Same injection. Same treatment?

Two clinicians document the same procedure.

Same diagnosis. Same medication. Same dose.

One deposits the medication within a tissue. The other places it alongside that tissue.

Did those patients receive the same treatment?

We spend considerable time debating what to inject. I think we need to spend more time discussing exactly how we deliver it.

What I notice before the injection

When I see procedural videos on social media, I often focus on details that receive little attention in the caption.

The needle length. The syringe size. The patient’s position. The clinician’s hand support. Whether imaging is used and, when it is, whether the needle tip is actually visible.

Sometimes the choices make sense. Other times, the setup seems to make the procedure unnecessarily difficult.

A short video cannot reveal the full clinical context. But it raises a question worth asking about our own work: how many of these decisions are deliberate, and how many are habit?

As I have advanced in practice, I have become increasingly convinced that procedural judgment and technical skill are major contributors to the outcomes we see.

What does “a plantar fascia injection” actually mean?

Imagine reading a study evaluating an injection for plantar fasciopathy.

Was the injectate delivered within the fascia or adjacent to it? If adjacent, was it superficial, toward the plantar fat pad, or deep to the fascia? What volume was delivered? Was the tissue repeatedly needled or simply approached for medication delivery?

Those can represent different interventions under the same procedure name.

Even “ultrasound-guided” leaves questions unanswered. Where was the tip during delivery? Where did the fluid spread?

Not every technical variation has been proven to change outcomes. But we need to know what was done before we can determine which differences matter.

Even the syringe can change what we collect

Bone marrow aspirate concentrate, or BMAC, is a treatment used in regenerative medicine in which a patient’s bone marrow is collected and processed to concentrate cellular components before delivery to a treatment site.

Collecting marrow with a large syringe, commonly 50 or 60 mL, has been a conventional approach. It was the approach we used, too. Chahla et al., 2017​

Research by Hernigou and others has helped refine harvesting techniques, emphasizing smaller syringes and small-volume draws to improve progenitor-cell recovery and limit dilution with peripheral blood.

In a study of 30 adults, Hernigou and colleagues found substantially higher concentrations of colony-forming progenitor cells using 10-mL syringes than using 50-mL syringes. Hernigou et al., 2013​

We now generally use 10-mL syringes with a brisk aspiration maneuver. The smaller syringe facilitates a rapid application of suction. The rationale is to recover cell-containing marrow material efficiently, while limiting blood dilution through small draws from each location. Syringe size, aspiration volume, and how suction is applied are distinct technical choices.

These findings do not establish that switching syringes alone improves pain relief or tissue healing. They demonstrate that technique can change the biological material we obtain before we ever inject it.

What the evidence tells us, and leaves out

Some technical choices have comparative outcome data. A 2024 review of four randomized trials involving 338 patients with knee osteoarthritis found better procedural pain, follow-up pain, and function with ultrasound-guided injections than with landmark guidance. That supports guidance in the setting studied, without establishing that every procedure requires it. Oo et al., 2024​

Other details remain less well studied or incompletely reported.

The TIDieR reporting framework helps researchers describe interventions for replication. But its broad categories do not explicitly prompt authors for every procedural variable, such as tissue plane, needle passes, or injectate distribution. Those details can be included, but authors must recognize their relevance. Hoffmann et al., 2014​

A plantar fascia study might report the drug, dose, and use of ultrasound while leaving the actual deposition site unclear.

That uncertainty matters. It also cannot become an excuse to dismiss negative research. A technically excellent procedure still needs an appropriate indication and an effective treatment.

Before your next procedure

If you perform procedures, ask yourself:

“Could I explain the reason for each part of this setup?”

The target, position, approach, equipment, volume, and method of confirming delivery. “That is how I was taught” is a starting point worth revisiting.

If you are a patient considering a procedure, you can ask:

• What structure are you treating, and why?
• How will you determine where the treatment is delivered?
• What benefit should I expect, and what are the alternatives?

Whether we are interpreting research, learning a procedure, or discussing treatment with a patient, we should be able to describe more than what was in the syringe.

The technique is part of the treatment.