Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Strange concept
- Yogi Sehgal (15 April 2009)
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Image guided injections
- Louise Gaunt (16 April 2009)
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Deja Vu!
- Sidha Sambandan (16 April 2009)
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Trochanteric Bursitis: Easy Diagnosis, Easy Location for CS Injection
- Francisco Ramirez Lafita MD, FACP, A Duran MD, A Amigó MD, M Castellŕ MD (17 April 2009)
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Repeat injection is not the next course of action
- Adnan Saithna (25 April 2009)
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Distinguishing variables
- Jon P Driver-Jowitt (28 April 2009)
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Acupuncture treatment of Trochanteric Bursitis
- Rosemary E Alexander (29 April 2009)
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Corticosteroid injections for greater trochanteric pain syndrome not the best option
- Nicola Maffulli, Mile End Hospital, 275 Bancroft Road, London E1 4DG (9 May 2009)
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Time for a re-think on the role of corticosteroid injections?
- Bill Vicenzino (12 May 2009)
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The concept of this aricticle has been distorted by the misinterpretation of the data.
- Tien-Jen Lin, I-Jen Wang and Yu-Ting Tai (28 July 2009)
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"Overkill"
- Ralph D. Lausa (28 July 2009)
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Yogi Sehgal, Rural Family Physician Sioux Lookout, Canada p8t 1A8
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I am not sure what the point of this study was. The trochanteric bursa is one of the easiest points in the body to inject, I don't know why fluoroscopy, which in Canada is relatively expensive and a bit of a precious resource, would even be studied for this. It is difficult to argue that without fluoroscopy it is a "blind" injection when it is going in to a depth of at most only a few cm into a very definite area. I am, however, glad that my experience is supported by the evidence that patients do benefit from this (along with a good stretching program). Competing interests: None declared |
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Louise Gaunt, Consultant radiologist Princess Elizabeth Hospital, Guernsey GY4 6UU
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As a radiologist I perform a number of image guided injections when "blind" injections have not been as effective as possible. However, I always use ultrasound guidance - it is more readily available, and in my hands a much more effective technique, plus avoiding ionising radiation. For those clinicians regularly performing injections who require some form of image guidance the use of ultrasound should be considered. It is a technique that can be easily learnt, and gives confidence that the needle has actually been placed where it is needed. I would strongly advocate usage of ultrasound for as many superficial injections as possible. Competing interests: None declared |
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Sidha Sambandan, GP/GPwSI (Orth)/H.Senior Lecturer Yare Valley Medical Practice, 202 Thorpe Rd, Norwich NR1 1TJ
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For many years Clinical Practitioners who have been injecting without Ultrasound or Fluoroscopy, would assert from observational studies, that patients benefit from Steroid injections into Joints and soft tissues - especially in the latter and more so when there is an inflammatory component. In UK the Radiologists have begun to expand their skills by injecting joints and soft tissues. While trying to carve out a niche, they lack the clinical expertise needed to make a diagnostic clinical assessment. Despite the large observer variability, and the lack of correlation between Imaging and clinical findings, they sometimes inject steroids "at the same sitting", if the GP had requested USS - especially when patients dont respond to steroid injections for Trochanteric bursitis. My observation is that if they dont respond to one or two steroid injections given in primary care, they dont seem to respond to those given under Ultrasound/Fluoroscopy. This applies to "Facetal injections" too. A recent BMJ article (9th January 2009) also confirmed that injecting into the Subacromial bursa for rotator cuff diesease gave no better results than injecting steroid into the buttock! But it makes good clinical sense to ascertain where the problem is in the 3 dimensional plane, consider the nature of the problem (in the pathological sense) and consider the differential diagnosis, before injecting. It is important to consider other options such as stretching, and advice on activity modification (such as taking shorter strides), which any good GP or GPwSI should be able to do. This article at least provides further evidence that absolute accuracy is not needed when injecting steroids into the peri- trochanteric bursae. Knowing "what" to inject and "when" is far more important than knowing "How & Where" to inject. A sound knowledge of clinical anatomy helps the "where" to inject. However injecting a hip joint, especially in an over weight individual is perhaps better done under Imaging as it is quite deep. I am not aware of any RCT comparing fluoroscopic and non-fluoroscopic injection outcomes in the hip joint. Competing interests: None declared |
