Vincennes University Tobacco User Surcharge Vincennes University's greatest asset is the well-being of its employees. The institution's wellness initiatives are designed to prevent illness, improve quality of life and decrease health care costs. Effective January 1, 2013, tobacco users on the Vincennes University health care plan will pay a $25 biweekly surcharge. It is important that em
CardoneJoint and Soft Tissue Injection
DENNIS A. CARDONE, D.O., C.A.Q.S.M., and ALFRED F. TALLIA, M.D., M.P.H., University of
Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey
Injection techniques are helpful for diagnosis and therapy in a wide variety of muscu-
loskeletal conditions. Diagnostic indications include the aspiration of fluid for analysis
and the assessment of pain relief and increased range of motion as a diagnostic tool.
tion handout aboutjoint and soft tissue Therapeutic indications include the delivery of local anesthetics for pain relief and the
delivery of corticosteroids for suppression of inflammation. Side effects are few, but
may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tis-
sue atrophy. Injection technique requires knowledge of anatomy of the targeted area
and a thorough understanding of the agents used. In this overview, the indications,
contraindications, potential side effects, timing, proper technique, necessary materials,
pharmaceuticals used and their actions, and post-procedure care of patients are pre-
sented. (Am Fam Physician 2002;66:283-8,290. Copyright 2002 American Academy of
pathology. Physical examination is extremely helpful in ascertaining the diagnosis. Knowl- edge of the anatomy of the area to be injected nated by Dennis A.
Cardone, D.O.,C.A.Q.S.M., associateprofessor, and Alfred F. sheaths, and soft tissues of the humanbody is a useful diagnostic and thera-peutic skill for family physicians.
is essential. Intratendinous injection should be avoided because of the likelihood of weak- porate joint and soft tissue injection into ening the tendon. Corticosteroid injections daily practice, yielding many benefits. For also should be avoided in cases of Achilles or example, a lidocaine (Xylocaine) injection into the subacromial space can help in the Medicine, UMDNJ–Robert Wood Johnson injections are variable.4 The patient’s response dromes, and the injection of corticosteroids to previous injection is important in deciding into the subacromial space can be a useful whether and when to proceed with reinjec- tion. Most patients, if they are going to respond, will respond after the first injection.
tendinopathies. Evidence-based reviews of If the patient has achieved significant benefit joint and soft tissue injection procedures after the first injection, an argument can be have found few studies that support or refute made to give a second injection if symptoms the efficacy of common joint interventions in recur. However, patients who have gained no medical practice.1-3 However, substantial practice-based experience supports the effec- after two injections should probably not have tiveness of joint and soft tissue injection for any additional injections, because a subse- If therapeutic effect is achieved, a maximum instances of joint or tissue injury and inflam- of four injections per year is recommended.
mation. History of pain, local and referred, There is some concern that corticosteroid will provide important clues to the underlying preparations, with repeated use, may acceleratenormal, aging-related articular cartilage atro-phy or may weaken tendons or ligaments.
When symptoms are resistant, or when there is Joint and soft tissue injection is most useful in instances of a history of trauma, a radiograph or other joint and tissue injury and in inflammatory conditions. imaging study should be performed to helpassist in the diagnosis.
the possibility of introducing infection and Patients who have not gained any symptom relief after two precipitating further or new bleeding into thejoint. Also, early reaccumulation of fluid can steroid injections should probably not have any additional Therapeutic injection with corticosteroids should always be viewed as adjuvant therapy.6The improper or indiscriminate use of corti- Indications
costeroids is likely to have a bad outcome.
The indications for joint or soft tissue aspi- These injections should never be undertaken ration and injection fall into two categories: without diagnostic definition and a specific diagnostic and therapeutic. A common diag- treatment plan in place. Physicians should nostic indication for placing a needle in a joint resist external pressure for a quick return of is the aspiration of synovial fluid for evalua- athletes to playing sports by the use of joint or tion. Synovial fluid evaluation can differenti- soft tissue injections. Table 1 lists soft tissue ate among various joint disease etiologies and joint condition indications for diagnostic trauma. A second diagnostic indicationinvolves the injection of a local anesthetic to Contraindications
confirm the presumptive diagnosis through As with any invasive diagnostic or thera- symptom relief of the affected body part.
