Joint and Soft Tissue Injection in Primary Care

2. Joint and Soft Tissue Injection in Primary Care Peter J. Carek, MD, MS Department of Family Medicine Medical University of South Carolina

3. Joint and Soft Tissue Injection • Family Medicine • SC AHEC Family Medicine Graduates • 81% perform joint aspiration / injection (Carek, 2004) • Canadian GP/FPs (Sempowski, 2006) • 31.6% perform shoulder injections • 43.0% perform knee injections • Common injections • Lateral epicondyle • Glenohumeral joint • Knee joint • Supraspinatus tendon • Carpal tunnel

4. Introduction • Hollander introduced local corticosteroid injection therapy for treatment of inflammatory arthritis in 1951 • Reported medical benefits of intra-articular injection inconsistent • Diagnosis • Site of injection • Medications used • Additional incorporated therapies

5. Indications • Evaluate spontaneous, unexplained joint effusion with/without associated trauma • Analysis of synovial fluid (especially if septic arthritis suspected) • Limit joint damage from infectious process and provide relief from large effusion

6. Synovial Fluid • Physical characteristics • Color, clarity, and viscosity • White blood cell count and differential • Presence of crystals (polarized light) • Microbiology (gram stain, bacterial culture)

7. Classes of Synovial Fluid PMN = polymorphonuclear leukocytes Klippel, 2001

8. Differential Diagnosis by Synovial Class

9. Conditions Often Treated with Local Injection therapy • Articular conditions • Rheumatoid arthritis • Seronegative spondyloarthropathies • Ankylosing spondylitis • Arthritis associated with inflammatory bowel disease • Psoriasis • Reiter’s syndrome • Crystal-induced arthritis • Gout • Pseudogout • Osteoarthritis (acute exacerbation) Adapted from Pfenninger, 1991 and Cardone, 2002

10. Conditions Often Treated with Local Injection therapy • Nonarticular disorders • Fibrositis • Bursitis • Subacromial • Trochanteric • Anserine • Prepatellar • Tenosynovitis/tendinitis • DeQuervain’s disease • Stenosing tenosynovitis (Trigger finger) • Bicipital • Lateral epicondylitis (Tennis elbow) • Medial epicondylitis (Golfer’s elbow) • Plantar fasciitis • Neuritis • Carpal tunnel syndrome • Tarsal tunnel syndrome Adapted from Pfenninger, 1991 and Cardone, 2002

11. Contraindications *absolute contraindications Adapted from Pfenninger, 1991 and Cardone, 2002

12. General Technique • Materials and Equipment • Pharmacologic Agents • Site Preparation • Post-injection Care

13. Equipment used for Injections • Alcohol wipes • Gloves • 20 – 25 gauge 1.0 – 1.5 inch needle • 1 mL to 10 mL syringe* • Local anesthetic • Corticosteroid preparation • Adhesive bandage dressing *Larger syringe may be required for aspiration of a large joint (i.e. knee).

14. Pharmacologic Agents • Corticosteroids • Modify local inflammatory response • Increase viscosity of synovial fluid • Alter production of hyaluronic acid synthesis • Change synovial fluid leukocyte activity Short-term benefit of intra-articular corticosteroids in treatment of knee OA well established; longer term benefits not confirmed. Cochrane Collaboration, 2006

15. Relative Potency Corticosteroid Preparations

16. Dosages Corticosteroid Preparations

17. Pharmacologic Agents • Hyaluronic Acid • Used to treat pain associated with OA of knee • Safe and effective (Grade of Recommendation: A) “Hyaluronic acid products had more prolonged effects than intra-articular corticosteroids.” Cochrane Collaboration, 2007

18. Other Injection Materials • Autologous blood • Polidocanol • Prolotherapy • Dextrose • Morrhuate sodium

19. Site Preparation Sterile ethyl chloride Aseptic technique Injection site clearly identified Immediate injection site cleaned with alcohol swab Use of local anesthetic on skin / subcutaneous tissues overlying the injection site optional Sterile ethyl chloride Immediate injection site cleaned with alcohol swab

20. Injection Do not inject directly into tendon or ligament Reposition needle if resistance encountered Aspirate to avoid intravascular deposition of medicine Injection Techniques

21. Post-Injection Care • Pain relief following joint or soft tissue injection with local anesthetic may indicate appropriate structure infiltrated. • Avoid poly-injection syndrome • Not be performed more than three times per year • Separated by six or more weeks.

