Indications For Musculoskeletal Injections

Indications forMusculoskeletal Injections:Focus on CorticosteroidInjectionsErica Martin, M.D.PGY4, University of Michigan Sports Medicine Fellow2018 Sports Medicine for the Primary Care Physician & Fall Update in FamilyMedicineOctober 3rd, 2018

History of corticosteroid injections Early 1900s- Janet Travell,MD 1951- Joseph Hollander, MD

Risks/Aims of Corticosteroid InjectionsRisks Damage to underlying structures Skin depigmentation Muscle atrophy Tendon rupture Infection Bleeding HyperglycemiaPotential Benefits Improved pain Improved function

Where are we headed? Shoulder Elbow Hand Hip Knee

Shoulder

Indications: Shoulder corticosteroid injection Adhesive capsulitis Impingement syndrome Glenohumeralosteoarthritis ons/shoulder-pain-andcommon-shoulder-problems/

Indications: Shoulder corticosteroid injectionAdhesivecapsulitis What is adhesive capsulitis? Presentation? Evidence: Injected steroid versus oral steroids, PT, NSAIDs? Intra-articular versus subacromial? Duration of effectiveness? Bottom line?Steroid injections for AC are generally effective in the short term given ineither the subacromial space or in the glenohumeral joint. May not providebetter outcomes than PT, but may be helpful for pain relief and QOL.

Indications: Shoulder corticosteroid injectionImpingement Syndrome What is impingement syndrome? Presentation? Evidence: Injection approach? Injected steroid versus other treatment modalities? Bottom line?Try conservative measures for impingement syndrome first, then considersubacromial injection.

Indications: Shoulder corticosteroid injectionGlenohumeral Osteoarthritis What is glenohumeral osteoarthritis? Presentation? Evidence: Only one study at this point looking at corticosteroid injection Bottom line?For glenohumeral OA, there is no great evidence for CS injection at this time.Could try in cases of refractory pain.

Ultrasound-guided injections versus landmarkbased injections in the shoulder? Glenohumeral joint? Ultrasound ideal Subacromial space?

Elbow

Indications: Elbow corticosteroid injection Lateral epicondylitis Medial ews/2016/07/07/30290013/30290013-01.jpg

Indications: Elbow corticosteroid injectionLateral epicondylitis What is it? Presentation? Evidence: Duration of effect? Recurrence rate? Bottom line?For lateral epicondylitis, there is high recurrence rate with injection, andimprovements are short-term.

Indications: Elbow corticosteroid injectionMedial Epicondylitis What is it? Presentation? Evidence: Improvement in pain? Duration of effect? Bottom line?CSI for medial epicondylitis shows short term decreases in pain levels, butlong term pain relief is not consistently seen.

Ultrasound-guided injections versus landmarkbased injections in the elbow? Studies only done for intra-articular injections, no studies for lateral or medial epicondylitis. Lack of evidence to give concrete recommendation.

Hand/Wrist

Indications: Hand/wrist corticosteroid injection Carpal tunnel syndrome DeQuervain’s tenosynovitis Trigger finger Osteoarthritishttps://www.google.com/

Indications: Hand/wrist corticosteroid injectionCarpal Tunnel Syndrome What is it? Presentation? Evidence: Improvement in symptoms?Versus systemic corticosteroid?Duration of benefit?Rates of surgical intervention? Bottom line?CS injection for CTS can help with symptoms in short term and may increase timebefore surgery is required, but high recurrence rate and many patients end upneeding carpal tunnel release.

Indications: Hand/wrist corticosteroid injectionDeQuervain’s tenosynovitis What is it? Presentation? Evidence: Somewhat difficult injection Efficacy? Bottom line?For DeQuervain’s tenosynovitis, consider CS injection. Refer if no improvementin symptoms with injection as there may be anatomic variation in first dorsalcompartment affecting injection efficacy.

Indications: Hand/wrist corticosteroid injectionTrigger Finger What is it? Presentation? Evidence: Duration of pain symptom relief? Repeat injections? Surgery? Bottom line?Physicians should offer steroid injection for trigger finger.

Indications: Hand/wrist corticosteroid injectionHand/wrist osteoarthritis What is it? Presentation? Evidence: Very little Bottom line?There is insufficient evidence to recommend corticosteroid injection forhand/wrist OA. Refer to subspecialist if you feel may be beneficial for patientas technically difficult area.

Ultrasound-guided injections versus landmarkbased injections in the wrist/hand? Carpal tunnel syndrome? 1 study, 46 median nerves Improvements in symptom severity scores greater and average time tosymptom relief shorter in US guided group. DeQuervain’s? Can have multiple subcompartments which can affect efficacy

Ultrasound-guided injections versus landmarkbased injections in the wrist/hand? Trigger finger? Study done by Cecen et al. in 2014 no significant difference in US versuslandmark-guided injection. Hand/wrist osteoarthritis? Multiple studies show increased injection accuracy with US guidance.

