management of localised tender points
DESCRIPTION
trigger points, local steroid injections, pain in heel, tennis elbowTRANSCRIPT
Management of localized Tender Points
Vinod Naneria
Classification – According to Pathology
Stenosing Tenosynovitis De Quervain’s Trigger thumb and fingers Bicep’s tenosynovitis Tibialis Posterior and Peroneal tendon
tenosynovitis
Classification – cont….
Traumatic and/or degenerative Tendenous avascular origin/insertion
Tennis / Golfer’s elbow Planter fasciitis Bursitis
Retrocalcaneal bursitis Periarthritis shoulder Trochanteric bursitis Olecranon bursitis
Classification – cont….
Trigger zones Supra and periscapular Costochondritis / Titze’s disease Gluteus maximums origin
Intra Articular CMC joint Knee Joint TM joint
Classification – cont…. Synovitis
Flexor tendons at wrist Extensor tendons at wrist
Miscellaneous Accessory Navicular Os trigonum Ganglions Osteitis Pubis Coccygodynia
Management Counseling
Self limiting conditions No long term disability Treatment may fail quite often Nothing to worry about
Drug Therapy Indomethacin 75mg H.S., with milk for 3
weeks and gradual withdrawal by alternate day / substitute by mild NSAID
Caution: Hypertension
Rule out Hypertension No anti inflammatory long term drug in
Hypertension Better to inject than drug therapy. Always ask for – serum creatinine and
urine for albumin
Management – cont…
Physiotherapy Local ultrasound heating Stretching exercises Corrective orthosis ( scooped heel) Wrist Band Elbow immobilizer
Management – Local Steroid Triamcinolone Acetonide – 10mg No Xylocain / Hylase 2cc syringe, 22 gauge needle, 1.5” long Lying down patient Multiple puncture for spread of drug Post injection massage Local band-aid dressing NSAID for two days Informed consent
Management – cont…
Injection – Intra lesional Planter fasciitis Tennis and Golfer’s elbow All trigger points All joints All bursitis
Injection – Peri lesional Into Sheath – all tenosynovitis
Instructions to patients
To come prepared after cleaning the part to be injected.
Especially the heel or coccyx Always ask the patient to bring an
attendant for inadvertent Drug reaction Vaso-vagal reaction or sudden hypotension
Caution: Diabetes
Avoid injection in cases of high blood glucose level.
Predispose to infection Affect serum glucose management Better skin preparation
Management – cont… PrecautionsAvoid All weight bearing joint Avoid hitting the tendon directlyAvoid hitting the nerves directlyAvoid injecting directly in to artery or veinWatch for allergic reactions for an hour
Instructions to patient after local steroid injection
Inform about post injection flair Inform about skin and local soft tissue
atrophy Watch for infection Avoid repeating injection at the same
site for at least 6 weeks
Cortisone induced Leucoderma of the wrist
A word of caution:
To avoid possible depigmentation and subcutaneous atrophy, intra-lesional doses should not be placed too superficially in easily visible sites in deeply pigmented patients
Soft tissue necrosis
Tips….. Planter fasciitis:
Hit directly from the planter surface on the medial calcaneal tuberosity.
Feel the medial calcaneal tuberosity with the tip of the needle and push it distally so that it can slip over the calcaneum. This the place.
Inject the drug and make multiple punctures in the planter apponeurosis.
Massage the site after the injection
Tips….. De Quervains disease
Start just proximal to the nodule Inject the drug into the sheath See the filling of the sheath up to the base
of thumb Do not inject in to the tendons A tight sheath will give the same resistance
as the injection into the tendon – you have to differentiate.
Tips…..
Coccygodynia Feel maximum tender point The place for injection is the junction
between the two mobile parts. So do not
inject over the bone but inject into the space between two pieces of coccyx.
Tips…..
Tennis Elbow Always just anterior to the epicondyle Occasionally over the lateral epicondyle Inject into the soft tissue over the
epicondyle anteriorly and not over the bone.
With the needle hit the bone and then withdraw it before injection
Make multiple punctures
Caution :Temporaryskin de-pigmentation.Local subcutaneous tissue necrosis.
Contraindications for use Hypersensitivity to ingredients of triamcinolone Preparation Systemic infections or local infections Infected joints Where previous injections have produced local atrophy Active peptic ulcer, myasthenia gravis, osteoporosis, acute
glomerular nephritis, fresh intestinal anastamoses, diverticulitis, thrombophlebitis,
Psychic disturbances, pregnancy, diabetes mellitus, hyperthyroidism,
Acute coronary artery disease, hypertension, limited cardiac reserve,
Triamcinolone is crystalline suspention
The duration of effect is inversely related to the solubility of the preparation: the less soluble an agent, the longer it remains in the joint and the more prolonged the effect. Consequently, suspensions are longer acting.
Crystals of Triamcinolone can be detected in joint fluid even after 6 months after injection
DISCLAIMER
Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 30 years.
It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal
opinion. Depending upon the x-rays and clinical presentations, viewers can
make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best
suited to him. I am not responsible for any controversies arise out of this presentation.
For any correction or suggestion please contact [email protected]