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Rapid response to:

Research

Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: multicentre randomised controlled trial

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1088 (Published 14 April 2009) Cite this as: BMJ 2009;338:b1088

Rapid Response:

Deja Vu!

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

Competing interests: No competing interests

16 April 2009
Sidha Sambandan
GP/GPwSI (Orth)/H.Senior Lecturer
Yare Valley Medical Practice, 202 Thorpe Rd, Norwich NR1 1TJ