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Management Of Localised Tender Points


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

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Management Of Localised Tender Points

  1. 1. Management of localized Tender Points Vinod Naneria
  2. 2. Classification – According to Pathology <ul><li>Stenosing Tenosynovitis </li></ul><ul><ul><li>De Quervain’s </li></ul></ul><ul><ul><li>Trigger thumb and fingers </li></ul></ul><ul><ul><li>Bicep’s tenosynovitis </li></ul></ul><ul><ul><li>Tibialis Posterior and Peroneal tendon tenosynovitis </li></ul></ul>
  3. 3. Classification – cont…. <ul><li>Traumatic and/or degenerative </li></ul><ul><li>Tendenous avascular origin/insertion </li></ul><ul><ul><li>Tennis / Golfer’s elbow </li></ul></ul><ul><ul><li>Planter fasciitis </li></ul></ul><ul><ul><li>Bursitis </li></ul></ul><ul><ul><ul><li>Retrocalcaneal bursitis </li></ul></ul></ul><ul><ul><ul><li>Periarthritis shoulder </li></ul></ul></ul><ul><ul><ul><li>Trochanteric bursitis </li></ul></ul></ul><ul><ul><ul><li>Olecranon bursitis </li></ul></ul></ul>
  4. 4. Classification – cont…. <ul><li>Trigger zones </li></ul><ul><ul><li>Supra and periscapular </li></ul></ul><ul><ul><li>Costochondritis / Titze’s disease </li></ul></ul><ul><ul><li>Gluteus maximums origin </li></ul></ul><ul><li>Intra Articular </li></ul><ul><ul><li>CMC joint </li></ul></ul><ul><ul><li>Knee Joint </li></ul></ul><ul><ul><li>TM joint </li></ul></ul>
  5. 5. Classification – cont…. <ul><li>Synovitis </li></ul><ul><ul><li>Flexor tendons at wrist </li></ul></ul><ul><ul><li>Extensor tendons at wrist </li></ul></ul><ul><li>Miscellaneous </li></ul><ul><ul><li>Accessory Navicular </li></ul></ul><ul><ul><li>Os trigonum </li></ul></ul><ul><ul><li>Ganglions </li></ul></ul><ul><ul><li>Osteitis Pubis </li></ul></ul><ul><ul><li>Coccygodynia </li></ul></ul>
  6. 6. Management <ul><li>Counseling </li></ul><ul><ul><li>Self limiting conditions </li></ul></ul><ul><ul><li>No long term disability </li></ul></ul><ul><ul><li>Treatment may fail quite often </li></ul></ul><ul><ul><li>Nothing to worry about </li></ul></ul><ul><li>Drug Therapy </li></ul><ul><ul><li>Indomethacin 75mg H.S., with milk for 3 weeks and gradual withdrawal by alternate day / substitute by mild NSAID </li></ul></ul>
  7. 7. Caution: Hypertension <ul><li>Rule out Hypertension </li></ul><ul><li>No anti inflammatory long term drug in Hypertension </li></ul><ul><li>Better to inject than drug therapy. </li></ul><ul><li>Always ask for – serum creatinine and urine for albumin </li></ul>
  8. 8. Management – cont… <ul><li>Physiotherapy </li></ul><ul><ul><li>Local ultrasound heating </li></ul></ul><ul><ul><li>Stretching exercises </li></ul></ul><ul><ul><li>Corrective orthosis ( scooped heel) </li></ul></ul><ul><ul><li>Wrist Band </li></ul></ul><ul><ul><li>Elbow immobilizer </li></ul></ul>
  9. 9. Management – Local Steroid <ul><li>Triamcinolone Acetonide – 10mg </li></ul><ul><li>No Xylocain / Hylase </li></ul><ul><li>2cc syringe, 22 gauge needle, 1.5” long </li></ul><ul><li>Lying down patient </li></ul><ul><li>Multiple puncture for spread of drug </li></ul><ul><li>Post injection massage </li></ul><ul><li>Local band-aid dressing </li></ul><ul><li>NSAID for two days </li></ul><ul><li>Informed consent </li></ul>
  10. 10. Management – cont… <ul><li>Injection – Intra lesional </li></ul><ul><ul><li>Planter fasciitis </li></ul></ul><ul><ul><li>Tennis and Golfer’s elbow </li></ul></ul><ul><ul><li>All trigger points </li></ul></ul><ul><ul><li>All joints </li></ul></ul><ul><ul><li>All bursitis </li></ul></ul><ul><li>Injection – Peri lesional </li></ul><ul><ul><li>Into Sheath – all tenosynovitis </li></ul></ul>
  11. 11. Instructions to patients <ul><li>To come prepared after cleaning the part to be injected. </li></ul><ul><li>Especially the heel or coccyx </li></ul><ul><li>Always ask the patient to bring an attendant for inadvertent </li></ul><ul><ul><li>Drug reaction </li></ul></ul><ul><ul><li>Vaso-vagal reaction or sudden hypotension </li></ul></ul>
  12. 12. Caution: Diabetes <ul><li>Avoid injection in cases of high blood glucose level. </li></ul><ul><li>Predispose to infection </li></ul><ul><li>Affect serum glucose management </li></ul><ul><li>Better skin preparation </li></ul>
