Soft tissue & intra-articular local injection for sports medicine and Physical therapy, Rheumatology and Rehabilitation residents

1. Soft Tissue And Intra-articular
Local Injection
Dr. Hoda M.
Physical Medicine , Rheumatology and Rehabilitation

2. Clinic-based valuable diagnostic and/or therapeutic
MSK injection management procedures
• Principles of treatment techniques.
• Indications. When?
• Contraindications. When not?
• Pharmacology of injectable agents. What?
(Mode of action, precautions and contra-indications, interactions
with other medications, possible complications).
• Precautions.
• Techniques used for UL and LL. How? & Where?
• Supervised practice of techniques. (Hands on training)

3. Benefits outweigh risks?
•Proper aseptic technique
•Proper selection of patient
•Avoid repeated injection

4. Safety- of provider AND patient

5. Eclipse Safety needle

6. Automatic retractable needle syringe

7. • Diagnostic &/or therapeutic.
• Blind or guided (US, Floroscopic or CT guided).
• Surface anatomy, DD.
• Possible complications.
• Pharmacology of injectable agents.
• Informed consent.
• Documentation.
Principles of treatment techniques.

8. • - Cotton wool
- Sterile gauze
- synovial fluid collection bottle. Syringe 20ml
- Safety box

10. Sterile needles 23, 21, 19 gauge, syringes 2ml, 3ml,5ml,10ml)

11. ISO color
standards

12. Ordinary Or Dual Syringes for local
injection

14. Prior to Giving The Injection
1. Disinfect the work area (where the drug and syringe will
be set up) Povidone-Iodine # chlorhexidine, alcohol swab
2. Mark skin , sterile no-touch technique.
3. Check the drug label:
– Is it what has been prescribed? - Check ‘dose for Pt
– Check the expiration date on the vial.
*Do not use a drug if: – It is past the expiration date
– Precipitate is noted floating in the solution.
– The solution is discolored.
3 -Removal of air bubbles is necessary to ensure accurate
dose of medication.

15. Why inject?
• • Local delivery of medications
Avoid systemic complications or long term use of
NSAIDs
Patient satisfaction
Immediate pain relief & improved function, ROM
Diagnostic and therapeutic
Enhance physician-patient relationship
Treat without referral
Revenue

16. Where to inject?
• Intra-articular
• Intramuscular ..trigger points
• Intrabursal
• Pericapsular
• Periligamentous
• Peritendonius/Tendon sheath

17. What to inject?
• • MOST COMMON
Local anesthetic ; MPS
Corticosteroid
Viscosupplementation
• • • ALTERNATIVE
Botulism toxin…spasticity
Platelet rich plasma
Prolotherapy (hypertonic saline or dextrose 20%)

18. Mechanism of action of Corticosteroids:
Suppression of inflammation in the form of:
Decrease local vasodilatation.
Decrease capillary permeability.
Suppression of the release of cytokines.
Suppression of leukocytic infiltration.

20. kenacort

21. Side Effects: CS Injections
• Infection (1 in 50,000 injections)
• Post injection flare (2% crystal induced
synovitis)
• Skin hypopigmentation, subcutaneous atrophy
• Vasovagal syncope (procedure related)
• Tendon rupture (rare)
• Osteonecrosis (rare)
West, S Rheumatology Secrets 2 rd edition 2002

22. General Indications
• • Injection
Pain relief
Osteoarthritis (OA)
Bursitis
Tendonitis
Epicondylitis
Trigger points
Inflammatory arthritis
Entrapment neuropathy;
CTS
• • Aspiration
Decrease effusion size
Evaluate for infection
Crystalloid arthropathies
Ganglion cysts
Inflamed total joint

23. CS
• Acute arthritis in one or two joints due to OA
• Crystal induced arthropathy
• Adjuvant for systemic therapy in inflammatory
arthritis as RA.
• For treatment of inflamed joints which are
resistant to systemic therapy.

24. Consider:
• One or multiple injections can be required for
a comprehensive treatment.
• Avoid multiple injections in the same setting
because there is increased risk of systemic SE.
• If multiple injections are indicated, it will be
given as only one injection every one week.
• Resting the injected area after injection 48-72h

25. Why is HA used to treat pain in O/A?
• Cannot take NSAIDs
• Cannot take CS injections
• Too young for total knee replacement
• Not ready for total knee replacement
• “nothing else has worked”

26. General Contraindications
ABSOLUTE
• Lack of informed consent
• Allergy to injection med
• Hx of severe steroid flare
• Infection (systemic , local , overlying cellulitis, Ps plaques)
• Prosthetic joint.
• Intra-articular #.

27. General Contraindications
RELATIVE
• Proximity to vascular or neural structure.
• Caution with coagulopathy .
ALWAYS CHECK MOST RECENT INR!!! Hemorrhage risk if INR >4.
Thumboo et al. Arth&Rheum 1998
• Immunocompromised …..infection
• Uncontrolled DM , HTN
• Prior to joint replacement
• Injection of steroid into/around wt-bearing tendons
(Achilles, patellar) esp if high risk

28. Cases examples

29. Trigger finger

32. CTS: Entrapment of median
nerve at wrist .

33. CTS

34. Technique of local injection

35. Dupuytren’s Contracture

36. Dupuytren’s Contracture

37. Technique of local injection

38. Ganglion

39. De Quervain's Disease
(tenosynovitis)

40. De Quervain's Disease
(tenosynovitis)

41. MRI : Quervain's Disease

42. Technique of local injection

43. Olecranon Bursitis

44. Technique of local injection

45. Tennis Elbow

46. Technique of local injections

47. Golfer’s Elbow

48. Technique of local injection

49. Boxer’s Elbow

50. Boxer’s elbow:
Calcification within the triceps
tendon.

51. SHOULDER PAIN OF
SOFT TISSUE ORIGIN:

52. Bicipital tendonitis

53. Supra
spinatus
tendinitis

54. Technique of local injection for
Bicipital tendonitis:

55. X-ray & US
of calcific
tendinitis of
supraspinatus
tendon.
D deltoid muscle
T Supra spinatus tendone
H Humerus.

57. Technique of local injection
supraspinatus tendonitis:

58. Knee bursitis

59. Anserine bursitis

60. MRI in Anserine Bursitis

61. ANSERINE BURSA:

62. Popliteal cyst

64. MRI in Pop.
cyst

65. Technique of local injection

67. Meralgia Parathetica

69. Plantar fasciitis

70. MRI: Calcaneal spur.

72. Technique of local injection for
Calcaneal spur
US

73. Morton’s Metatarsalgia

75. Technique of local injection

76. Achilles' Tendonitis

77. MRI in Achilles' Tendonitis

78. Lateral approach to inject Achilles'
Tendonitis.

79. Ischial bursitis

80. Examples of Intra-articular injection

89. Aftercare instructions
Thankyou