulder-specific exercise reduced pain out to 52 weeks, and that adding injections, manual therapy or electrotherapy to it added little (Silveira, PLoS One 2024).","fit":"Loading the shoulder properly is the treatment. An injection is occasionally used to settle pain enough to start, which is a different claim from treating the problem.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested trigger point injection in calcific tendinopathy. The needling literature at this tendon is barbotage - ultrasound-guided needling and lavage of the calcium deposit itself, which is a different procedure aimed at a different structure. In a randomised trial of 48 people, barbotage added to a subacromial corticosteroid injection was ahead at one year but by five years the shoulder scores no longer differed (Constant 90 against 87, p = 0.58), although 4 of the barbotage group went on to further treatment against 16 of those given the corticosteroid alone (de Witte, Am J Sports Med 2017). The Dutch Orthopaedic Association guideline lists shockwave or ultrasound-guided needling as the options for calcific disease (Diercks, Acta Orthop 2014).","fit":"Considered only where examination finds a separate tender muscle band reproducing part of your pain. Barbotage of the deposit is a different procedure and is discussed under its own heading.","reviewedOn":"2026-09-11"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Bursal and sheath targets are small, often deep, and poorly identified by surface landmarks; ultrasound guidance improved accuracy across shoulder girdle targets and improved efficacy where the target was a sheath rather than a large space (Aly, Br J Sports Med 2014).","fit":"Where an inflamed bursa is the identified target, this is a reasonable step, with the number of injections kept low. See the note on cortisone.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Searched 18 October 2026: radial shockwave with calcific or calcifying shoulder tendinopathy (19 records), a randomised-trial pass (6) and a systematic-review pass (19), all read from their abstracts. The old line here said the trials used focused devices; several used radial. In 90 people with X-ray-confirmed calcific tendinitis, radial shockwave beat a less active look-alike treatment on pain and shoulder function after treatment and at six months, and the deposit disappeared completely in 87% of treated shoulders against none of the controls (Cacchio, Phys Ther 2006). In 80 people, adding four weekly radial sessions to physiotherapy gave more improvement in pain, movement and arm function than physiotherapy alone, measured at the end of treatment only (Duymaz, Arch Rheumatol 2019). A network meta-analysis of 14 randomised trials and 1,105 people found radial shockwave, high-energy focused shockwave and ultrasound-guided needling all reduced pain and cleared the deposit, with high-energy focused shockwave best for function (Wu, Arch Phys Med Rehabil 2017). Against that: in a sham-controlled trial of 143 people with shoulder pain, all doing supervised exercise, the benefit in the subgroup with calcification (12.8 points on the SPADI at 24 weeks) had gone by one year (Kvalvaag, Am J Sports Med 2017; Eur J Phys Rehabil Med 2018), and ultrasound-guided needling did better than radial shockwave at six weeks in 25 people, with no difference in pain at one year (de Boer, J Orthop 2017). Both positive trials are single-centre.","fit":"A reasonable non-invasive option alongside a shoulder loading program when a calcific deposit stays painful. High-energy focused shockwave has the larger evidence base and ultrasound-guided needling clears the deposit fastest, so the three are usually discussed together.","reviewedOn":"2026-10-18"},"focusedShockwave":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"High-energy focused shockwave is better than placebo for pain, shoulder function and resorption of the calcific deposit (Bannuru, Ann Intern Med 2014; Gerdesmeyer, JAMA 2003). A 27-study review concluded it is reasonable to trial alongside ultrasound-guided needling before considering surgery (Angileri, J Shoulder Elbow Surg 2023).","fit":"One of the strongest indications for focused shockwave anywhere. Ultrasound-guided needling clears the deposit more reliably; the two are often discussed together.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Platelet-rich plasma here is an add-on to needling the calcium, not a treatment in its own right. In a double-blind randomised trial, 80 people had ultrasound-guided needle aspiration of the deposit followed by either platelet-rich plasma or corticosteroid: platelet-rich plasma was worse at six weeks, better at six months, and the same at one and two years, with fewer people needing a second procedure (24% against 49%) but more complications, mostly frozen shoulder (6 against 1). The authors concluded corticosteroid remained their treatment of choice (Oudelaar, Am J Sports Med 2021). A network meta-analysis of 19 randomised trials and 1,160 patients ranked platelet-rich plasma highest for improving shoulder function, at 85% probability, though not for pain (Moggio, Orthop Surg 2025).","fit":"Worth discussing, and only after the calcium has been needled. The barbotage is what does the work, and platelet-rich plasma is a choice about what goes in afterwards. It buys less early relief than cortisone and costs more, so the case for it is where you want to avoid a repeat procedure or repeated cortisone. The frozen-shoulder signal in that trial is part of the conversation.","reviewedOn":"2026-09-04"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested prolotherapy in calcific tendinopathy of the shoulder. The only published report is a single case in which a large deposit resorbed after ultrasound-guided prolotherapy given alongside physiotherapy and a nutritional regimen, so the prolotherapy cannot be separated from the rest (Yoon, Cureus 2026).","fit":"Not the treatment to reach for here. Barbotage, shockwave and a loading programme are the options with actual evidence in calcific disease, and they target the deposit directly.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies found","evidence":"No study of perineural injection in calcific tendinopathy. Searching perineural injection, neural prolotherapy, glucopuncture, dextrose and D5W terms against calcific tendinitis and calcific tendinopathy returns one shoulder report, and it describes a different treatment: a single case in which 10% dextrose was injected into the glenohumeral joint and the subacromial space alongside physiotherapy and nutritional supplements, with the deposit largely resorbed at two weeks (Yoon, Cureus 2026). Nothing in it concerns a nerve, and one uncontrolled case cannot show cause.","fit":"Considered only where hypersensitive skin overlies the painful area. It does nothing to the calcium deposit itself.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of hydrodissection in calcific tendinopathy was found: hydrodissection, hydrorelease and hydrodilatation searched against calcific, rotator cuff and subacromial terms returned no calcific-specific record. The fluid-based procedure that has been studied here is barbotage (needling and washing out the calcium deposit), which targets the deposit rather than a nerve or tissue plane and is a different procedure. In 48 people randomised to barbotage plus a subacromial cortisone injection or the injection alone, the one-year advantage had gone by five years, although 4 of the barbotage group needed further treatment against 16 of the others (de Witte, Am J Sports Med 2017).","fit":"Only where a nerve is separately implicated. Barbotage, if it is being considered, is a separate conversation.","reviewedOn":"2026-09-29"}}},{"slug":"shoulder-instability-dislocation","title":"Shoulder Dislocation and Instability","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/shoulder-instability-dislocation","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Rehabilitation is the starting point for most people, and the trials show where it falls short. In a randomised trial of 40 people under 30 after a first traumatic dislocation, redislocation at two years was 47% after sling and rehabilitation against 16% after arthroscopic stabilisation (Kirkley, Arthroscopy 1999); at about six years redislocation still differed but general shoulder function scores did not (Kirkley, Arthroscopy 2005). A 2025 meta-analysis of 11 comparative studies and 694 patients found arthroscopic repair markedly reduced redislocation and later stabilisation surgery (Abdel Khalik, Orthop J Sports Med 2025). For atraumatic multidirectional instability, a randomised trial of 41 people found a specific instability program gave better shoulder scores than a general one at 12 and 24 weeks (Warby, Am J Sports Med 2017).","fit":"The usual starting point for most people: restoring movement, then rotator cuff and shoulder blade strength and control, then sport-specific work, with return to sport decided on criteria. For a young athlete in a collision or overhead sport an early surgical opinion is raised, because that is where the trials favour stabilisation. Over 40, the rotator cuff is checked early.","reviewedOn":"2026-10-30"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of trigger point needling or injection as a treatment for shoulder instability was found. A PubMed search on 30 October 2026 pairing shoulder dislocation, shoulder instability and glenohumeral instability with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned nine records; the only needling trial was after surgery, adding dry needling to rehabilitation following a stabilisation repair (Halle, Int J Sports Phys Ther 2020).","fit":"Only where a tender band in the shoulder girdle muscles is adding to pain during rehabilitation. It does nothing for the instability.","reviewedOn":"2026-10-30"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No trial of a guided injection as a treatment for shoulder instability was found. A PubMed search on 30 October 2026 pairing shoulder dislocation, shoulder instability and glenohumeral instability with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned nine records, none testing an injection for an unstable shoulder.","fit":"Not a treatment for instability. Considered only for a separate problem in the same shoulder, such as an irritated subacromial bursa, on that problem's evidence.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-10-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Radial shockwave has not been studied in shoulder instability. A PubMed search on 30 October 2026 pairing shoulder dislocation and shoulder instability with shockwave, platelet-rich plasma, prolotherapy and dextrose terms returned 22 records, none testing shockwave in this condition.","fit":"May ease tender muscles around the shoulder blade during the strengthening program. It does not stabilise the joint.","reviewedOn":"2026-10-30"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested focused shockwave in shoulder instability. A PubMed search on 30 October 2026 pairing shoulder dislocation and shoulder instability with shockwave, platelet-rich plasma, prolotherapy and dextrose terms returned 22 records, none testing shockwave in this condition.","fit":"Not a treatment for an unstable shoulder. Considered only for a coexisting rotator cuff or calcific tendon problem, on that problem's evidence.","reviewedOn":"2026-10-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-10-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only for a separate problem","evidence":"No study of platelet-rich plasma as a non-operative treatment for shoulder instability was found. A PubMed search on 30 October 2026 pairing shoulder dislocation and shoulder instability with shockwave, platelet-rich plasma, prolotherapy and dextrose terms returned 22 records. The one clinical PRP study in this area injected it during arthroscopic labral repair, as a surgical adjunct, in a case-control design (Azharuddin, Shoulder Elbow 2025).","fit":"Not offered for the instability, which is a matter of the labrum, the bony socket and muscle control. Considered only for a separate problem in the same shoulder, such as a rotator cuff tendon, on that problem's evidence.","reviewedOn":"2026-10-30"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"No study of prolotherapy or dextrose injection for shoulder instability was found. A PubMed search on 30 October 2026 pairing shoulder dislocation and shoulder instability with shockwave, platelet-rich plasma, prolotherapy and dextrose terms returned 22 records, none testing prolotherapy in this condition.","fit":"Not offered for a dislocated or unstable shoulder. A torn labrum or bone lost from the socket is not something an injection repairs, and the routes with evidence are rehabilitation and, where warranted, surgical stabilisation.","reviewedOn":"2026-10-30"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"No study of hyaluronic acid injection for shoulder instability was found. A PubMed search on 30 October 2026 pairing shoulder dislocation, shoulder instability and glenohumeral instability with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned nine records.","fit":"Not offered. Hyaluronic acid is considered only for arthritis inside a joint, and instability is not arthritis.","reviewedOn":"2026-10-30"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of perineural injection in shoulder instability was found. A PubMed search on 30 October 2026 pairing shoulder dislocation, shoulder instability and glenohumeral instability with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned nine records, none testing it in this condition.","fit":"Not a treatment for instability, or for a nerve injured by the dislocation, which needs assessment and time. Considered only where a superficial nerve is separately part of the pain.","reviewedOn":"2026-10-30"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of nerve hydrodissection in shoulder instability was found. A PubMed search on 30 October 2026 pairing shoulder dislocation, shoulder instability and glenohumeral instability with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned nine records, none testing it in this condition.","fit":"Not a treatment for instability. Considered only where examination and ultrasound find a nerve entrapped separately from the joint problem.","reviewedOn":"2026-10-30"}}},{"slug":"shoulder-labral-tear","title":"Shoulder Labral Tear (including SLAP Tears)","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/shoulder-labral-tear","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"For degenerative structural problems, exercise matches surgery. A trial of 321 patients found exercise-based physiotherapy non-inferior to arthroscopic partial meniscectomy for knee function at five years, with the same rate of radiographic osteoarthritis progression (Noorduyn, JAMA Netw Open 2022), confirming an earlier trial at two years that also found better thigh strength in the exercise group (Kise, Br J Sports Med 2016). Even in adults aged 18 to 40 with MRI-verified tears, traumatic or not, early surgery was no better than twelve weeks of exercise and education at one year (Damsted, J Orthop Sports Phys Ther 2024).","fit":"A tear on a scan is not automatically the thing to fix. Rehabilitation comes first, with surgical review where the history, examination and imaging together point to a problem that loading will not solve: mechanical locking, instability, or a failure to progress despite doing the work.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Radial shockwave has not been studied in a labral tear. PubMed searches on 25 October 2026 for shockwave terms with labrum, labral, SLAP or shoulder instability (3 records, none a treatment study) and for radial device terms with shoulder tears, dislocation, instability or labral injury (12 records, all in the rotator cuff, the elbow or the knee) found nothing in this condition.","fit":"May help the tender muscle around the shoulder blade during rehabilitation. It does nothing for the labrum.","reviewedOn":"2026-10-25"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a labral tear or an unstable shoulder. A PubMed search on 25 October 2026 for shockwave, shock wave, ESWT or pressure wave with labrum, labral, SLAP or shoulder instability returned three records, none a shockwave treatment study (a kidney-stone trial named SLAP, a shoulder ultrasound review that excluded shockwave, and a frozen shoulder review). A trial pass over tears, ruptures and instability (12 records) found none at the labrum.","fit":"Not a treatment for a labral tear. Considered only for a coexisting rotator cuff or biceps tendinopathy, alongside the shoulder stability program.","reviewedOn":"2026-10-25"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Only studied alongside surgery","evidence":"Searched for PRP at the shoulder labrum, including SLAP tears. Ten records, and a second pass that added bone marrow concentrate, contained no trial or case series of an injection used on its own. The only comparative study used PRP during an operation: in 40 people having a keyhole Bankart repair for recurrent dislocation, PRP placed at the repair was followed by better shoulder scores and greater labral height on MRI at twelve months, in a comparison that was not randomised (Azharuddin, Shoulder Elbow 2025). One published case, a woman with a SLAP tear, cuff tendinosis and frozen shoulder together, improved after three injections and physiotherapy, in a report that says it was not assessing whether the injection worked (Klausing, Cureus 2026). A panel of 71 shoulder surgeons could not reach agreement on any role for biologic injections in the non-operative care of posterior labral problems (Hurley, Arthroscopy 2024).","fit":"Not something to rely on for a torn labrum. Rehabilitation is the core of non-operative care, and a surgical opinion is the next step where the shoulder stays unstable or keeps catching. PRP may come up where a painful cuff tendon sits alongside the labral tear, and the evidence for that belongs to the tendon, not the labrum.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested prolotherapy in a glenoid labral tear. An Orthoregeneration Network review lists prolotherapy among the biological options studied around the shoulder, including the labrum, but grades the whole field level V expert opinion with mixed results and names no labral prolotherapy study (Condron, Arthroscopy 2021).","fit":"Nothing about an injection reattaches a torn labrum. Considered only for the surrounding capsule and cuff pain that often accompanies the tear, and never presented as a repair.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"There is no trial of hydrodissection for a labral tear, and the technique does not repair one. What has been published is two case reports in which shoulder pain attributed to a labral tear settled when a nerve was treated rather than the labrum: a national-level gymnast whose pain and restricted elevation resolved immediately after hydrodissection of the thoracodorsal and axillary nerves (Omodani, Cureus 2024), and an arm wrestler with persistent front-of-shoulder pain and weak internal rotation after labral debridement, who became pain-free within a month after hydrodissection of the lower subscapular nerve combined with subscapularis retraining (Naoi, Cureus 2025). Single cases, and both authors say so.","fit":"Only where the assessment suggests a nerve is driving the pain alongside the labral finding. Worth considering, since labral tears are often seen on scans of shoulders that do not hurt. The shoulder itself is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"shoulder-osteoarthritis","title":"Shoulder Osteoarthritis","region":"Shoulder","url":"https://www.backpaindoctor.com.au/conditions/shoulder-osteoarthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested any needling technique in shoulder osteoarthritis. A search pairing dry needling, trigger point needling and trigger point injection with arthritis of the shoulder, elbow, wrist, thumb base and big toe returned 19 records, and none tested needling in an arthritic shoulder; the shoulder records were reviews of other ultrasound-guided procedures (Messina, Br J Radiol 2015) or concerned the rotator cuff. A second pass restricted to clinical trials returned five records, none at this joint.","fit":"Only where the assessment finds a separate tender muscle band around the shoulder reproducing part of the pain. It does not treat the arthritic joint.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Large placebo effect","evidence":"Injections into an arthritic shoulder reliably improve symptoms, but so do dummy injections. In a multicentre double-blind randomised trial of 300 people, three weekly hyaluronate injections improved pain by 19.9 mm on a 100 mm scale against 16.3 mm for buffered saline, a difference that was not statistically significant (Kwon, J Shoulder Elbow Surg 2013). A meta-analysis found hyaluronic acid reduced pain by 26.2 mm at three months (95% CI 22.0 to 30.3) while noting that control groups improved to a similar degree (Zhang, J Shoulder Elbow Surg 2018). A systematic review of 1,125 shoulders found consistent but modest benefit from hyaluronic acid, limited evidence for platelet-rich plasma and stem cell preparations, and a 7.2 per cent complication rate (Migliorini, Eur J Med Res 2025); in a double-blind randomised trial of 70 people, ultrasound-guided platelet-rich plasma and hyaluronic acid were no different from one another at any point over 12 months, and both improved (Kirschner, Clin J Sport Med 2022).","fit":"Reasonable when pain is blocking the strengthening and range work, with the size of the likely benefit set out. Used sparingly: see the note on cortisone.