Presented by Chris Parfitt MD FRCS

1. Musculoskeletal InjectionsMusculoskeletal Injections
Chris Parfitt MD FRCS©Chris Parfitt MD FRCS©

2. MSK Clinical injectionsMSK Clinical injections
• This presentation (and others!)This presentation (and others!)
• At my website:At my website:
canadian-rural-orthopedics-cjp.cacanadian-rural-orthopedics-cjp.ca

3. DisclosuresDisclosures
• nonenone
• (I like giving injections)(I like giving injections)

4. Musculoskeletal InjectionsMusculoskeletal Injections
• A bit like mooseA bit like moose
huntinghunting

5. Moose HuntingMoose Hunting
• Hunting licenceHunting licence
• Right animal(moose)Right animal(moose)
• Right caliber rifleRight caliber rifle
• Right type of bulletRight type of bullet
• YOU HAVE TO HITYOU HAVE TO HIT
THE TARGETTHE TARGET

6. Musculoskeletal InjectionsMusculoskeletal Injections
• Medical licenceMedical licence
• Right diagnosis (egRight diagnosis (eg
arthritis)arthritis)
• Right needleRight needle
• Right dose ofRight dose of
medicinemedicine
• YOU HAVE TO HITYOU HAVE TO HIT
THE TARGETTHE TARGET

7. MSK Injections GeneralMSK Injections General
• Informed consentInformed consent
• ProcedureProcedure
• BenefitsBenefits
• Risks (duty of care)Risks (duty of care)
• In writing or verbalIn writing or verbal

8. MSK Injections EquipmentMSK Injections Equipment
• AntisepticsAntiseptics
• bandagesbandages

9. Clinical MSK injectionsClinical MSK injections
• Chlorhexidine swabChlorhexidine swab
stickssticks

10. MSK Injections Needle sizeMSK Injections Needle size
• 1.5 inch 25 gauge needle1.5 inch 25 gauge needle
on 5 cc syringe for fineon 5 cc syringe for fine
injectionsinjections
• 1.5 inch 21 gauge needle1.5 inch 21 gauge needle
on 10 cc syringe ison 10 cc syringe is
optimal for larger jointsoptimal for larger joints
(shoulder and knee)(shoulder and knee)
• These are all you reallyThese are all you really
needneed

11. MSK Injections GeneralMSK Injections General
• Assorted syringesAssorted syringes
• Preneedled syringesPreneedled syringes
are time savingare time saving

12. MSK Injections EquipmentMSK Injections Equipment
• Assorted long andAssorted long and
short acting localshort acting local
anestheticsanesthetics
• Patients thank you forPatients thank you for
longest acting whenlongest acting when
indicatedindicated
• Saline solution??Saline solution??

13. Local Anesthetics andLocal Anesthetics and
ChondrolysisChondrolysis
• Lots of literatureLots of literature
showing chondralshowing chondral
damage with alldamage with all
steroids and localsteroids and local
anestheticsanesthetics
• I have been talkingI have been talking
about this for yearsabout this for years
and felt like Ignazand felt like Ignaz
SemmelweisSemmelweis
• Who?Who?

14. Ignaz Semmelweis 1818-1865Ignaz Semmelweis 1818-1865
• Who was this?Who was this?
• Established that handEstablished that hand
washing in chloride ofwashing in chloride of
lime reducedlime reduced
peurperal fever topeurperal fever to
less than 1%less than 1%
• Why did he die soWhy did he die so
youngyoung

15. Ignaz SemmelweisIgnaz Semmelweis
• He could not convinceHe could not convince
other doctors at theother doctors at the
time that handtime that hand
washing workedwashing worked
• Had nervousHad nervous
breakdown, placed inbreakdown, placed in
asylum, beaten byasylum, beaten by
guards and died ofguards and died of
septicemiasepticemia

16. Bupivacaine and ChondrolysisBupivacaine and Chondrolysis
• Bupivocaine infusionBupivocaine infusion
pumps caused highpumps caused high
rates of chondrolysisrates of chondrolysis
• Pain pumps werePain pumps were
used to giveused to give
analgesia post op foranalgesia post op for
shoulders and kneesshoulders and knees

