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How to perform local soft-tissue glucocorticoid injections

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Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae are the hallmark of many inflammatory rheumatic diseases, but inflammation – or rather irritation – of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

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.

References (105)

  • C. Zingas et al.

    Injection accuracy and clinical relief of de Quervain's tendinitis

    J Hand Surg [Am]

    (1998)
  • M.F. Hurdle et al.

    Ultrasound-guided blockade of the lateral femoral cutaneous nerve: technical description and review of 10 cases

    Arch Phys Med Rehabil

    (2007)
  • S.P. Tavares et al.

    Nerve injury following steroid injection for carpal tunnel syndrome. A report of two cases

    J Hand Surg [Br]

    (1996)
  • A.A. Wang et al.

    The effect of corticosteroid injection for trigger finger on blood glucose level in diabetic patients

    J Hand Surg [Am]

    (2006)
  • B.T. Fitzgerald et al.

    Delayed flexor digitorum superficialis and profundus ruptures in a trigger finger after a steroid injection: a case report

    J Hand Surg [Am]

    (2005)
  • J.G. Skedros et al.

    Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians

    BMC Musculoskelet Disord

    (2007)
  • M.N. Kang et al.

    The accuracy of subacromial corticosteroid injections: a comparison of multiple methods

    J Shoulder Elbow Surg

    (2008)
  • J.A. Eustace et al.

    Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms

    Ann Rheum Dis

    (1997)
  • M.J. Chen et al.

    Ultrasound-guided shoulder injections in the treatment of subacromial bursitis

    Am J Phys Med Rehabil

    (2006)
  • S. Akkus et al.

    Does fibromyalgia affect the outcomes of local steroid treatment in patients with carpal tunnel syndrome?

    Rheumatol Int

    (2002)
  • J.A. Davidson et al.

    Warming lignocaine to reduce pain associated with injection

    BMJ

    (1992)
  • T. Altay et al.

    Local injection treatment for lateral epicondylitis

    Clin Orthop Relat Res

    (2002)
  • H.T. Draeger et al.

    A randomised controlled trial of the reciprocating syringe in arthrocentesis

    Ann Rheum Dis

    (2006)
  • R.G. Berger et al.

    Immediate “steroid flare” from intraarticular triamcinolone hexacetonide injection: case report and review of the literature

    Arthritis Rheum

    (1990)
  • J.M. Mens et al.

    Disturbance of the menstrual pattern after local injection with triamcinolone acetonide

    Ann Rheum Dis

    (1998)
  • J.L. Hollander

    Intrasynovial corticosteroid therapy in arthritis

    Md State Med J

    (1970)
  • P. Seror et al.

    Frequency of sepsis after local corticosteroid injection (an inquiry on 1160000 injections in rheumatological private practice in France)

    Rheumatology (Oxford)

    (1999)
  • C.J. Kaandorp et al.

    The outcome of bacterial arthritis: a prospective community-based study

    Arthritis Rheum

    (1997)
  • J.M. DeSio et al.

    Facial flushing and/or generalized erythema after epidural steroid injection

    Anesth Analg

    (1995)
  • D.M. Black et al.

    Hyperglycemia with non-insulin-dependent diabetes following intraarticular steroid injection

    J Fam Pract

    (1989)
  • V. DiStefano et al.

    Skin and fat atrophy complications of local steroid injection

    Pa Med

    (1974)
  • D.J. McCarty et al.

    Treatment of rheumatoid joint inflammation with intrasynovial triamcinolone hexacetonide

    J Rheumatol

    (1995)
  • M. Kleinman et al.

    Achilles tendon rupture following steroid injection. Report of three cases

    J Bone Joint Surg Am

    (1983)
  • M.E. Linskey et al.

    Median nerve injury from local steroid injection in carpal tunnel syndrome

    Neurosurgery

    (1990)
  • R.P. Sheon

    Repetitive strain injury. 2. Diagnostic and treatment tips on six common problems. The Goff Group

    Postgrad Med

    (1997)
  • G. Riley

    The pathogenesis of tendinopathy. A molecular perspective

    Rheumatology (Oxford)

    (2004)
  • S. Saunders

    Injection techniques in orthopaedic and sports medicine

    (2002)
  • A.W. Nichols

    Complications associated with the use of corticosteroids in the treatment of athletic injuries

    Clin J Sport Med

    (2005)
  • J.I. Acevedo et al.

    Complications of plantar fascia rupture associated with corticosteroid injection

    Foot Ankle Int

    (1998)
  • J.R. Sellman

    Plantar fascia rupture associated with corticosteroid injection

    Foot Ankle Int

    (1994)
  • M. Alexeeff

    Ligamentum patellae rupture following local steroid injection

    Aust N Z J Surg

    (1986)
  • J.G. Jones

    Achilles tendon rupture following steroid injection

    J Bone Joint Surg Am

    (1985)
  • C.M. Yu et al.

    Subacromial injections of corticosteroids and xylocaine for painful subacromial impingement syndrome

    Chang Gung Med J

    (2006)
  • K.I. Gruson et al.

    Subacromial corticosteroid injections

    J Shoulder Elbow Surg

    (2008)
  • R. Buchbinder et al.

    Corticosteroid injections for shoulder pain

    Cochrane Database Syst Rev

    (2003)
  • W.C. Patton et al.

    Biceps tendinitis and subluxation

    Clin Sports Med

    (2001)
  • L.T. Ford et al.

    Tendon rupture after local steroid injection

    South Med J

    (1979)
  • S. Green et al.

    Acupuncture for lateral elbow pain

    Cochrane Database Syst Rev

    (2002)
  • E. Zeisig et al.

    Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study

    Knee Surg Sports Traumatol Arthrosc

    (2006)
  • R.P. Calfee et al.

    Management of lateral epicondylitis: current concepts

    J Am Acad Orthop Surg

    (2008)
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