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies at this joint","evidence":"Searching shockwave, shock wave, ESWT and radial shockwave against shoulder and glenohumeral osteoarthritis returns no trial of either device in this condition, and restricting the same search to randomised trials returns a single record which turns out to be about rotator cuff tendon pain rather than arthritis (Saggini, J Biol Regul Homeost Agents 2010). The shoulder shockwave literature is calcific tendinopathy and rotator cuff disease, which are different problems at different structures.","fit":"Offered for the tender muscle around an arthritic shoulder, commonly the cuff and the muscle between the shoulder blade and the spine, rather than for the joint. If the scan shows a calcific deposit or a cuff tendon problem alongside the arthritis, that is where shockwave has its evidence.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial has tested shockwave for shoulder osteoarthritis: searching shockwave, shock wave and ESWT against shoulder and glenohumeral osteoarthritis returns no study of either device. The case for it rests on other arthritic joints. Pooled trials at the knee favour shockwave over sham for pain and function (Tang, Int J Surg 2024), and at the hip a 148-person trial found focused shockwave better than sham (Şah, J Pers Med 2022). Shockwave's own evidence at the shoulder is in calcific tendinopathy and rotator cuff disease, which are separate conditions with their own guides.","fit":"A reasonable option to try on the strength of the knee and hip trials, with the gap at this joint explained. Most useful where a cuff tendon problem or calcific deposit is contributing alongside the arthritis, since that is where the shoulder evidence is. Alongside the movement and strength programme, not instead of it.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"One trial, equal to hyaluronic acid","evidence":"One randomised trial at this joint, and it found no difference from the comparison injection. Seventy people with glenohumeral osteoarthritis were randomised, double-blind, to a single ultrasound-guided injection of leukocyte-poor PRP or hyaluronic acid into the joint. Pain and function improved in both groups from one to two months and stayed improved to twelve months, with no difference between them at any point and no effect of how many platelets the PRP contained (Kirschner, Clin J Sport Med 2022). There was no dummy-injection arm, and hyaluronic acid itself did not clearly beat saline in a 300-person trial at this joint (Kwon, J Shoulder Elbow Surg 2013), so how much of the improvement was due to either injection is not known. Outside trials the picture is thin. In a French multicentre review of arthritic shoulders in people under 50, 28 were treated with PRP and 88 with viscosupplementation, and together these were reported to postpone joint replacement by an average of 3.5 years in 86% - pooled, retrospective and uncontrolled (Kany, Orthop Traumatol Surg Res 2020). In a single-clinic series, the 12 treated for shoulder arthritis had the poorest results of any group at six months, with unsatisfactory outcomes outnumbering satisfactory ones (Godek, Ortop Traumatol Rehabil 2022). A systematic review of injections for this condition judged the evidence for PRP and other orthobiologics limited (Migliorini, Eur J Med Res 2025).","fit":"Can be discussed where shoulder arthritis pain is limiting the range and strengthening work and simpler measures have not been enough, with the evidence stated as it is: one trial, no better than the comparison injection, and no trial against a dummy injection. Reviewed at about three months and not repeated without a clear benefit.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy in shoulder arthritis. A search on 12 October 2026 for dextrose or prolotherapy in arthritis of the shoulder returned seven records. A systematic review of injected biological treatments at the shoulder found five prolotherapy studies, all in rotator cuff problems, and no study in glenohumeral arthritis that met its criteria (Robinson, J Back Musculoskelet Rehabil 2021). The nearest report is a single man with long-standing shoulder pain, not stated to be arthritis, injected into the joint, the acromioclavicular joint, the space under the acromion and the supraspinatus attachment, who reported 90% less pain after three sessions (Seenauth, Altern Ther Health Med 2018). The trials of dextrose injection into an arthritic joint are in the knee and the fingers (Chen, Clin Rehabil 2022; Reeves, J Altern Complement Med 2000).","fit":"Prolotherapy is offered here and can be discussed for shoulder arthritis pain that persists despite a shoulder exercise program, with the absence of studies at this joint stated. Where the rotator cuff is the main source of pain, the cuff evidence on that page is the better guide. Any injection is there to make the exercise work possible, not to replace it.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Edge over saline too small to feel","evidence":"Searched PubMed for hyaluronic acid, hyaluronate, hyaluronan, viscosupplementation or hylan with glenohumeral or shoulder osteoarthritis: 21 records with a trial filter and 8 reviews. Two large multicentre trials compared hyaluronic acid with saline injected into the shoulder joint, and both missed their main goal. In 660 people with persistent shoulder pain, five or three weekly injections did not beat saline at 13 weeks; the people with arthritis did better than saline over 26 weeks in a secondary analysis (Blaine, J Bone Joint Surg Am 2008). In 300 people with shoulder arthritis, three weekly injections improved pain by 20 mm on a 100 mm scale against 16 mm with saline at 26 weeks, which was not a significant difference; in those with no other shoulder problem the gap was 4 mm (Kwon, J Shoulder Elbow Surg 2013). A review found the difference from placebo never reached the smallest change patients notice (Colen, Int J Shoulder Surg 2014), and a diclofenac-hyaluronate conjugate was no better than placebo in the shoulder group of a four-joint trial (Kubo, BMC Musculoskelet Disord 2022). On the other side, a meta-analysis of 15 trials and 1,023 people found less pain than after a cortisone injection, and better results with physiotherapy than physiotherapy alone (Familiari, J Orthop Res 2023), and a 2025 review called the benefit consistent but modest (Migliorini, Eur J Med Res 2025).","fit":"May be discussed for shoulder arthritis where cortisone is unsuitable or has been used repeatedly, to settle pain enough to keep the strengthening and range-of-movement program going. Expect an improvement close to what a saline injection gives, possibly a little more, and longer-lasting than cortisone.","reviewedOn":"2026-10-26"},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial has tested hydrodissection in shoulder osteoarthritis. Hydrodissection, hydrorelease, hydrodilatation, brisement and perineural injection searched against glenohumeral and shoulder osteoarthritis returned three records: a clinical commentary proposing capsular hydrodilatation with physiotherapy, with no outcome data (Liotta, Int J Sports Phys Ther 2025); a single retrospective case of a proprietary amniotic-membrane allograft injected by hydrodissection (Sullivan, Orthop Nurs 2025); and a narrative review (Vargas-Figueroa, Cureus 2025): distending the joint capsule is a different procedure from separating a nerve from surrounding tissue.","fit":"Only if assessment suggests a separate nerve pain source alongside the arthritis; suprascapular nerve pain is the pattern that occasionally fits.","reviewedOn":"2026-09-29"}}},{"slug":"slipped-disc-bulging-disc","title":"Slipped Disc and Bulging Disc","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/slipped-disc-bulging-disc","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"The muscle around a painful disc is a separate, treatable target from the disc itself. A randomised trial of 100 people with lumbar disc herniation found trigger-point-directed needling improved pain, movement and quality of life more than standard acupuncture (Li, Zhen Ci Yan Jiu 2024). Against that, the largest trial of trigger point injection in low back pain randomised 180 people to injection or standard care alone and found no difference in pain or function (Lajeunesse, Ann Emerg Med 2025). No trial has used the dilute glucose solution used here.","fit":"Directed at tender muscle, never at the disc. Offered as an adjunct where examination reproduces part of your pain from a muscle band, and only alongside the loading work that does the real job.","reviewedOn":"2026-09-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small, short-term effect","evidence":"The same evidence as the disc herniation guide, and the same caveat: these are epidural corticosteroid injections given under X-ray or CT by a radiologist or pain specialist, not ultrasound-guided injections. Twenty-five placebo-controlled randomised trials in 2,470 people found epidural corticosteroid probably better than a placebo injection for short-term leg pain, by 4.9 points on a 0 to 100 scale (95% CI -8.8 to -1.1), and for short-term disability by 4.2 points (-6.0 to -2.2), with moderate-quality evidence and mostly minor side effects (Oliveira, Spine 2020). A review of 90 randomised trials put it at roughly one extra person helped for every four treated in the short term, with too little evidence to judge pain beyond six months (Armon, Neurology 2025). An injection does not shrink a bulge or repair a disc.","fit":"Not performed here. Considered as a referral where leg pain is severe or is not settling, and framed as buying a working window rather than fixing the disc. A bulging disc on a scan is a common finding in people with no pain at all, so the decision follows the symptoms rather than the image. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the disc","evidence":"The same tested absence as the disc herniation guide this page describes in plainer terms: searching lumbar disc herniation, disc herniation, sciatica and radiculopathy against shockwave, shock wave and ESWT returned nine records and no trial of shockwave for a bulging or herniated disc. Benefit has been shown in non-specific chronic low back pain, where 22 studies of 1,749 patients found pain -1.14 (95% CI -1.47 to -0.80) and Oswestry disability -6.01 (-7.97 to -4.05), still lower at three months (Wu, Medicine 2023), and ten randomised trials of 455 people found pain at one month a standardised mean difference of -0.81 (-1.21 to -0.42) with no serious adverse events (Yue, Biomed Res Int 2021). Neither tells you anything about a disc.","fit":"Not a treatment for the disc itself. It is offered for the tender back and buttock muscle that commonly comes with a disc problem, and that muscular component is often a bigger part of the day-to-day pain than the disc is.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Not for the disc","evidence":"A tested absence for the disc and nerve root: shockwave, shock wave and ESWT crossed with disc herniation, herniated, radiculopathy, sciatica, spinal stenosis and spondylolisthesis returned ten records on 19 October 2026, and none is a trial of shockwave for a bulging or herniated disc. The nearest controlled evidence is a sham-controlled trial of focused shockwave in 40 people with chronic low back pain and a worn L5/S1 disc, in which the benefit over sham lasted only to the end of treatment and disability never differed (Rajfur, Med Sci Monit 2022).","fit":"Not a treatment for the disc or a compressed nerve root. Considered only for a separate tender muscle or attachment contributing to the pain, once any leg symptoms are being managed on their own terms.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Searched 20 October 2026 (the searches named on the sciatica page: 26 nerve-root records and 13 trial and review records). For a bulging or prolapsed disc that is pressing on a nerve, PRP has been tested only as an injection beside the nerve root, and only against cortisone. The largest trial, 124 people under ultrasound guidance, found no difference at any point over twelve months (Xu, Neural Plast 2021). Smaller trials found cortisone ahead in the first weeks and PRP ahead later: at six and twelve weeks in 107 people (Sonkar, J Clin Orthop Trauma 2026), and at six weeks and six months in a double-blind trial of 46 that was level again at one year (Gupta, Asian Spine J 2024). Pooled, cortisone was better at one month and PRP 1.5 points better on the 0 to 10 pain scale at six months in three trials and 132 people (Ermawan, Spine Surg Relat Res 2025), while a larger pooling found nothing between them after four weeks (Wang, J Orthop Surg Res 2025). The certainty of this evidence has been graded very low (Kubrova, Biomedicines 2022). Injecting PRP into the disc itself is a different procedure, and was no better than saline at twelve months in the largest trial, with one disc infection (Schepers, Interv Pain Med 2022). For a bulge with back pain and no nerve symptoms there is no trial.","fit":"Not offered here: PRP is not injected into a disc or beside a nerve root in this clinic. A bulging disc on a scan is a common finding that is frequently unrelated to the pain, so the first question is whether the disc is the problem at all. Where leg pain from a disc has not settled, an image-guided nerve-root injection is a referral conversation, and on these trials PRP is an alternative to cortisone there rather than a clear improvement on it. The rehabilitation program is what carries most people through.","reviewedOn":"2026-10-20"},"prolotherapy":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"The trials in disc-related back pain disagree. A 2026 systematic review of twelve studies found pain relief lasting six to twenty-four months, though only three were randomised (Nazwar, J Anaesthesiol Clin Pharmacol 2026), while an American Pain Society evidence review found prolotherapy not effective for low back pain (Chou, Spine 2009) and the one randomised epidural prolotherapy trial showed no benefit past forty-eight hours (Desai, Pain Practice 2020).","fit":"Nothing about this injection repairs a bulging disc. It is considered only where tender ligaments or attachments are contributing to the pain, and only after core care.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Hyaluronic acid has been put into a lumbar disc, but only as the carrier for something else. In trials of intradiscal stem-cell injection it is the fluid the cells are suspended in and one of the comparison arms rather than the treatment being tested: 100 people in the first (Amirdelfan, Spine J 2020) and 404 in a larger trial whose main measure of success was not met (Beall, Spine J 2025). Its other use is as an additive to a nerve root block, where in 44 people it reduced the flare of pain in the first fortnight but made no difference by six weeks or to function (Ko, Spine J 2018). Neither of those is lubrication of a joint.","fit":"Not offered for this problem. A bulging disc is not a joint that can be lubricated, and bulges are common findings on scans in people with no pain at all.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. No controlled study has tested dextrose injected just under the skin for a bulging or slipped disc. The nearest records are an uncontrolled series of 654 people with low back pain or disc herniation that used subcutaneous 5% dextrose as a test injection before prolotherapy and reported large improvements without a comparison group (Solmaz, J Back Musculoskelet Rehabil 2022), and a randomised trial of 5% dextrose given into the epidural space rather than under the skin, which beat saline for 48 hours but not at two weeks (Maniquis-Smigel, Anesth Pain Med 2016).","fit":"Not a treatment for the disc itself. Considered only where a tender superficial nerve in the back or buttock is part of the pain alongside the disc.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 29 October 2026: radiculopathy, radicular pain, sciatica, nerve root, disc herniation or spinal stenosis with dextrose, 5% glucose, D5W, hydrodissection, hydrorelease, perineural injection or neural prolotherapy (53 records, all read), with a randomised-trial pass, a systematic-review pass and a pass on ultrasound-guided cervical root injection. Hydrodissection has not been tested for a bulging or slipped disc as such. Its only lumbar study is an uncontrolled series of 46 people with nerve-root leg pain of unstated cause, in whom saline-and-lignocaine hydrodissection around the root lowered leg pain from 7.1 to 3.8 out of 10 at three months, with no comparison group (Arima, Spine Surg Relat Res 2026). In the randomised trials of injections for a herniated disc, saline used as the control often did nearly as well as cortisone: 158 people with no difference in function at three months or in surgery at a year (Carette, N Engl J Med 1997). A disc bulge seen on a scan without nerve-root symptoms is common in people with no pain and is not a target for this treatment.","fit":"Only where a disc is irritating a nerve root and causing leg pain that has not settled with time and rehabilitation, and then as an alternative to a cortisone nerve-root injection, with the thin evidence stated. Back pain with a bulge on the scan but no nerve-root signs is treated by the options higher up this page.","reviewedOn":"2026-10-29"}}},{"slug":"snapping-hip","title":"Snapping Hip","region":"Hip & Pelvis","url":"https://www.backpaindoctor.com.au/conditions/snapping-hip","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"The strongest evidence here is what does not work. In a placebo-surgery controlled trial, arthroscopic subacromial decompression gave no benefit over a sham operation or over exercise therapy, at two years, at five, and at ten (Paavola, BMJ 2018; Paavola, Br J Sports Med 2020; Kanto, BMJ 2025). A network meta-analysis of 54 trials and 3,893 patients found shoulder-specific exercise reduced pain out to 52 weeks, and that adding injections, manual therapy or electrotherapy to it added little (Silveira, PLoS One 2024).","fit":"Loading the shoulder properly is the treatment. An injection is occasionally used to settle pain enough to start, which is a different claim from treating the problem.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled series only","evidence":"No randomised trial was found. In 40 people with a painful snapping hip, anaesthetic injected into the iliopsoas bursa gave complete or partial relief in 29; of the 18 who also had triamcinolone and did not go on to surgery, 16 reported sustained relief (Blankenbaker, Skeletal Radiol 2006). In 68 people with iliopsoas tendinopathy, bursitis or snapping hip, ultrasound-guided corticosteroid injection into the bursa was followed by better pain and function at three and six months, without a comparison group (Smith, Kans J Med 2024). A 2025 systematic review of six uncontrolled studies found pain falling from 7.3 to 2.5 out of 10, 29% going on to surgery and no complications reported (Katz, JBJS Rev 2025); it mixes snapping hip with other iliopsoas problems. No injection study was found for the outer (iliotibial band) form of snapping hip.","fit":"Stretching, strengthening and movement retraining come first. For a painful inner snapping hip that is not settling, a guided injection around the iliopsoas tendon may be discussed, both for relief and to confirm where the pain is coming from. See the note on cortisone.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched 18 October 2026 (the searches named in the focused row: 14 shockwave records and 14 trial and review records on snapping hip, all read). The old line here said the trials in this condition used focused devices; there are no shockwave trials in snapping hip with either device. The only mention is an editorial suggesting shockwave for mild external snapping (Zhang, Arthroscopy 2022). The radial evidence at the outer hip is in greater trochanteric pain syndrome, a different diagnosis.","fit":"Radial reaches the band over the outer hip, near the skin, so it is plausible for painful external snapping alongside a strengthening program; patients are told no trial has tested it in this condition.","reviewedOn":"2026-10-18"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched 18 October 2026: shockwave, shock wave or ESWT with snapping hip, coxa saltans, snapping or iliopsoas (14 records), and a randomised-trial and systematic-review pass on snapping hip (14 records), all read. No clinical study of shockwave in snapping hip, internal or external. The two randomised trials in the results were in a snapping shoulder blade, a different condition. The only mention is an editorial suggesting shockwave, physiotherapy or injection for mild external snapping before surgery is considered (Zhang, Arthroscopy 2022). The shockwave trials at the outer hip are in greater trochanteric pain syndrome, a related but different diagnosis.","fit":"Plausible for painful external snapping over the outer hip, alongside a hip-strengthening program, and can be discussed on that basis, but patients are told the trials have not been done in snapping hip.","reviewedOn":"2026-10-18"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched for PRP in snapping hip and in iliopsoas tendon and bursa problems. Five records, and no study of a snapping hip of either kind. The only clinical report at the iliopsoas is a safety study in three people whose tendon was catching on a hip replacement: one improved almost completely and two still had groin pain afterwards (Homma, Regen Ther 2023). The PRP trials sometimes quoted for the outer hip are in gluteal tendon pain, which is a different problem from a band snapping over the bone and is covered on its own page.","fit":"Not part of the plan for a snapping hip, which usually settles with a strengthening and movement-control program. With no study in this condition, PRP is not something to choose ahead of that. If tendon pain at the outer hip is the real problem, that is assessed and treated as such.