17. Pain pumps: chondrotoxicityPain pumps: chondrotoxicity
• 72 hours of72 hours of
intermittent marcaineintermittent marcaine
epi infusion causedepi infusion caused
30% incidence of30% incidence of
significantsignificant
chondrolysischondrolysis

18. Chondrotoxicity, local anestheticsChondrotoxicity, local anesthetics
• Literature reviewLiterature review
• Jayam et al Nov.Jayam et al Nov.
2018 “all local2018 “all local
anesthetics haveanesthetics have
deleterious effects ondeleterious effects on
chondrocytes madechondrocytes made
worse with theworse with the
administration ofadministration of
steroids”steroids”

19. Chondrotoxicity localChondrotoxicity local
anestheticsanesthetics
• Literature reviewLiterature review
• Kreuz et all MarchKreuz et all March
20182018
• Single doseSingle dose
administration of localadministration of local
anesthetics impedeanesthetics impede
chondrocyte functionchondrocyte function
• Avoid using lidocaineAvoid using lidocaine

20. Recent guidelines AAOS 2O19Recent guidelines AAOS 2O19
• Dr. Jason DragooDr. Jason Dragoo
StanfordStanford
• Recommend to use only .Recommend to use only .
25% marcaine plain or25% marcaine plain or
ropivocaineropivocaine
• Avoid marcaine .5%,Avoid marcaine .5%,
lidocaine, or anylidocaine, or any
anesthetic usinganesthetic using
epinephrineepinephrine
• For joints with intactFor joints with intact
chondrocyteschondrocytes

21. Chondrotoxocity local anestheticsChondrotoxocity local anesthetics
• Potentiated in arthriticPotentiated in arthritic
jointsjoints
• Increased absorptionIncreased absorption
due to increaseddue to increased
exposureexposure

22. Chondrotoxicity localChondrotoxicity local
anestheticsanesthetics
• Don’t worry aboutDon’t worry about
chondrotoxicity if thechondrotoxicity if the
joint is worn outjoint is worn out
• xray will guide youxray will guide you

23. Chondrotoxicity localChondrotoxicity local
anestheticsanesthetics
• If xray shows bone onIf xray shows bone on
bone it is kind to usebone it is kind to use
long acting locallong acting local
anestheticsanesthetics

24. Chondrotoxicity localChondrotoxicity local
anestheticsanesthetics
• In joints with intactIn joints with intact
chondrocyteschondrocytes
• Use saline solution toUse saline solution to
dilute and dispersedilute and disperse
the cortisonethe cortisone
• Can freeze approachCan freeze approach
through skin andthrough skin and
capsule!capsule!

25. MSK injections types of cortisoneMSK injections types of cortisone
• Triamcinolone 40 mg milTriamcinolone 40 mg mil
• Methylprednisolone 40Methylprednisolone 40
mg milmg mil
• Betamethasone 6mg milBetamethasone 6mg mil
DON’T USE IN JOINTSDON’T USE IN JOINTS
• Zilretta? Not yet availableZilretta? Not yet available
in Canada. Extendedin Canada. Extended
release triamcinilonerelease triamcinilone
product.product.

26. Zilretta : new LA triamciniloneZilretta : new LA triamcinilone
• Only available in USOnly available in US
• Studies show 2 to 3Studies show 2 to 3
months reliefmonths relief
• Little systemic effectLittle systemic effect
• Cost 500$ plusCost 500$ plus
americanamerican
• Only approved forOnly approved for
one dose currentlyone dose currently

27. Cortisone Differences?Cortisone Differences?
• MethylprednisoloneMethylprednisolone
caused less bloodcaused less blood
sugar elevation thansugar elevation than
either betamethasoneeither betamethasone
or triamciniloneor triamcinilone
• Read this study a fewRead this study a few
years ago (can’t find ityears ago (can’t find it
now)now)

28. MSK: frequency of injectionsMSK: frequency of injections
• General advice is toGeneral advice is to
limit injections to oncelimit injections to once
every 3 months forevery 3 months for
the same joint forthe same joint for
cortisonecortisone
• Really no limit for HAReally no limit for HA
injections, but usuallyinjections, but usually
approved for every 4approved for every 4
to 6 month per jointto 6 month per joint

29. MSK ViscosupplementationMSK Viscosupplementation
In 2013 AAos issuedIn 2013 AAos issued
statement that HAstatement that HA
was no better thanwas no better than
salinesaline
• Now concensus isNow concensus is
that HA is effectivethat HA is effective

