Joint injection Dr Amit Saha Consultant Rheumatologist & Clinical Lead for Rheumatology- Maidstone and Tunbridge Wells NHS Trust Spire Tunbridge Wells-

Joint injectionJoint injection

Dr Amit Saha Dr Amit Saha Consultant Rheumatologist & Clinical Lead for Consultant Rheumatologist & Clinical Lead for Rheumatology- Maidstone and Tunbridge Wells Rheumatology- Maidstone and Tunbridge Wells

NHS TrustNHS Trust

Spire Tunbridge Wells- TALKSpire Tunbridge Wells- TALK

Introduction course- Introduction course- Focus on 90% of injections- knee, wrists Focus on 90% of injections- knee, wrists

shoulder shoulder When to inject and aspirate – need When to inject and aspirate – need

diagnosis firstdiagnosis first SafetySafety

ShoulderShoulder

Frozen shoulder (adhesive capsulitis)Frozen shoulder (adhesive capsulitis) Subacromial impingement syndromesSubacromial impingement syndromes

Frozen ShoulderFrozen Shoulder

Stiffened gleno-humeral joint that has lost Stiffened gleno-humeral joint that has lost significant range of motion (abduction and significant range of motion (abduction and rotation). rotation).

40-60s40-60s Dis-use – sling, recent operation, pre-Dis-use – sling, recent operation, pre-

existing shoulder complaintexisting shoulder complaint 50% reduction in all movements 50% reduction in all movements

(especially external rotation)(especially external rotation)

Frozen ShoulderFrozen Shoulder

In SAI – though active movement reduced, In SAI – though active movement reduced, passively you can push full movement.passively you can push full movement.

Patients with frozen shoulder have varying Patients with frozen shoulder have varying degrees of pain early in the disease course, but degrees of pain early in the disease course, but complain primarily of joint stiffness. Symptoms complain primarily of joint stiffness. Symptoms generally develop over the course of weeks to generally develop over the course of weeks to months. months.

No X-rays generally needed (exception if you No X-rays generally needed (exception if you think there is gleno-humeral OA)think there is gleno-humeral OA)

TreatmentTreatment

Acute (first 8 weeks)- NSAIDs and avoid Acute (first 8 weeks)- NSAIDs and avoid excessive activitiesexcessive activities

Gentle exercises- Pendular exercises Gentle exercises- Pendular exercises (evidence weak) plus stretching exercises.(evidence weak) plus stretching exercises.

Revaluate in 8 weeks – Continue or injectRevaluate in 8 weeks – Continue or inject

Randomized trial of 109 patients.Randomized trial of 109 patients.

At seven weeks, 40 of 52 patients randomly At seven weeks, 40 of 52 patients randomly assigned to glucocorticoid injection were assigned to glucocorticoid injection were considered to have a treatment success considered to have a treatment success compared with 26 of 56 patients (46 percent) compared with 26 of 56 patients (46 percent) treated with physiotherapy. treated with physiotherapy.

van der Windt DA et al. BMJ. 1998;317(7168):1292.

Glucocorticoid injection may hasten Glucocorticoid injection may hasten recovery, and the addition of supervised recovery, and the addition of supervised physical therapy following glucocorticoid physical therapy following glucocorticoid injection may result in more rapid injection may result in more rapid improvement than injection alone. improvement than injection alone. However, the long-term outcome of However, the long-term outcome of adhesive capsulitis may not be much adhesive capsulitis may not be much affected by either intervention.affected by either intervention.

Four groups: steroid plus supervised physiotherapy (PT), Four groups: steroid plus supervised physiotherapy (PT), glucocorticoid injection alone, saline injection plus glucocorticoid injection alone, saline injection plus supervised PT, or saline injection alone.supervised PT, or saline injection alone.

Those who received a glucocorticoid injection and Those who received a glucocorticoid injection and supervised PT improved significantly more, and more supervised PT improved significantly more, and more rapidly, than any other group at six weeks; those who rapidly, than any other group at six weeks; those who received glucocorticoid injections were better than those received glucocorticoid injections were better than those who did not at three months. who did not at three months.

But by one year there was no discernible difference in But by one year there was no discernible difference in improvement among the four groups. improvement among the four groups.

Carette et al. Arthritis Rheum. 2003;48(3):829.Carette et al. Arthritis Rheum. 2003;48(3):829.