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report only","evidence":"No trial or case series of prolotherapy for a snapping hip was found. A PubMed search on 13 October 2026 (prolotherapy, dextrose or hyperosmolar with snapping hip, coxa saltans or the iliopsoas tendon) returned two records, and a pass restricted to randomised trials, systematic reviews and meta-analyses returned none. One is a published case letter describing ultrasound-guided prolotherapy for a snapping hip caused by gluteus medius tendinopathy; it has no abstract and its outcome has not been read (Hung, Pain Med 2015). The other describes two people with ischiofemoral impingement, a different condition, treated with polydeoxyribonucleotide, a different injectate (Kim, Pain Pract 2014).","fit":"Can be discussed where a painful snap persists despite a targeted rehabilitation program and the pain is coming from an irritated tendon, with the single-case evidence stated. A painless snap needs no injection.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"There is no trial of hydrodissection in snapping hip. The only published report at this site is a single case of internal, iliopsoas-type snapping hip diagnosed on dynamic ultrasound and treated with ultrasound-guided hydrodilatation of the iliopsoas bursa (Chang, Kaohsiung J Med Sci 2019): distending a bursa with fluid, which is a different procedure from separating a nerve from the tissue around it.","fit":"Only where the assessment finds a nerve contributing to the hip or groin pain alongside the snapping. The snapping itself is a movement and loading problem and is treated by the options higher up this page.","reviewedOn":"2026-09-15"}}},{"slug":"spondylolysis","title":"Spondylolysis (Pars Stress Fracture)","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/spondylolysis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Load is what builds bone; nothing else offered here does. A meta-analysis of 80 studies and 5,581 postmenopausal women found exercise improved bone mineral density at the lumbar spine, femoral neck and total hip, and that supervision was not required for the effect (Mohebbi, Osteoporos Int 2023). A network meta-analysis of 97 trials found every exercise type beat no exercise at the femoral neck, with resistance training ranking best for total hip (Zhang, J Clin Nurs 2021). Moderate-to-high impact loading also improves bone structure, not just density, and the effect is site-specific. It accrues where the load is applied (Ng, J Bone Miner Res 2023).","fit":"For a bone stress injury the sequence is relative rest until it settles, then a graded return to load that is progressed slowly enough for the bone to keep up. For bone density, the loading is the treatment and it has to continue. The gains reverse when it stops. Energy availability, vitamin D and medical contributors are assessed alongside it.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial evidence in pars stress injury. Protective paraspinal muscle guarding is common alongside the bone injury and is treated as muscular pain.","fit":"Occasionally used for secondary muscular pain once the diagnosis and the loading plan are settled. It does not treat the fracture.","reviewedOn":"2026-08-30"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Injection has no role in bone healing, and corticosteroid is generally avoided around a healing stress injury. An image-guided injection is occasionally used diagnostically in established, long-standing pars defects where the source of pain is genuinely unclear.","fit":"Not part of treating the fracture. Used only as a diagnostic step in selected chronic cases.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Vibration applied over a healing bone stress injury is not appropriate, and there is no study supporting it here.","fit":"Not used for a pars injury.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Radial pressure waves lose energy within the first few centimetres of tissue. The pars sits deep to the paraspinal muscles, beyond useful radial penetration. Focused shockwave is the device that reaches that depth and the one that carries the bone-healing literature, so where shockwave is discussed at all for this injury it is focused, not radial.","fit":"Not used for a pars injury. See focused shockwave above.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study of shockwave aimed at a pars defect was found. Search on 2026-10-22: PubMed, shockwave terms with spondylolysis, pars interarticularis, pars defect, spondylolisthesis or scoliosis (10 records, all read), with a trial and systematic-review pass. The one report that touches it is a 69-year-old with a slip and pars defects whose radial shockwave went to the buttock and thigh muscles within nine months of mixed care, so its effect cannot be separated out (Chu, Cureus 2026). The shockwave bone literature is in long bones: 73% union across 1200 long-bone non-unions on systematic review (Sansone, J Clin Med 2022), and equivalence with surgery for hypertrophic long-bone non-union in a randomised trial of 126 patients (Cacchio, JBJS Am 2009), with a small series in resistant stress fractures in athletes (Taki, Am J Sports Med 2007). A Cochrane review of acute fracture found only one shockwave trial and rated the evidence very low certainty (Searle, Cochrane 2023). None of that has been tested at the pars, which is a different bone in a different loading environment.","fit":"Not part of the standard plan. Where shockwave is considered at all for an established pars non-union (after an adequate trial of activity restriction and rehabilitation) focused is the appropriate device: it is the one with the bone-healing literature behind it, and the only one that reaches the depth of the pars. The gap in the evidence is explained before any such conversation.","reviewedOn":"2026-10-22"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Not part of managing a bone stress injury. Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of any kind was found. A PubMed search on 11 October 2026 pairing platelet, platelet-rich, bone marrow aspirate and orthobiologic terms with spondylolysis, pars interarticularis, pars defect, pars fracture, pars stress and pars repair returned no records, and a second search using the abbreviation PRP returned four, none of them about a pars injury. There is nothing to report in either direction: no benefit shown and no harm described.","fit":"Not part of managing a pars stress injury. Time away from extension and impact loading, then a graded return through rehabilitation, is the treatment, and nothing published suggests an injection would add to it.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study in this condition","evidence":"No study of prolotherapy for a pars stress injury or defect. PubMed searches on 16 October 2026 (prolotherapy, dextrose or hypertonic glucose with spondylolysis, pars interarticularis or spondylolisthesis, 10 records; then prolotherapy with spondylolisthesis, pars or spinal instability, 1 record) found no trial, series or case report in this condition. Spondylolisthesis appears only as a listed cause of back pain in a review of prolotherapy for low back pain (Mociu, Medicina 2025).","fit":"Not part of managing a healing bone stress injury, which an injection into ligament cannot repair. Load management and progressive rehabilitation lead.","reviewedOn":"2026-10-16"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A treatment for an arthritic peripheral joint, with no application to a stress fracture.","fit":"Not used for this condition.","reviewedOn":"2026-08-30"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study of perineural injection in spondylolysis (pars stress injury) was found. Searching perineural injection, neural prolotherapy, subcutaneous and perineural dextrose, glucopuncture, Lyftogt and neurofascial terms against spondylolysis, spondylolisthesis, the pars interarticularis and stress fracture, with separate passes for randomised trials and systematic reviews, returned no study in this condition.","fit":"Not part of managing this condition.","reviewedOn":"2026-11-04"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Trapped nerve, not the pars","evidence":"No study of hydrodissection for spondylolysis was found, and it does not act on the bone. Two case reports bear on it indirectly. A 14-year-old girl with an L5 pars defect on imaging turned out to have her pain from superior cluneal nerve entrapment: a steroid injection over the iliac crest relieved it, one over the pars defect did not, and she reported at least 90% improvement after surgical release of the nerve (Ruan, J Am Acad Orthop Surg Glob Res Rev 2023). Separately, a 41-year-old man with a slow-to-heal stress fracture of a lumbar transverse process (a different part of the vertebra) had an 80% immediate and 95% sustained fall in pain after three weekly ultrasound-guided 5% dextrose hydrodissections, with the fracture healing on follow-up imaging (Yoon, Cureus 2025). Neither is a pars stress injury treated with hydrodissection, and single cases cannot show cause.","fit":"Not a treatment for the pars injury. Considered only where assessment finds a trapped nerve, such as the superior cluneal nerve, contributing to the pain.","reviewedOn":"2026-11-04"}}},{"slug":"sprains-strains-soft-tissue-injuries","title":"Sprains, Strains and Soft-Tissue Injuries","region":"General","url":"https://www.backpaindoctor.com.au/conditions/sprains-strains-soft-tissue-injuries","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Case series in professional athletes","evidence":"Searched 8 November 2026 (PubMed: muscle strain and contusion, ligament sprain, and wrist and finger sprain searches with corticosteroid, steroid or anaesthetic injection, 23, 51 and 13 records; and a randomised-trial and systematic-review pass, which found no controlled trial of corticosteroid or anaesthetic injection for a fresh strain or sprain). The positive evidence is uncontrolled and comes from professional sport: one NFL team's 58 intramuscular corticosteroid and anaesthetic injections for severe hamstring injuries, with 16% of players missing a game and no complications (Levine, Am J Sports Med 2000), and another team's 37 injections for strains and sprains, with every player returning and no complications (Drakos, HSS J 2014). For pain persisting after a sprain, series exist at the knee (Jones, Knee 2008: 34 people, deep MCL, sustained relief at 20 months) and the ankle (Xu, Zhongguo Gu Shang 2024: 88 people, sinus tarsi, 65% recurrence within a year). Against: a placebo-controlled trial of PRP with local anaesthetic in acute ankle sprains found no benefit (Rowden, J Emerg Med 2015); local anaesthetic injected into muscle damages muscle fibres (Reurink, Sports Med 2014); and in Australian rugby league, ankle and wrist injections given to keep playing were judged less safe than others at long-term follow-up (Orchard, Am J Sports Med 2010).","fit":"Not a routine treatment for a fresh strain or sprain, which is protected movement and progressive loading. Considered for a specific problem identified on assessment, most often pain that has persisted from one structure, as an adjunct that lets the rehabilitation program progress. See the note on cortisone.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"One small trial, no sham","evidence":"There is no shockwave trial in a fresh sprain or strain. In persistent ankle sprains, one randomised trial of 30 people added shockwave to joint mobilisation and compared it with mobilisation alone: the shockwave group gained more on the Karlsson ankle function score (about 20 points against 14), but there was no sham, no between-group test in the abstract, no follow-up after treatment and no named device type (Aslam, Insights J Health Rehabil 2025). The one study naming its device in a ligament injury used focused shockwave (Hoshika, JSES Int 2025). PubMed searches for shockwave with sprain, ligament injury or soft-tissue injury (34 records, all read) and a trial and systematic-review pass (17 records) found no radial trial in an acute sprain or strain.","fit":"Not part of early care. Considered once pain persists well beyond the expected healing time, mainly for the tender muscle and fascia around the injury, alongside the rehabilitation program.","reviewedOn":"2026-10-23"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small studies in persistent sprains","evidence":"There is no shockwave trial in a fresh sprain or strain. In persistent ligament problems the evidence is small and unblinded. In 63 young baseball pitchers with an elbow ligament (ulnar collateral) injury still painful after two months of physiotherapy, those who chose to add focused shockwave returned to sport more often than those who did not (86% against 59%) and started throwing a week sooner; the groups were not randomised (Hoshika, JSES Int 2025). In persistent ankle sprains, one 30-person randomised trial of shockwave added to joint mobilisation reported larger gains in ankle function, without a sham, a between-group test in the abstract, or a named device type (Aslam, Insights J Health Rehabil 2025). PubMed searches for shockwave with sprain, ligament injury or soft-tissue injury (34 records, all read) and a trial and systematic-review pass (17 records) found no trial in an acute sprain or strain. Shockwave for muscle strains is covered on the hamstring and calf pages.","fit":"Not part of early care for a fresh sprain or strain. Discussed for a ligament or tendon attachment that is still painful months later, as an add-on that helps the person get back to loading while the rehabilitation program does the main work.","reviewedOn":"2026-10-23"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"The answer depends on the tissue, and for most sprains and strains it is not established. Muscle strains: the hamstring is the one muscle with randomised trials of its own, and they disagree. Pooled, return to sport was about a week sooner across nine trials and 474 people on limited-quality evidence (Bensa, Sports Med Open 2026), while the largest double-blind trial found no benefit over a placebo injection in 80 athletes (Reurink, N Engl J Med 2014; Br J Sports Med 2015), and re-injury was no less common, 15% against 16% (Nakagawa, Br J Sports Med 2026). No clinical study has tested it in a calf strain or a muscle bruise. Ligament sprains: in a small double-blind trial in severe ankle sprains, PRP was no better than a saline injection for pain or function (Rowden, J Emerg Med 2015), and in 21 people with a moderate sprain an advantage at eight weeks had gone by 24 weeks (Blanco-Rivera, Foot Ankle Surg 2019). The exception is the high ankle sprain, where a randomised trial in 16 elite athletes found return to play at 41 days against 60 (Laver, Knee Surg Sports Traumatol Arthrosc 2015). A German-Austrian-Swiss consensus found no clear evidence that any injection into an injured muscle helps (Hotfiel, J Exp Orthop 2018).","fit":"Not offered for an acute muscle tear. These are monitored and rehabilitated. A torn muscle has already bled into the injury, so an injection of concentrated platelets is unlikely to add to what is there. Protection, graded loading and a staged return to sport are what change the outcome. For ligament sprains the answer differs by ligament and is set out on the ankle sprain, high ankle sprain and knee ligament pages.","reviewedOn":"2026-10-10"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Ankle trials: balance, not pain","evidence":"Prolotherapy has been tested against saline in ligament sprains at one site only, the ankle, and only once a sprain has become long-standing. In 114 people with chronic ankle instability, four dextrose injections into the anterior talofibular ligament did not change the main instability score at one year, but improved a balance test and reduced repeat sprains (Sit, Arch Phys Med Rehabil 2025); in 27 people with a chronic ankle ligament sprain, dextrose plus home physiotherapy was no better than saline plus physiotherapy for pain at 12 weeks (Wu, Arch Phys Med Rehabil 2025). For sprains at the knee's medial collateral ligament, the wrist, the fingers and the high ankle, the same search found a single knee case report and nothing else. Across chronic soft-tissue injury more broadly, a network meta-analysis of 87 trials, mostly shoulder and elbow tendon problems, found no statistically significant pain advantage for prolotherapy over other therapies overall (Goh, PLoS One 2021). No trial in an acute sprain or a muscle strain was found. PubMed search, 14 October 2026: prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain, ankle instability, collateral ligament or syndesmosis terms (21 records), and prolotherapy with ligament, ankle, wrist, finger, thumb or soft-tissue injury terms (121 records, all screened), each with randomised-trial and systematic-review passes.","fit":"Not for a fresh sprain or strain, which is managed with graded rehabilitation. Can be discussed for a ligament that stays painful or unstable months after a completed rehabilitation program, with the evidence for that site stated. The rehabilitation program remains the treatment.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Tested once, in one joint. In 158 competitive athletes with a mild to moderate ankle sprain, hyaluronic acid injected around the ligaments within 48 hours and again on day four, on top of rest, ice, compression and elevation, gave less pain at day eight than a placebo injection and a return to sport at 11 days against 17 (Petrella, Clin J Sport Med 2007), with fewer repeat sprains over two years, 7 against 16 (Petrella, Phys Sportsmed 2009). That is a single research group, the injection went around the joint rather than into it, and a meta-analysis of 19 randomised trials in soft-tissue problems found no second sprain trial to set beside it (Khan, Sports Health 2022). Searches at the wrist, finger, knee ligament and syndesmosis, and in muscle strains and contusions, found no trial at all.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and a sprain or strain is not one.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"This treatment has not been tested in a fresh sprain or strain. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against sprain, strain, muscle injury, contusion and the common injury sites returns 23 records, and the only one that treats an injury with this technique is in the long-standing ankle sprain: 25 people with chronic ankle instability, two sessions of neurofascial 12.5% dextrose a month apart, large improvements in instability and pain scores at six months, no comparison group (Kazempour Mofrad, Anesth Pain Med 2022). A randomised-trial search over any dextrose injection for a sprain, strain or muscle injury finds one trial, also in the chronic ankle sprain, where 15% dextrose was no better than saline for pain or ankle function over 12 weeks (Wu, Arch Phys Med Rehabil 2025). No study was found for a muscle strain, a bruised muscle, or a wrist, finger or syndesmosis sprain. Two harm reports are worth knowing: complex regional pain syndrome after a small skin nerve was injured during prolotherapy for a lateral ankle sprain (Kim, Medicine 2021), and a fibrous nodule needing surgery after repeated prolotherapy in a finger (Oh, J Surg Case Rep 2023).","fit":"Not part of treating a new sprain or strain. Occasionally worth discussing much later, where tender, hypersensitive skin or nerve-type pain persists over the injured area after the tissue has healed and a proper rehabilitation programme has had a fair trial.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small series, persistent pain only","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with sprain, ligament injury, syndesmosis, contusion or the ligaments of the knee, wrist and hand, 5 records; with quadriceps and thigh terms, 24 records; with tendon rupture terms, 23 records; a randomised-trial and systematic-review pass returned none), together with this programme's 3 and 6 November searches of hamstring, calf and ankle injuries. No trial exists, and no study treated a fresh strain or sprain. The largest study is a series of seven people with pain persisting at least eight weeks after a hamstring injury and thickened tissue around a skin nerve on ultrasound: after an ultrasound-guided injection of 6 mL saline with 0.17% lignocaine, pain fell from 10 to under 1 out of 10, with no adverse events over a mean of 6.6 months, but there was no comparison group and three people needed two to four sessions (Shiwaku, J Funct Morphol Kinesiol 2025). Single case reports describe a nerve caught after an ankle sprain and freed this way (Zhu, Clin Case Rep 2026; Wu, Diagnostics 2024) and the sural nerve after recurrent calf strains (Fader, Orthopedics 2015).","fit":"Not a treatment for a fresh strain or sprain, which is protected movement and progressive loading. Where pain persists months later and ultrasound shows a nerve caught in the healing tissue, hydrodissection may be discussed as a way to let the rehabilitation program progress.","reviewedOn":"2026-11-10"}}},{"slug":"foot-ankle-stress-fracture","title":"Stress Fractures of the Foot and Ankle","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/foot-ankle-stress-fracture","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Load is what builds bone; nothing else offered here does. A meta-analysis of 80 studies and 5,581 postmenopausal women found exercise improved bone mineral density at the lumbar spine, femoral neck and total hip, and that supervision was not required for the effect (Mohebbi, Osteoporos Int 2023). A network meta-analysis of 97 trials found every exercise type beat no exercise at the femoral neck, with resistance training ranking best for total hip (Zhang, J Clin Nurs 2021). Moderate-to-high impact loading also improves bone structure, not just density, and the effect is site-specific. It accrues where the load is applied (Ng, J Bone Miner Res 2023).","fit":"For a bone stress injury the sequence is relative rest until it settles, then a graded return to load that is progressed slowly enough for the bone to keep up. For bone density, the loading is the treatment and it has to continue. The gains reverse when it stops. Energy availability, vitamin D and medical contributors are assessed alongside it.