Common Shoulder Injections for the Family Physician General Principles and Specific Techniques

1. Common Shoulder Injections for the Family PhysicianGeneral Principles and Specific Techniques Jeff Leggit, MD Primary Care Sports Medicine

2. Objectives • Review the general indications, contraindications, benefits, and risks of injections • Discuss consent, equipment, anesthesia, corticosteroid choice and technique • Discuss specific anatomic injections detailing indications, clinical landmarks, technique, needle size and dosage

3. Diagnostic: Synovial fluid analysis Therapeutic trial Imaging studies Synovial biopsy Therapeutic: Remove tense effusions Remove blood or pus Therapeutic lavage Injection of steroids or other intra-articular therapies Indications

4. Risks/Complications • Tendon rupture • Post-injection flare • Cartilage degeneration • Local trauma • Infection: 1/20,000 - 50,000 injections • Atrophy/hypo or hyperpigmentation • Hyperglycemia

6. Contraindications • Cellulitis or broken skin over needle entry site • Anticoagulation or a coagulopathy (relative) • Intra-articular fractures (for steroids) • Septic effusion (for steroids) • Lack of response to prior injections • More than 3 prior injections in the last year to a weight bearing joint • Inaccessible joints; joint prostheses

7. Evidence-Based Medicine There is currently insufficient quality data to provide a definitive answer on the efficacy of steroid injections.

8. General Principles • Consent • Equipment • Anesthesia • Corticosteroids • Technique • Post-Procedure Care

9. Consent • Consent should be obtained on all diagnostic and therapeutic injections! • A detailed discussion of benefits, risks and the expected results should be covered. • Consent should be witnessed and documented.

10. Equipment • Controversies: • sterile prep vs. alcohol prep • sterile gloves vs. nonsterile • Injections: 21 - 27 gauge 1-10cc syringes • Aspirations: 18 - 20 gauge 3 - 50cc syringes • Anesthesia:1-2% lidocaine, 0.5% bupivicaine? and/or topical (Ethyl Chloride, EMLA, TAC) • Steroid: Celeston 6mg/cc, Triamcinolone 40mg/cc • Sponges, Band-Aids • Access to equipment for allergy/anaphylaxis

11. Anesthesia • Aids in providing pain relief, assisting in diagnosis, and providing a volume for the steroid. • Lidocaine: 0.5% to 2%; amide; 1 - 5 min onset of action; duration 1 hr. • Bupivicaine: 0.25 - 0.5%; amide; 30 min onset of action; duration 8 hr. • Ethyl chloride, EMLA, TAC

12. Anesthesia • Anesthetics work by causing a reversible block to impulse conduction along nerve fibers. Loss of Pain Sensation Loss of All Sensation Loss of Motor Power As Dose of Local Anesthetic Increases Max Dose of Lidocaine = 4/mg/kg

13. Corticosteroids • Treats the local inflammatory response (if present)- not the clinical problem. • Modify Pain Receptors • Goal is to maximize glucocorticoid effects; minimize mineralocorticoid effects. • Increased solubility = shorter duration = lower risk for post-injection steroid flare = lower risk for local atrophy. Celestone (6mg/ml)- Has Short & Long Acting Properties may be best all around agent (hard to find and keep) Triamcinolone (10/ml & 40mg/ml) – Low Solubility so last longer and may be better for Joint Injections

14. Alternate Compounds-Prolotherapy Theory of strengthening tendons or ligaments by injecting a noxious stimulus that cause a proliferation of new cells, but avoids the possible catabolism of steroids • Dextrose • Saline • Phenol • Calcium Gluconate • Autologus Blood • Aprotinin • Heparin Poorly studied, but gaining interest. May be worth a try

15. Technique • Be prepared! • Landmarks • Aseptic vs. Sterile technique • Local anesthesia • Needle insertion • Delivering the volume: • bolus vs. peppering “This is gonna hurt a lot”

16. Post-Procedure Care • Evaluation of relief in the office (>50% improvement = efficacious) • Discussion of steroid effects/expectations • Afterpain treatment • Ice vs. short course NSAID • Activity Recommendations • Follow-up visit!

17. Pain Relief and Injection Therapy Corticosteroid Anesthetic Pain Pain Threshold 48hrs Time

18. Evidence-Based Medicine There is currently insufficient quality data to provide a definitive answer on the efficacy of steroid injections.

19. Specific Injections • Subacromial • Acromioclavicular • Lateral Tennis Elbow * Time Permitting • Elbow Joint * Time Permitting

20. Subacromial Injection • Indications: - Relief of pain in subacromial impingement syndrome - Diagnostic to help r/o adhesive capsulitis or rotator cuff tear, or confirm RTC impingement • Needle Size and Dosage: • 21-22 gauge needle • 6-10cc anesthesia and 1cc Celestone 6mg/ml or Kenalog 40mg/cc

21. Acromioclavicular Joint • Indications: • AC degenerative disease • evaluation of AC pathology as an etiology for shoulder pain • Needle size and dosage: • 1/2 -1 inch 25 gauge needle is appropriate • 0.5ml of Anesthesia w/ 0.5ml of Celestone 6mg/ml or Kenalog 40mg/cc

22. Glenohumeral Injection • Indications: • Arthritis (Inflammatory or Degenerative) • Adhesive Capsulitis • Needle size and dosage: • 1 ½- 2 inch, 25 gauge needle • 2-3 ml of Anesthesia w/ 1 ml of Celestone 6mg/ml or Kenalog 40mg/cc Can Also Try a Posterior Approach, Enter like Subacromial Injection but aim for the Nipple

23. Elbow JointInjection/Aspiration • Olecranon Bursitis

24. Conclusion • Injections are very satisfying and rewarding for both the patient and the Family Physician. • Indications and Contraindications must be known. • An appreciation for the mostly anecdotal evidence must be kept in mind.