30. MSK viscosupplementationMSK viscosupplementation
• Concensus is thatConcensus is that
products with highproducts with high
molecular weightmolecular weight
mimicking normalmimicking normal
joint fluid (6 daltons)joint fluid (6 daltons)
are effectiveare effective
• CrosslinkingCrosslinking
lenghens the time inlenghens the time in
jointjoint

31. MSK ViscosupplementationMSK Viscosupplementation
• Research and use theResearch and use the
product you think isproduct you think is
best and the bestbest and the best
priceprice
• I use Synvisc OneI use Synvisc One
• Cost 340$, some drugCost 340$, some drug
plans and wcb willplans and wcb will
covercover

32. MSK viscosupplementationMSK viscosupplementation
• Relatively safeRelatively safe
• 2 to 4% reaction which2 to 4% reaction which
can mimic infection!*#can mimic infection!*#
• I don’t use these in mostI don’t use these in most
patients who are readypatients who are ready
for TKRfor TKR
• Make sure you get itMake sure you get it
where it is supposed towhere it is supposed to
go!go!

33. Platelet enriched plasmaPlatelet enriched plasma

34. MSK injections PRPMSK injections PRP
• Patients likePatients like
autologous biologicalautologous biological
productsproducts
• Prp overall rated asPrp overall rated as
as good or slightlyas good or slightly
better than hyaluronicbetter than hyaluronic
acidacid
• Price 375$ and upPrice 375$ and up

35. MSK injections:ACSMSK injections:ACS
• AutologousAutologous
conditioned serumconditioned serum
• Very standardVery standard
preparationpreparation
• Incubate venousIncubate venous
bloodblood
• Centrifuge and injectCentrifuge and inject
• Looks promisingLooks promising
• Watch for nowWatch for now

36. Ultrasound guided injectionsUltrasound guided injections
• What is in Dr.What is in Dr.
McCoy’s left handMcCoy’s left hand
• (?PRP in right hand)(?PRP in right hand)
• Seriously, any doctorSeriously, any doctor
in the future will bein the future will be
using ultrasoundusing ultrasound
almost routinelyalmost routinely
• Ok, not psychiatristsOk, not psychiatrists

37. MSK injections us guided vsMSK injections us guided vs
clinicalclinical
• AdvantagesAdvantages
• More accurate inMore accurate in
some joints (shoulder)some joints (shoulder)
(plantar fasciitis)(plantar fasciitis)
• Patients love itPatients love it
• Pays morePays more
• DisadvantagesDisadvantages
• takes more timetakes more time
• (but pays more)(but pays more)

38. MSK : us guided injectionsMSK : us guided injections
• Cost of us machinesCost of us machines
decreasingdecreasing
• Same principles ofSame principles of
injection for clinical orinjection for clinical or
us guided injectionsus guided injections

39. MSK Injections TechniqueMSK Injections Technique
• One needle (mixed)One needle (mixed)
• Two needlesTwo needles
(prefreezing)(prefreezing)
• Less experiencedLess experienced
should prefreezeshould prefreeze

40. MSK Injections TechniqueMSK Injections Technique
• Betadine best as youBetadine best as you
can see where it iscan see where it is
but very messy!but very messy!
• I prefer chlorhexidineI prefer chlorhexidine
stickssticks
• Prep, then preparePrep, then prepare
the injectionthe injection

41. Sterility concernsSterility concerns
• Watch the way youWatch the way you
open needles andopen needles and
syringessyringes
• Use only new orUse only new or
known localknown local
anesthetic containersanesthetic containers
• BC College guidelineBC College guideline
• Use gloves or noUse gloves or no
touch techniquetouch technique

42. Tricks of the trade: targetingTricks of the trade: targeting
• Before you do sterileBefore you do sterile
prep, mark entry pointprep, mark entry point
and relevant anatomyand relevant anatomy
with a sharpie typewith a sharpie type
penpen
• Use long 25 needleUse long 25 needle
with freezing towith freezing to
ascertain trajectoryascertain trajectory
• And to freeze skinAnd to freeze skin