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":false},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Not appropriate over a systemic inflammatory process, healing bone, an area of osteonecrosis or a complete tendon or ligament rupture.","fit":"Not offered for this.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"No study of radial shockwave in a stress fracture was found. A search on 11 November 2026 for radial shockwave or pressure wave with stress fracture, medial tibial stress syndrome, nonunion or delayed union returned 20 records, of which 17 were read. The only human bone reports for the radial device are in fractures that failed to unite, not in stress fractures: a retrospective series of 22 non-united fractures of bones close to the skin, in which 16 (73%) had united on X-ray at six months, with no comparison group (Kertzman, J Orthop Surg Res 2017), and single cases in a child's thigh bone (Shang, Front Surg 2025) and an adult collarbone (Yue, World J Clin Cases 2021). An uncontrolled series and two case reports are not enough to offer it for bone. The trial evidence for bone union is with the focused device and is set out in the focused row.","fit":"Not offered for the bone. Focused is the form used here for bone union, where shockwave is considered for a stress fracture that has not healed on a proper offloading programme.","reviewedOn":"2026-11-11"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"The bone evidence is in RESISTANT injury rather than acute. Shockwave healed resistant stress fractures in athletes that had failed conservative and operative treatment (Taki, Am J Sports Med 2007), and in long-bone nonunion 73% of 1,200 cases united (Sansone, J Clin Med 2022), with a randomised trial finding it as effective as surgery for hypertrophic nonunion (Cacchio, J Bone Joint Surg Am 2009). For an acute, uncomplicated stress fracture the Cochrane evidence remains uncertain (Searle, Cochrane 2023).","fit":"Relevant to a stress fracture that has not united on a proper offloading programme, not to a fresh one. Focused is the only form that reaches bone.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"A few case reports only","evidence":"No controlled study has tested PRP for a stress fracture. A PubMed search in October 2026 pairing platelet-rich plasma and related platelet products with stress fracture, bone stress injury, the fifth metatarsal and the navicular returned 13 records, and the reports in people are small and uncontrolled. Seven professional footballers with fractures of the fifth metatarsal at the two sites known for slow healing were treated with a boot, calcium and vitamin D and PRP injections, and returned to training at 43 to 50 days with no recurrence at six months; the paper lists stress fracture as a keyword without saying how many of the seven were stress fractures (Bezuglov, Foot Ankle Spec 2022). Three teenage athletes with long-standing sesamoid injuries went back to running and jumping six to nine weeks after a single injection, their own doctors noting that other parts of their care probably contributed (Le, Phys Sportsmed 2022). One teenage sprinter whose stress fracture of the big toe had not healed after three months healed six weeks after PRP combined with shockwave (Omodani, Cureus 2024). In every report PRP was given with other treatment, so its own contribution cannot be separated. A 2024 review concluded that the role of biologic injections in stress fractures is still undetermined and that randomised trials have been registered but not yet reported (Jacob, J ISAKOS 2024). The nearest controlled evidence is in slow-healing fractures of the long bones: 40 people were randomised to a platelet injection at the fracture or to observation, and 78% against 59% went on to heal, a difference that was not statistically significant (Samuel, Eur J Orthop Surg Traumatol 2018).","fit":"Not part of the standard care of a stress fracture, which is offloading, a graded return to load and attention to bone health, with surgical review for the higher-risk sites. PRP can be discussed only for a fracture that is slow to heal on a proper offloading program, on the understanding that it rests on a handful of uncontrolled cases.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study has tested prolotherapy in a foot or ankle stress fracture. Two case reports describe dextrose injection or hydrodissection used near stress fractures elsewhere (a lumbar transverse process and a scapular body) with the injection aimed at the surrounding soft tissue rather than the bone (Yoon, Cureus 2025; Yoon, Diagnostics 2025).","fit":"Not offered for the fracture. A stress fracture heals with load reduction and time, and the work that matters is finding why the bone failed: training load, energy availability, vitamin D and bone density.","reviewedOn":"2026-09-05"},"viscosupplementation":{"reviewed":false},"perineural":{"reviewed":false},"hydrodissection":{"reviewed":false}}},{"slug":"syndesmosis-injury","title":"Syndesmosis Injury (High Ankle Sprain)","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/syndesmosis-injury","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Trainer survey only","evidence":"Searched 8 November 2026 (PubMed: syndesmosis or syndesmotic with corticosteroid, steroid, anaesthetic or lidocaine injection, within a 51-record sprain search; and a randomised-trial and systematic-review pass, which found no trial). No study has measured the result of an injection for a high ankle sprain. In a 1999 mailed survey, 23 of 30 National Football League head athletic trainers listed corticosteroid injection among the treatments they believed shortened recovery, while the author noted that no treatment had been shown to return players early and safely (Doughtie, J Athl Train 1999). A review of foot and ankle injections in athletes judges the evidence inconclusive (Ochoa, Sports Health 2021), and a review of professional footballers advises preferring other injections to corticosteroid because of long-term health effects (Jader, Int Orthop 2024).","fit":"Not a treatment for a high ankle sprain, which is protected loading and a staged return to sport, with surgical review where the joint is unstable. Considered only for a specific complication identified on assessment.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave, radial or focused, in a high ankle (syndesmosis) sprain. A PubMed search for shockwave with syndesmosis or syndesmotic injury, ankle sprain or ankle instability (9 records, all read) found none in this injury, and a trial and systematic-review pass over shockwave in ligament injuries (17 records) found none either. The nearest evidence is one small unblinded trial in persistent lateral ankle sprains (Aslam, Insights J Health Rehabil 2025).","fit":"Not part of early management. Considered only if pain persists well beyond the expected healing time, and then for the tender muscle and soft tissue around the ankle rather than the injured ligament.","reviewedOn":"2026-10-23"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a high ankle (syndesmosis) sprain. A PubMed search for shockwave with syndesmosis or syndesmotic injury, ankle sprain or ankle instability (9 records, all read) found none in this injury, and a trial and systematic-review pass over shockwave in ligament injuries (17 records) found none either. The nearest evidence is one small unblinded trial in persistent lateral ankle sprains (Aslam, Insights J Health Rehabil 2025), a different ligament and a different injury.","fit":"Not part of early management, which is about protecting the joint and, for an unstable injury, a surgical opinion. It may become a question only if pain persists in the ligament well after healing, and then without trial evidence in this injury.","reviewedOn":"2026-10-23"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Unusually for an acute ligament injury, the syndesmosis trials are positive, but they are very small. In a randomised trial of 16 elite athletes with anterior inferior tibiofibular ligament tears, ultrasound-guided PRP shortened return to play from 59.6 to 40.8 days and left less residual pain (Laver, Knee Surg Sports Traumatol Arthrosc 2015). A controlled pilot in 10 rugby union players against 11 matched historical controls found the same direction of effect, with better agility and vertical jump on return (Samra, BMJ Open Sport Exerc Med 2015). A review of injection therapy in professional footballers singles out the syndesmosis as one of the few sites where PRP may have a role, while calling for proper trials (Marin Fermin, Int Orthop 2024).","fit":"Worth a conversation where the injury is confirmed on imaging and a firm return-to-sport deadline is the reason for asking. Both studies were in elite athletes with full-time rehabilitation behind them, if that is not your situation the case is weaker, and time remains the main treatment.","reviewedOn":"2026-09-02"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy for a high ankle (syndesmosis) sprain was found. A PubMed search on 14 October 2026 (prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain, ankle instability, collateral ligament or syndesmosis terms, 21 records; prolotherapy with ligament or ankle terms, 121 records, all screened, with randomised-trial and systematic-review passes) returned one record naming the syndesmosis: a case report using a different injectate (polydeoxyribonucleotide) for a tendon problem after syndesmotic screw fixation, which does not bear on this injury. The nearest evidence is in a different ligament, the chronic lateral ankle sprain, where two randomised trials against saline found better balance and fewer repeat sprains but no difference in pain or in the main instability score (Sit, Arch Phys Med Rehabil 2025; Wu, Arch Phys Med Rehabil 2025).","fit":"An unstable syndesmosis needs imaging and often a surgical opinion, which an injection does not replace. For a stable injury that stays painful despite a completed rehabilitation program, prolotherapy can be discussed, with the absence of any study in this ligament stated.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Untested. A search pairing hyaluronic acid with syndesmosis, high ankle sprain and tibiofibular terms returned four records, and none was a treatment study of this injury. Two were laboratory studies, one described hyaluronic acid given into the ankle joint after keyhole surgery for impingement (Sun, Zhongguo Gu Shang 2016), and one was a review of injections in professional footballers, which gives hyaluronic acid a role only for cartilage injury (Jader, Int Orthop 2024). The one ankle sprain trial, in 158 athletes, enrolled mild to moderate lateral sprains, not syndesmosis injuries (Petrella, Clin J Sport Med 2007).","fit":"Not offered for this problem. A syndesmosis injury is managed with protection and graded loading, and the stability of the joint decides whether a surgical opinion is needed.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested dextrose injections of any kind for a syndesmosis injury. Searching dextrose and prolotherapy against syndesmosis and the muscle-injury terms returns no study of this ligament, and the one record that mentions the syndesmosis is about a tendon problem three years after syndesmosis surgery, treated with a different injectate (Lim, Medicine 2016). The nearest evidence is at the outer ankle ligaments, in long-standing sprains. Twenty-five people with chronic ankle instability had two sessions of neurofascial 12.5% dextrose a month apart and improved markedly on instability and pain scores by six months, with no comparison group (Kazempour Mofrad, Anesth Pain Med 2022). In a randomised trial of 27 people with a chronic anterior talofibular ligament sprain, 15% dextrose was no better than saline for pain or ankle function over 12 weeks (Wu, Arch Phys Med Rehabil 2025). Skin nerves at the front and outer side of the ankle can be the source of pain that lingers after a sprain: a handball player with three months of nerve pain down the outer shin and top of the foot after an ankle sprain improved for three weeks after an ultrasound-guided anaesthetic block and fluid injection around the superficial peroneal nerve, and needed a further procedure for lasting relief (Martins da Silva, Cureus 2023). There is also a harm report: complex regional pain syndrome after a small skin nerve was injured during prolotherapy for a lateral ankle sprain (Kim, Medicine 2021).","fit":"Not part of treating the ligament injury itself. Considered only much later, if tender, hypersensitive skin or nerve-type pain over the front or outer ankle persists once the ligament has healed.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with sprain, ligament injury, syndesmosis, contusion, collateral ligament, volar plate, scapholunate or triangular fibrocartilage, 5 records; a randomised-trial and systematic-review pass on these injuries returned none). No study has tested hydrodissection for a high ankle sprain, and none of the five records mentions the syndesmosis. What exists after ordinary ankle sprains is three single case reports of a nerve caught after the injury and freed with an ultrasound-guided fluid injection: the sural nerve (Zhu, Clin Case Rep 2026), the medial plantar nerve, where pain fell from 8 to 2 out of 10 after two sessions of 5% dextrose with local anaesthetic (Wu, Diagnostics 2024), and the superficial peroneal nerve, with three weeks of relief (Martins da Silva, Cureus 2023). None had a comparison group, and none was a syndesmosis injury.","fit":"Not a treatment for a high ankle sprain, which is protection, a graded return to loading and, for an unstable joint, fixation. Considered only where burning, tingling or numbness persists after the injury and ultrasound shows a nerve caught in the healing tissue.","reviewedOn":"2026-11-10"}}},{"slug":"tarsal-tunnel-syndrome","title":"Tarsal Tunnel Syndrome","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/tarsal-tunnel-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line, and a long trial","evidence":"Conservative care is the mainstay: footwear and orthoses to offload the nerve including a medial heel wedge for overpronation, activity modification, calf stretching, tibialis posterior strengthening and nerve gliding. One review recommends a trial of at least 12 to 24 months before surgery is considered, unless there is wasting, motor involvement or an identified lesion.","fit":"The starting point, alongside looking hard for a treatable cause. Diabetic polyneuropathy is the mimic that matters most and is assessed at the same time.","reviewedOn":"2026-09-13"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search for dry needling, trigger point treatment, acupuncture and prolotherapy in tarsal tunnel syndrome returned six records and not one of them treats this condition with needling. Three are studies of surgical nerve decompression in diabetic neuropathy that happen to measure vibration sense, and the rest name tarsal tunnel syndrome only as something to exclude when assessing heel pain.","fit":"Only where a separate tender band of calf muscle is reproducing part of the pain. It does nothing about the compression in the tunnel.","reviewedOn":"2026-09-14"},"guidedInjection":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"Corticosteroid injection into the tarsal tunnel is both therapeutic and diagnostic, and the response carries some prognostic information about whether decompression is likely to help. In 61 people with tarsal tunnel syndrome, an ultrasound-guided injection around the tibial nerve improved both symptoms and measured nerve conduction, and the authors use that response to predict who will do well from surgery (Iborra, Front Neurol 2023). Injection is described as a bridge to surgery rather than a replacement for it, since decompression remains the definitive treatment where a structure is compressing the nerve (Urits, Pain Ther 2020).","fit":"Given under ultrasound, which also shows the causes worth finding: ganglion, varicose veins, accessory muscle, tenosynovitis. Not a substitute for decompression where a structural cause is compressing the nerve.","reviewedOn":"2026-09-14"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search for vibration therapy in tarsal tunnel syndrome returned no records at all. Every record that mentions vibration at this nerve is using vibration sense as a way of measuring the nerve, not as a treatment.","fit":"Not a treatment for the compressed nerve, and not applied over it. Considered only where tight calf muscle is a separate contributor.","reviewedOn":"2026-09-14"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No randomised trial of shockwave in tarsal tunnel syndrome. The published material is a case report in post-burn tarsal tunnel syndrome, and the nerve entrapment trial literature is carpal tunnel syndrome.","fit":"Not offered as a treatment for this condition. Where plantar fasciitis is the actual problem, that is a different page and shockwave does have support there.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No randomised trial in tarsal tunnel syndrome.","fit":"Not offered as a treatment for this condition.","reviewedOn":"2026-09-13"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of EMTT in this condition.","fit":"Not part of managing this condition.","reviewedOn":"2026-09-13"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published trial of PRP in tarsal tunnel syndrome.","fit":"Not offered for this condition.","reviewedOn":"2026-09-13"},"prolotherapy":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No outcome study of prolotherapy in tarsal tunnel syndrome. An anatomical paper maps the ultrasound approach to the lower part of the tunnel specifically so that prolotherapy, PRP and hydrodissection can be delivered there accurately, but it reports technique rather than results (Fernandez-Gibello, Healthcare 2024).","fit":"Not relevant to this diagnosis. There is no painful attachment to treat, and the problem is space around the nerve.","reviewedOn":"2026-09-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for hyaluronic acid, hyaluronate or viscosupplementation at the tarsal tunnel or the tibial nerve returned no study of this treatment in this condition. A review of injections across the whole foot discusses hyaluronic acid for a Morton's neuroma but names nothing for the tarsal tunnel (Urits, Pain Ther 2020), and there is no joint here to inject.","fit":"Not offered for this problem.","reviewedOn":"2026-09-14"},"perineural":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"No dextrose trials","evidence":"Injection immediately around the tibial nerve at the ankle has been studied in 61 people and improved both symptoms and measured nerve conduction, but the fluid was dilute local anaesthetic given to confirm the diagnosis and predict the result of surgery, not dextrose given as a treatment (Iborra, Front Neurol 2023). No trial has tested a course of dilute dextrose here.","fit":"Considered where burning and hypersensitivity in the sole persist and the compression itself has been dealt with. Framed as unproven at this nerve.","reviewedOn":"2026-09-14"},"hydrodissection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Emerging, not established","evidence":"Ultrasound-guided approaches to the tibial nerve at the ankle are described, but the outcome literature is small series and cadaveric work. The randomised hydrodissection evidence is in carpal tunnel syndrome and does not transfer.","fit":"Discussed for persistent symptoms where no space-occupying lesion has been found and surgery is being avoided, framed as emerging. A ganglion or accessory muscle compressing the nerve needs treating on its own terms.","reviewedOn":"2026-09-13"}}},{"slug":"tendinopathy-overview","title":"Tendinopathy (Overuse Tendon Pain)","region":"General","url":"https://www.backpaindoctor.com.au/conditions/tendinopathy-overview","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No trial evidence for needling the tendon itself as a treatment for tendinopathy. Tender muscle bands in the same limb are a separate problem and are treated as such.","fit":"Used for associated muscular pain where it is limiting the rehabilitation programme.","reviewedOn":"2026-08-30"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Corticosteroid gives short-term relief in several tendinopathies but performs worse than exercise at longer follow-up, and repeated injections around tendon are avoided. Where an injection is used, ultrasound confirms the target and keeps the needle out of the tendon itself.","fit":"Occasionally used to settle pain enough to start loading, not as the treatment. The loading programme is the treatment.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"As with focused shockwave, the answer is site-specific, and at some sites the two devices do not perform the same way. The category-level statements made for shockwave in tendon pain are not supported by the trial evidence.","fit":"Assessed per tendon rather than as a treatment for tendinopathy in general.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"There is no single answer for tendinopathy as a category: the trial evidence separates sharply by tendon, and this site rates each one individually. It is supported at some sites, of mixed benefit at others, and untested at several. At the lateral elbow the answer even inverts by device type. Reading a result from one tendon across to another is the most common error made with this treatment.","fit":"Whether shockwave is reasonable depends on which tendon, how long it has been symptomatic and what loading has already been tried. See the guide for your specific tendon, where the evidence for that site is set out.