Myotoxicity of injections for acute muscle injuries: a systematic review.
BACKGROUND
Injection therapies are widely used for muscle injuries. As there is only limited evidence of their efficacy, physicians should be aware of the potential harmful effects of these injected preparations.


OBJECTIVE
The purpose of this review was to systematically review the literature on the myotoxic effects of intramuscular injection preparations commonly used for acute muscle injuries.


METHODS
The databases of PubMed, Embase, Web of Science, Cochrane Library, CINAHL and SportDiscus were searched in March 2013.


METHODS
Studies reporting histological evaluation or creatine kinase activity after intramuscular injection with local anaesthetics, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), platelet-rich plasma (PRP), Traumeel(®) and Actovegin(®), or combination preparations were eligible for inclusion.


METHODS
Two authors independently screened the search results and assessed the risk of bias. A best-evidence synthesis was used to identify the level of evidence.


RESULTS
Forty-nine studies were included in this systematic review. There is strong to moderate evidence that intramuscularly injected local anaesthetics and NSAIDs are myotoxic, and there is conflicting evidence of the myotoxicity of PRP. There is limited evidence that single corticosteroid injections are not myotoxic but have a synergistic myotoxic effect when used together with local anaesthetics. There is no information to assess whether Actovegin(®) and Traumeel(®) are myotoxic.


CONCLUSIONS
Local anaesthetics and NSAID injections are not recommended for the treatment of muscle injuries in athletes, as they are myotoxic. The possible myotoxic effects of corticosteroids, PRP, Traumeel(®) and Actovegin(®) should be assessed in future research.
Room Hs-104, Department of Orthopedics, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands, g.reurink@erasmusmc.nl.
Gustaaf
G
Reurink
Gert Jan
GJ
Goudswaard
Maarten H
MH
Moen
Adam
A
Weir
Jan A N
JA
Verhaar
Johannes L
JL
Tol
D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000009:adverse effects; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects*; D000818:Animals; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage / Q000009:adverse effects*; D003402:Creatine Kinase / Q000378:metabolism; D006418:Heme / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives; D006705:Homeopathy / Q000009:adverse effects; D006801:Humans; D007273:Injections, Intramuscular; D008903:Minerals / Q000008:administration & dosage / Q000009:adverse effects; D018482:Muscle, Skeletal / Q000187:drug effects* / Q000201:enzymology / Q000293:injuries*; D010936:Plant Extracts / Q000008:administration & dosage / Q000009:adverse effects; D053657:Platelet-Rich Plasma
D000305:Adrenal Cortex Hormones; D000779:Anesthetics, Local; D000894:Anti-Inflammatory Agents, Non-Steroidal; D008903:Minerals; D010936:Plant Extracts; C433370:Traumeel S; D006418:Heme; C015646:Actovegin; D003402:Creatine Kinase