peutic injection procedure, there are absolute Therapeutic indications for joint or soft tis- and relative contraindications (Table 2).7 sue aspiration and injection include decreased Drug allergies, infection, fracture, and tendi- mobility and pain, and the injection of med- nous sites at high risk of rupture are absolute ication as a therapeutic adjunct to other forms contraindications to joint and soft tissue injection. Relative contraindications are less when removing fluid for pain relief because of well defined and should be considered on acase-by-case basis. Physicians should be awarethat the contraindications listed are for thera- peutic injection and do not apply for diagnos- Indications for Diagnostic and
tic aspiration of joints or soft tissue areas. For Therapeutic Injection
instance, suspected septic arthritis is a con-traindication for therapeutic injection, but an Soft tissue conditions
Timing of Injections
cations and allow a clear diagnosis or thera- peutic response. For diagnostic injections, the or chronic symptoms are present, when the Joint conditions
diagnosis is unclear or needs to be confirmed, Effusion of unknown origin or suspected infection when consideration has been given to other diagnostic modalities, and when septic arthri- tis has been ruled out (by aspiration and fluid analysis). For therapeutic injections, the pro- cedure should be performed when acute orchronic symptoms are present, after the diag- Joint Injections
nosis and therapeutic plan have been made,and after consideration has been given to obtaining radiographs. Therapeutic injection Absolute and Relative Contraindications
should be performed only with or after the to Therapeutic Joint and Soft Tissue Injection
initiation of other therapeutic modalities (e.g.,physical therapy). In the absence of an under- Absolute contraindications
lying chronic inflammatory arthritis, any joint with an effusion should be radiographed to rule out a fracture or other intra-articular Corticosteroids
Achilles or patella tendinopathiesHistory of allergy or anaphylaxis MECHANISM OF ACTION
After intra-articular injection, cortico- steroids function to suppress inflammationand decrease erythema, swelling, heat, andtenderness of the inflamed joint. These effectsare believed to result from several mecha- acting. A short-acting solution, such as dexa- nisms, including alterations in neutrophil methasone sodium phosphate (Decadron), is chemotaxis and function, increases in viscos- less irritating and less likely to cause a postin- ity of synovial fluid, stabilization of cellular jection flare than a long-acting dexamethasone lysosomal membranes, alterations in hyal- suspension. Many clinicians use injectables that uronic acid synthesis, transient decreases in combine short-acting compounds with long- synovial fluid complements, alterations in synovial permeability, and changes in synovial sodium phosphate and acetate suspension), fluid leukocyte count and activity.8 Whetherthis is exactly the same mechanism of actionthat occurs with orally or parenterally admin- Corticosteroid Agents by Relative Potencies, Duration, and Dose
SELECTION OF CORTICOSTEROID
Many corticosteroid preparations are avail- able for joint and soft tissue injection. The agents differ according to potency (Table 3), solubility, and crystalline structure. Potency is generally measured against hydrocortisone, and ranges from low-potency, short-acting agents such as cortisone, to high-potency, Few studies have investigated the efficacy or duration of action of the various agents in joints or soft tissue sites. The duration of effect is inversely related to the solubility of the prepa- ration: the less soluble an agent, the longer it remains in the joint and the more prolonged the effect. Consequently, suspensions are longer attention to the depth of needle insertion to Low-solubility corticosteroid agents should not be used avoid needle trauma to articular cartilage.
Finally, avoid injecting several large joints for soft tissue injection because of the increased risk of simultaneously because of the increased risk of hypothalamic-pituitary-adrenal suppres-sion and other adverse effects.9 thereby obtaining the beneficial effects of both types of preparations. Mixing the cortico- Dosing is site dependent. As a rule, larger steroid preparation with a local anesthetic is a joints require more corticosteroid. Table 3 lists common practice for avoiding the injection of general corticosteroid dosing guidelines.
a highly concentrated suspension into a singlearea. The anesthetic provides early relief of Local Anesthetics
symptoms and helps confirm the diagnosis.
