Dr. TAREK NASRALA, MD, Department of RHEUMATOLOGYALAZHAR University

• Hollander introduced local corticosteroid injection therapy for treatment of inflammatory arthritis in 1951

• Reported medical benefits of intra-articular injection inconsistent

• Pain relieve • 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

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

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

ContraindicationsOverlying cellulitis*Severe coagulopathy ; Anticoagulant therapySeptic effusionMore than three injections per year in a weight-bearing jointLack of response after two to four injectionsBacteremia*Unstable jointsInaccessible joints (i.e. facet joints of spine)Joint prosthesis*Evidence of surrounding osteoporosisRecent intra-articular joint osteoporosisHistory of allergy or anaphylaxis to injectable pharmaceuticals

*absolute contraindicationsAdapted from Pfenninger, 1991 and Cardone, 2002

• Materials and Equipment• Pharmacologic Agents• Site Preparation• Post-injection Care

• 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).

• 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

Relative PotencyCorticosteroid PreparationsCorticosteroid Relative anti-

inflammatory potency

Approximate equivalentdose (mg)

Short-acting preparations

Cortisone 0.8 25

Hydrocortisone 1.0 20

Intermediate-acting preparations

Prednisone 3.5 5

Methylprednisolone acetate (Depo-Medrol)

5 4

Long-acting preparations

Dexamethasone sodium phosphate (Decadron)

25 0.6

Betamethasone (Celestone Soluspan) 25 00.6

Dosages Corticosteroid Preparations

Corticosteroid Preparation strength

(mg per mL)

Common dosagefor site (mg)

Tendon sheathsand bursae

Smalljoints

Largejoints

Hydrocortisone 25, 50 8-40 10-25 50-125

Methylprednisolone(Depo-Medrol)

20, 40, 80 4-10 2-5 10-25

Betamethasone(Celestone Soluspan)

6 1.5-3.0 0.8-1.0 2-4

• 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

• Autologous blood• Polidocanol• Prolotherapy

•Dextrose•Morrhuate sodium

• is an increasingly popular therapy for chronic musculoskeletal and arthritic pain in which a small volume of an irritant solution is injected at multiple sites on painful ligament and tendon insertions (enthesis) and in adjacent joint spaces..

• Injected substances (proliferants) are purported to initiate a local inflammatory response with resultant hypertrophy and strengthening of collagenous structures

• mesotherapy involves injecting various types of medications and plant extracts into layers of fat and connective tissue under the skin with the object of dissolving fat.

• In the same way using other medical drugs in minute amounts injected in the affected site to relief symptoms without side effects

• Homeopathy is a distinct, comprehensive and deep healing system originally developed by Samuel Hahnemann about 200 years ago.

• It uses small doses of specially prepared (“potentized”) remedies to set the body’s systems back in order and stimulate a persons own energies toward a natural healing process.

• It is entirely distinct in both theory and in practice from other healing systems – most notably from ordinary or main-stream (“allopathic”) medicine, but also from acupuncture, chiropractics, naturopathy, etc., although some homeopathy often finds its way into these other fields of practice.

Sterile ethyl chlorideAseptic 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

Injection•Do not inject directly into tendon or ligament

•Reposition needle if resistance encountered

•Aspirate to avoid intravascular deposition of medicine

• 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.

Complications Estimated prevalence

Postinjection flare 2-5%Steroid arthropathy 0.8%

Tendon rupture <1%Facial flushing <1%

Skin atrophy, depigmentation <1%Iatrogenic infectious arthritis <0.001 to 0.072%Transient paresis of injected extremity Rare

Hypersensitivity reaction RareAsymptomatic pericapsular calcification 43%

Acceleration of cartilage attrition Unknown

• 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)

• Common sites• Shoulder• Elbow• Hand and wrist• Hip• Knee• Ankle

• With the jaw fully opened, enter the joint 1⁄4 to 3⁄8 inch directly anterior to the tragus in the depression formed over the joint;

• Angle perpendicular to the skin• Needle: 5⁄8-inch, 25-gauge• Depth: 1⁄4 to 1⁄2 inch into the joint• Volume: 0.5 to 1 mL anesthetic, 0.5 mL K40,

or both• NOTE: Identify the temporal artery by

palpation, mark its course, and enter the skin on either side of it.