22. Complications

23. Postinjection Flare • Most commonly associate with injection of steroids other than triamcinolone or methylprednisolone (Binder, 1983; Kumar, 1999) • Occurs and resolves within 48 hrs • Flares occur more frequently in soft tissue injections (Roberts, 2005)

24. Injections by Site • Shoulder • Elbow • Hand and wrist • Hip • Knee • Ankle

25. Shoulder • Corticosteroid injection of shoulder may be utilized for treatment of such conditions as subacromial bursitis, rotator cuff tendonitis, adhesive capsulitis, and biceps tendonitis (Grade of Recommendation: D). • Subacromial bursa • Glenohumeral joint • Biceps tendon

26. Shoulder Needle inserted 1 – 2 cm below midpoint of lateral edge of acromion • Needle inserted 1 - 2 cm below posterior lateral aspect of acromion

27. Shoulder Needle placement acccuracy (Kang, 2008) • 60 shoulders with impingement • 70% subacromial accuracy rate • No differences among injection approaches • Clinical improvement did not correlate with accuracy

28. Glenohumeral Joint • Glenohumeral injection • Injection point is 1 cm lateral of coracoid process

29. Biceps Tendinitis

30. Acromioclavicular Joint

31. Elbow • Corticosteroid injection of the elbow is indicated in the management of lateral epicondylitis and medial epicondylitis • Lateral epicondyle • Grade of Recommendation: A • Medial epicondyle • Grade of Recommendation: D

32. Elbow

33. Hand and Wrist • Trigger finger. • Corticosteriod injection appears to be effective treatment option for trigger finger • Grade of recommendation: C • De Quervain’s tenosynovitis. • De Quervain’s tenosynovitis can be effectively treated with corticosteroid injections • Strength of recommendation: C • Carpal tunnel. • For carpal tunnel syndrome, corticosteroid injection provides temporary, short-term improvement • Grade of recommendation: A

34. Trigger Finger

35. De Quervain’s Tenosynovitis

36. Carpal Tunnel • Identify and mark distal palmar crease and palmaris longus and FCR tendon • Mark spot 4 cm proximal to distal palmar crease and between tendons

37. Trochanteric bursa For treatment of trochanteric bursitis, corticosteroid injection is effective treatment option Grade of Recommendation: C Hip

38. Knee Injections of knee recommended for treatment of such conditions as OA and bursitis (Grade of Recommendation: A). • Intra-articular space • Anserine bursa

39. Knee Lateral approach • Draw horizontal line one fingerbreadth above superior margin of patella • Draw vertical line at lateral margin of patella • Needle inserted at intersection of these lines and directed parallel to floor (also parallel to undersurface of patella). Infrapatellar approach • Needle inserted 1 -2 cm lateral (or medial) to patellar tendon

40. Knee

41. Knee

42. Knee • Pes anserine bursa

43. Ankle • Intra-articular space

44. Plantar fascia. Corticosteroid injection considered initial treatment option for plantar fasciitis (Grade of Recommendation: D) Limited evidence that corticosteroid injection provides short-term benefit. Foot

45. Morton’s Neuroma Injection is on dorsum of foot, in-between metatarsel heads at point of maximum tenderness

46. Grades of Recommendations Selected Injections.

47. Charges and Reimbursement for Selected Injections

48. Injection Supplies – Cost