4How to perform local soft-tissue glucocorticoid injections
Introduction
Many inflammatory rheumatic diseases are characterized not only by joint inflammation but also by inflammation of periarticular tissues – the so-called soft tissues: tendons, tendon sheaths, entheses, bursae, ligaments and fasciae. These local inflammations can be treated by local glucocorticoid injection in addition to systemic anti-inflammatory therapy. Local soft-tissue structures can also be painful in absence of a generalized inflammatory rheumatic disease and show inflammatory signs, probably secondary to microtraumata or overloading. Although this pathogenesis questions the rationale of glucocorticoid injection, in practice local glucocorticoid injection is often also beneficial for these lesions. The injection and post-injection rest diminish swelling and possibly in this way enhance healing of the lesion.
This chapter reviews injection of soft-tissue structures to diminish local inflammation or irritation or to treat nerve compression syndromes (Table 1). However, contrasting with the frequent application of local glucocorticoid injection in common soft-tissue disorders is the paucity of data on its efficacy, potential risks and contraindications. In general, there is limited evidence to support the superiority of glucocorticoid injections over other kinds of treatment, such as rest, local cooling, analgesics and non-steroidal anti-inflammatory drugs [1]. Most randomized, controlled trials demonstrate a superior effect of glucocorticoid injection in the short term but no clear difference on the long term, compared with other treatment modalities. However, glucocorticoid injection usually is perceived as simple, safe and effective.
For each indication, this chapter summarizes the scarce literature on indications, efficacy and adverse effects, and describes the most common method of injection [2]. Although other useful alternative methods of injection exist, and other preparations of glucocorticoid and dosages *[3], [4], it seems best to gain experience with limited techniques and dosages. Also, only general guidelines can be given; for example, the length of the needle used would depend on the thickness of the skin and subcutaneous fat tissue layer of the individual patient.
Section snippets
General considerations and technical recommendations
Published recommendations on soft-tissue injections are mostly not ‘evidence based’ but ‘eminence based’, i.e. based on expert opinion. This holds true for many of the recommendations in this chapter, but lack of evidence is not equivalent to evidence of a lack of relevance or efficacy.
The efficacy of injection depends on patient and physician variables. Local injection therapy should, first of all, be based on a clear and accurate diagnosis; the effect depends on the right diagnosis. For
Specific injection sites and indications
This section covers local soft-tissue lesions (tendons, tendon sheets and bursae) and nerve compression syndromes. For the materials used for injection into the specific sites, see Table 5.
De Quervain's tenosynovitis
The abductor pollicis longus and extensor pollicis brevis tendons usually have a common tendon sheet at the base of the first metacarpal and the radius styloid process, where often the area of maximal pain is experienced. Overloading is often the cause of pain. The injection is considered very effective *[60], [61], [62], but the effect depends on accuracy of injection [63].
Subacromial/subdeltoid bursitis
The symptoms resemble those of supraspinatus tendinitis: pain in the C5 dermatome, no restriction of passive movement of the shoulder, painful arc and often also painful isometric resisted abduction because of the cranial movement of the humeral head with compression of the bursa during this test. Isometric resisted abduction test during caudal traction of the arm is often negative. There might be local tenderness on palpation of the bursa and local swelling. Causes are tendon degeneration or
Nerve compression syndromes
Nerve compression syndromes are not rare. In primary care in the year 2000, the age-standardized incidence rates per 100,000 were as follows: for carpal tunnel syndrome, 88 men/193 women; for Morton's metatarsalgia, 50 men/88 women and for meralgia paraesthetica, 11 men/13 women. New presentations occurred most frequently at ages 55–64 years except for carpal tunnel syndrome, which was most frequent among women aged 45–54 years [76]. In rheumatological practices the incidence of carpal tunnel
Summary
Soft-tissue rheumatic disorders are common and, although not life-threatening or resulting in organ damage, they result in significant morbidity, loss of productivity and socioeconomic impact. Early intervention aims to look at and treat underlying causes, such as inflammatory rheumatic diseases and overloading, to prevent chronicity and recurrence. Soft-tissue glucocorticoid injections are commonly reserved for chronic cases, with evidence for relief in the short term, but there are scarce
Acknowledgments
Thanks to AWJM van Bree abd Fag Jacibs for modeling for the photographs.
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Cited by (25)
Comparison of high- and low-dose intra-articular triamcinolone acetonide injection for treatment of primary shoulder stiffness: a prospective randomized trial
2017, Journal of Shoulder and Elbow SurgeryCitation Excerpt :Even in diabetic patients, a corticosteroid injection decreases the pain perception and accelerates functional recovery in the early postinjection period.21 However, there is no consensus on the optimal injection dose for the treatment of shoulder stiffness; instead, doses have been chosen empirically on the basis of individual experience or previously published papers, with a wide range of injected doses from 10 mg to 80 mg.1,3,12,18,19,21,22,24 To date, there are 3 prospective studies that compared the results of different doses of corticosteroid injection for the treatment of shoulder stiffness.
Ultrasound-guided versus palpation-guided local corticosteroid injection therapy for treatment of plantar fasciitis
2016, Egyptian RheumatologistCitation Excerpt :Subsequently, local injection of large volume (corticosteroid and local anesthetic agent) in PF within the relatively small potential space increases the risk for local corticosteroid complications as heel fat pad atrophy and plantar fascia rupture [38]. This is also to assess the occurrence of any early side effects of injection as postinjection pain and flare which occurs in the first 24 hours following injection [22]. In addition, it was reported that no therapeutic advantage could be detected by adding of a local anesthetic to the corticosteroid in the local injection of PF [39].
Rheumatic conditions
2014, A Comprehensive Guide to Geriatric Rehabilitation, Third EditionGlucocorticoid Therapy
2012, Kelley's Textbook of Rheumatology: Volume 1-2, Ninth EditionArthrocentesis and Injection of Joints and Soft Tissue
2012, Kelley's Textbook of Rheumatology: Volume 1-2, Ninth EditionUnique Complications of Foot and Ankle Injuries Secondary to Warfare
2010, Foot and Ankle ClinicsCitation Excerpt :Aspiration of the bursa may be necessary to obtain a culture, if there is a concern for infection, as well as to decompress the bursa.19,20 A steroid injection may help decrease the inflammation associated with the bursa.21,22 Custom modification of the prosthesis may sometimes be all that is needed to prevent recurrence after resolution of the acute inflammation.