Before injection of a joint or soft tissue, a small quantity of 1 percent lidocaine or 0.25 injection, should not be used for soft tissue to 0.5 percent bupivacaine (Sensorcaine) can injection because of the increased risk of sur- be injected subcutaneously with a 25- to 30- rounding tissue atrophy. Methylprednisolone gauge needle to provide local anesthesia. For (Depo-Medrol) is often the agent selected for the actual joint or soft tissue injection, most physicians mix an anesthetic with the cortico-steroid preparation. This provides temporary PRECAUTIONS
analgesia, confirms the delivery of medication to the appropriate target, and dilutes the crys- using steroid injections. Care should be taken talline suspension so that it is better diffused to avoid direct injection of tendons because of within the injected region. Manufacturers the danger of rupture. Avoid injection into advise against mixing corticosteroid prepara- adjacent nerves of the target area (e.g., ulnar tions with lidocaine because of the risk of nerve when injecting for medial epicondyli- clumping and precipitation of steroid crystals.
tis). Allow adequate time between injections, However, the authors have never experienced generally a minimum of four to six weeks. Pay For most injections, 1 percent lidocaine or 0.25 to 0.5 percent bupivacaine is mixed with acorticosteroid preparation. The dose of anes- thetic varies from 0.25 mL for a flexor tendon DENNIS A. CARDONE, D.O., C.A.Q.S.M., is associate professor and director of sports sheath (trigger finger) to 5 to 8 mL for larger medicine and the sports medicine fellowship in the Department of Family Medicine at joints. On rare occasions, patients exhibit signs the University of Medicine and Dentistry of New Jersey (UMDNJ)–Robert Wood John-son Medical School, New Brunswick, N.J. He is a graduate of New York College of of anesthetic toxicity, including flushing, hives, Osteopathic Medicine and completed a residency at the UMDNJ–Robert Wood John- chest or abdominal discomfort, and nausea. It son Medical School Family Medicine Residency program, New Brunswick. He com- can take as long as 20 to 30 minutes following pleted his sports medicine fellowship at UMDNJ. the injection for these symptoms to present. For ALFRED F. TALLIA, M.D., M.P.H., is associate professor and vice chair in the Department this reason, and to monitor for allergic reac- of Family Medicine at UMDNJ–Robert Wood Johnson Medical School. He is a gradu-ate of the UMDNJ–Robert Wood Johnson Medical School and completed a residency tions, patients should be observed in the office at the Thomas Jefferson University Family Medicine Residency program, Philadelphia.
for at least 30 minutes following the injection.
He received his public health degree from Rutgers University, New Brunswick, N.J.
Address correspondence to Dennis A. Cardone, D.O., Department of Family Medicine, Potential Complications
University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, 1 Robert Wood Johnson Pl. MEB288, New Brunswick, NJ 08903 (e-mail: firstname.lastname@example.org). Reprints are not available from the authors. arise from use of joint and soft tissue proce- Joint Injections
dures.10 Local infection is always possible, but it can be avoided by following the proper tech- for the procedure was given and understood.
nique. Joint injections should always be per- A third party should witness the patient’s formed using sterile procedure to prevent signing. Documentation is kept as part of the iatrogenic septic arthritis. Local reactions at the injection site may include swelling, tender-ness, and warmth, all of which may develop a Necessary Equipment
few hours after injection and can last up to All joint and soft tissue injection or aspira- tion techniques should be performed wearing thought to be a crystal-induced synovitis gloves. When injecting or aspirating a joint caused by preservatives in the injectable sus- space, sterile technique should be used. Non- pension, may occur within the first 24 to 36 sterile gloves can be used when injecting or hours after injection.11 This is self-limited and aspirating soft tissue regions. Necessary responds to application of ice packs for no equipment for joint and soft tissue injection or aspiration is listed in Table 4. Soft tissue (fat) atrophy and local depig- mentation are possible with any steroid injec- Site Preparation
tion into soft tissue, particularly at superficial The entry point for injection or aspiration sites (e.g., lateral epicondyle). Periarticular should be identified. The point of entry can be calcifications are described in the literature, nail, a needle cap, or an indelible ink pen. The avoided by not injecting directly into the ten- important goal is to minimize risk of infection at the site. Prepare the area with an alcohol or Systemic effects are possible (especially after triamcinolone acetonide [Aristocort] injec-tion or injection into a vein or artery), andpatients should always be acutely monitored for reactions. Alterations in taste have been Equipment Tray Contents for Joint
reported for one to two days after steroid or Soft Tissue Injection or Aspiration
injection. Hyperglycemia is possible inpatients who have diabetes.
