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Published byLizeth Tharrington Modified over 10 years ago
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Dr Paul Annett MBBS FACSP Sports Physician Visiting Fellow UNSW
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Cortisone Injection
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Historical Hench & Co-workers 1950 Hollander 1951 - Local use via injection Use evolved with soft tissue use to sports
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Cortisone Actions Inhibit early inflammation –Edema, leukocyte migration, etc Inhibit late manifestations –Fibroblasts –Collagen deposition –Scar formation
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Cortisone Injection Important questions to ask: What to inject? When to inject? Where to inject? How to inject? Complications of injection? Advice to Patients?
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What to inject? Joint Bursa Peri-tendinous Synovial sheath Enthesis Ligament Muscle
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What to inject? Shoulder - Sub-acromial, AC joint, Glenohumeral joint Elbow - CEO, CFO, Elbow joint Wrist - DeQuervains,SL ligament,Ganglion Hand - Tenosynovitis Ankle - Post sprain synovitis, Tendinopathy Foot - Plantar fascial insertion, 1st MTP Knee - Knee joint, Patella tendon Hip - Greater trochanter, Hip Joint Spine - Facet joint, Epidural space
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When To Inject? Appropriate diagnosis –History –Examination –Judicious investigation 4-6 weeks of appropriate pre-injection management –Relative rest & X-train –Ice, NSAIDS, modalities –Well structured rehabilitation program NEVER in children
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Advice to Patients NOT A CURE - Rehab essential! Will this hurt? What are the side effects? –Systemic (NB diabetes) –Infection - 1:20,000 –Crystal flare - ice + paracetamol –Skin changes - atrophy & pigment loss –Bleeding –Neuritis How long to rest?
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What to Inject? Cortisone More soluble - short acting Depot preparations Local anaesthetic additive –Dilute cortisone –Reduces initial pain –Confirms diagnosis Relative volumes
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How to Inject? GENERAL PRINCIPLES Informed consent Aseptic no touch technique Avoid skin infection Appropriate needle & syringe size Be confident! Skin anesthesia
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Failure of Injection Physician –Wrong diagnosis –Poor injection technique –Inadequate rehabilitation program Athlete / Patient –Persistent overuse –Poor technique –Intrinsic factors –Advanced degenerative disease
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How Many Injections? Repeat at least once if initial failure –Incorrect position –? Need imaging guidance Failure of 3 injections - Re-think! Repetition causes collagen weakness 3 is not set in stone
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Now - On To Injections
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Shoulder - Sub-acromial Overuse or degenerative rotator cuff pathology Posterolateral approach 2ml cortisone + 5ml local Re-examine
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Shoulder - AC joint Degenerative pathology Superior approach 1ml cortisone + 1ml local
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Shoulder – Glenohumeral Joint Capsulitis, GH OA, post traumatic pathology Posterior approach 2cm inferior and medial to posterolateral acromial edge Needle angled superomedial to the coracoid (palpate with other hand) 2ml cortisone + 5ml local
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Thank You
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