You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > THERAPEUTIC MODALITIES Corticosteroid Injections of Joints and Soft TissuesArticle Last Updated: Jun 4, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Jess D Salinas Jr, MD, Medical Director, Lake Mary Clinic, National Pain Institute, LLC; Associate Medical Director, Winter Park Clinic, National Pain Institute, LLC Jess D Salinas, Jr, is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, and Physiatric Association of Spine, Sports and Occupational Rehabilitation Coauthor(s): Jerrold N Rosenberg, MD, Director of Rehabilitation Services, Providence Veterans Hospital; Clinical Assistant Professor, Departments of Orthopedics and Rehabilitation, Rhode Island Hospital, Brown University Editors: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center Author and Editor Disclosure Synonyms and related keywords: trigger point, cortisone, dry needling, articular injection, intra-articular injection, periarticular injection INTRODUCTIONSection 2 of 9
  Use of cortisone injections in the treatment of muscle and joint inflammatory reactions is becoming increasingly popular. First popularized by Janet Travell, MD, muscle injections are a remarkably effective adjunct to pharmacologic and physical therapies and are safe and easy to perform. Joint injections, while technically more difficult to perform, also can be of great benefit in the patient's recovery. The purpose of this article is to introduce the basic principles of muscle and joint injections.1, 2, 3, 4 MECHANISM OF INFLAMMATIONSection 3 of 9
Inflammation is one of the body's first reactions to injury. Release of damaged cells and tissue debris occurs upon injury. These expelled particles act as antigens to stimulate a nonspecific immune response and to cause the proliferation of leukocytes. Local blood flow increases to transport the polymorphonuclear leukocytes, macrophages, and plasma proteins to the injured area. A redistribution of arteriolar flow produces stasis and hypoxia at the injury site. The resulting infiltration of tissues by the leukocytes, plasma proteins, and fluid causes the redness, swelling, and pain that are characteristic of inflammation. Inflammatory muscle and joint injuries are associated with many causes, including the following:
Initially, the inflammatory reaction serves several important purposes. The influx of leukocytes facilitates the process of phagocytosis and the removal of damaged cells and other particulate matter. Pain and tenderness remind the patient to protect the injured area; however, the inflammatory reaction eventually becomes counterproductive. The extravascular pressure exerted by the edema may retard blood flow into the area and delay healing. Sometimes, the debris coagulates and forms hard masses, scarring, and/or trigger points in the muscle or joint, preventing normal function from returning. ACTIONS OF CORTICOSTEROIDSSection 4 of 9
The mechanism of corticosteroid action includes a reduction of the inflammatory reaction by limiting the capillary dilatation and permeability of the vascular structures. These compounds restrict the accumulation of polymorphonuclear leukocytes and macrophages and reduce the release of vasoactive kinins.5 They also inhibit the release of destructive enzymes that attack the injury debris and destroy normal tissue indiscriminately. EVALUATION OF THE PATIENTSection 5 of 9
As with the treatment of any disorder, a carefully taken patient history and a carefully made physical examination are of paramount importance. Sharp, severe, intense pain suggests the presence of a more acute, traumatic reaction with marked inflammation. Dull, low-grade, chronic pain indicates the existence of a mild inflammatory reaction, a chronic overuse injury, or arthritis. Radiation of pain or additional neurologic symptoms (eg, tingling, burning, numbness) imply additional neurologic involvement. Medication history is important because discontinuation of anti-inflammatory medications often precipitates a reaction. Dietary changes also may precipitate reactions, such as an attack of gout. The physical examination is performed to assess the location and severity of the reaction. Determination of whether the inflammation is in the muscle, tendon, or joint is of paramount importance. Trigger points in muscles can be easily identified if the clinician uses the appropriate palpation skills. Many clinicians ask their patients to identify the site of greatest discomfort. Patients often know exactly where the source of their pain is, having spent hours localizing it. Radiographic studies may or may not be beneficial, because it takes a significant amount of effusion for the injury to appear on a routine radiograph. Usually, clinical symptoms are present and treatable long before a radiographic abnormality may be identified. On the other hand, radiographs are important in evaluating for fracture or determining acuity. If joint and cartilage damage exists, the clinician knows that a long-standing process is involved. Electromyograms (EMGs) are extremely beneficial in determining whether there is a significant neurologic component to the patient's symptoms. This determination is important in targeting injection sites. Blood work can include blood counts and chemistry series. An elevated leukocyte or white blood cell count may indicate infection. An elevated erythrocyte sedimentation rate suggests that a significant myopathic or arthritic process has developed. Elevated rheumatoid factor implies chronic arthritic conditions, such as rheumatoid arthritis. Elevated uric acid levels are sometimes observed in patients with gout. TREATMENT OF THE PATIENTSection 6 of 9
Treatment of the patient with an inflammatory condition involves a multidisciplinary approach. Anti-inflammatory medications (eg, aspirins, nonsteroidal anti-inflammatory drugs [NSAIDs], oral prednisone) are indicated in patients with acute and chronic inflammation. It should be remembered that a full therapeutic dose should initially be used. Many patients discontinue their medication after they have begun to feel better, leaving a low-lying inflammatory reaction. This author recommends first prescribing the NSAID for a 10- to 14-day period, with instructions to use up the medication as long as side effects do not develop. This should be followed up with an as-needed (prn) prescription. Nonnarcotic pain medications, such as Elavil, may be beneficial in reducing the pain associated with inflammatory reactions. Although this is an area of some controversy, the use of narcotic medications is dependent on the severity of the pain, and these drugs should be used only for a limited duration. In acute situations, rest, ice, heat, splinting, and bracing are important elements of care. With time, physical therapy, massage therapy, and general rehabilitation management become increasingly effective. While injection therapy is relatively safe, there are inherent dangers in any procedure where the skin is pierced, including infection, bleeding, joint ruptures, and perforation of vital structures. Indications for injection therapy may include any of the following inflammatory conditions6:
