The Essential Toolkit For Musculoskeletal Injections In .

The Essential Toolkit forMusculoskeletal Injectionsin Primary CareLaurel Short, MSN, NP-c

DisclosureI have no current affiliation or financial interest withany grantor or commercial interests that might havedirect interest in the subject matter of the CEProgram.

Objectives List the indications and precautions for muscular andjoint injections Identify rationale for using injectable corticosteroidsand local anesthetics Describe safety considerations and aseptic technique formusculoskeletal injections Review functional anatomy for the shoulder, elbow,wrist, hip, and knee Demonstrate injection technique guidelines anddescribe aftercare

Roadmap Didactic: generalinjection principles andsafety 6 breakout sessions forspecific injectionsdescription/demonstration followed by practicetime Review

Injections: Part of a Comprehensive Plan!InjectionRestRehab

General Principles Anatomic vs. trigger point injection Arthrocentesis joint space aspiration Local anesthetic as diagnostic tool– Followed by corticosteroid injection OR– Combo corticosteroid local anesthetic

Shopping ListMedications &Supplies

The DrugsCorticosteroids, Local Anesthetics, Viscosupplementation

Commonly Used CorticosteroidsIntermediate ActingLong ActingMethylprednisoloneacetateTriamcinolone acetonideDepomedrol 40 mg/mlDepomedrol lidocaineMay cause more injection sitepain, premixed notrecommended due to difficultyadjusting dosesKenalog 40 mg/mlRecommended -easy to adjustvolume and administer

Corticosteroid Injection Indications Diagnostic AND/OR Therapeutic– Suppressing inflammation/inflammatory “flares”– Breaking up inflammatory damage-repairdamage cycle (?)– Possible chondroprotective effect on cartilagemetabolism or other process not related toinflammation– Pain relief for tolerance of physical therapy

Local Anesthetics Work by causing a reversible conduction block alongsensory nerve fibers Can make the procedure more comfortable Diagnostic tool Dilution- increased volume helps spread steroid to alarger surface area

Local AnestheticsShort ActingLong ActingLidocaine hydrochlorideBupivacaine (Marcaine)0.5% 5mg/ml0.25% 2.5mg/ml1.0% 10mg/ml0.5% 5mg/ml2.0% 20mg/mlRecommended. Acts rapidly,within seconds. Duration 30minutes.Slower onset, 30 minutes forfull effect. Duration 8 hours.

Viscosupplementation Osteoarthritis of the knee can be treated bylubricant injections OA less lubrication and shock absorption withinthe joint In part related to less hyaluronic acid, part ofsynovial fluid– HA molecules produce viscous solution that is both alubricant and shock absorber

Viscosupplementation Indication- OA of knee– Failed conservative treatments (oral NSAIDs, cortisoneinjection)– Prolonging need for joint arthroplasty, or patients whoare not good surgical candidates Proposed mechanisms of action– Cytokines/PGE inhibitor– Inhibition of cartilage degredation– Direct protective action on nociceptive endings

Hyaluronan (Orthovisc )No avian protein allergy (not from rooster comb),Largest molecule, Series of 3 injectionsHylan G-F 20 (Synvisc Synvisc-One )Avian protein allergyUses formaldehyde & vinyl sulfone to increase molecular weightSodium Hyaluronate (Euflexxa , Gel-one , Hyalgan , Supartz ,Neovisc )3 - 5 weekly injectionsCAUTION: avian protein allergy (eggs, feathers, poultry)

Platelet Rich Plasma (PRP)Still considered experimental Patient’s whole blood (citrate dextrose asanticoagulant) Platelets spun down & activated by Thrombin &CaCl Thought to repair & regenerate cartilage, ligaments,muscle, tendons, and bone throughcytokinens/growth factors Ultrasound guided injection, CPT Code 0232T

Additional SuppliesGlovesGauzePovidone-iodine swabAlcohol wipeAdhesive bandageEthyl chloride spray orice (optional)Needles & Syringes

