Management Of Localised Tender Points
Upcoming SlideShare
Loading in...5

Like this? Share it with your network


Management Of Localised Tender Points



trigger points, local steroid injections, pain in heel, tennis elbow

trigger points, local steroid injections, pain in heel, tennis elbow



Total Views
Views on SlideShare
Embed Views



0 Embeds 0

No embeds



Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment
  • A wide bore needle is required as triamcinolone is a crystal suspention and is quite thick.
  • Dermal/sub-dermal atrophy or changes in the make-up of the connective tissue and depressions in the skin at the injection site may occur due to the presence of adrenal steroid crystals in the dermis. The skin should regenerate within a few months after all the crystals have been absorbed.

Management Of Localised Tender Points Presentation Transcript

  • 1. Management of localized Tender Points Vinod Naneria
  • 2. Classification – According to Pathology
    • Stenosing Tenosynovitis
      • De Quervain’s
      • Trigger thumb and fingers
      • Bicep’s tenosynovitis
      • Tibialis Posterior and Peroneal tendon tenosynovitis
  • 3. 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
  • 4. Classification – cont….
    • Trigger zones
      • Supra and periscapular
      • Costochondritis / Titze’s disease
      • Gluteus maximums origin
    • Intra Articular
      • CMC joint
      • Knee Joint
      • TM joint
  • 5. Classification – cont….
    • Synovitis
      • Flexor tendons at wrist
      • Extensor tendons at wrist
    • Miscellaneous
      • Accessory Navicular
      • Os trigonum
      • Ganglions
      • Osteitis Pubis
      • Coccygodynia
  • 6. 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
  • 7. 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
  • 8. Management – cont…
    • Physiotherapy
      • Local ultrasound heating
      • Stretching exercises
      • Corrective orthosis ( scooped heel)
      • Wrist Band
      • Elbow immobilizer
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. Caution: Diabetes
    • Avoid injection in cases of high blood glucose level.
    • Predispose to infection
    • Affect serum glucose management
    • Better skin preparation
  • 13. Management – cont…
    • Precautions
    • Avoid All weight bearing joint
    • Avoid hitting the tendon directly
    • Avoid hitting the nerves directly
    • Avoid injecting directly in to artery or vein
    • Watch for allergic reactions for an hour
  • 14. 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
  • 15. Cortisone induced Leucoderma of the wrist
  • 16. 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
  • 17. Soft tissue necrosis
  • 18. 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
  • 19.  
  • 20. 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.
  • 21.  
  • 22. 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.
  • 23.  
  • 24. 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
  • 25.
      • Caution :
      • Temporary
      • skin de-pigmentation.
      • Local subcutaneous tissue necrosis.
  • 26.  
  • 27. 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 ,
  • 28. 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
    • 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_address]