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Depends on the tendon","evidence":"The trials of PRP point in different directions at different tendons, so there is no single answer for tendinopathy. At the outer elbow, a pooled analysis of 11 randomised trials in 730 people found PRP slower than cortisone but better from six months on (Xu, Am J Sports Med 2024), and at the kneecap tendon, pooled analyses rank PRP among the best non-surgical options in the longer term (Chen, Arthroscopy 2019; Andriolo, Am J Sports Med 2019). At the Achilles, the largest trial, 240 people in 24 UK hospitals, found one PRP injection no better than a sham at six months (Kearney, JAMA 2021). At the outer hip, PRP outlasted cortisone in a Melbourne trial of 80 people (Fitzpatrick, Am J Sports Med 2018) but was no better than placebo in a double-blind trial of 79 (Atchia, J Bone Joint Surg Am 2025). At the hamstring origin the evidence is small case series with inconsistent results. Each tendon's page sets out its own trials.","fit":"Discussed only for a specific tendon, after a loading program has had a fair trial, and only where that tendon's evidence supports it. Loading rehabilitation remains the treatment; PRP is at most a way to get further with it.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Strongest at the elbow","evidence":"A systematic review of 20 randomised trials in 1,136 people found prolotherapy as good as or better than the comparison in 85% of trials across tendon problems, with most of the trials at the outer elbow, the rotator cuff and the plantar fascia, and few at the Achilles; 19 of the 20 used dextrose (Capotosto, Orthop J Sports Med 2024). The trials are mostly small and many compare prolotherapy with another active treatment rather than a dummy injection. Not every trial is positive: in a double-blind trial in 38 children with Osgood-Schlatter knee pain, dextrose did no better than saline (Nakase, Arch Orthop Trauma Surg 2019). At the kneecap tendon and the outer hip there are no trials. Each tendon's page sets out its own evidence.","fit":"Prolotherapy is offered here and discussed for a specific tendon, after a loading program has had a fair trial, with that tendon's evidence stated. Loading rehabilitation remains the treatment; the injection is a way to get further with it.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"Hyaluronic acid is used in arthritic joints, not in tendon.","fit":"Not used for tendon pain.","reviewedOn":"2026-08-30"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Perineural injection targets irritated small nerves rather than the tendon. It is not a tendinopathy treatment, and there is no evidence for it as one.","fit":"Relevant only where assessment suggests a nerve is contributing to the pain.","reviewedOn":"2026-08-30"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Hydrodissection is a treatment for a nerve that is tethered or compressed, not for a degenerative tendon.","fit":"Relevant only where a nerve problem sits alongside, or is mistaken for, the tendon problem.","reviewedOn":"2026-08-30"}}},{"slug":"tennis-golfers-elbow","title":"Tennis & Golfer's Elbow","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/tennis-golfers-elbow","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Dry needling evidence","evidence":"This is the best-evidenced needling target in the tendinopathy group, but the evidence is for dry needling rather than for an injection. A meta-analysis of 17 randomised trials in 979 people found dry needling improved pain within the first week (mean difference -0.95 points, 95% CI -1.88 to -0.02), elbow disability both within the first week and beyond it (SMD -1.37, -1.88 to -0.86; and -1.32, -2.23 to -0.40) and grip strength, with better pain results when the needling produced a local twitch response (Ma, Arch Phys Med Rehabil 2024). An earlier meta-analysis of seven trials in 320 people found similar effects on pain (SMD -1.13, -1.64 to -0.62) and disability (SMD -2.17, -3.34 to -1.01), rated low to moderate certainty and concentrated at short term (Navarro-Santana, Clin Rehabil 2020). The injection trials at this elbow test the tendon with platelet-rich plasma, corticosteroid or dextrose rather than testing a trigger point.","fit":"Directed at tender bands in the forearm extensor or flexor muscles that reproduce part of your pain, alongside the loading programme. Expect the benefit to be early and to need the loading work behind it.","reviewedOn":"2026-09-11"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Worse than placebo at a year","evidence":"This is one of the few places where a corticosteroid injection has been shown to leave people worse off. That is evidence of harm, not an absence of evidence. In 165 people with tennis elbow, those given a corticosteroid injection were less likely than those given a placebo injection to be completely recovered or much improved at one year (83% against 96%) and far more likely to have had a recurrence (54% against 12%); adding physiotherapy did not change that (Coombes, JAMA 2013). Pooling the trials against no intervention, corticosteroid gave a large benefit at four weeks (SMD 1.44, 95% CI 1.17 to 1.71) that had reversed by six months (-0.40, -0.67 to -0.14) and at one year (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). At the inner elbow, a double-blind trial in 60 elbows found methylprednisolone ahead of saline at six weeks and no different at three months or one year (Stahl, J Bone Joint Surg Am 1997). Ultrasound guidance does not rescue it: in 44 people, ultrasound-guided corticosteroid injections were no better than injections placed by feel at four or twelve weeks (Malahias, Handchir Mikrochir Plast Chir 2018).","fit":"A corticosteroid injection is not offered for the tendon here, for the reason above. The injections with supporting trials at this elbow are platelet-rich plasma and prolotherapy, each rated in its own row, alongside the loading programme. See the note on cortisone.","reviewedOn":"2026-10-02"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Where the device subgroups were separated, RADIAL shockwave showed a benefit on pain in lateral epicondylitis and focused did not (Yoon, Clin Orthop Relat Res 2020, confirmed in the accompanying CORR Insights commentary). A 40-trial network meta-analysis ranked shockwave the best option for grip strength recovery and better than corticosteroid injection (Liu, Arthroscopy 2022).","fit":"The form of shockwave the evidence supports for this diagnosis. Offered where symptoms have run beyond six months, which is the subgroup that benefited.","reviewedOn":"2026-08-30"},"focusedShockwave":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Evidence mixed","evidence":"Genuinely contested, and the device matters. A 40-trial network meta-analysis found shockwave beat placebo for short and medium-term pain and ranked best of all options for grip strength recovery (Liu, Arthroscopy 2022), and a 2025 umbrella review found it beats both ultrasound therapy and corticosteroid injection (Zhu, J Orthop Traumatol 2025). Against that, two large reviews found no clinically important difference versus sham (Yoon, Clin Orthop Relat Res 2020; Karanasios, Clin Rehabil 2021), and Yoon's device subgroup found the benefit was in RADIAL shockwave, not focused.","fit":"Where shockwave is used for tennis elbow here, radial is the form the evidence supports. Worth knowing that shockwave outperformed corticosteroid injection in both network syntheses.","reviewedOn":"2026-08-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"A meta-analysis of 11 randomised trials and 730 patients found PRP worse than corticosteroid in the first two months but clearly better at six months and beyond: VAS mean difference -2.18, DASH -8.13, Mayo Elbow Performance Score +16.53 (Xu, Am J Sports Med 2024). A 2-year four-arm randomised trial of 231 patients found PRP the best of PRP, prolotherapy, shockwave and physiotherapy at 24 months, with a DASH reduction of 31.2 points against 17.6 for shockwave (Lhee, Am J Sports Med 2025).","fit":"The strongest long-term data of any injection option for tennis elbow. The trade-off is that it is slower than corticosteroid to take effect, and dearer.","reviewedOn":"2026-08-30"},"prolotherapy":{"reviewed":true,"status":"supported","statusLabel":"Good support","tag":"Good support","evidence":"A 40-trial network meta-analysis ranked dextrose prolotherapy the single best option for both short-term and medium-term pain relief in lateral epicondylitis (SUCRA 87.3% and 98.6%) (Liu, Arthroscopy 2022). A 2-year randomised trial of 231 patients found prolotherapy outperformed both physiotherapy and shockwave at 24 months on DASH and satisfaction (Lhee, Am J Sports Med 2025). A systematic review of 20 randomised trials found prolotherapy superior or equal to control in 83% of lateral epicondylitis and rotator cuff studies (Capotosto, Orthop J Sports Med 2024).","fit":"One of the strongest indications for prolotherapy. Best data of any injection option here at two years apart from PRP.","reviewedOn":"2026-08-30"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here. A meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems, 1,629 patients in all, reported less pain than the comparison treatments overall, but its elbow group was two trials that disagreed sharply, with heterogeneity of 99% (Khan, Sports Health 2022). These are injections around a tendon, which is a different procedure from the joint injection in this row.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and this is a tendon problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A PubMed search returns no study of perineural dextrose injection in lateral or medial epicondylalgia. The dextrose nerve literature around the elbow and forearm concerns radial nerve palsy and radial nerve entrapment at the wrist, which are different diagnoses (Chen, Medicine 2018; Yoon, Diagnostics 2026).","fit":"Not offered for the tendon problem. It would only come into the conversation if the forearm symptoms proved to be nerve entrapment rather than tendinopathy, which is a change of diagnosis rather than an added treatment.","reviewedOn":"2026-09-05"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"The elbow hydrodissection evidence is for nerve entrapments that mimic or accompany tennis elbow, not for the tendon problem itself. In radial tunnel syndrome, which is readily mistaken for tennis elbow, 11 surgical candidates treated with ultrasound-guided hydrodissection all had complete symptom resolution lasting at least two years and none went on to surgery, alongside a review of seven studies covering 61 patients that reported benefit in every one (Gill, Curr Sports Med Rep 2022). A clinical review names radial tunnel syndrome and ulnar neuropathy at the elbow among the entrapments that may suit the technique in selected cases (Colorado, Muscle Nerve 2025). No study of hydrodissection for lateral or medial epicondylalgia itself was found.","fit":"Only where examination and ultrasound point to a nerve as part of the problem (the radial nerve in the radial tunnel, or the ulnar nerve at the elbow) rather than for the tendon at the epicondyle.","reviewedOn":"2026-09-08"}}},{"slug":"thoracic-outlet-syndrome","title":"Thoracic Outlet Syndrome","region":"Neck","url":"https://www.backpaindoctor.com.au/conditions/thoracic-outlet-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"First line where there is no weakness","evidence":"Conservative treatment is indicated first in the absence of motor signs. Across prospective studies in which patients had standardised physiotherapy and proceeded to surgery only on failure, 27–59% had a satisfactory result (Dengler, Dtsch Arztebl Int 2022). The components (anterior neck and chest stretching, scapular stabiliser strengthening, postural retraining and activity modification) are not standardised between centres, and the literature is vague on specifics.","fit":"The starting point, alongside ergonomic change, where there is no weakness or wasting. Weakness, loss of muscle bulk or hand wasting changes the plan: that goes to a surgical opinion within weeks rather than after a long trial of therapy.","reviewedOn":"2026-09-25"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No trials, and a safety caveat","evidence":"No trial of trigger point injection in neurogenic thoracic outlet syndrome. Botulinum toxin into the scalenes reduced pain but did not improve function scores, and that is a different intervention (Dengler, Dtsch Arztebl Int 2022). Manual trigger point therapy has been described helping a cervical-rib case (Głowa, J Bodyw Mov Ther 2024), without an injectate. The safety point is not theoretical: in a feasibility study needling the pectoralis minor in five cadavers and ten volunteers, a less experienced clinician punctured the pleura in one cadaver using the pincer approach, and the authors recommend a flat, ultrasound-guided approach instead (Sánchez-Sánchez, J Funct Morphol Kinesiol 2026).","fit":"Only where a separate myofascial contributor in the neck or shoulder girdle is identified, and under ultrasound. It does nothing about compression at the thoracic outlet.","reviewedOn":"2026-09-25"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Mainly diagnostic","evidence":"A properly performed scalene test injection is one of the four Society for Vascular Surgery diagnostic criteria (Illig, J Vasc Surg 2016). As treatment the picture is mixed: botulinum toxin into the anterior and middle scalenes reduced pain without improving DASH or paraesthesia scores, while one randomised crossover trial found corticosteroid injection reduced pain more than scalene stretching (Dengler, Dtsch Arztebl Int 2022).","fit":"Discussed chiefly for its diagnostic value where the criteria are otherwise borderline. Given the proximity of the brachial plexus and subclavian vessels, this is image-guided work and is best done by, or in concert with, the team who would manage any surgery.","reviewedOn":"2026-09-25"},"vactor":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for local vibration, vibration therapy and whole-body vibration against thoracic outlet syndrome and the scalene muscles returns no records at all, and the supraclavicular fossa contains the brachial plexus and subclavian vessels immediately beneath the skin.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"radialShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"No published trial of shockwave in neurogenic thoracic outlet syndrome. Shockwave is contraindicated over major nerve trunks and large vessels, and the brachial plexus and subclavian artery and vein all lie within the target area. The one report at this site is a harm report: a patient with a cervical rib and fibrous band was found at operation to have a ruptured fascicle in the lower trunk of the brachial plexus, with no history of trauma but repeated manual therapy and one session of shockwave to the neck beforehand (Nam, J Brachial Plex Peripher Nerve Inj 2025).","fit":"Not offered for this condition, on safety grounds as well as absence of evidence.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"No published trial, the same harm report applies (Nam, J Brachial Plex Peripher Nerve Inj 2025), and the anatomical objection applies with greater force to a focused device, which concentrates energy at depth: the depth at which the plexus and vessels sit.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search for EMTT and magnetotransduction against thoracic outlet syndrome and the scalene muscles returns no records at all, and there is no guideline support.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"prp":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"No trial of PRP in neurogenic thoracic outlet syndrome. A review of ultrasound-guided injections for refractory disease groups PRP and dextrose together as regenerative options that remain under investigation, with limited data and no robust clinical trials (Gharaei, Pain Physician 2025). There is no tendon or joint target here, and injecting around the brachial plexus is not an established indication.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"No trial of dextrose prolotherapy in neurogenic thoracic outlet syndrome; the review that names it for refractory disease places it among treatments still under research, without standardised protocols or trial data (Gharaei, Pain Physician 2025).","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Hyaluronic acid has been used in this condition, but as a surgical adhesion barrier rather than as an injection into a joint: it was credited with reducing recurrent scarring at reoperation in a fifty-year surgical series (Urschel, Ann Surg 1998), and a hyaluronic acid hydrogel wrap placed around the plexus at decompression surgery in 94 patients was safe with numerically but not significantly lower rates of persistent pain and reoperation (Cervantes Valadez, Hand 2026). Neither is viscosupplementation, and there is no joint at the thoracic outlet to viscosupplement.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"perineural":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Perineural injection targets irritated superficial cutaneous nerve branches. The problem in this condition is compression of a nerve plexus at the thoracic outlet, which is not that target.","fit":"Not offered for this condition.","reviewedOn":"2026-09-25"},"hydrodissection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"There is no trial of brachial plexus hydrodissection in neurogenic thoracic outlet syndrome. What exists is a single case, in which serial ultrasound-guided hydrodissection gave immediate and sustained relief in a patient whose plexus was tethered by a cervical rib (Yoon, Cureus 2026), and a review listing hydrodissection among the ultrasound-guided options for refractory disease (Gharaei, Pain Physician 2025). The randomised hydrodissection evidence in this region belongs to a different diagnosis: 60 people with dorsal scapular nerve entrapment did better when the injection was placed in the middle scalene than below the levator scapulae (Elawamy, J Pain Res 2026). Neither settles the question for a plexus lying alongside the subclavian artery and vein.","fit":"Not offered for this condition. Symptoms that persist after a fair trial of physiotherapy go to a vascular, neurosurgical or thoracic surgical opinion rather than to a further injectate.","reviewedOn":"2026-09-25"}}},{"slug":"thoracic-spine-pain","title":"Thoracic Spine Pain (Mid-Back Pain)","region":"Back","url":"https://www.backpaindoctor.com.au/conditions/thoracic-spine-pain","pairings":{"rehab":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Thin thoracic evidence","evidence":"No clinical guideline is written for thoracic spine pain alone, and the trials are small. In 100 adults with thoracic spinal pain, adding manipulation to strengthening exercise gave about 1 point less pain (out of 10) than exercise alone at the end of eight sessions, with no difference at 12 weeks (Waqas, Biomed Res Int 2023, open-label). In 34 people, real and placebo mobilisation both eased pain straight away (Pecos-Martin, Physiotherapy 2016), and a pilot of 30 found manipulation beat sham ultrasound after six sessions (Schiller, J Manipulative Physiol Ther 2001). None tested exercise alone against no treatment. Education and staying active are borrowed from low back pain guidance, which states it covers low back pain only (Australian Low Back Pain Clinical Care Standard, Med J Aust 2023).","fit":"The starting point, because it is low risk and the alternatives have less behind them, not because thoracic trials prove it. Screening for heart, lung, fracture, infection and cancer causes happens at the first visit, and exercise and manual therapy are framed as short-term helpers rather than a proven fix.","reviewedOn":"2026-10-04"},"wetNeedling":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Case reports only","evidence":"No controlled trial of dry or wet needling in thoracic spine pain was found. Searching thoracic pain with needling and trigger point terms returned case reports (one 78-year-old, Perry, Physiother Theory Pract 2021; one patient, Anandkumar, Physiother Theory Pract 2017; two soldiers, Rock, Int J Sports Phys Ther 2014) and an expert review noting there is little evidence that trigger points in the thoracic region are a source of pain (Fernandez-de-las-Penas, J Man Manip Ther 2015). Lung puncture has been reported after needling or trigger point injection of the back and chest wall (Reindorf, Cureus 2025; Weagle, Cureus 2021), and in a study of 202 ribs experienced therapists found the rib by touch only 73 per cent of the time (Cushman, J Bodyw Mov Ther 2021).","fit":"Only for a tender band in the muscles beside the spine that reproduces your pain, and not over the ribcage, where the lung lies close beneath the skin. It is a short-term muscle measure, not treatment of a joint or disc.","reviewedOn":"2026-10-04"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Small trials, no sham control","evidence":"When a thoracic facet joint is the suspected source, imaging-guided joint injection or medial branch block is used. A randomised trial of 40 people found both eased pain over six months, with 65 per cent (joint injection) and 40 per cent (nerve block) reporting at least half their pain gone and no significant difference between them, and no sham group (Lee, Spine 2018). A 2023 review found only three randomised trials of thoracic medial branch blocks or radiofrequency and graded the evidence moderate (Laxmaiah, Pain Physician 2023), and an earlier review noted the positive nerve-block studies came from one author group (Manchikanti, Pain Physician 2012). In pain-clinic patients, diagnostic blocks pointed to the facet joints in 34 to 48 per cent but with false-positive rates of 42 to 48 per cent (Boswell, Pain Physician 2015). On guidance, a 2025 narrative review holds that facet injections need imaging (Rekatsina, Pain Ther 2025) and a cadaver study placed 80 per cent of ultrasound-guided thoracic facet injections inside the joint (Hurdle, J Ultrasound Med 2011); no thoracic trial comparing guided with landmark injection was found.","fit":"Considered when examination points to a defined target, such as a facet joint, and pain is blocking rehabilitation. Always imaging-guided because of the lung and spinal canal nearby, and used sparingly. Not a treatment for undiagnosed pain, and serious causes are excluded first.","reviewedOn":"2026-10-04"},"vactor":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A search for vibration, percussion and magnetic therapies with thoracic, mid-back and upper-back pain terms returned five records, none of them a treatment study. The hits were studies of whole-body vibration at work, which is linked with more upper back pain (for example, mining dumper operators, Upadhyay, Work 2022), not local vibration as a therapy.","fit":"A comfort adjunct at most for tight muscle beside the spine. It does not treat a joint or a disc, and it is not part of the plan for this condition.","reviewedOn":"2026-10-04"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Neck and upper-back muscle trials only","evidence":"No shockwave trial in thoracic spine pain was found. The nearest evidence is in neck and upper-back muscle pain, where results differ: a 2025 double-blind trial of 70 people found radial shockwave no better than a no-energy placebo at 4, 8 and 12 weeks (Ogbeivor, BMC Musculoskelet Disord 2025), while other trials in upper trapezius trigger points report benefit over sham or ultrasound, and a meta-analysis of 10 trials found it did not beat dry needling or trigger point injection (Zhang, Arch Phys Med Rehabil 2020). A small retrospective comparison of 68 people with interscapular and trapezius pain used shockwave only as the comparison arm (Park, J Clin Med 2024).","fit":"Only where a tender trapezius or rhomboid muscle is clearly part of your pain. It addresses muscle, not the spine or ribs, and it is not used while a fracture, infection or tumour has not been excluded.","reviewedOn":"2026-10-04"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Upper trapezius trials only","evidence":"No focused shockwave study in thoracic spine pain was found. In upper trapezius myofascial pain a sham-controlled trial of 57 people found focused and radial shockwave both gave more pain relief than sham after the course, though over the one- to six-month follow-ups the difference between groups was no longer significant (Senlikci, Lasers Med Sci 2025), and a sham-controlled trial of 64 office workers found less pain, though the sham group also improved late (Vasvit, Complement Ther Med 2025). Both treated the neck-shoulder muscle, not the thoracic spine.","fit":"Rarely relevant. Reserved for a specific deep tender point in muscle found on examination, and treated on those limited terms.