1. Joint and Soft Tissue Injections Deb Jacobson, MD 3/18/04

2. Introduction n Diagnostic and therapeutic benefits n Evidence-based reviews find few studies to support or refute efficacy n Lots of practice-based experience supports effectiveness

3. Introduction n Relatively easy to learn –Anatomy, anatomy, anatomy n Relatively safe n Relatively good reimbursement –charges per unit time equal or better than other office procedures

4. Introduction

5. Indications n Soft tissue –Bursitis –Tendonitis/tendinosis –Trigger points –Ganglion cysts –Neuromas –Entrapment syndromes –Fasciitis n Joint –Diagnosis of effusion n infection, crystals, trauma, inflammation –Crystalloid arthropathies –Synovitis –Inflammatory arthritis –Osteoarthritis

6. Contraindications n Absolute –local cellulitis –septic arthritis –acute fracture –bacteremia –joint prosthesis –Achilles or patellar tendinopathies –History of allergic reaction n Absolute –suspected bacteremia –severe primary coagulopathy

7. Contraindications n Relative –minimal relief after two injections –anticoagulation therapy n recent therapuetic INR –surrounding osteoporosis n Relative –inaccessible joints n hip, SI, facets –uncontrolled diabetes –more than three previous injections in the last year

8. Complications

9. Equipment n Betadine sticks n Alcohol wipes n gloves n 22- to 25- gauge 1.5-inch needles for injection n 18- to 20- gauge 1.5-inch needles for aspiration n 1 to 10cc syringes for injection n 3 to 60cc syringes for aspiration n lidocaine/bupivacaine n hemostat n tubes for lab/culture n corticosteroid preparation n gauze pads n bandaids/dressing

10. Corticosteroids n Solubility –duration inversely related to solubility –less soluble- longer it remains in the joint, more prolonged effect n Dexamethasone suspension, Celestone –used for joint injections –more soluble- shorter acting, less irritating, less post-injection flare, less fat atrophy n Depo-Medrol, Dexamethasone solution –used for soft tissue injection

11. Corticosteroids

12. Corticosteroids

13. Corticosteroids

14. Prior to Procedure n Clarify diagnosis n Consider radiographs –trauma, tumor, resistant symptoms n Discuss risks, benefits, alternatives n Obtain informed consent n Palpate landmarks n Identify the site of entry

15. Post Procedure Care n Rest for few days n Ice n NSAIDs n Exercise/PT –Injections treat symptoms, need rehab to fix the problem n Infection precautions

16. Subacromial Injection

17. Tennis Elbow

18. Knee

19. deQuervain’s Tenosynovitis

20. Trochanteric Bursitis

21. Trigger Finger

22. Carpal Tunnel

23. IT Band Syndrome

24. Olecranon Bursitis

25. Elbow Joint

26. Pes Anserine Bursitis

27. Plantar Fasciitis

28. Ankle Joint

29. Morton’s neuroma

30. References n n Cardone D, Tallia A. Joint and Soft Tissue Injection. Am Fam Phys July 2002;66:283-8 n n Martz W. How to Boost Your Bottom Line with an Office Procedure. Fam Prac Man Nov/Dec 2003;38-40 n n Thumboo J, O'Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum April 1998;41:736-9 n n Zuber T. Knee Joint Aspiration and Injection. Am Fam Phys October 2002;66:1497-1500