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Francisco Ramirez Lafita MD, FACP, Dept of Occupational Health ANAV Dept of Health. L'Hospitalet de l'Infant 43890, Spain, A Duran MD, A Amigó MD, M Castellŕ MD
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Trochanteric bursitis is a common cause of hip pain secondary to an inflammation of the subgluteus maximus bursa. However, inflammatory findings have not ever been found in tissue samples (1). Diagnosis is easily made in clinical settings but, in some instances, ultrasounds and MRI were found to be useful diagnostic tools (2) (3). Steroid injection have been postulated as preferred and definitive treatment in trochanteric bursitis (4) Cohen and colleagues study (5) demonstrated that local steroid injection using a fluoroscopic guide improved not outcomes as compared to blind local steroid injection alone, increasing costs. We also postulate that fluoroscopic guide exposes patients and heath personnel to unnecessary radiation doses according to ALARA basis (As Low As Reasonably Achievable) for Radiation Safety. We support blind local steroid injection as basis for trochanteric bursitis therapy but also emphasize the complementary role of rehabilitation therapy (ultrasounds and stretching programs) Silva F, Adams T, Feinstein J. Arroyo RA. Trochanteric bursitis: refuting the myth of inflammation. J Cli Rheumatol 2008; 14 (2): 82-6 Kong A, Van der Vliet A, Zadow S. MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome. Eur Radiol 2007; 17: 1772-1783 Blakenbaker DG, Ullricik SR, Davis KW, De Smet AA, Haaland B, Fine JP. Correlation of MRI findings with clinical findings of trochanteric pain syndrome. Skeletal Radiol 2008; 37(10): 903-9 Stephens MB, Beutler AI, O’Connor FG. Musculoskeletal injections: a review of the evidence. Am Fam Physician 2008; 78 (8): 971-6 Cohen SP, Strassels SA, Foster L, Marvel J, Williams K, Crooks M, Gross A, Kurihara C, Nguyen C, Williams N. Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial. BMJ 2009; 338: b1008 Competing interests: None declared |
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Adnan Saithna, Specialist Registrar, Trauma and Orthopaedics Birmingham Heartlands Hospital
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Cohen and colleagues are to be commended for demonstrating that the use of fluoroscopy is unhelpful in improving outcome following injection for greater trochanter pain syndrome (GTPS).1 Although the results are unsurprising, the author’s conclusions provoke discussion. GTPS is a commonly used term that fails to specifically identify the underlying pathology. There are numerous anatomical structures that can cause pain around the greater trochanter and it is well recognised that pain experienced over the lateral aspect of the hip may be referred from other sources. It is therefore inappropriate to manage all patients with GTPS in the same way and a focussed history, examination and investigation are required to accurately diagnose and treat these patients. It is interesting that Cohen and colleagues chose to use fluoroscopy to target injection therapy because although fluoroscopy is useful for confirming intra-bursal injection the bursa itself is rarely involved (hence a departure from the previously popular term “trochanteric bursitis”). Although the authors recognise this, it remains unsurprising that they showed no difference between the groups, as even in an extra- bursal injection, the therapy cannot be accurately located to the site of the lesion using the methodology described. Ultrasound would be more useful in improving the accuracy of placement of therapeutic or diagnostic injection and can also provide information about the degree of tendinopathy, the presence of neovascularity and whether a partial or full tear is present.2 It is surprising that Cohen et al, conclude that patients should be referred to a pain clinic with fluoroscopic capability if they fail landmark guided injection as they did not demonstrate any advantage of fluoroscopic guided injection! In addition the role of corticosteroid injection in tendinopathies in general, is controversial. Although commonly administered there is concern about their influence on the mechanical integrity of tendons and rupture is a recognised complication.3 Given the lack of studies evaluating the treatment effect of corticosteroids it is fair to state that there is little evidence to support their use in chronic tendon lesions and therefore referring a patient for a second injection when the first did not work seems counter- intuitive.3 It would perhaps be more important to try and accurately determine the underlying pathology in these patients by means of focussed clinical examination and further imaging. The 30-second single-leg stance and resisted external de-rotation tests have been reported to have very good sensitivity and specificity for the diagnosis of tendinous lesions around the greater trochanter.4 MRI also has a role but the results must be taken in context as a high proportion false positives occur, with up to 50% of asymptomatic patients demonstrating gluteal tendinopathy on T2 imaging sequences in one particular series.5 Patients with symptoms refractory to non-operative management, a documented tear on imaging studies, a positive ultrasound guided injection test and absence of retraction or fatty degeneration of the tendon should be referred for a surgical opinion.6 Although there are no controlled studies to estimate the treatment effect of surgery a recent review article identified several case series that report good outcome.6 Patients should be referred to a pain clinic if symptoms do not warrant surgery, they are unfit for surgery or do not have a surgically amenable lesion. 