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not established","evidence":"A search for electromagnetic, magnetotransduction and magnetic stimulation therapies with thoracic and mid-back pain terms returned no study treating this condition.","fit":"Not part of managing this condition.","reviewedOn":"2026-10-04"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Not studied in the thoracic spine","evidence":"Searches of thoracic pain, thoracic facet and mid-back pain with PRP found no study of this treatment. A review of PRP in the spine searched for cervical and thoracic papers and found none, so it covered the lumbar spine only (Yum, Pain Physician 2024), and a 2025 review of PRP for facet joint pain found trials in the lumbar and cervical joints only (Manchikanti, Curr Pain Headache Rep 2025). In the lumbar facet, PRP was no better than corticosteroid at six months in a double-blind trial of 76 people (Geoffroy, Joint Bone Spine 2025).","fit":"Not offered for thoracic pain. If raised, it would be described as experimental, with the absence of any thoracic evidence part of the discussion.","reviewedOn":"2026-10-04"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No modern thoracic trial","evidence":"A 2005 critical review of prolotherapy for spinal pain found 31 clinical studies, of which only three concerned thoracic ('dorsal') pain, most of them observational and using very different mixtures and protocols (Dagenais, Spine J 2005). A search pairing dextrose, prolotherapy and PRP with thoracic pain terms found no newer study of the treatment in this condition; the one result was a retrospective series of 28 people in which dextrose was added to radiofrequency of the thoracic medial branches, which is a different procedure (Derby, Interv Pain Med 2021).","fit":"Not offered routinely. It could be discussed as experimental for persistent ligament-type pain after standard care, with the lack of a thoracic trial made clear.","reviewedOn":"2026-10-04"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A search pairing hyaluronic acid with thoracic pain, thoracic facet and mid-back pain terms returned no study of this treatment in this condition.","fit":"Not offered for this problem.","reviewedOn":"2026-10-04"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of perineural dextrose injection in thoracic spine pain was found. The nearest reports are of nerve entrapment in the mid-back rather than spinal pain: a series of 14 people with posterior cutaneous nerve entrapment, in whom 81 per cent had more than half their pain relieved by a local anaesthetic injection but long-term success was 57 per cent and needed surgery in most (Maatman, J Pain Res 2019), and a retrospective comparison of 68 people in which saline injection at nerve entrapment points beat shockwave for interscapular pain (Park, J Clin Med 2024). Neither used dextrose and neither had a controlled design.","fit":"Only where examination points to a superficial nerve pattern, such as a small area of tender, hypersensitive skin beside the spine. It does not treat a joint, disc or rib problem.","reviewedOn":"2026-10-04"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Retrospective reports only","evidence":"No controlled trial of hydrodissection in thoracic spine pain was found. A retrospective review of an ultrasound-guided technique that included hydrodissection of the dorsal scapular and spinal accessory nerves reported significant pain relief in interscapular and mid-thoracic myofascial pain (Modi, Interv Pain Med 2023), and a retrospective comparison of 68 people favoured saline at nerve entrapment points over shockwave (Park, J Clin Med 2024). Single case reports describe an erector spinae plane block for posterior cutaneous nerve entrapment (Minamii, BMJ Case Rep 2026). None had a control group, and the broader hydrodissection literature is mainly in limb nerve entrapment.","fit":"Only where a peripheral nerve in the mid-back or shoulder-blade region is implicated alongside the spinal pain, and offered with those limits explained. It is not a treatment for the thoracic joints or discs.","reviewedOn":"2026-10-04"}}},{"slug":"thumb-base-osteoarthritis","title":"Thumb Base Osteoarthritis","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/thumb-base-osteoarthritis","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is clear about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).","fit":"Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot: strength, capacity and weight.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No controlled trial has tested trigger point needling or injection at the thumb base. What exists is a case series of nine people given six sessions of periosteal dry needling, with pain 2.6 points lower at 12 weeks and no comparison group (Staehli Wiser, J Clin Med 2023); a controlled but non-randomised trial of 31 people in which a trigger point in the first dorsal interosseous muscle was treated by sustained pressure rather than a needle (Lopez-Royo, Int J Environ Res Public Health 2021); and a single case report of 5% glucose injected into the tender tissue, the procedure closest to this row's (Lam, Cureus 2025). The one sham-controlled needle trial at this joint was of acupuncture, and in 70 people real acupuncture did no better than non-penetrating sham needling (Barnard, J Hand Surg Eur Vol 2020).","fit":"Considered where a tender band in the thumb muscles is reproducing part of the pain. It does not treat the joint, and the only sham-controlled needle trial at the thumb base found no specific effect.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Depends on the injectate","evidence":"Cortisone into the thumb base has been tested against a dummy injection and did not come out ahead. In a double-blind randomised trial of 40 people, imaging-guided triamcinolone produced no improvement in pain at 24 weeks and no difference from saline on stiffness, tenderness or global assessment at any point (Meenagh, Ann Rheum Dis 2004), and a meta-analysis of ten randomised trials, two of them at this joint in 121 people, found repeated corticosteroid gave no benefit over placebo at 12 to 24 months (Donovan, Osteoarthritis Cartilage 2022). Other injectates have done better in comparative trials: adding hyaluronic acid to corticosteroid reduced pain on activity more than corticosteroid alone at three months in a randomised trial of 149 people (difference 1.1 points on a 0 to 10 scale, 95% CI 0.2 to 1.9), though grip and opposition strength were unchanged (Cormier, Joint Bone Spine 2025).","fit":"Discussed when a splint, load changes and hand therapy have not been enough. The choice of injectate matters more than the decision to inject, and cortisone alone is not the option the evidence supports here.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report, focused device","evidence":"Searching shockwave, shock wave, ESWT and radial shockwave against thumb carpometacarpal and hand osteoarthritis returns no randomised trial of either device, and the only report at this joint used the focused form rather than this one: a single 64-year-old woman given three weekly focused treatments, whose QuickDASH disability score fell from 20.5 to 2.3 and whose grip strength rose by about 30% over twelve months (Gustafsson, Front Rehabil Sci 2026). One patient, no control group, and a different device from the one this row describes.","fit":"Not a treatment for the thumb joint. Considered only where tender thenar or forearm muscle is a separate part of the pain, and alongside the splint and grip retraining that are what the evidence supports at this joint.","reviewedOn":"2026-09-25"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One encouraging case report","evidence":"There is one published report of focused shockwave at this joint, and it is encouraging, but it is one person. A 64-year-old woman with arthritis at the base of both thumbs, not helped by earlier treatment, had three weekly focused sessions: her QuickDASH disability score fell from 20.5 to 2.3 and her grip strength rose by 17% in one hand and 30% in the other at twelve months, with no side effects (Gustafsson, Front Rehabil Sci 2026). No randomised trial has been done at the thumb or anywhere in the hand. The trial evidence for shockwave in osteoarthritis is at the knee and hip (Tang, Int J Surg 2024; Şah, J Pers Med 2022).","fit":"A reasonable option to try where splinting and hand therapy have not been enough and you would like to avoid or defer an injection, with the thin evidence explained. The energy is adjusted to what you can comfortably tolerate at a small joint this close to the skin.","reviewedOn":"2026-10-04"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"No better than saline in two trials","evidence":"Tested in four randomised trials at the thumb base, and the two that used a dummy injection did not favour it. Ninety people were randomised, double-blind, to a single injection of PRP or saline into the joint. At six months pain on load had fallen by a median of 10 points out of 100 with PRP and not at all with saline, a difference that was not statistically significant (-10, 95% CI -20 to 0; p = 0.22), with no clinically relevant difference in function, grip or pinch (Evans, JB JS Open Access 2025). In a four-arm trial of 95 people, only fat combined with PRP reduced pain more than saline; PRP on its own did not (Winter, Plast Reconstr Surg 2023). Against other injections the results conflict. Two ultrasound-guided PRP injections beat two corticosteroid injections on pain, function and satisfaction at twelve months in 33 people (Malahias, Cartilage 2018). In 45 people randomised to PRP, hyaluronic acid or corticosteroid, all three helped at four weeks, but the PRP and corticosteroid gains had faded by twelve weeks and only hyaluronic acid still held (Abdelsabor Sabaah, Ortop Traumatol Rehabil 2020). A network meta-analysis of eight studies found no injection better than placebo for pain in the short term or for function at any point, with a medium-term pain advantage for PRP that rested on two studies (Thakker, J Orthop 2023) and was published before the larger saline-controlled trial.","fit":"Can be discussed when splinting, hand therapy and load changes have not been enough, with the position that a single injection did no better than saline in the best trial. The possible advantage is over cortisone at a year rather than over a dummy injection, and it is not offered as a way of rebuilding the joint.","reviewedOn":"2026-10-08"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Outlasted cortisone in one trial","evidence":"Tested in randomised trials at the thumb base, none of them large. In 60 people with thumb-base arthritis, three monthly injections of 20% dextrose were compared with one cortisone injection: cortisone was better at one month, the two were level at two months, and dextrose was ahead at six months by 1.1 points out of 10 for pain and 1.0 point on a function score (Jahangiri, J Orthop Sci 2014). In a double-blind trial of 27 people and 150 arthritic finger and thumb-base joints, dextrose injected on each side of each joint reduced pain on movement by 42% against 15% with a local-anaesthetic dummy injection and improved bending, but pain at rest and on gripping did not differ significantly (Reeves, J Altern Complement Med 2000). Pooling 14 randomised trials in 674 people with hand arthritis, dextrose improved pain and hand function at six months or more, ranked second to PRP, with no major adverse effects reported (Chen, Am J Phys Med Rehabil 2024). Against this, an earlier review of nine thumb-base trials found no injection shown to be better than placebo, though it had only one dextrose trial to judge (Riley, BMJ Open 2019).","fit":"Worth discussing for thumb-base pain that persists despite a splint, hand therapy and pacing, particularly where cortisone has helped only briefly. It is a slower treatment than cortisone, given as a short course, and the evidence is a handful of small trials. Hand therapy continues alongside it.","reviewedOn":"2026-10-12"},"viscosupplementation":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Little edge over placebo pooled","evidence":"Searched PubMed for the same hyaluronic acid terms with trapeziometacarpal, carpometacarpal, rhizarthrosis or thumb base (58 records; 9 trials and 13 reviews), plus a placebo and saline pass (20). Against placebo the trials disagree. In 60 people, hylan was no better than placebo on pain at any point to 26 weeks (Heyworth, J Hand Surg Am 2008). In 33 women with both thumbs affected, the hand given hylan improved on pain, function and pinch at 24 weeks while the saline hand did not (Figen Ayhan, Clin Rheumatol 2009). In 150 people, adding hyaluronic acid to a cortisone injection lowered activity pain by a further 1.1 points out of 10 at three months, but not at six or twelve (Cormier, Joint Bone Spine 2025). Pooled, injections into this joint have not been shown to beat placebo for pain (Riley, BMJ Open 2019, nine trials; Døssing, RMD Open 2023), with a function benefit in one pooling of two trials (Trellu, Joint Bone Spine 2015). Against cortisone the results run both ways: only hyaluronic acid was still helping at 12 weeks in a 45-person three-arm trial with PRP (Abdelsabor Sabaah, Ortop Traumatol Rehabil 2020), it was no worse in 56 (Fuchs, Osteoarthritis Cartilage 2006), and cortisone was better in 40 (Bahadir, Clin Rheumatol 2009).","fit":"May be discussed where cortisone is unsuitable or has worn off, alongside splinting and hand therapy. Any benefit is likely to be modest; the largest recent trial suggests a small, short-lived extra gain when it is added to cortisone.","reviewedOn":"2026-10-26"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"One case report only","evidence":"One published case describes this technique at the thumb base. A woman with advanced thumb base osteoarthritis had three sessions of palpation-guided glucopuncture, 0.5 mL of 5% dextrose under the skin at each painful point and 1 mL into painful muscle, with pain falling from 8 or 9 out of 10 to 0 or 1 and QuickDASH from 55 to 25, still holding at one year (Lam, Cureus 2025). That is a single uncontrolled case and cannot show cause. No trial of perineural injection at this joint was found.","fit":"Considered where examination finds tender, hypersensitive skin over the thumb base rather than pain coming from the joint line itself.","reviewedOn":"2026-09-16"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"One source addresses the thumb base directly and it reports no outcomes. A fifteen-point ultrasound-guided fascial hydrorelease protocol covering five overlapping causes of thumb pain includes carpometacarpal osteoarthritis, and proposes release around the radial artery on the hypothesis that fascial constriction contributes to it, which the authors describe explicitly as hypothesis-generating, calling for observational studies and randomised trials to test it (Kimura, J Funct Morphol Kinesiol 2026). No trial has tested hydrodissection at the thumb base.","fit":"Only where assessment finds a nerve or a gliding problem alongside the arthritis. The arthritis itself is treated by the options higher up this page.","reviewedOn":"2026-09-08"}}},{"slug":"trigger-finger","title":"Trigger Finger","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/trigger-finger","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).","fit":"This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Pulley needling only, one week","evidence":"Searched 7 November 2026 (PubMed: trigger point, dry needling, wet needling, trigger point injection, myofascial or intramuscular stimulation with trigger finger or stenosing tenosynovitis, 7 records; and a randomised-trial and systematic-review pass). No study has injected a muscle trigger point in trigger finger. One 58-person randomised trial needled the A1 pulley and flexor tendon themselves, with nothing injected, against no treatment: pulley-tendon thickness, grip and DASH scores were better one week later, with no longer follow-up and no figures in the abstract (Azizian, J Phys Ther Sci 2019). That is needling of the pulley, not of a muscle band, and is not this treatment. The studied injection here is cortisone into the tendon sheath, which sits in the guided injection row.","fit":"Triggering comes from the tendon catching at its pulley in the palm, not from a muscle knot, so a trigger point injection is rarely relevant. A sheath injection (see guided injection) or splinting are the established options.","reviewedOn":"2026-11-07"},"guidedInjection":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"A randomised trial of 74 patients found ultrasound-guided and blind corticosteroid injection of the flexor sheath equally effective for pain and triggering at 6 weeks and 6 months (Çeçen, Arch Orthop Trauma Surg 2014). Injection itself works well here.","fit":"Injection is a good option for trigger finger; guidance is not what makes the difference.","reviewedOn":"2026-08-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Non-randomised study and case series","evidence":"Searched 17 October 2026 (27 records, all read). The old line here said the trials used focused devices; that is true of the one sham-controlled trial (Chen, Arch Phys Med Rehabil 2021) but not of the rest. Radial devices have a non-randomised comparison and case series of their own. In 42 people treated in sequence, a steroid injection relieved pain faster at six weeks, radial shockwave did better at six months on pain, stiffness and function, and fewer people in the shockwave group went on to surgery by two years (Suárez Cabañas, Rev Esp Cir Ortop Traumatol 2026; J Hand Surg Eur 2026). Two uncontrolled series of 18 and 44 people improved over three and twelve months (Dogru, Cureus 2020; Malliaropoulos, Open Access J Sports Med 2016). No radial trial against sham was found. The pooled analyses that favour shockwave over a placebo injection (Chiang, Ann Phys Rehabil Med 2026) and find it level with steroid (Shen, Clin Rehabil 2020) do not separate the two devices.","fit":"The tendon pulley sits close to the skin of the palm, within reach of a radial device. Worth discussing as an alternative to a steroid injection for triggering that is not locking, alongside splinting and tendon-gliding exercises; where the finger locks, release is the more reliable option.","reviewedOn":"2026-10-17"},"focusedShockwave":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Beat sham in one 60-person trial","evidence":"Searched 17 October 2026: shockwave, shock wave or ESWT with trigger finger, trigger digit, trigger thumb or stenosing tenosynovitis (27 records, all read). One double-blind trial used a wide-focused device: in 60 people with grade II triggering, four weekly high-energy sessions gave lower pain and better QuickDASH function than sham at six months, a lower-energy setting did not separate from sham, and no adverse effects were reported (Chen, Arch Phys Med Rehabil 2021); three letters followed, one headed 'Major concerns' (Ogihara, Arch Phys Med Rehabil 2022). Across the wider literature, where most trials do not name the device, a network meta-analysis of 27 trials found shockwave more often successful than a placebo injection (odds ratio 7.49, 95% CI 1.02 to 55.26, a wide interval) and no different from a steroid injection, with surgical release the most effective option (Chiang, Ann Phys Rehabil Med 2026). A trial of 40 people found shockwave level with a steroid injection at six months (Yildirim, J Hand Surg Eur 2016), and in a three-arm trial of 116 people high-intensity laser did better than shockwave, both added to home exercise (Çetin Duru, Rheumatol Int 2026).","fit":"Worth discussing as an alternative to a steroid injection for triggering that is not locking, alongside splinting and tendon-gliding exercises. Where the finger locks or will not straighten, release is the more reliable option, and patients are told so.