Management Of Localised Tender Points
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Management Of Localised Tender Points

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

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

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  • 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
  • 29. 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_address]