Joint and Soft TissueJoint and Soft TissueInjectionsInjections

Deb Jacobson, MDDeb Jacobson, MD

3/18/043/18/04

IntroductionIntroduction

Diagnostic and therapeutic Diagnostic and therapeutic benefitsbenefits

Evidence-based reviews find few Evidence-based reviews find few studies to support or refute studies to support or refute efficacyefficacy

Lots of practice-based experience Lots of practice-based experience supports effectivenesssupports effectiveness

IntroductionIntroduction

Relatively easy to learnRelatively easy to learn– Anatomy, anatomy, anatomyAnatomy, anatomy, anatomy

Relatively safeRelatively safe Relatively good reimbursementRelatively good reimbursement

– charges per unit time equal or better charges per unit time equal or better than other office proceduresthan other office procedures

IntroductionIntroduction

IndicationsIndications

Soft tissueSoft tissue– BursitisBursitis– Tendonitis/tendinosisTendonitis/tendinosis– Trigger pointsTrigger points– Ganglion cystsGanglion cysts– NeuromasNeuromas– Entrapment Entrapment

syndromessyndromes– FasciitisFasciitis

JointJoint– Diagnosis of effusionDiagnosis of effusion

infection, crystals, infection, crystals, trauma, inflammationtrauma, inflammation

– Crystalloid Crystalloid arthropathiesarthropathies

– SynovitisSynovitis– Inflammatory arthritisInflammatory arthritis– OsteoarthritisOsteoarthritis

ContraindicationsContraindications

AbsoluteAbsolute– local cellulitislocal cellulitis– septic arthritisseptic arthritis– acute fractureacute fracture– bacteremiabacteremia– joint prosthesisjoint prosthesis– Achilles or patellar Achilles or patellar

tendinopathiestendinopathies– History of allergic History of allergic

reactionreaction

AbsoluteAbsolute– suspected suspected

bacteremiabacteremia– severe primary severe primary

coagulopathycoagulopathy

ContraindicationsContraindications

RelativeRelative– minimal relief minimal relief

after two after two injectionsinjections

– anticoagulation anticoagulation therapytherapy

recent therapuetic recent therapuetic INRINR

– surrounding surrounding osteoporosisosteoporosis

RelativeRelative– inaccessible jointsinaccessible joints

hip, SI, facetship, SI, facets

– uncontrolled uncontrolled diabetesdiabetes

– more than three more than three previous injections previous injections in the last yearin the last year

ComplicationsComplications

EquipmentEquipment Betadine sticksBetadine sticks Alcohol wipesAlcohol wipes glovesgloves 22- to 25- gauge 1.5-inch 22- to 25- gauge 1.5-inch

needles for injectionneedles for injection 18- to 20- gauge 1.5-inch 18- to 20- gauge 1.5-inch

needles for aspirationneedles for aspiration 1 to 10cc syringes for 1 to 10cc syringes for

injectioninjection 3 to 60cc syringes for 3 to 60cc syringes for

aspirationaspiration

lidocaine/bupivacainelidocaine/bupivacaine hemostathemostat tubes for lab/culturetubes for lab/culture corticosteroid preparationcorticosteroid preparation gauze padsgauze pads bandaids/dressingbandaids/dressing

CorticosteroidsCorticosteroids SolubilitySolubility

– duration inversely related to solubilityduration inversely related to solubility– less soluble- longer it remains in the joint, less soluble- longer it remains in the joint,

more prolonged effectmore prolonged effect Dexamethasone suspension, CelestoneDexamethasone suspension, Celestone

– used for joint injectionsused for joint injections

– more soluble- shorter acting, less irritating, more soluble- shorter acting, less irritating, less post-injection flare, less fat atrophyless post-injection flare, less fat atrophy

Depo-Medrol, Dexamethasone solutionDepo-Medrol, Dexamethasone solution– used for soft tissue injectionused for soft tissue injection

CorticosteroidsCorticosteroids

CorticosteroidsCorticosteroids

CorticosteroidsCorticosteroids

Prior to ProcedurePrior to Procedure

Clarify diagnosisClarify diagnosis Consider radiographsConsider radiographs

– trauma, tumor, resistant symptomstrauma, tumor, resistant symptoms Discuss risks, benefits, alternativesDiscuss risks, benefits, alternatives Obtain informed consentObtain informed consent Palpate landmarksPalpate landmarks Identify the site of entryIdentify the site of entry

Post Procedure CarePost Procedure Care

Rest for few daysRest for few days IceIce NSAIDsNSAIDs Exercise/PTExercise/PT

– Injections treat symptoms, need rehab to fix Injections treat symptoms, need rehab to fix the problemthe problem

Infection precautionsInfection precautions

Subacromial InjectionSubacromial Injection

Tennis ElbowTennis Elbow

KneeKnee

deQuervain’s deQuervain’s TenosynovitisTenosynovitis

Trochanteric BursitisTrochanteric Bursitis

Trigger FingerTrigger Finger

Carpal TunnelCarpal Tunnel

IT Band SyndromeIT Band Syndrome

Olecranon BursitisOlecranon Bursitis

Elbow JointElbow Joint

Pes Anserine BursitisPes Anserine Bursitis

Plantar FasciitisPlantar Fasciitis

Ankle JointAnkle Joint

Morton’s neuromaMorton’s neuroma

ReferencesReferences Cardone D, Tallia A. Joint and Soft Tissue Injection. Am Fam Phys July 2002;66:283-8

Martz W. How to Boost Your Bottom Line with an Office Procedure. Fam Prac Man Nov/Dec 2003;38-40

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

Zuber T. Knee Joint Aspiration and Injection. Am Fam Phys October 2002;66:1497-1500