1. Cohen SP, Strassels SA, Foster L, Marvel J, Williams K, Crooks M, et al. Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanter pain syndrome: multicentre randomised controlled trial. BMJ 2009;338:986-88. 2. Kong A, Van der Vliet A, Zadow S. MRI and US of gluteal tendinopathy in greater trochanteric pain syndrome. Eur Radiol 2007;17(7):1772-83. 3. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology 2006;45:508–521 4. Lequesne M, Mathieu P, Vuilleman-Bodaghi V, Bard H, Dijan P. Gluteal Tendinopathy in Refractory Greater Trochanter Pain Syndrome: Diagnostic Value of Two Clinical Tests. Arthritis & Rheumatism (Arthritis Care & Research) 2008;59(2):241-246 5. Blankenbaker DG, Ullrick SR, Davis KW, De Smet AA, Haaland B, Fine JP. Correlation of MRI findings with clinical findings of trochanteric pain syndrome. Skeletal Radiol 2008;37(10):903-9 6. Lequensne M. From “periarthritis” to hip “rotator cuff” tears. Trochanteric tendinobursitis. Joint Bone Spine 2006;73:344-348 Competing interests: None declared |
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Jon P Driver-Jowitt, Orthopaedic surgeon 3 Norfolk Road, Newlands 7700, Cape Town
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Foundation flaws in this paper are to not recognise (at least) these two variables in the subjects of this research.
1. No distinction between pathologies is made. This is fundamental if any pronouncements of therapeutic efficacy are intended. The paper refers to “gluteal bursitis”. While this undoubtedly occurs, it is rare. Most pain in the trochanteric region is an entheseopathy of the insertion of the great abductors.
Competing interests: None declared |
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Rosemary E Alexander, Hospital Practitioner Rheumatology Edgware Community Hospital,Edgware,HA8 OAD
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Dear Sir, I was interested to read the article from the BMJ 2009;338;b1088 on the comparison between fluoroscopically guided and blind injections for greater trochanteric pain syndrome; in particular that most steroid injections are positioned outside the bursa. I have been a practising acupuncturist for over 25 years, initially training in China. I have treated many patients with this condition, as a single-handed GP, where one or two treatments usually suffices, as well as in the rheumatology clinic(1,2), where patients have often had unsuccessful steroid injections or physiotherapy in the past. I audit my results and find that I have had sometimes to treat up to six times with an average improvement in pain of approximately 75%. I have mainly treated the trigger (tender)points of gluteus medius and minimus(surrounding the trochanteric bursa), which presumably are due to a small tear or abnormal contraction of muscle. Ultrasound has not normally been available to make a diagnosis.Occasionally there are trigger points along the iliotibial band, which I also treat.The steroid injection may be producing an acupuncture effect from the needle, releasing contracted muscle, causing the release of endogenous encephalins or by the delivery of cells which stimulate healing. Rosemary Alexander(Dr) MRCP Dip Ac(Shanghai) 1)Alexander RE,White AR Acupuncture in a Rheumatology Clinic.Acupuncture in Medicine Dec 2000 VOL 18(2) 2)Alexander RE,White AR Acupuncture in a Rheumatology Clinic. Rheumatology April 2001;VOL 40;412 Competing interests: None declared |
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Nicola Maffulli, Centre Lead and Professor of Sports and Exercise Medicine, Consultant Trauma and Orthopaedic Surgeon Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG
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Sir, we read with interest the recent article by Cohen et al. “Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial“ [2] highlighted in the Editorial from Bahr and Khan “Management of lateral hip pain”. [1] The study in question [2] had a main follow-up of one month, and, at three months, outcome data from 39 of 65 subjects (= 60%) were provided. The trial design did not provide any news on how to improve our management of greater trochanter pain syndrome, focusing on the usefulness and economic issues of performing local imaging guided steroid injection. In a trial recently accepted for publication in the American Journal of Sports Medicine, [4] we tested the null hypothesis that local corticosteroid injection, home training, and repetitive low-energy shock wave therapy produced equivalent outcome at four months from baseline. In a quasi-randomized controlled clinical setting, 229 patients with refractory unilateral greater trochanter pain syndrome were assigned to a home training program, a single local corticosteroid injection without imaging guidance (25 mg prednisolone), or repetitive low-energy radial shockwave treatment. Patients underwent