The packing insert for corticosteroids lists additional significant precautions and contraindications. The physician should be familiar with all of these restrictions before considering injection therapy. Potential local side effects of corticosteroid injections include infection, subcutaneous atrophy, skin depigmentation, and tendon rupture.5 These complications often result from poor technique, too large a dose, too frequent a dose, or a failure to mix and dissolve the medications properly. Regarding injections for myofascial pain, some clinicians prefer to perform trigger point injections of corticosteroid, while others prefer to perform trigger point injections containing only local anesthetics or no medication at all ("dry needling"). PROCEDURESection 7 of 9
The procedure for injection therapy is uncomplicated and well established. The object is to inject the corticosteroid preparation with as little pain and as few complications as possible. The technique is similar for muscle, periarticular, or articular injections. Selection of the site and careful attention to surface and deep anatomy are of paramount importance.14 Injections in the vicinity of known nerve or arterial landmarks should not be attempted. For example, a lateral epicondyle injection is relatively easy. An injection into at the medial epicondyle (near the ulnar nerve) carries greater risk, and extra care must be taken to identify the nerve, outline its course, and avoid it. Opinions abound regarding whether to give a separate injection with just a local anesthetic (eg, lidocaine) prior to the corticosteroid injection. Some physicians prefer to give 1 injection (the corticosteroid preparation, perhaps mixed with a local anesthetic). Their rationale is that 1 needle is less painful than 2; however, the cortisone injection involves a thicker material, and therefore, a larger-gauge needle is used. Thus, this author prefers a 2-needle technique, feeling that this method is better tolerated by patients. The 2-needle technique starts with the physician anesthetizing the area with a small, 25-gauge needle and waiting 3-5 minutes for the anesthesia to take full effect; a larger-bore needle (21-22 gauge) is then used for the corticosteroid injection. It should be remembered that the povidone-iodine solution should dry on the skin to have its full antibacterial effect. Just swabbing on the disinfectant and injecting increases the risk of infection. Another important tip is to consider changing the needle used to aspirate the medication into the syringe with the one used to do the injection, especially when using multidose vials. Finally, gentle distraction of the joint being injected may improve accessibility. The material used for the injection is left to the discretion of the physician. Numerous philosophies and theories exist regarding the use of the different materials that are available.15 Many physicians prefer a simple, long-acting methylprednisolone preparation. This author prefers a cocktail consisting of equal parts of the following:
For muscle trigger point injections, the needle is inserted directly into the trigger point. The plunger should always be withdrawn to confirm that a blood vessel has not been penetrated before injecting the cortisone. The needle may remain in place but can be moved up and down and turned without withdrawing it from the skin. The needle should be angled into 3-4 areas of the trigger point. It should be remembered that some of the benefit of the injection is the mechanical disruption of scar tissue. For periarticular injections, the injection should not be made directly into the tendon, lest the patient develop mechanical disruption or weakening of the tendon. Injection of the cortisone is accomplished in small droplets around the area of inflammation. Multiple injections may be required to infiltrate several centimeters of the tendon and muscle. Joint injections are accomplished by inserting the needle directly into the joint. Identification of joint injection sites is beyond the scope of this article, but information can easily be found in several guides to injection. This author's personal favorite reference for muscle trigger points is Myofascial Pain and Dysfunction:The Trigger Point Manual, by J Travell and D Simons.16 Following the injection procedure, it is often helpful to ice the area. The injection itself is traumatic and results in swelling and edema, the very problems requiring treatment. Immediate icing of the area reduces this inflammatory response. The patient should be told what to expect. For the first 2 hours, the patient may feel quite comfortable because the area is numb from the local anesthetic. However, this lack of discomfort lasts only 2 hours and is replaced by increased pain that is often worse than the pain experienced before the injection. Frequently, multiple injections are required for comprehensive treatment of the patient. Typically, patients have multiple trigger points, and 3 sets of injections are required; however, it has been this author's observation that administration of up to 10 rounds of trigger point injections may be necessary. Each week, the patient may return with a new "worst spot." This phenomenon tends to be more common in patients with a chronic muscle disorder, such as fibromyalgia or a chronic pain syndrome. Tendon and joint injections generally are limited to no more than 3 in 1 joint per calendar year because of the potential for mechanical disruption of the joint space and structures. Shoulder
Knee
Hand and wrist
Elbow
Hip
Related eMedicine topics: CONCLUSIONSection 8 of 9
The use of corticosteroid injections can be a useful addition to the treatments employed in treating musculoskeletal and joint injuries and pain. An injection regimen is most effective when combined with other pharmacologic and rehabilitation measures, such as the administration of NSAIDs, the use of stretching, and the employment of treatment modalities (eg, ice, heat). The injection of corticosteroids is a relatively safe procedure that can be managed by specialists and general practitioners alike. Treatment with corticosteroids has been a vital part of the practice of medicine for this author and can be used to benefit many other physicians and their patients. REFERENCESSection 9 of 9
Corticosteroid Injections of Joints and Soft Tissues excerpt Article Last Updated: Jun 4, 2008 |