• Gently advance the needle into the joint. If arterial blood enters the syringe, exit the skin, hold pressure for 5 minutes, and reenter either slightly anterior or posterior to the artery

• 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

• Enter 1 to 11⁄2 inches below the midpoint of the acromial process; parallel the angle of the acromion to the subacromial bursa

• Needle: 11⁄2-inch, 22-gauge• Depth: 1 to 11⁄2 inches to 31⁄2 inches (obese patient)

• Volume: 2 to 3 mL anesthetic and 1 mL D80

• NOTE: Never inject under pressure or if the patient experiences dramatic pain (intratendinous or periosteal);

• if pain develops or resistance to injection is encountered, withdraw 1⁄2 inch and redirect

Needle inserted 1 – 2 cm below midpoint of lateral edge of

acromion

Needle inserted 1 - 2 cm below posterior lateral aspect of

acromion

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

(a) Preferred needle gauge; length; type: 22-gauge; 3½-in.; spinal (b) Recommended dosage: Total volume of up to 100 mL have been injected

• The joint can be injected from a posterior approach with the patient seated.

• The arm is positioned in front of the trunk and is medially (internally) rotated, with the forearm across the abdomen, in order to help open the posterior aspect of the joint space.

• The injection site can be localized by palpating the mediastinal posterolateral corner of the scapular spine; one can also identify the coracoid process anteriorly.

• pierce the skin just below the scapular spine insertion site and direct the needle toward the anterior coracoid process until it reaches the articular surfaces.

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

Patient positioning:· Place the patient in a seated position, generally with the affected arm hanging down to the side.

Identification and marking of injection site:· Palpate and locate the biceps tendon in the bicipital groove.

· Mark the target using a marker or by depressing the skin with a plastic needle cap.

Identification and marking of injection site.· Palpate laterally along the clavicle until reaching an anterior curvature. Move laterally beyond this until you feel a distinct depression between the end of the clavicle and the acromion.· Adjust as necessary, and mark the overlying skin by depressing it with a plastic needle cap or a marker.

• Indications:• (a) Adhesive capsulitis diagnosis as pain generator• (b) Differentiation of rotator cuff impingement vs.

rotator cuff tear• (c) Rotator cuff impingement • (d) Rotator cuff tendinitis, tendinosis • (e) Subacromial region: diagnosis as pain

generator • (f) Subacromial bursitis (sometimes referred to as

subdeltoid bursitis)

• Patient positioning:• · The patient is seated on the exam table, with

the affected arm hanging • down to the side.• · If necessary, a weighted object may be placed

in the patient’s hand to • distract the humerus inferiorly and thus increase

subacromial space.• Identification and marking of injection site:• Identify the posterolateral corner of the scapula by

palpating laterally along the scapular spine until the discrete corner is appreciated.

• Identify a point that is one-finger-breadth below this location .

• 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

Step-by-step procedure: Patient positioning: With the patient in a seated position, the elbow resting on a flat surface, the hand is in full pronation, and the elbow is flexed to 60–90°. Identification and marking of injection site: Identify the lateral epicondyles by direct palpation and with palpation of the origin of the common extensor tendon as the patient extends and relaxes the wrist on the affected side.

Step-by-step procedure:Patient positioning: With the patient in a seated position, the elbow resting on a flat surface, the hand is in full pronation, and the elbow is flexed to 60–90°.Identification and marking of injection site:Identify the medial epicondyle by direct palpation and with palpation of the origin of the common flexor tendon as the patient flexes and relaxes the wrist on the affected side.

Step-by-step procedure:Patient positioning:• Place the patient in a seated position with the elbow

resting on a flat surface, the hand in full pronation, and the elbow flexed to 90°.

• Approaching the bursa from a posterolateral angle is preferred to avoid potential injury to the ulnar nerve.

• Identification and marking of injection site:• Identify the center of the distended, painful bursa, or

the olecranon process if the bursa is not significantly distended. Care should be taken to select an injection site slightly lateral to the area described earlier to avoid the ulnar nerve.

• Mark the target using a marker or by depressing the skin with a plastic needle cap.

• Step-by-step procedure:• Patient positioning:• · Place the patient in a seated position The

elbow is placed on a flat surface and positioned in 50–90° of elbow flexion, with the palm facing downward (pronated).

• Identification and marking of injection site:• The capitellum and radial head are palpated

and identified. The space between the capitellum and radial head is identified by palpation.

• Mark the target using a marker or by depressing the skin with a plastic needle cap.

• Step-by-step procedure:• Patient positioning:• · The elbow is placed on a flat surface

and positioned in 50–90° of elbow flexion, with the palm facing downward (pronated).

• Identification and marking of injection site:

• The lateral epicondyle, radial head, and posterior aspect of the olecranon are palpated and identified.

• Identify the groove between the lateral epicondyle and posterior olecranon; it is palpated lateral to the radial head.

• Trigger finger.