  13. 13. Management – cont… <ul><li>Precautions </li></ul><ul><li>Avoid All weight bearing joint </li></ul><ul><li>Avoid hitting the tendon directly </li></ul><ul><li>Avoid hitting the nerves directly </li></ul><ul><li>Avoid injecting directly in to artery or vein </li></ul><ul><li>Watch for allergic reactions for an hour </li></ul>
  14. 14. Instructions to patient after local steroid injection <ul><ul><li>Inform about post injection flair </li></ul></ul><ul><ul><li>Inform about skin and local soft tissue atrophy </li></ul></ul><ul><ul><li>Watch for infection </li></ul></ul><ul><ul><li>Avoid repeating injection at the same site for at least 6 weeks </li></ul></ul>
  15. 15. Cortisone induced Leucoderma of the wrist
  16. 16. A word of caution: <ul><li>To avoid possible depigmentation and subcutaneous atrophy, intra-lesional doses should not be placed too superficially in easily visible sites in deeply pigmented patients </li></ul>
  17. 17. Soft tissue necrosis
  18. 18. Tips….. <ul><li>Planter fasciitis: </li></ul><ul><ul><li>Hit directly from the planter surface on the medial calcaneal tuberosity. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Inject the drug and make multiple punctures in the planter apponeurosis. </li></ul></ul><ul><ul><li>Massage the site after the injection </li></ul></ul>
  19. 20. Tips….. <ul><li>De Quervains disease </li></ul><ul><ul><li>Start just proximal to the nodule </li></ul></ul><ul><ul><li>Inject the drug into the sheath </li></ul></ul><ul><ul><li>See the filling of the sheath up to the base of thumb </li></ul></ul><ul><ul><li>Do not inject in to the tendons </li></ul></ul><ul><ul><li>A tight sheath will give the same resistance as the injection into the tendon – you have to differentiate. </li></ul></ul>
  20. 22. Tips….. <ul><li>Coccygodynia </li></ul><ul><ul><li>Feel maximum tender point </li></ul></ul><ul><ul><li>The place for injection is the junction between the two mobile parts. So do not </li></ul></ul><ul><ul><li>inject over the bone but inject into the space between two pieces of coccyx. </li></ul></ul>
  21. 24. Tips….. <ul><li>Tennis Elbow </li></ul><ul><ul><li>Always just anterior to the epicondyle </li></ul></ul><ul><ul><li>Occasionally over the lateral epicondyle </li></ul></ul><ul><ul><li>Inject into the soft tissue over the epicondyle anteriorly and not over the bone. </li></ul></ul><ul><ul><li>With the needle hit the bone and then withdraw it before injection </li></ul></ul><ul><ul><li>Make multiple punctures </li></ul></ul>
  22. 25. <ul><ul><li>Caution : </li></ul></ul><ul><ul><li>Temporary </li></ul></ul><ul><ul><li>skin de-pigmentation. </li></ul></ul><ul><ul><li>Local subcutaneous tissue necrosis. </li></ul></ul>
  23. 27. Contraindications for use <ul><li>Hypersensitivity to ingredients of triamcinolone Preparation </li></ul><ul><li>Systemic infections or local infections </li></ul><ul><li>Infected joints </li></ul><ul><li>Where previous injections have produced local atrophy </li></ul><ul><li>Active peptic ulcer, myasthenia gravis, osteoporosis, acute glomerular nephritis, fresh intestinal anastamoses, diverticulitis, thrombophlebitis, </li></ul><ul><li>Psychic disturbances, pregnancy, diabetes mellitus, hyperthyroidism, </li></ul><ul><li>Acute coronary artery disease, hypertension, limited cardiac reserve , </li></ul>
  24. 28. Triamcinolone is crystalline suspention <ul><li>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. </li></ul><ul><li>Crystals of Triamcinolone can be detected in joint fluid even after 6 months after injection </li></ul>
  25. 29. DISCLAIMER <ul><li>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. </li></ul><ul><li>It is intended for use only by the students of orthopaedic surgery. </li></ul><ul><li>Views and opinion expressed in this presentation are personal opinion. </li></ul><ul><li>Depending upon the x-rays and clinical presentations, viewers can make their own opinion. </li></ul><ul><li>For any confusion please contact the sole author for clarification. </li></ul><ul><li>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. </li></ul><ul><li>For any correction or suggestion please contact </li></ul><ul><li>[email_address] </li></ul>