Cheat SheetKnee:2cc 1 % Lidocaine2cc 10mg Triamcinolone acetonide25g x 1 ½” NeedleShoulder:3cc 1 % Lidocaine2cc 10mg Triamcinolone acetonide25g x 1 ½” NeedleCTS, DEQ, Trigger Finger:1/2cc 1 % Lidocaine1/4cc 40mg Triamcinoloneacetonide27g x 1/2” NeedleElbow (Medial & Lateral), PesAnserine Bursa, AC Joint:1cc 1 % Lidocaine1/2cc 40mg Triamcinoloneacetonide25g x 1 ½” NeedleTrigger Point Injection:2cc 0.25 % Bupivacaine2cc Sodium Chloride25g x 1 ½” NeedleTrochanteric Bursa:4cc 1 % Lidocaine2cc 0.25% Bupivacaine1cc 40mg Triamcinolone acetonide21g x 2” Needle (or longer if needed)

Organize Team Members

Billing Codes: Aspiration/Injection20610 Shoulder, Hip, or Knee64450 Occipital nerve block(20605 Wrist, Elbow, or Ankle)20600 Fingers or ToesMedications20551 Tendon origin/insertionTriamcinalone J330120550 Tendon sheath, ligamentDexamethasone J1100Trigger point injection(Bupivacaine J7799)20552 (1-2) Muscles20553 (3 ) MusclesIce pack applies 97010

GuidelinesKey Points to Assess Before Injecting

Identify underlying etiology good MSK exam Discuss risks & benefits with patient Knowledge of functional anatomy Avoid injecting an unstable joint (e.g. suspectedrotator cuff or ACL tear) Avoid repeating injection too soon/too often- rule ofthumb is no sooner than q 3 months

Potential Adverse Effects Postinjection flare (2-10%) Subcutaneous atrophy and/or skindepigmentation- more commonwith superficial injection Bleeding or bruising Steroid arthropathy – no realevidence for promotion of diseaseprogression! Joint sepsis- rare Tendon rupture- minimized bygood technique Facial flushing (1-5%) Hyperglycemia- usually 1 week Menstrual irregularity Decreased ESR/CRP levels Anaphylaxis- rare

ContraindicationsAbsoluteRelative Sepsis- local or systemic Diabetes Fracture site Immunocompromised Prosthetic joint Pediatric patients Large tendons (Achilles,infrapatellar) Bacteremia Sickle cell anemia Allergy Anticoagulation therapyinjection does not increasebleeding risk Uncontrolled bleedingdisorder

Talking Points Gain patient confidence by discussing risks,benefits, additional recommendations Informed consent- verbal or written Steroids– Serious side effects usually seen PO rather than injectiondue to less systemic absorption– The body makes 20-30mg cortisone daily we are using asmall dose similar to your natural hormone– You will better tolerate physical therapy/exercise whenpain is controlled

General Injection TipsComfortable position for you and patient!Identify landmarksMark with tip of prep swab, needle cap, or make-up pencilPrep skin, optional “cold” sprayQuick insertion, Steady rate of injectionIf there is resistance, withdraw slightlyPost-injection compression & directions

What if it is not going as planned?

Post-injection Instructions Avoid excessive activity for 24-48 hours Gradual return to full activity Apply ice 3 x per day for 3 days (easy toremember) Ok to take NSAID/pain reliever Patient specific directions (DM, etc) Follow-up in 1-2 weeks, then rehab

Assess OutcomesFeel like a hero! Follow-up within 2 weeks postinjection Consider physical therapy or ahome exercise program to reducerisk of recurrence Additional modalities: ice/heat,oral or topical NSAID, essentialoils, massage, yoga, exercise, PT If adequate improvement is notseen in 6-8 weeks, considerreferral

Helpful Resources

Conference Adventures

Neck and ShoulderTrigger point and posterior shoulder injections

Shoulder Anatomy 3 Bonesscapulaclaviclehumerus Rotator cuff muscles (SITS)SupraspinatusInfraspinatusTeres MinorSubscapularis

Posterior View

Shoulder Indications Tendinitis/tendinosis Impingement syndrome Bursitis Osteoarthritis