43. Tricks of the tradeTricks of the trade
• Prefreezing the skinPrefreezing the skin
and capsule allowsand capsule allows
you some “pokeyou some “poke
tolerance” to changetolerance” to change
the trajectory withoutthe trajectory without
patient discomfortpatient discomfort

44. Tricks of the tradeTricks of the trade
• Quick draw contestQuick draw contest
• Unless you haveUnless you have
infinite patience,infinite patience,
always draw upalways draw up
solutions with a largesolutions with a large
bore needlebore needle

45. Tricks of the tradeTricks of the trade
• HydraulicsHydraulics
• Do not inject (attack)Do not inject (attack)
against stiffagainst stiff
resistanceresistance
• Assess resistanceAssess resistance
against tissue, not theagainst tissue, not the
needle barrel ie use aneedle barrel ie use a
needle large enoughneedle large enough
to assess tissueto assess tissue
resistanceresistance

46. Tricks of the tradeTricks of the trade
• When needle is inWhen needle is in
right spot, piston backright spot, piston back
and forth a bit to findand forth a bit to find
the area of leastthe area of least
resistanceresistance

47. Tricks of the TradeTricks of the Trade
• Injecting hyaluronicInjecting hyaluronic
acid products isacid products is
difficult with smalldifficult with small
needlesneedles
• Pre freeze and use aPre freeze and use a
long 18 gauge needlelong 18 gauge needle

48. Dogma and DigitsDogma and Digits
• To use epinephrine orTo use epinephrine or
not use epinephrine innot use epinephrine in
digits.digits.

49. Dogma and DigitsDogma and Digits
• Numerous studies inNumerous studies in
the last 15 yearsthe last 15 years
show no damage inshow no damage in
using epinephrineusing epinephrine
concentrationconcentration
• 1:100,0001:100,000
• Don’t use in digitsDon’t use in digits
with damagedwith damaged
borderline circulationborderline circulation
• Great for pain reliefGreat for pain relief
after suturing fingerafter suturing finger
etc.etc.

50. TRIGGER FINGERTRIGGER FINGER
INJECTIONSINJECTIONS
• Evidence basedEvidence based
• ANN RHEM DIS 2008ANN RHEM DIS 2008
sept;7(9) 1262-1266sept;7(9) 1262-1266

51. Trigger FingerTrigger Finger
• 1cc steroid mix with1cc steroid mix with
4cc local anesthetic4cc local anesthetic
• Inject about 2cc ofInject about 2cc of
solution into andsolution into and
around the A1 pulleyaround the A1 pulley
• Use pistoning to findUse pistoning to find
right spotright spot

52. Trigger FingerTrigger Finger
• HOT OFF THEHOT OFF THE
PRESSPRESS
• Peri pulley injectionPeri pulley injection
had higher successhad higher success
rate than intra sheathrate than intra sheath
injectioninjection

53. Basal Joint arthritisBasal Joint arthritis
• CMC joint arthritisCMC joint arthritis

54. Basal Joint ArthritisBasal Joint Arthritis
• Slight tractionSlight traction
• Prefreezing very helpfulPrefreezing very helpful
• Mix 1cc steroid with 4 ccMix 1cc steroid with 4 cc
marcaine E and injectmarcaine E and inject
about 1 t 2 cc.about 1 t 2 cc.
• Watch for joint distensionWatch for joint distension
to confirm locationto confirm location

55. De Quervains DiseaseDe Quervains Disease
• Evidence basedEvidence based
• BMC MSK disordersBMC MSK disorders
2009 Oct 27;10;1312009 Oct 27;10;131
• Mix 4cc marcaine E .Mix 4cc marcaine E .
25% with 1cc steroid.25% with 1cc steroid.
Inject 2cc to 3 cc.Inject 2cc to 3 cc.

56. De Quervain’s DiseaseDe Quervain’s Disease
• Inject into or aroundInject into or around
the sheaththe sheath

57. Tennis ElbowTennis Elbow
• Evidence thatEvidence that
cortisone is beneficialcortisone is beneficial
for at least short termfor at least short term
reliefrelief

58. Tennis elbow injectionsTennis elbow injections
• Almost all injectionsAlmost all injections
helphelp
• Cortisone, hyaluronicCortisone, hyaluronic
acid, prp,acid, prp,
prolotherapy, botullinprolotherapy, botullin
toxin…)toxin…)
• Is it the injection, orIs it the injection, or
the needling?the needling?