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"One case report only","evidence":"Searched for PRP in trigger finger and trigger thumb. Nineteen records across the hand tendon conditions, and a randomised-trial pass, contained no trial in this condition. The only clinical report is a single case, a 63-year-old woman whose triggering resolved after three injections over two weeks and had not returned at three months (Medina-Porqueres, Agri 2022). A three-arm blinded trial of PRP, cortisone and saline was registered in Helsinki (Aspinen, Trials 2020); no results from it were found on PubMed in October 2026.","fit":"Not something to choose ahead of the established options. Splinting, a cortisone injection and, where those fail, a small release procedure are the usual treatments for a trigger finger. PRP can be discussed only on the understanding that it rests on one published case.","reviewedOn":"2026-10-09"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Case reports only","evidence":"No trial of prolotherapy in trigger finger was found. A PubMed search on 13 October 2026 (prolotherapy, dextrose or hypertonic glucose with trigger finger, stenosing tenosynovitis or de Quervain) returned seven records, and passes restricted to randomised trials and to systematic reviews or meta-analyses found nothing in this condition. The clinical records are three case reports. Two, from one group, describe triggering that resolved after ultrasound-guided prolotherapy in unusual variants: a calcium deposit in the A1 pulley, treated with three sessions alongside physiotherapy and night splinting, and a problem where the flexor tendons attach to the finger bones that had not responded to cortisone (Yoon, Cureus 2025, two reports). The third is a harm report: a man whose triggering worsened after repeated prolotherapy needed surgery to remove a large fibrous nodule on the pulley and an inflamed tendon sheath (Oh, J Surg Case Rep 2023). A 2026 review puts prolotherapy forward only as a hypothesis to be tested for the tendon-dominant pattern (Kim, Life 2026).","fit":"Not a first-line option: cortisone injection and, where needed, release of the pulley are the treatments with trial evidence. Can be discussed for an unusual pattern on ultrasound where the problem is not the classic pulley narrowing, with the case-report-only evidence and the reported harm stated.","reviewedOn":"2026-10-13"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used for tendons","evidence":"Not offered here. A meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems, 1,629 patients in all, reported less pain than the comparison treatments overall, but its trigger finger group was two trials with uncertain benefit (Khan, Sports Health 2022). These are injections around a tendon, which is a different procedure from the joint injection in this row.","fit":"Not offered for this problem. Hyaluronic acid is considered only for a problem inside a joint, and trigger finger is a tendon and pulley problem.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Different injection target","evidence":"The dextrose evidence at this finger goes into the tendon or the pulley, not under the skin. Two case reports describe ultrasound-guided prolotherapy resolving the triggering completely: two sessions into the flexor tendon entheses in a 61-year-old whose problem was insertional tendinopathy rather than the A1 pulley, and three sessions where a calcium deposit sat in the A1 pulley itself (Yoon, Cureus 2025, two reports). A review of ultrasound phenotypes lists prolotherapy and hydrodissection among the adjuncts for tendon-dominant patterns, explicitly as a hypothesis rather than a validated pathway (Kim, Life 2026). None of that is a series of small injections just under the skin over a nerve. The search also returns a harm report: repeated prolotherapy at the A1 pulley left a 47-year-old with worse flexor tenosynovitis and a firm fibrous nodule that had to be surgically removed (Oh, J Surg Case Rep 2023).","fit":"Considered only where examination finds tender, hypersensitive skin over the palm rather than a catching tendon. The triggering itself is mechanical, at the pulley, and this treatment does not address it.","reviewedOn":"2026-09-28"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No trial of hydrodissection in trigger finger. A review synthesising the 2010–2025 literature proposes it as an adjunct for the tendon-dominant pattern rather than the classic A1 pulley bottleneck, but presents that framework explicitly as a hypothesis to be tested rather than a guideline (Kim, Life 2026). Beyond it the literature is a single case report: a 25-year-old cook with triggering and normal A1 pulleys whose symptoms resolved after 5% dextrose hydrodissection at an unstable flexor digitorum superficialis in the forearm (Yoon, Cureus 2026). A review of ultrasound-guided wrist and hand procedures describes hydrodissection only for carpal tunnel syndrome (Mezian, Acta Chir Orthop Traumatol Cech 2025).","fit":"Not a first-line option. Relevant mainly where ultrasound does not show the expected A1 pulley problem and the triggering appears to come from higher up the tendon: an uncommon picture, and one where the published evidence is a single reported case.","reviewedOn":"2026-09-08"}}},{"slug":"turf-toe","title":"Turf Toe (Big Toe Joint Sprain)","region":"Foot, Ankle & Lower Leg","url":"https://www.backpaindoctor.com.au/conditions/turf-toe","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Most turf toe injuries are managed without surgery. In five seasons of US college football surveillance, fewer than 2% of turf toe injuries needed an operation and mean time lost was 10.1 days (George, Foot Ankle Int 2013). A 2023 review described non-operative rehabilitation in three phases lasting up to about ten weeks, with low-grade injuries usually returning to their prior level and about 70% of athletes with higher-grade injuries maintaining performance (Gupta, Curr Rev Musculoskelet Med 2023).","fit":"The plan for nearly everyone: protection with taping, a stiff-soled shoe or carbon insert and a short period in a boot for higher grades, then restoring movement, foot and calf strength and a graded return to running, cutting and jumping. A complete tear, an unstable joint or a displaced sesamoid goes to a foot and ankle surgeon.","reviewedOn":"2026-10-30"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of trigger point needling for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe and plantar plate with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned ten records, most about lesser-toe joint instability, imaging or injection technique, none testing needling in this condition.","fit":"Only where a tender band in the calf or foot muscles is adding to pain during rehabilitation. It does not treat the sprained joint.","reviewedOn":"2026-10-30"},"guidedInjection":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"No trial of a guided injection for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe and plantar plate with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned ten records, most about lesser-toe joint instability, imaging or injection technique. A case report describes lesser-toe joints dislocating after repeated steroid injections for forefoot pain (Ito, SAGE Open Med Case Rep 2021).","fit":"Cortisone is not injected into a freshly sprained big toe joint. The injury is a tear of the tissue that holds the joint stable, and steroid weakens soft tissue.","reviewedOn":"2026-10-30"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-10-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of shockwave for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe, plantar plate and first metatarsophalangeal terms with platelet-rich plasma, prolotherapy, dextrose and shockwave returned nine records. The nearest reports are a technique description using shockwave with exercise for big toe arthritis (Reilly, Video J Sports Med 2022) and a single case of radial shockwave for sesamoid osteonecrosis (Thompson, BMJ Case Rep 2017).","fit":"May ease tight calf and foot muscles during rehabilitation. It does not heal the sprained joint.","reviewedOn":"2026-10-30"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of focused shockwave for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe, plantar plate and first metatarsophalangeal terms with platelet-rich plasma, prolotherapy, dextrose and shockwave returned nine records. The nearest reports are a technique description using shockwave with exercise for big toe arthritis (Reilly, Video J Sports Med 2022) and a single case of radial shockwave for sesamoid osteonecrosis (Thompson, BMJ Case Rep 2017).","fit":"Not a treatment for a sprained joint. Considered only for a related problem such as persistent sesamoid pain, on that problem's evidence.","reviewedOn":"2026-10-30"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-10-30"},"prp":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Uncontrolled series only","evidence":"No controlled trial of platelet-rich plasma for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe, plantar plate and first metatarsophalangeal terms with platelet-rich plasma, prolotherapy, dextrose and shockwave returned nine records. A retrospective series of 20 patients (23 feet) with forefoot plantar plate injuries that had failed non-operative care reported that 87% reached a clinically important improvement after ultrasound-guided PRP at a mean of almost five years, with 3 of 23 feet later needing surgery; the abstract does not separate the big toe from the lesser toes (Rubin, J Foot Ankle Surg 2026). A single case describes PRP for a partial ligament tear at the big toe joint in a ballet dancer (Lavigne, Foot Ankle Spec 2025).","fit":"Can be discussed for a plantar plate injury that has not settled after a full protection and rehabilitation program, as a step before a surgical opinion, on the understanding that the evidence is one uncontrolled series and a case report.","reviewedOn":"2026-10-30"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No study of prolotherapy at the big toe joint was found. A PubMed search on 30 October 2026 pairing turf toe, plantar plate and first metatarsophalangeal terms with platelet-rich plasma, prolotherapy, dextrose and shockwave returned nine records. The nearest report is a single professional dancer with second-toe joint instability who had prolotherapy alongside taping, padding and physiotherapy (Ojofeitimi, J Orthop Sports Phys Ther 2016).","fit":"Offered here and can be discussed for persistent capsular pain after a full rehabilitation program, on the understanding that no study has tested it at this joint. Not used for an unstable joint, which needs a surgical opinion.","reviewedOn":"2026-10-30"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"No study of hyaluronic acid injection for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe and plantar plate with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned ten records, most about lesser-toe joint instability, imaging or injection technique.","fit":"Not offered. Hyaluronic acid is considered only for arthritis inside a joint, and a sprain is not arthritis.","reviewedOn":"2026-10-30"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of perineural injection for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe and plantar plate with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned ten records, most about lesser-toe joint instability, imaging or injection technique, none testing it in this condition.","fit":"Considered only where a superficial nerve at the big toe is separately part of the pain. It does not treat the sprain.","reviewedOn":"2026-10-30"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study of nerve hydrodissection for turf toe was found. A PubMed search on 30 October 2026 pairing turf toe and plantar plate with needling, trigger point, perineural, hydrodissection, corticosteroid and hyaluronic acid terms returned ten records, most about lesser-toe joint instability, imaging or injection technique, none testing it in this condition.","fit":"Considered only where examination and ultrasound find a nerve entrapped near the joint. It does not treat the sprain.","reviewedOn":"2026-10-30"}}},{"slug":"ulnar-tunnel-syndrome","title":"Ulnar Tunnel Syndrome","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/ulnar-tunnel-syndrome","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Conservative care comes first, and it holds up well. A network meta-analysis of 49 randomised trials and 3,323 patients with carpal tunnel syndrome ranked manual therapy first for both short- and medium-term pain relief, ahead of every injection option including corticosteroid (Chen, Arch Phys Med Rehabil 2025).","fit":"Load management, splinting where it fits, and addressing what is irritating the nerve come before any injection. Where the nerve is being compressed structurally and function is being lost, surgical review is the right conversation rather than more conservative care.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested any needling technique for ulnar nerve compression at the wrist. A search pairing dry needling, trigger point needling and needling with Guyon's canal, the ulnar tunnel and ulnar neuropathy returned nine records, and none was at the wrist. What the search did find is that trigger points can mimic the condition: tender points in the third and fourth dorsal interosseous muscles of the hand referred pain to the ring and little fingers and the ulnar side of the hand and wrist in healthy volunteers (Choi, Pain Physician 2015), and a trigger point in the teres minor at the back of the shoulder has produced numbness in the same fingers (Escobar, Am J Phys Med Rehabil 1988).","fit":"Relevant mainly to telling the two apart, where a tender hand or shoulder muscle rather than the nerve at the wrist is reproducing the finger symptoms. It does not release the nerve.","reviewedOn":"2026-10-01"},"guidedInjection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search on Guyon's canal and ulnar tunnel syndrome against injection, corticosteroid and hydrodissection returned eleven records and no clinical trial of any injection. What exists is an anatomical study: ultrasound-guided perineural injection was performed in 21 limbs from 11 cadavers and reached the sheath of the ulnar nerve inside the tunnel every time, with no spread into the nerve itself or into the adjacent artery and tendons, and the authors concluded that clinical trials are now needed (Meng, Ultrasound Med Biol 2015). So the injection can be placed accurately at this site. Whether it helps has not been tested.","fit":"Considered where the diagnosis is confirmed and the compression is not structural. The absence of trial evidence is acknowledged rather than borrowed from the carpal tunnel, which is a different tunnel with a different literature.","reviewedOn":"2026-09-10"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No studies at this site","evidence":"A tested absence. A search pairing Guyon's canal and the ulnar tunnel with shockwave, shock wave, ESWT and extracorporeal returned two records, both false matches on a hospital of the same name, so there is no study of shockwave at this site at all. The carpal tunnel evidence that the class-level verdict rests on is a different nerve in a different tunnel. The one report linking shockwave to this nerve is a harm report from the elbow rather than the wrist: severe partial axonotmesis of the ulnar nerve immediately after shockwave given for medial epicondylitis (Shim, PM R 2015).","fit":"Considered only for a separate myofascial problem in the forearm or hand, not for the nerve in Guyon's canal. Where a ganglion or another structural cause is compressing the nerve, imaging and a surgical opinion come before any physical therapy.","reviewedOn":"2026-09-13"},"focusedShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No study at this site","evidence":"A tested absence. Searched 17 October 2026: shockwave, shock wave, shock waves, ESWT or pressure wave with Guyon's canal, the ulnar tunnel, hypothenar hammer syndrome or the ulnar side of the wrist returned no records, and a wider search on the ulnar nerve (5 records, all read) found studies only at the elbow. The one trial at that nerve was in cubital tunnel syndrome after burns, a different site (Mohamed, Arch Phys Med Rehabil 2026), and the one harm report linking shockwave to the ulnar nerve is also from the elbow (Shim, PM R 2015). The carpal tunnel evidence is a different nerve in a different tunnel.","fit":"Plausible for a mild compression on the same reasoning as at the elbow, but untested at the wrist, and patients are told so. Where a ganglion or another structural cause is compressing the nerve, imaging and a surgical opinion come first.","reviewedOn":"2026-10-17"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of any kind at this site. A PubMed search on 11 October 2026 pairing platelet-rich plasma with Guyon, ulnar tunnel and handlebar palsy returned no records, and a wider search of 24 records on PRP and the ulnar nerve found nothing about entrapment at the wrist. The nearest was a single report of PRP used inside a collagen tube to bridge a gunshot injury of the nerve, which is nerve reconstruction and not this problem (Foy, Plast Reconstr Surg Glob Open 2023). The randomised trials of PRP around a trapped nerve are at the carpal tunnel, a different nerve in a different tunnel, where an analysis of 12 trials and 749 people ranked it ahead of glucose and cortisone over the short term (Gao, Arch Phys Med Rehabil 2023). At the elbow, PRP injected into the ligament beside this same nerve was followed by scarring around it in three athletes (Thompson, JSES Rev Rep Tech 2020).","fit":"Not offered for this at present, because nothing has been published at this site in either direction. Ulnar tunnel syndrome often has a specific cause pressing on the nerve, and finding and removing that cause, with rehabilitation, comes first. Weakness or wasting in the hand needs nerve testing and a surgical opinion.","reviewedOn":"2026-10-11"},"prolotherapy":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not offered for this","evidence":"A search of dextrose and prolotherapy against ulnar nerve entrapment including Guyon's canal found no study of either at this site. The 13 records returned all concerned the ulnar nerve at the elbow rather than the wrist, and a review of nerve hydrodissection lists the elbow, radial tunnel, saphenous, sciatic and fibular nerves as candidate sites without mentioning Guyon's canal (Colorado, Muscle Nerve 2025).","fit":"Not offered for this. Ulnar tunnel syndrome at the wrist usually has an identifiable cause (a ganglion, a cyst, or sustained pressure on the heel of the hand) and finding and removing that cause comes first.","reviewedOn":"2026-09-03"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"A tested absence rather than an assumption: searches pairing hyaluronic acid, hyaluronate and viscosupplementation with Guyon's canal, the ulnar tunnel and the ulnar nerve returned no trial of hyaluronic acid in this condition, only a volunteer study in which adding it to local anaesthetic did not change how long an ulnar nerve block lasted (Johansson, Acta Anaesthesiol Scand 1985), and reviews that list it as one of several fluids used for nerve hydrodissection (Colorado, Muscle Nerve 2025). There is no joint in the ulnar canal at the wrist to viscosupplement.","fit":"Not offered for this problem.","reviewedOn":"2026-09-12"},"perineural":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched 29 October 2026: Guyon's canal, ulnar tunnel, ulnar canal, ulnar neuropathy at the wrist, handlebar palsy or distal ulnar with dextrose, glucose, hydrodissection, hydrorelease, perineural, prolotherapy, nerve block or ultrasound-guided (24 records), and a randomised-trial and systematic-review pass (3 records, none a treatment study). All were read. There is no treatment study of dextrose, or of any other injection, for ulnar tunnel syndrome at the wrist. The only injection records at Guyon's canal are a cadaver study and a single case of a cortisone nerve block given there for a different condition, complex regional pain syndrome after shingles (Swarnakar, Cureus 2024). Ulnar tunnel syndrome is uncommon and is often caused by a ganglion or another space-occupying lesion, which an injection under the skin cannot address. The dextrose trials at the ulnar nerve are at the elbow, which is the cubital tunnel page.","fit":"Considered only once imaging has excluded a ganglion or other lesion pressing on the nerve, and only for tender, hypersensitive skin along the nerve's branches in the hand, with the absence of any study at this site stated.","reviewedOn":"2026-10-29"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"Searched 29 October 2026: Guyon's canal, ulnar tunnel, ulnar canal, ulnar neuropathy at the wrist, handlebar palsy or distal ulnar with dextrose, glucose, hydrodissection, hydrorelease, perineural, prolotherapy, nerve block or ultrasound-guided (24 records), and a randomised-trial and systematic-review pass (3 records, none a treatment study). All were read. No study has tested hydrodissection for ulnar tunnel syndrome. What exists is groundwork: in 21 cadaver arms, an ultrasound-guided injection aimed at the ulnar nerve inside the ulnar tunnel coated the outside of the nerve in every case without entering it, and the authors say clinical trials are needed (Meng, Ultrasound Med Biol 2015). The hydrodissection trials are at the median nerve in the carpal tunnel. Ulnar tunnel syndrome is often caused by a ganglion or another space-occupying lesion, which needs imaging and usually surgery rather than an injection.","fit":"Considered only where imaging shows no ganglion or other lesion compressing the nerve and symptoms have not settled with rest from pressure on the heel of the hand (cycling grips, tools) and a splint, with the absence of any study at this site stated.","reviewedOn":"2026-10-29"}}},{"slug":"whiplash-neck-sprain","title":"Whiplash & Neck Sprain","region":"Neck","url":"https://www.backpaindoctor.com.au/conditions/whiplash-neck-sprain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Every high-quality guideline says the same thing. The American College of Physicians makes a strong recommendation that chronic low back pain be treated first with exercise and multidisciplinary rehabilitation rather than drugs or procedures (Qaseem, Ann Intern Med 2017). An overview of 15 primary-care guidelines found consistent agreement on education, staying active, exercise and reassurance, and on discouraging routine imaging (Oliveira, Eur Spine J 2018). For neck pain the strongest effects also belong to exercise, with strengthening of the neck and upper quadrant showing a moderate short-term effect (Sterling, J Clin Med 2019). Adding pain-science education to exercise improves pain, disability and fear of movement over exercise alone (Bonatesta, J Pain 2021).","fit":"Understanding why the back hurts, and moving well, does more than anything injected. Imaging is used to answer a specific question, not as a starting point. Degenerative findings are near universal and frequently unrelated to the pain.