Subacromial Shoulder Injection Subacromial space– Bursa is at anterior margin– Size of a silver dollar Posterior approach– Least pain receptors– Biggest portal of entry– Acromion slopes down in back- Angle up (about15 ) with injection

Shoulder- Posterior Approach: 5ml syringe, 25 g1.5” needle, 2cc 10mg Kenalog 3cc 1% Lidocaine

Posterior Neck- Trigger Point Injections

Trigger Point Injections Focal, hyper-sensitive areas in tight areas of muscle Tender to palpation and can produce pain in areferral pattern May cause tension headaches, TMJ pain, regionalpain, low back pain No steroid needed: 2ml normal saline 2 mlanesthetic 4ml total volume Inject 1ml to each trigger point, may see twitchresponse

ElbowLateral Epicondylitis, Medial Epicondylitis

Elbow Anatomy

3ml syringe, 25 g 1.5” needle, 1/2cc 40mgKenalog 1cc 1% Lidocaine Mostly Lateral– Tennis elbow– Extensor-supinator. Occurs at the origin of the commonextensor tendon. Anterior facet of the lateral epicondyle. Medial– Golfer’s elbow– Flexor-pronator. Origin of the common flexor tendon.Anterior facet of the medial epicondyle.– Careful of Cubital tunnel- ulnar nerve

Elbow Video

Wrist/HandDe Quervain’s tenosynovitis, Trigger finger

De Quervain’s Tenosynovitis Overuse injury of abductor pollicis longus &extensor pollicis brevis Pain at base of thumb & over radial styloid process Finklestein’s test

3ml syringe, 25 g 1.5” needle, 1/4cc 40mgKenalog 1/2cc 1% Lidocaine Thumb in slight flexion Feel gap between the 2 tendons Insert needle into the gap, then advance between thetendons Inject solution as a bolus

Trigger finger or trigger thumb May be acute or chronic Painful clicking and/orlocking of finger orthumb May have painful, tendernodule at the base of thedigit More common in thosewith diabetes

3ml syringe, 25 g 1.5” needle, 1/2cc 40mgKenalog 1cc 1% Lidocaine Position hand palm up Mark nodule at the A1pulley Insert needle into thenodule Inject ½ solution into thenodule, then advance theneedle slightly and injectthe other ½ into the tendonsheath

On Your Mark, Get Set, Practice!

HipTrochanteric Bursitis

Greater Trochanteric Pain Syndrome Bursa- in line with pubis symphysis Rarely the primary issue! Key point- assess gait &strength Hip “rotator cuff”– Abductor muscles: gluteus medius, minimus– Abductor external rotation: piriformis

Lateral hip Tenderness over thegreater trochanter Pain with sidelying,difficult to sleep Painful passive hipabduction/adduction May be chronic ifunderlying gait ormuscle imbalance issuesnot addressed

5ml syringe, 18 g 2” needle, 1cc 40mg Kenalog 4cc 1% Lidocaine Patient lies on unaffected side Upper leg extended Identify and mark point of maximum tenderness,over or near greater trochanter Insert needle perpendicular and advance to touchbone Pull back slightly, inject as bolus

KneeKnee joint, Pes anserine bursitis

Knee Joint Primary indication:osteoarthritis Can be used for kneestrain and pain associatedwith meniscus tear

Knee Anatomy3 bones articulate:Femur, tibia,patellaMain ligaments:lateral, medial,patellar, ACL, PCLMeniscus: medial& lateral

5ml syringe, 25 g 1.5” needle, 2cc 10mg Kenalog 2cc 1% Lidocaine Patient sits or lies supinewith knee flexed Identify and markintersection of lateral andinferior joint lines Insert needle and advanceslowly Injection solution as bolus

Pes Anserine bursitis Overuse injurycommon in athletes Pain at the attachmentsite: medial side tibiajust below joint line Combined tendoninsertion

3ml syringe, 25 g 1.5” needle, 1/2cc 40mgKenalog 1cc 1% Lidocaine Patient sits or lies supine with knee flexed Identify and mark tender area over the bursa, ifneeded have patient flex knee against resistence Insert needle and advance to touch bone Pull back slightly and inject solution as bolus

Review andDocumentation