•Corticosteroid 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

• Identify a tender, palpable nodule along the flexor tendon sheath, most commonly just distal to the A1 pulley of the hand if the finger is extended (near the distal end of the metacarpal).

• The nodule may be proximal to the finger pulley if the finger is locked in flexion.

• The injectate does not need to be deposited into the nodule per se, though injection into the peritendinous sheath close to the nodule is appropriate

• The injection is generally performed with the needle pointing toward the fingertip (proximal to distal approach).

• Pierce the overlying skin and soft tissue and angle the needle into the nodule and subsequently into the tendinous sheath.

• When satisfactory needle position is achieved, there should be mild resistance to injection

• Gentle passive finger flexion may also precipitate needle movement, which can suggest that the needle is in contact with or lodged in the actual flexor tendon

Identification and marking of injection site:Have the patient actively extend the thumb to identify the two tendons noted previously. Passively flex the thumb, and again note the location of these tendons by palpation over the base of the first metacarpal. If possible, palpate a space between the tendons and mark this as the ideal injection site.Mark the target using a marker or by depressing the skin with a plastic needle cap.

• Identification and marking of injection site:• •Palpate the radio-ulnar joint by feeling for the mobility of the radius and ulnar and identifying the joint space in-between.

• After localizing the separation of the radius and ulna, the distal end of the ulna is identified by palpating the prominent distal tip. The joint space is generally located just medial and proximal to this most distal tip.

• The median nerve generally runs directly under the palmaris longus tendon, which can often be identified by having the patient oppose the thumb to the tip of the fifth finger.

• Once the palmaris longus has been identified, the needle entry site can be marked on the skin between the palmaris longus tendon and the FCR tendon.

• Mark spot 4 cm proximal to distal palmar crease and between tendons

• Palpate the carpal bones and locate a spot half-way between the distal end of the radius and ulna and the proximal aspect of the metacarpals.

• Continue to palpate and identify locations between the carpal bones as potential injection sites.

• The joint can be accessed through anyone of several sites.

• Choose the site that appears to provide the easiest

access

• Patient positioning:• Place the patient in a seated position with the

affected hand laying flat (palm-down) on the table

• Identification and marking of injection site:

• Palpate the location of the first CMC joint by feeling for the distal end of the trapezium where it articulates with the first metacarpal in the anatomical snuff box.

• Entry through the skin overlying the anatomical snuff box is generally preferred. Active and passive movement of the first digit in flexion and extension while feeling for the trapezium-first metacarpal articulation is also helpful

• Patient positioning:• For MCP joint injections, the hand can be positioned resting on the procedure table with the palm down, to be accessed from the dorsal aspect of the hand.

• For IP joint injections, the joints can be accessed from either the medial or lateral side of the joint

• Identification and marking of injection site:

• The target joint space can be identified by passively flexing and extending the digit across the target joint to identify the space between the two bones

Trochanteric bursa•For treatment of trochanteric bursitis, corticosteroid injection is effective treatment option• Grade of

Recommendation: C

Injections of knee recommended for treatment of such conditions as OA and bursitis (Grade of Recommendation: A).

•Intra-articular space•Anserine bursa

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

• Pes anserine bursa

• Intra-articular space

• Plantar fascia. • Corticosteroid injection considered initial treatment option

for plantar fasciitis (Grade of Recommendation: D)

• Limited evidence that corticosteroid injection provides short-term benefit.

Injection is on dorsum of foot, in-between metatarsel heads at point of maximum tenderness

Grades of Recommendations Selected Injections.

Injection Site / Diagnosis Grade of Recommendation

Shoulder (subacromial bursitis, rotator cuff tendonitis, adhesive capsulitis, and biceps tendonitis)

D

Lateral epicondylitis A

Medial epicondylitis D

Trigger finger C

DeQuervain’s tenosynovitis C

Carpal tunnel A

Trochanteric bursitis C

Knee (osteoarthritis, bursitis) A

Plantar fasciitis D

• Joint and soft tissue injections should be used in conditions that are clearly demarcated and well diagnosed and in which the injector is comfortable with the procedure. Some general guidance follows:

• • exact location of the needle is not always necessary as even the more experienced injectors can obtain good response rates with periarticular injections

• it is a clean, not sterile procedure; evidence suggests that, despite wide variation in precaution against sepsis, this is rare

• anatomical landmarks are important and using them reduces the discomfort of scraping bone

• a drawing-up needle should be used that is separate from the injecting needle (no touch technique)

• 24-48 hours rest is beneficial, especially in weight-bearing joints

• they should be administered at a maximum of 3 a year as they tend to lose their efficacy over time in noninflammatory conditions