59. Tennis ElbowTennis Elbow
• Use 4cc, marcaine withUse 4cc, marcaine with
epi .25%, cortisone 40epi .25%, cortisone 40
mgmg
• Inject the extensor originInject the extensor origin
(painful area) with 3cc of(painful area) with 3cc of
solution and wait 15 minsolution and wait 15 min
• Review and inject anyReview and inject any
remaining painful arearemaining painful area
• Patient should leavePatient should leave
office pain freeoffice pain free

60. Shoulder InjectionsShoulder Injections
• Cochrane summaryCochrane summary
says no bettersays no better
injection success withinjection success with
clinical vs ultrasoundclinical vs ultrasound
guided injectionguided injection
• That was 3 years ago,That was 3 years ago,
now most reviewsnow most reviews
show improvedshow improved
accuracy withaccuracy with
ultrasoundultrasound

61. Shoulder injectionsShoulder injections
• Despite the US givingDespite the US giving
a little better accuracya little better accuracy
it is acceptable to giveit is acceptable to give
clinical injection if youclinical injection if you
are careful and goodare careful and good
at it.at it.
• Until US available inUntil US available in
your communityyour community

62. Shoulder InjectionsShoulder Injections
• Rotator CuffRotator Cuff
Tendinitis or tear inTendinitis or tear in
elderlyelderly
• Evidence basedEvidence based
• Duration of benefitDuration of benefit
variable in differentvariable in different
studiesstudies

63. Shoulder InjectionsShoulder Injections
• Subacromial injectionSubacromial injection
• Use 1 to 2 cc of steroidUse 1 to 2 cc of steroid
(40 -80) mg (depending(40 -80) mg (depending
on size of patient) with 8on size of patient) with 8
cc of long acting localcc of long acting local
anestheticanesthetic
• Posterior, slide needlePosterior, slide needle
under acromionunder acromion
• You can feel the fluidYou can feel the fluid
distend bursa in thinnerdistend bursa in thinner
patientspatients
• Remember hydraulicsRemember hydraulics

64. Shoulder Joint InjectionsShoulder Joint Injections
• Arthritis or frozenArthritis or frozen
shouldershoulder
• 8cc marcaine with epi8cc marcaine with epi
(for advanced OA), 1-(for advanced OA), 1-
2 cc steroid (40 to2 cc steroid (40 to
80mg)80mg)
• Elect to use NS orElect to use NS or
plain marcaine .25%plain marcaine .25%
for shoulders withfor shoulders with
intact joint surfaceintact joint surface

65. Shoulder InjectionsShoulder Injections
• Glenohumeral injectionGlenohumeral injection
• Posterior, in soft spotPosterior, in soft spot
• Arm internally rotatedArm internally rotated
• Prefreeze and getPrefreeze and get
trajectory with long 25trajectory with long 25
needleneedle
• Inject 40 to 80 mgInject 40 to 80 mg
cortisone with appropriatecortisone with appropriate
LA or salineLA or saline

66. Trochanteric Bursa injectionsTrochanteric Bursa injections
• Evidence basedEvidence based
• Journal rheum. 1996Journal rheum. 1996
• Dec;23;(12) 2104-6Dec;23;(12) 2104-6

67. Trochanteric bursitisTrochanteric bursitis
• 2cc 80 mg steroid2cc 80 mg steroid
• 8cc marcaine with epi8cc marcaine with epi
• Lateral position, hipLateral position, hip
extendedextended
• Long needle 21Long needle 21
gaugegauge
• Inject at 90 degreesInject at 90 degrees

68. MSK injections: trochanteric bursitisMSK injections: trochanteric bursitis
• When needle hits bone,When needle hits bone,
back off 1 to 2 mm andback off 1 to 2 mm and
inject (should flow easily)inject (should flow easily)
deep to the gluteal fasciadeep to the gluteal fascia
• Danger is sciatic nerveDanger is sciatic nerve
posterior, stay on bone,posterior, stay on bone,
ask about paresthesiaask about paresthesia
before injectionbefore injection

69. Knee injectionsKnee injections
• Evidence basedEvidence based
• Cochrane databaseCochrane database
• Both steroids andBoth steroids and
viscosupplemtationviscosupplemtation
• prpprp