Injection Approach - posterior approachInjection Approach - posterior approach

Subacromial impingement Subacromial impingement syndromessyndromes

Rotator cuff may be compressed during Rotator cuff may be compressed during glenohumeral movementglenohumeral movement

Painful daily activities may include putting on a Painful daily activities may include putting on a shirt or brushing hair. shirt or brushing hair.

Patients may localize the pain to the lateral Patients may localize the pain to the lateral deltoid and often describe pain at night, deltoid and often describe pain at night, especially when lying on the affected shoulder. especially when lying on the affected shoulder.

Inspection – Rotator cuff atrophyInspection – Rotator cuff atrophy Palpation- focal subacromial tenderness at the Palpation- focal subacromial tenderness at the

lateral or posterior-lateral border of the lateral or posterior-lateral border of the acromion. acromion.

Painful ROM that occurs between 60 and 120 Painful ROM that occurs between 60 and 120 degrees of active abduction marks a positive arc degrees of active abduction marks a positive arc test test

Normal passive range of movement and Normal passive range of movement and powerpower

Beyond 150 degrees possible acromio-Beyond 150 degrees possible acromio-clavicular OAclavicular OA

TreatmentTreatment

X-rays generally not neededX-rays generally not needed Simple things firstSimple things first Injections- evidence weak. Systematic Injections- evidence weak. Systematic

review poor trials.review poor trials.

Knee Knee

OA kneesOA knees Aspirate- gout/pseudogout/infectionAspirate- gout/pseudogout/infection Works – can be up to 6 monthsWorks – can be up to 6 months Certain patients better to use than othersCertain patients better to use than others

Carpal Tunnel syndrome

Median nerve entrapment Classically 1-31/2 fingers Classic symptoms Tinel’s and phalens Splints first Surgery if severe damage Inject if splints fail

InjectionsInjections Discussed benefits alreadyDiscussed benefits already Risks – Bleeding and infection – less than 1 in 10,000Risks – Bleeding and infection – less than 1 in 10,000 AsepticAseptic INR less than 3 for large jointsINR less than 3 for large joints Post-injection flare- last few hours usually within 24-48 hours.Post-injection flare- last few hours usually within 24-48 hours. Tendon damage – Tendon rupture is most commonly encountered Tendon damage – Tendon rupture is most commonly encountered

when undiluted glucocorticoid is given very near or into tendonwhen undiluted glucocorticoid is given very near or into tendon Nerve damage Nerve damage Skin depigmentationSkin depigmentation Do Do not inject not inject prosthetic jointsprosthetic joints Avoid general exertion for 24 hours.Avoid general exertion for 24 hours.

Shoulder – 40mg (1ml) Depo-medrone Shoulder – 40mg (1ml) Depo-medrone (methylprednisolone acetate) plus (methylprednisolone acetate) plus approximately1-2mls of 1% lidocaineapproximately1-2mls of 1% lidocaine

Knee - 80mg (2ml) Depo-medrone Knee - 80mg (2ml) Depo-medrone (methylprednisolone) plus approximately (methylprednisolone) plus approximately 2mls of 1% lidocaine2mls of 1% lidocaine

Wrist 20mg (0.5ml) Depo-medrone plus Wrist 20mg (0.5ml) Depo-medrone plus 0.5ml 1% lidocaine0.5ml 1% lidocaine

Frequency- evidence limitedFrequency- evidence limited

Inject very active large joints affected by Inject very active large joints affected by rheumatoid arthritis as often as 3 rheumatoid arthritis as often as 3 injections per year for any given joint. injections per year for any given joint.

For joints affected by osteoarthritis, can For joints affected by osteoarthritis, can inject glucocorticoids as often as once inject glucocorticoids as often as once every six months only if no other therapy is every six months only if no other therapy is effective. effective.

Green needle – 21 gauge (knee and Green needle – 21 gauge (knee and shoulder)shoulder)

Orange needle – 25 gauge (wrist)Orange needle – 25 gauge (wrist) 10ml syringe for knee and shoulder10ml syringe for knee and shoulder 1ml syringe for wrist1ml syringe for wrist Universal containerUniversal container Alcohol swabs (with 70% isopropyl Alcohol swabs (with 70% isopropyl

alcohol)alcohol)

Knee injectionKnee injection

MedialMedial

InferiorInferior

SuperiorSuperior

LateralLateral