Hip

Indications: Hip corticosteroid injection Greater trochanteric painsyndrome Osteoarthritishttps://www.google.com/

Indications: Hip corticosteroid injectionGreater trochanteric pain syndrome What is it? Change in nomenclature based on histologic changes Presentation? Evidence? Injection versus “usual care”? Pain relief/”recovery” Duration? Bottom line?For greater trochanteric pain syndrome, can consider injection if patients desirequicker relief of pain.

Indications: Hip corticosteroid injectionOsteoarthritis What is it? Presentation? Evidence? Numbing agent /- steroid Duration of efficacy? Bottom line?Steroid injections can be helpful for relief of pain in hip OA; however, this is ananatomically difficult area to inject without imaging guidance and wouldrecommend referral for this procedure.

Ultrasound-guided injections versus landmarkbased injections in the hip? Trochanteric pain syndrome Mitchell et al., RCT of 40 patients more improvement in pain scores in USguided group at 6 months. Hip osteoarthritis 2 studies looking at accuracy of landmark-guided injections. Between 67 and78% accuracy. Case series done by Pourbagher et al. showed 80% with improvements infunction and pain after US guided injection No comparative studies to date

Knee

Indications: Knee corticosteroid injection 300.jpg

Indications: Knee corticosteroid injectionOsteoarthritis What is it? Presentation? Evidence? Duration of pain relief? Bottom line?For knee osteoarthritis, CS injection can be used prior to referral for surgicalevaluation.

Ultrasound-guided injections versus landmarkbased injections in the knee? Osteoarthritis Landmark-based injections Accuracy depends on approach taken, ranges between 67-91% Superolateral approach most accurate Landmark versus US guided injections Accuracy of injection ranging from 63-100% with ultrasound versus landmark accuracybetween 39 and 100% based on 2012 review Study done by Sibbitt et al. suggestive of cost benefit for US guided injection versuslandmark

Okay, but what kind of steroid do I use? And howmuch?Injection locationSteroid typeSteroid DoseGlenohumeral jointTA may be better than MPA foradhesive capsulitis40 mg no better than 20 mg foradhesive capsulitisSubacromial spaceMPA may be better than TA forpain80 mg similar to 40 mg, but 40 mgbetter than 20 mgHip jointSimilar efficacy for MPA or TALonger duration of improvementin 80 mg compared to 40 mgKnee jointTH better than TA, MP, and B40 mg equivalent to 80 mgTA triamcinolone acetate; MPA methylprednisolone acetate; TH triamcinolone hexacetonide;B betamethasoneTable adapted from Table 1 in Cushman, Daniel M., et al. “Efficacy of Injected Corticosteroid Type, Dose,and Volume for Pain in Large Joints: A Narrative Review.” PM&R, vol. 10, no. 7, 2018, pp. 748–757

Parting thoughts Biomechanics are key forlong term outcomes!https://www.verywellfit.com/

Works Cited Amin, Nirav H., et al. “Medial Epicondylitis.” Journal of the American Academy of Orthopaedic Surgeons, vol. 23, no. 6, 2015,pp. 348–355., doi:10.5435/jaaos-d-14-00145. Block, J., B., & M. (2012). Clinical utility of ultrasound guidance for intra-articular knee injections: A review. ClinicalInterventions in Aging, 89. doi:10.2147/cia.s29265 Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for greater trochanteric pain syndrome: a randomizedcontrolled trial in primary care. Ann Fam Med. 2011;9(3): 226-234. Buchbinder, Rachelle, et al. “Corticosteroid Injections for Shoulder Pain.” Cochrane Database of Systematic Reviews, 2003,doi:10.1002/14651858.cd004016. Cecen, G.S., Gulabi, D., Saglam, F. et al. Arch Orthop Trauma Surg (2015) 135: 125. 014-2110-9 Colen, S., et al. “Intra-Articular Infiltration Therapy for Patients with Glenohumeral Osteoarthritis. a Systematic Review of theLiterature.” Osteoarthritis and Cartilage, vol. 22, Oct. 2014, doi:10.1016/j.joca.2014.02.748. Cushman, Daniel M., et al. “Efficacy of Injected Corticosteroid Type, Dose, and Volume for Pain in Large Joints: A NarrativeReview.” Pm&r, vol. 10, no. 7, 2018, pp. 748–757., doi:10.1016/j.pmrj.2018.01.002. Dardas, Agnes Z., et al. “Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger.” The Journal of HandSurgery, vol. 42, no. 4, 2017, pp. 227–235., doi:10.1016/j.jhsa.2017.02.001. Hepper, C. Tate, et al. “The Efficacy and Duration of Intra-Articular Corticosteroid Injection for Knee Osteoarthritis: A SystematicReview of Level I Studies.” Journal of the American Academy of Orthopaedic Surgeons, vol. 17, no. 10, 2009, pp. 638–646.,doi:10.5435/00124635-200910000-00006. Ilyas, Asif M., et al. “De Quervain Tenosynovitis of the Wrist.” Journal of the American Academy of Orthopaedic Surgeons, vol.15, no. 12, 2007, pp. 757–764., doi:10.5435/00124635-200712000-00009. Krogh, Thøger Persson, et al. “Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis.” The American Journalof Sports Medicine, vol. 41, no. 6, Dec. 2012, pp. 1435–1446., doi:10.1177/0363546512458237.