70. Knee injections: indicationsKnee injections: indications
• I don’t use cortisoneI don’t use cortisone
in patients under 50in patients under 50
years old for ongoingyears old for ongoing
treatmenttreatment
• Sometimes forSometimes for
diagnosisdiagnosis
• History is important,History is important,
rule out mechanicalrule out mechanical
symptoms from achesymptoms from ache
and painand pain

71. Knee injections indicationsKnee injections indications
• Always get an xrayAlways get an xray
• Xray needs to be aXray needs to be a
full weight AP viewfull weight AP view
(stork view)(stork view)
• If symptoms are acheIf symptoms are ache
and pain, and anyand pain, and any
sign of arthritis onsign of arthritis on
xray , then treat forxray , then treat for
arthritisarthritis

72. Knee injections indicationsKnee injections indications
• If your clinical andIf your clinical and
radiologicalradiological
consistent withconsistent with
arthritis then anarthritis then an
injection can be partinjection can be part
of your arthritisof your arthritis
treatment plantreatment plan
• If the treatment planIf the treatment plan
fails, consider furtherfails, consider further
investigation/ referralinvestigation/ referral

73. Knee injections: indicationsKnee injections: indications
• Use this classificationUse this classification
• Once bone on boneOnce bone on bone
or grade 4, usually,or grade 4, usually,
but not always thebut not always the
injections don’t help ainjections don’t help a
lotlot
• Refer for TKRRefer for TKR

74. Knee injection: techniqueKnee injection: technique
• Leg extendedLeg extended
• RelaxedRelaxed
• Pull kneecap laterallyPull kneecap laterally
• Needle goes underNeedle goes under
the superior patellathe superior patella
• Great for aspirationGreat for aspiration

75. Knee injections : techniqueKnee injections : technique
• Large jointLarge joint
• Use 2 cc steroidUse 2 cc steroid
• (80 mg)(80 mg)
• Long 1 gauge needleLong 1 gauge needle
• Prefreeze skin andPrefreeze skin and
capsule until you arecapsule until you are
good at itgood at it
• 8cc saline (unless bone8cc saline (unless bone
on bone)on bone)
• Lateral subpatellarLateral subpatellar
approachapproach

76. Injection kneeInjection knee
• What is wrong withWhat is wrong with
this picture?this picture?

77. MSK injections hipMSK injections hip
• In general allIn general all
recommendations forrecommendations for
the knee can bethe knee can be
carried out for the hipcarried out for the hip
• But need fluoro or usBut need fluoro or us

78. Hallux Rigidus InjectionHallux Rigidus Injection
• Arthritis great toeArthritis great toe
• King et al. 2017King et al. 2017
• Positive evidence forPositive evidence for
use of cortisone anduse of cortisone and
forfor
viscosupplementionviscosupplemention
injectionsinjections

79. Hallux rigidus injectionHallux rigidus injection
• Better done with 2Better done with 2
needle (prefreeze)needle (prefreeze)
• 25 guage needle25 guage needle
• Small jointSmall joint

80. Hallux rigidus injectionHallux rigidus injection
• Use 5 cc syringe, long 25Use 5 cc syringe, long 25
needleneedle
• Cortisone 40 mg withCortisone 40 mg with
long acting freezinglong acting freezing
• Inject usually about 2 ccInject usually about 2 cc
• Pull toe into flexion andPull toe into flexion and
inject into superior aspectinject into superior aspect
of jointof joint
• Hydraulic sensation veryHydraulic sensation very
helpfulhelpful

81. MSK injections ankle injectionMSK injections ankle injection
• Inject anteriorly, eitherInject anteriorly, either
medial or lateralmedial or lateral
• Look at lateral viewLook at lateral view
ankleankle

82. MSK injections ankle arthritisMSK injections ankle arthritis
• Avoid centralAvoid central
injection, go medial orinjection, go medial or
laterallateral
• Use 10cc syringe,Use 10cc syringe,
long 21 needle, 40long 21 needle, 40
mg steroid and 9 ccmg steroid and 9 cc
saline (intactsaline (intact
cartilage) or localcartilage) or local
anesthetic (bone onanesthetic (bone on
bone)bone)

83. MSK InjectionsMSK Injections
• QuestionsQuestions