Steroid Injections in General Practice

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Steroid Injections in General Practice

• Bob Ward
• 19th September 2007
• CRESH VTS

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General Principles

• Controversial due to the incidence of
  side-effects and concern regarding their effect
  on tissue healing
• Injection maximises the concentration at the site
  of injury and minimises the risk of side-effects
• Generally use considering this a bridge
• Particularly useful for bursitis

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Adverse Effects

• Inhibit collagen synthesis
• Deleterious effects dose related
• Possible long-term damage to articular cartilage
• Concern re possible increase in tendon rupture
• Tendinitis

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Substance?

• Variation in speed of onset and half-life
• No convincing evidence that efficacy differs
• What alternatives?
• Oral/Iontophoresis
• NSAID
• Nitric Oxide donor
• Sclerosant injections
• Dry needling/autologous blood

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Site

• How accurate must one be?

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HITTING THE SPOT!

• DIAGNOSIS AND MANAGEMENT OF SHOULDER PAIN

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The Rotator Cuff

• Formed By 4 muscle Tendons
• Supraspinatus
• Infraspinatus
• Teres Minor
• And

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• Subscapularis

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SPECIFIC SHOULDER CONDITIONS

• Rotator Cuff Tendinitis and Subacromial Bursitis
  Impingement Syndrome (60)
• Adhesive Capsulitis (Frozen Shoulder) (12)
• Rotator Cuff Tears / Rupture (10)
• Acromio Clavicular Joint Arthritis (7)
• Bicipital Tendinitis (4)
• Other (7)
• 90 95 Periarticular NOT due to Arthritis
• Patient can have more than one problem occurring
  simultaneously
• The commonest cause of referred or non specific
  pain is Cervical Spondylosis

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COMMON AGE DISTRIBUTION

• Age alone will give a clue to diagnosis
• INSTABILITY
• 2nd and 3rd decades
• IMPINGEMENT, FROZEN SHOULDER INFLAMMATORY JOINT
  DISEASE
• 4th and 5th decades
• ROTATOR CUFF TEARS DEGENERATIVE JOINT DISEASE
• Beyond

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EXAMINATION
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NON SHOULDER EXAMINATION
CERVICAL SPINE
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SHOULDER EXAMINATION

• SHOULDER INSPECTION / PALPATION

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MOVEMENT

• ACTIVE/PASSIVE

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SUPRASPINATUS FUNCTION
FULL CAN TEST
EMPTY CAN TEST
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TERES MINOR/INFRASPINATUS FUNCTION
ELBOW AT 90 DEGREES
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THE DROP SIGN
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SUBSCAPULARIS FUNCTION
BELLY PRESS (NAPOLEONS) TEST
GERBERS LIFT OFF TEST
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BICEPS TENDON TESTS
SPEEDS TEST
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IMPINGEMENT SIGNS AND TESTS
NEERS IMPINGEMENT TEST
GREAT CAUTION! IN YOUNG PATIENTS CLOSELY EVALUATE
FOR SIGNS OF INSTABILITY, THE MOST LIKELY CAUSE
OF IMPINGEMENT
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SPECIAL TESTS

• DELTOID FUNCTION
• SUPRASPINATUS FUNCTION
• 1. EMPTY CAN TEST
• 2. FULL CAN TEST
• TERES MINOR/INFRASPINATUS FUNCTION
• DROP SIGN
• SUBSCAPULARIS FUNCTION
• 1. GERBERS LIFT OFF TEST
• 2. NAPOLEONS BELLY PRESS TEST
• BICEPS TENDON
• 1. YERGASSONS TEST
• 2. SPEEDS TEST

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INSTABILITY

• GENERAL EXAMINATION
• ANTERIOR POSTERIOR DRAW TEST
• ANTERIOR APPREHENSION TEST

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INVESTIGATIONS

• X RAY
• ULTRASOUND
• MRI SCAN (MRI ARTHROGRAM)
• CT SCAN
• EMG
• BONE SCAN
• ARTHROSCOPY

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Why do You need an X-ray for Shoulder Problems

• Arthritis? AC Jt GH Jt( OA/RA)
• Tumour? Proximal Humerus
• Fractures? Clavicle, Prox.Humerus, AC joint

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TREATMENT
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Cuff tendinitis/Impingement syndrome/Biceps
tendinitis

• Anti-inflammatories/analgesics
• Restrict activities
• Steroid injections
• Physiotherapy
• Pain persists---refer