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":true,"status":"mixed","statusLabel":"Evidence mixed","tag":"Sham matched it on pain","evidence":"Searched 1 November 2026 (PubMed: trigger point injection, lignocaine or dextrose in whiplash; 54 records, with one relevant randomised trial). In a double-blind crossover trial, 31 people with chronic trapezius pain after whiplash had local anaesthetic injected into a tender point, or a sham injection: pressure-pain thresholds and jaw opening improved only after the real injection, but overall pain improved to a similar extent after the sham (Nystrom, Pain Med 2018). A systematic review of trigger point injection in chronic musculoskeletal pain reported symptom relief in whiplash among other conditions, but found no clear evidence of either benefit or ineffectiveness because the trials were small and poorly reported (Scott, Pain Med 2009). Trials of botulinum toxin in the neck after whiplash test a different injection and are not counted here. No study of this row's dilute glucose in whiplash was found.","fit":"Directed at a tender muscle band that reproduces part of your pain, alongside the loading work. Not a treatment for the joint, disc or nerve itself.","reviewedOn":"2026-11-01"},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Diagnostic rather than curative","evidence":"The useful role here is working out where the pain is coming from, not treating it. Searching whiplash against intra-articular corticosteroid, corticosteroid injection and cervical zygapophysial injection returned sixteen records, and restricting to randomised trials returned eleven, none of which tested a guided injection as a treatment for persistent whiplash pain. What the literature does establish is that the cervical facet joints are the commonest source of persistent neck pain after whiplash and that the diagnosis can only be made with controlled blocks (Bogduk, Curr Opin Rheumatol 1998), and that those blocks need to be controlled: of 47 people with chronic whiplash pain given double-blind saline and local anaesthetic blocks, 29% were true positives, 60% did not respond and 11% responded to the placebo (Persson, Pain Med 2016). The response to an intra-articular facet corticosteroid injection also carries prognostic weight: among 40 people followed at least five years, those with more than 50% relief at one month were less likely to still have neck pain, to be taking analgesics, or to report their work affected (Yang, J Pain Res 2022).","fit":"Not part of early care, which is reassurance, movement and graded return to activity. Considered where pain has persisted well beyond the expected recovery period and one facet level is suspected: more to answer the question than to fix the problem, and with the placebo response rate in mind when interpreting a good result. See the note on cortisone.","reviewedOn":"2026-09-17"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No whiplash study","evidence":"A tested absence: shockwave, shock wave, ESWT and pressure wave crossed with whiplash, neck sprain or cervical sprain returned three records on 19 October 2026, all animal blast-injury research. The trials nearest to it are in chronic neck and shoulder muscle pain: radial shockwave beat sham in 57 people with upper trapezius trigger points (Senlikci, Lasers Med Sci 2025) and standard care in 45 (Anwar, Am J Transl Res 2022), and a meta-analysis of 10 trials found shockwave no better than dry needling or trigger point injection (Zhang, Arch Phys Med Rehabil 2020). None enrolled people after a whiplash injury.","fit":"Not used in the early weeks after the injury. Considered later only if a persistent tender muscle is part of the pain, alongside your exercise programme, on the understanding that it has not been studied after whiplash.","reviewedOn":"2026-10-19"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No whiplash study","evidence":"A tested absence: shockwave, shock wave, ESWT and pressure wave crossed with whiplash, neck sprain or cervical sprain returned three records on 19 October 2026, all animal blast-injury research. Focused shockwave has given short-term relief over sham in upper trapezius muscle pain (Senlikci, Lasers Med Sci 2025; Vasvit, Complement Ther Med 2025), but neither trial enrolled people after a whiplash injury.","fit":"Rarely relevant. Considered only later on, for a specific deep tender point in muscle, and not in the early weeks after the injury.","reviewedOn":"2026-10-19"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Worth discussing","evidence":"Nothing in acute whiplash. The only condition-specific evidence sits in chronic whiplash-associated disorder with facet-mediated pain confirmed by diagnostic medial branch block: in a prospective series of 44 such patients given cervical facet PRP, 53% exceeded the minimal clinically important difference for pain at twelve months and 37% reported more than 50% relief, with the authors noting that a controlled study is still needed (Smith, Interv Pain Med 2023). That is an uncontrolled case series in a heavily selected group, and some patients also had physiotherapy.","fit":"Not part of acute whiplash care, where reassurance, movement and a graded return are what the evidence supports. It becomes a conversation only if pain has persisted for months and the facet joints have been identified as the source.","reviewedOn":"2026-09-02"},"prolotherapy":{"reviewed":true,"status":"discuss","statusLabel":"Worth discussing","tag":"Uncontrolled series of 18","evidence":"No randomised trial of prolotherapy after whiplash was found. PubMed search, 14 October 2026: prolotherapy, dextrose injection, hypertonic dextrose or hypertonic glucose with neck, cervical, whiplash or cervicogenic (33 records, all read), a whiplash-specific pass including sclerosant terms, a randomised-trial pass (none) and a systematic-review pass; one Consensus search found none either. The best direct evidence is an uncontrolled series: 18 consecutive people with chronic whiplash-related neck pain that had not settled with other treatment had 20% dextrose placed into the cervical facet joints under X-ray guidance, and the Neck Disability Index fell from 24.7 to 10.9 at 12 months; there was no comparison group, 13 of the 14 crash-related cases were in litigation, and those who also attended physiotherapy did better (Hooper, Pain Physician 2007). A series of six people with neck pain after a car crash reported pain falling from 5.8 to 3.8 out of 10 after three X-ray-guided injections (Centeno, Pain Physician 2005), and one case report used a different solution (phenol, glycerin and glucose) with improvement held to 18 months (Stogicza, Regen Med 2020). Reports from the 1960s are not available as abstracts and were not read. Harms: one case of spinal cord injury after prolotherapy in the upper neck has been reported (Yun, Ann Rehabil Med 2011), and a practitioner survey recorded serious complications after spinal prolotherapy, without separating the neck from the back (Dagenais, Arch Phys Med Rehabil 2006).","fit":"Not for a recent whiplash injury, which is managed with staying active and a graded exercise program. Can be discussed for neck pain that persists for months after whiplash despite that program, as a way to let it progress, with the absence of controlled trials and the rare but serious risks of injecting near the cervical spine stated.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Searching hyaluronic acid, hyaluronate and viscosupplementation against whiplash, the cervical spine, cervical facet joints and the atlantoaxial joint returns thirteen records and not one concerns whiplash or any injection into the neck. There is no study of this injection after a whiplash injury of any design.","fit":"Not offered for this problem. Whiplash is a soft-tissue strain that settles with movement and graded activity, not a worn joint needing lubrication.","reviewedOn":"2026-09-20"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"A PubMed search combining perineural injection, neural prolotherapy, perineural dextrose, subcutaneous dextrose, glucopuncture and dextrose injection with whiplash, whiplash-associated disorder or neck sprain returns no records at all. Nothing of any design has tested this treatment after a whiplash injury.","fit":"Not part of managing whiplash. Recovery rests on early movement, reassurance about the natural course and a graded return to normal activity. An injection around a superficial nerve has no established place in that, and would only be considered much later if persistent pain proved to be nerve-related on examination.","reviewedOn":"2026-09-09"},"hydrodissection":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"A search of hydrodissection, interfascial injection and perineural injection against whiplash, whiplash-associated disorder and neck sprain found no study of any design. The nearest evidence is in chronic myofascial neck pain, where a double-blind trial of 35 people found interfascial dextrose hydrodissection better than sham for pain at 12 weeks (Hsu, Am J Phys Med Rehabil 2024). That is a plausible read-across, not a tested one.","fit":"Only considered for a persistent myofascial component well after the acute injury, with the absence of any direct study stated. Early whiplash care is reassurance, movement and a graded return to normal activity.","reviewedOn":"2026-09-06"}}},{"slug":"wrist-sprain","title":"Wrist Sprains","region":"Elbow, Wrist & Hand","url":"https://www.backpaindoctor.com.au/conditions/wrist-sprain","pairings":{"rehab":{"reviewed":true,"status":"core","statusLabel":"Core care","tag":"Core care","evidence":"Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).","fit":"For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.","reviewedOn":"2026-09-02"},"wetNeedling":{"reviewed":false},"guidedInjection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"No study in wrist sprain","evidence":"Searched 8 November 2026 (PubMed: wrist, finger or thumb with sprain, ligament injury or collateral ligament and corticosteroid, steroid, triamcinolone or anaesthetic injection, 13 records; and the randomised-trial and systematic-review pass across sprains, which found no trial). No study has measured an injection for a wrist sprain. The nearest record is a single case of tendon subluxation after a wrist sprain in which steroid injection and splinting failed and surgery followed (Kato, J Hand Surg Am 2002); reviews of lunotriquetral ligament injury list steroid injection with immobilisation as an option without data (Zelenski, J Am Acad Orthop Surg 2025). In professional football, injections of local anaesthetic into the wrist joint are advised against (Orchard, Sports Med 2004), and wrist injections were judged less safe than others at long-term follow-up (Orchard, Am J Sports Med 2010).","fit":"Not a treatment for a wrist sprain, which is protection, then graded movement and strengthening, with imaging where a ligament tear or fracture is suspected. Considered only for a specific complication identified on assessment.","reviewedOn":"2026-11-08"},"vactor":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.","fit":"A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.","reviewedOn":"2026-08-30"},"radialShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave, radial or focused, in a wrist sprain. A PubMed search for shockwave with the wrist, thumb, finger joints, the scapholunate ligament or the triangular fibrocartilage (TFCC) and ligament or injury terms (8 records, all read) found shockwave used only for slow-healing fractures. A 2026 narrative review of TFCC injuries lists shockwave as a possible add-on without citing a trial (Liu, Front Sports Act Living 2026).","fit":"Not part of early management. Considered only once pain persists well beyond the expected healing time, and then for tender forearm muscle rather than the injured ligament.","reviewedOn":"2026-10-23"},"focusedShockwave":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested shockwave in a wrist sprain. A PubMed search for shockwave with the wrist, thumb, finger joints, the scapholunate ligament or the triangular fibrocartilage (TFCC) and ligament or injury terms (8 records, all read) found shockwave used only for slow-healing fractures, not for ligament injury. A 2026 narrative review of TFCC injuries lists shockwave among possible add-on treatments without citing a trial (Liu, Front Sports Act Living 2026). A trial and systematic-review pass over shockwave in ligament injuries (17 records) found none at the wrist.","fit":"Not part of early management. May become a question only if the wrist stays painful long after the sprain, and then without trial evidence in this injury.","reviewedOn":"2026-10-23"},"emtt":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that could be identified. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative. A randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).","fit":"Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why it is described this way.","reviewedOn":"2026-08-30"},"prp":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"No studies of the injection alone","evidence":"No study has tested a PRP injection on its own for a wrist sprain. A PubMed search in October 2026 pairing platelet-rich plasma and platelet concentrate with wrist sprain, the scapholunate and lunotriquetral ligaments and the triangular fibrocartilage complex returned eight records. Every study in people at a wrist ligament is of PRP added to an operation on the triangular fibrocartilage complex, the cartilage and ligament structure on the little-finger side of the wrist. In the one comparison, 33 people had a keyhole repair with or without PRP, and those given PRP had the worse arm-function score afterwards (12.6 against 7.8 on the QuickDASH, where lower is better) with no difference in pain; it was not randomised (Asiry, Plast Reconstr Surg Glob Open 2024). A series of 201 people who all had PRP after the same kind of repair did well at an average of 32.6 months, but with no comparison group that says nothing about what PRP added (Yeh, BMC Musculoskelet Disord 2022).","fit":"Not offered for this. These settle with protection, graded loading and time, and no trial has shown an injection shortens that.","reviewedOn":"2026-10-12"},"prolotherapy":{"reviewed":true,"status":"untested","statusLabel":"Plausible: no studies","tag":"Plausible: no studies","evidence":"No clinical study of prolotherapy for a wrist sprain or a wrist ligament injury (scapholunate ligament or triangular fibrocartilage complex) was found. PubMed search, 14 October 2026: prolotherapy, dextrose, hypertonic glucose or hyperosmolar with sprain or ligament injury terms (21 records), prolotherapy with ligament, wrist, scapholunate, triangular fibrocartilage or TFCC terms (121 records, all screened), and a targeted pass on the named wrist ligaments, each with randomised-trial and systematic-review passes. The nearest record is one case of a ganglion cyst beside the triangular fibrocartilage complex in a golfer, treated by aspiration and then five sessions of 10% dextrose into the attachment of that complex with rehabilitation, after which the pain resolved (Yoon, Cureus 2026); it is a different problem and a single case.","fit":"An unstable scapholunate or triangular fibrocartilage tear needs a hand surgeon's opinion. Prolotherapy can be discussed for ligament pain that persists after imaging has excluded an unstable tear and a hand therapy program has been completed, with the absence of studies stated.","reviewedOn":"2026-10-14"},"viscosupplementation":{"reviewed":true,"status":"notOffered","statusLabel":"Not offered for this","tag":"Not used here","evidence":"Untested, rather than tested and found not to work. A search pairing hyaluronic acid with wrist, finger and thumb sprain and ligament injury terms returned one record, and it was not a wrist study: a meta-analysis of 19 randomised trials of hyaluronic acid in soft-tissue problems, in which the only hand condition was trigger finger and the benefit there was uncertain (Khan, Sports Health 2022). The only sprain in which the injection has been trialled is the ankle, where it was placed around the ligaments rather than into the joint (Petrella, Clin J Sport Med 2007). No study has used it for a sprained wrist.","fit":"Not offered for this problem. A sprained wrist settles with protection, graded loading and time.","reviewedOn":"2026-10-05"},"perineural":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"No study has tested dextrose injections of any kind for a sprained wrist. Searching dextrose, prolotherapy, glucopuncture and perineural injection against wrist sprain, wrist ligament, scapholunate and triangular fibrocartilage injury returns 15 records and no study of a wrist ligament injury. What it returns at the wrist are single cases of other problems treated by other procedures: 10% dextrose injected into the triangular fibrocartilage attachment after draining a ganglion in a golfer with pain on the little-finger side of the wrist (Yoon, Cureus 2026), and 5% dextrose for extensor tendon sheath inflammation in a weightlifter, pain 7 to 1 out of 10 (Yang, Int Med Case Rep J 2025). The report closest to this row's purpose is a nerve problem that followed a wrist injury. A 35-year-old with persistent pain and numbness over the thumb side of the wrist five years after a scaphoid fracture had the superficial branch of the radial nerve snapping over the bone, and after ten weekly ultrasound-guided 5% dextrose injections around the nerve her pain went from 8 to 0 out of 10 with thumb strength restored (Yoon, Diagnostics 2026). That is hydrodissection, which has its own row on this page, and it is one case.","fit":"Not part of treating a wrist sprain. Considered only if burning, numbness or tender, hypersensitive skin over the back or thumb side of the wrist persists after the sprain has healed, which points to a skin nerve rather than the ligament.","reviewedOn":"2026-10-06"},"hydrodissection":{"reviewed":true,"status":"situational","statusLabel":"Only if relevant","tag":"Only if relevant","evidence":"Searched 10 November 2026 (PubMed: hydrodissection, hydrorelease or perineural injection with sprain, ligament injury, scapholunate, triangular fibrocartilage or collateral ligament, 5 records, none at the wrist; the same terms with the superficial radial, posterior interosseous, anterior interosseous and digital nerves, 12 records; a randomised-trial and systematic-review pass returned none). No study has tested hydrodissection for a sprained wrist. The nearest are single case reports at the nerves of the forearm and wrist, none after a sprain: the skin nerve on the thumb side of the wrist (Wartenberg's syndrome) after an unspecified injury, with sustained relief after ultrasound-guided hydrodissection but no figures in the abstract (Maroc, Cureus 2025), the same nerve after a fracture operation (Wei, Pain Med 2020), and the posterior interosseous nerve in the forearm (Qin, World J Clin Cases 2023; Tsujino, J Ultrason 2021). In a retrospective series of 242 nerve injections in the arm, 52 of 89 people followed up reported a period of relief, averaging four months, with no complications at the injection sites (Walsh, AJR 2019); it was not a study of wrist injuries.","fit":"Not part of treating a wrist sprain. Considered only if burning, numbness or tender, hypersensitive skin over the back or thumb side of the wrist persists after the sprain has healed, which points to a skin nerve rather than the ligament.","reviewedOn":"2026-11-10"}}}]}