outcome assessments at baseline and a one, four, and 15 month follow-up from baseline. The primary outcome measures were degree of recovery, measured on a 6-point Likert scale (subjects with rating -completely recovered- or -much improved- were rated as treatment success), and severity of pain over the past week (0-10 points) at four month follow-up. At one month from baseline, the results after corticosteroid injection (success rate 75%; pain rating: 2.2 points) were significantly better than after home training (7%; 5.9 points) or shockwave therapy (13%; 5.6 points). Regarding treatment success at four months, radial shockwave therapy lead to significantly better results (68%; 3.1 points) than home training (41%; 5.2 points), and than corticosteroid injection (51%; 4.5 points). The null hypothesis was rejected. Fifteen months from baseline, radial shockwave therapy (74%; 2.4 points) and home training (80%; 2.7 points) were significantly more successful than the corticosteroid injection (48%; 5.3 points). We concluded that the role of corticosteroid injection for GTPS needs to be reconsidered. Patients should be informed about the advantages and disadvantages of the treatment options, including the economic burden. The significant short-term superiority of a single corticosteroid injection over home training and shockwave therapy declined after one month. Both corticosteroid injection and home training were significantly less successful than shockwave therapy at four month follow-up. Corticosteroid injection was significantly less successful than home training or shockwave therapy at 15 month follow-up. This study [4] contradicts three assumptions of the Editorial by Bahr and Khan [1]. Firstly, the study [4] demonstrated that there is an investigation of therapeutic exercises specifically related to the gluteal region. Secondly, home exercises and shockwave therapy should be tried before surgery is recommended. Thirdly, in light of another upcoming study [3] on shockwave treatment for greater trochanter pain - winner of the 2009 Achilles Orthopaedic Sports Medicine Research Award of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) - management of greater trochanter pain syndrome needs no longer to be based on evidence from other anatomical sites. Sincerely, Jan D. Rompe, John P. Furia, Nicola Maffulli (on behalf of the International GTPS study group) References: 1. Bahr R, Khan K. Management of lateral hip pain. BMJ 2009; 338:b713. 2. Cohen SP, Strassels SA, Foster L, Marvel J, Williams K, Crooks M, Gross A, Kurihara C, Nguyen C, Williams N. Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial. BMJ 2009;338:b1088. 3. Furia JP, Rompe JD, Maffulli N. Low energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome. Am J Sports Med/2008/058008. Accepted January 21, 2009. 4. Rompe JD, Segal NA, Cacchio A, Furia JP, Morral A, Maffulli N. Home training, local corticosteroid injection or radial shockwave therapy for greater trochanter pain syndrome. Am J Sports Med/2008/059485. Accepted Feb 6, 2009. Competing interests: None declared |
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Bill Vicenzino, Chair in Sports Physiotherapy and Head of Physiotherapy University of Queensland, 4072
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Although Cohen et al[1] did not study the efficacy of corticosteroid injections against a comparator treatment, their report and the rapid responses prompted thereafter do focus the spotlight on the role of corticosteroid injections for like musculoskeletal soft tissue problems (i.e., lacking in inflammatory markers, chronic (long term) pain states[2- 7]). They rightly concluded that a single study like theirs is not enough to change practice, yet a broad snapshot of the related evidence base reveals that there is mounting evidence that raises concern regarding the mid- to long-term effects of corticosteroid injections and brings into question their role in the management of musculoskeletal pain states. A number of studies, which are often cited in support of corticosteroid injections, have substantiated the frequently made clinical observation of a rapid and substantial improvement in a range of soft tissue injuries following these injections (e.g., [7-14]). However, like the paper of Cohen et al, many of these studies also report poor mid to long-term outcomes – indicative of delayed recovery, which is also frequently observed in clinical practice. The report of success rates in the order of 40-60% at 3 and 6 months, which are often inferior to control (e.g., adoption of a wait and see policy), across a number of studies[8 ,10 ,11 ,14], countries[9 ,12 ,13] and for a range of musculoskeletal pain sites [7 ,11 ,13] should now be considered as sufficient evidence to caution against the use of corticosteroid injections for these conditions. Paralleling this delay in recovery are very high recurrence rates (~72% of patients reporting success at 6 weeks reported otherwise at 3-12 months), which out strip recurrence rates (<10%) in control and physical therapies (e.g., exercise, manual therapy, electrophysical agents)[8]. Corroborating the delay in recovery and higher recurrence rates is the higher use of other treatments (co-interventions) by those receiving corticosteroid injections when compared to physiotherapy and control[8 ,11]. Individual papers like that of Cohen et al may not of themselves be sufficient evidence to change practice, but when taken in the context of the findings reported in these other cognate papers [15], should raise concerns regarding the use of corticosteroid injections. It is now timely to caution against the use of corticosteroid injections for chronic soft tissue injuries that are likely not inflammatory in nature. Along with the evidence for short-term gains with these injections, patients should be informed of the real prospect of long-term problems such as, delayed recovery and higher recurrence rates. 