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TREATMENT FROZEN SHOULDER

• NON-OPERATIVE
• XRAY
• NSAID
• INTRA-ARTICULAR CORTICOSTEROIDS
• PHYSIOTHERAPY
• OPERATIVE

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INJECTION TECHNIQUES
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Common Elbow Problems

• Tennis Elbow( Lateral Epicondylitis)
• Golfers Elbow( Medial Epicondylitis)
• Olecranon Bursitis

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TENNIS ELBOW
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Injection

• Patient sits with supported elbow bent at right
  angle
• Identify the facet lying anteriorly on lateral
  epicondyle
• Insert needle in line with cubital crease
  perpendicular to the facet until it touches bone

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Golfers elbow

• Pt. sits with supported arm extended
• Identify anterior facet on medial epicondyle
• Insert needle perpendicular to facet and touch
  bone

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OLECRANON BURSITIS
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Common Hand Problems

• Carpal Tunnel Syndrome
• De Quervain's stenosing tenosynovitis
• Trigger Finger

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Ganglion

• cystic swelling in the neighbourhood of
• tendon or joint

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Carpal Tunnel Syndrome (CTS)

• The entrapment of the median
• nerve at the fibro osseous
• tunnel of the carpus.

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CTSAetiology

• Decrease in the size of the canal
• osteoarthritis
• trauma
• acromegaly

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CTSAetiology 2

• Increase in the size of its contents
• pregnancy
• rheumatoid arthritis
• alcoholism
• tumour
• idiopathic

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CTSsigns

• Wasting of thenar eminence
• Numbness
• Weakness
• Tinels sign
• Phalens sign

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CTSTreatment

• non operative
• splint
• steroid injection
• surgical decompression

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De Quervains Disease

• Stenosing tenovaginitis of the first
  dorsal extensor compartment

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De QuervainsTreatment

• non operative
• rest
• steroid injection
• anti-inflammatory
• operative

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DeQuervain's Disease

• Patient places hand vertical with thumb held in
  slight flexion
• Identify gap between the tendons
• Insert needle into gap then slide proximally
  between the tendons
• Deposit solution as a bolus within tendon sheath

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Trigger Fingers

• Stenosing tenovaginitis of the
• flexor tendon sheath(A1 pulley)

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Trigger Fingeraetiology

• congenital (thumb)
• often not recognised until toddlers
• 30 resolve spontaneously
• acquired (middle aged)
• idiopathic
• traumatic
• diabetes
• rheumatoid

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Trigger Fingertreatment

• non operative
• steroid injection
• operative
• release of A1 pulley

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The Knee
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Anatomy
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Swelling of the knee? Bursitis/ ? Effusion

• Figure 1a Bursitis of the knee may be
• 1. Prepatellar bursitis common, usually red,
  obscures patella, easily diagnosed, may also be
  sympathetic mild knee effusion.
• 2. Superficial infrapatellar bursitis common,
  usually red, easily diagnosed.
• 3. Deep infrapatellar bursitis less common, not
  so red, signs less marked.
• Figure 1b.Effusions of the knee occupy the entire
  joint, the suprapatellar pouch extends 3 finger
  breadths above the patella. The patella is
  easily palpated.

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Knee joint injection

• Patient sits with knee supported
• Place the thumb on far side of relaxed patella
  and push toward you, tilting
• Identify edge of patella while maintaining
  position with thumb
• Insert needle horizontally at mid point of edge
  of patella between it and the femoral condyle and
  slide under patella

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Menisci - McMurray Test

• Have the patient lie supine with the knee
  completely flexed.
• Medially rotate the tibia if there is a loose
  fragment of the lateral meniscus, this action
  will cause a snap accompanied by pain.
• Laterally rotate the tibia if there is a loose
  fragment of the medial meniscus, this action will
  cause a snap accompanied by pain.
• When examining the lateral meniscus, rotate the
  foot medially (laterally for the medial
  meniscus).

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osteoarthritis
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• non operative treatment
• nsaids
• steroid
• viscosupplementation               
• wt loss
• valgus unloading knee brace

•  operative treatment      
• - arthroscopy of osteoarthritic knee
• - high tibial osteotomy
• - total knee arthroplasty

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Internal derangement

• Needs referral for further imaging/arthroscopy

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The hip
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Common Hip Problems

• Osteoarthritis ( OA )
• Trochanteric Bursitis

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Trochanteric bursa
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Injection