1. Cohen SP, Strassels SA, Foster L, Marvel J, Williams K, Crooks M, et al. Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial. BMJ 2009;338:b1088. 2. Coombes BK, Bisset L, vicenzino B. An integrative model of lateral epicondylalgia. British Journal of Sports Medicine 2008. 3. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the "tendinitis" myth. Bmj 2002;324(7338):626-7. 4. Hamilton B, Purdam CR. Patellar tendinosis as an adaptive process: a new hypothesis. British Journal of Sports Medicine 2004;38(6):758-61. 5. Kader D, Saxena A, Movin T, Maffulli N. Achilles tendinopathy: some aspects of basic science and clinical management. British Journal of Sports Medicine 2002;36(4):239-49. 6. Lewis JS. Rotator cuff tendinopathy: A review. British Journal of Sports Medicine 2008. 7. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford) 2006;45(5):508-21. 8. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333(7575):939. 9. Bisset L, Smidt N, Van der Windt DA, Bouter LM, Jull G, Brooks P, et al. Conservative treatments for tennis elbow do subgroups of patients respond differently? Rheumatology (Oxford) 2007;46(10):1601-5. 10. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999;319(7215):964-8. 11. Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR. A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. Ann Rheum Dis 2003;62(5):394-9. 12. Smidt N, Lewis M, Hay EM, Van der Windt DA, Bouter LM, Croft P. A comparison of two primary care trials on tennis elbow: issues of external validity. Ann Rheum Dis 2005;64(10):1406-9. 13. Smidt N, van der Windt DA. Tennis elbow in primary care. Bmj 2006;333(7575):927-8. Competing interests: None declared |
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Tien-Jen Lin, Neurosurgeon and Pain specialiast Wanfang Hospital,Taipei Medical University, I-Jen Wang and Yu-Ting Tai
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We agree on the authors 'point of view that giving any injection under radiographic guidance usually requires pain management services. This surely adds to the cost of treatment. But as the chief of the pain management center in this region of country, I have many referrals from local clinics for pain treatment in the lower back, hip or gluteal regions and many of them have already received failed corticosteroids injections. Diagnoses varies from physician to physician and injection of contrast medium to provoke and visually confirm the "hot spot" seems to be crucial to obtain the final diagnosis of the ailment. Patients with greater trochanteric pain syndrome who failed corticosteroid injections guided by landmarks are surely referred to the pain treatment centre. Then what next? Far more expensive CT or MR imaging studies of the affected region are warranted to make the diagnosis. Competing interests: None declared |
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Ralph D. Lausa, Physician, M. D. Semi-retired
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The use of epitrochanteric injection of corticosteroid is indeed so simple and safe that the use of an endoscope to visually place the injectable is useless and wasteful. There are some "tricks" and pointers to be made to the adapter of this highly useful procedure, which can be learned in minutes with simple study of anatomy charts and without direct observation of the technique by someone else before first performance. This treatment is so helpful to the grateful patients (almost exclusively women past 40 years of age) that it should be performed on the site by general practioners when it is first recognized on examination. I would agree with a previous commentator that the study using the endoscope is so flawed that it should be called overkill. The use of a spinal length needle is helpful in obese persons. The area of greatest tenderness must be carefully evaluated. The needle is first directed toward the most tender point and carried to the point of resistance to further advance. Injection of about 1/2 of the material to be given is used here, then the neddle withdrawn 1-2 cm and re-directed to a point about 1 cm to one side of the original injection. This area receives 1/4 of the remaining injectable. It is repeated by re-directing to each quadrant around the central injection site and dividing the remainder of the injectable in the similar sites. As to preparation, that may be open but I have found triamcinalone either 40 or 80 mg per ml to be easiest. 1 ml of this may be premixed with lidocaine 1ml of 1% sterile solution in the syringe. The entire amount is used for one entire treatment. Repeat treatment in 1-2 weeks may be given but is very seldom needed. Many with this problem may, however, return in 1-5 years for a repeat evaluation and treatment. Competing interests: None declared |
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