To avoid direct needle injury to articular cartilage or local nerves, attention should be injection. Other rare, but possible, complica- 25- to 30-gauge 0.5- to 1.0-inch needle for local tions include pneumothorax (when injecting thoracic trigger points), perilymphatic depig- 18- to 20-gauge 1.5-inch needle for aspirations mentation, steroid arthropathy, adrenal sup- 22- to 25-gauge 1.0- to 1.5-inch needle for injections pression, and abnormal uterine bleeding.
1 mL- to 10 mL-syringe for injections3 mL- to 60 mL-syringe for aspirations Informed Consent
Local anestheticCorticosteroid preparation Laboratory tubes for culture or other studies obtained for any invasive procedure. Discus- sion with the patient should include indica- Hemostat (if joint is to be aspirated and then tions, potential risks, complications and side effects, alternatives, and potential outcomes Adhesive bandage or other adhesive dressing from the injection procedure. Patients should Joint Injections
intra-articular injections, sterile technique tion because of the small possibility of local tissue tears secondary to temporarily highconcentrations of steroid. This risk lessens as Steps for Injection and Joint Aspiration
the steroid dissipates. Patients should be edu- When possible, the patient should be placed cated to look for signs of infection including in the supine position. This will help prevent erythema, warmth, or swelling at the site of or mitigate the effects of a vasovagal or synco- injection, or systemic signs including fever pal episode. Palpate the soft tissue or bony and chills. The patient should keep the injec- landmarks. Follow the steps for site prepara- tion. For soft tissue injections, the followingmodalities may be used for short-term partial The authors indicate that they do not have any con-flicts of interest. Sources of funding: none reported. anesthesia: applying ice to the skin for five to10 minutes; applying topical vapo-coolant spray; or firmly pinching the skin for three to 1. Nelemans PJ, de Bie RA, de Vet HC, Sturmans F.
four seconds at the injecting site.12 Once the Injection therapy for subacute and chronic benign skin is anesthetized, the needle should be low back pain. Cochrane Database Syst Rev inserted through the skin to the site of injec- 2. Assendelft WJ, Hay EM, Adshead R, Bouter LM. Cor- tion. To prevent complications, adhere to ster- ticosteroid injections for lateral epicondylitis: a sys- ile technique for all joint injections; know the tematic overview. Br J Gen Pract 1996;46:209-16.
3. van der Heijden GJ, van der Windt DA, Kleijnen J, Koes BW, Bouter LM. Steroid injections for shoul- anatomy; avoid neuromuscular bundles; avoid der disorders: a systematic review of randomized injecting corticosteroids into the skin and sub- clinical trials. Br J Gen Pract 1996;46:309-16.
cutaneous fat; and always aspirate before 4. Owen DS. Aspiration and injection of joints and soft tissues. In: Kelley WN. Textbook of rheumatol- injecting to prevent intravascular injection.
ogy. 5th ed. Philadelphia: Saunders, 1997:591- The injection should flow easily and should not be uncomfortable to the patient. Most pain 5. Nelson KH, Briner W Jr, Cummins J. Corticosteroid injection therapy for overuse injuries. Am Fam is the result of tissue stretching and can be mit- igated by injecting slowly. If there is strong 6. Zuckerman JD, Meislin RJ, Rothberg M. Injections resistance while injecting, the needle may be for joint and soft tissue disorders: when and howto use them. Geriatrics 1990;45:45-52,55.
intramuscular, intratendinous, or up against 7. Genovese MC. Joint and soft-tissue injection. A bone or cartilage, and it should be repositioned.
useful adjuvant to systemic and local treatment.
Postgrad Med 1998;103:125-34.
Postinjection Instructions and Care
8. Kerlan RK, Glousman RE. Injections and techniques in athletic medicine. Clin Sports Med 1989;8:541- An adhesive dressing should be applied to 9. Gray RG, Gottlieb NL. Intra-articular corticosteroids.
An updated assessment. Clin Orthop 1983;177: inflammation after leaving the office, the patient should be advised to apply ice to the 10. Stefanich RJ. Intra-articular corticosteroids in the injection site (for no longer than 15 minutes at treatment of osteoarthritis. Orthop Rev 1986;15:65-71.
a time, once or twice per hour), and non- 11. Pfenninger JL. Joint and soft tissue aspiration and steroidal anti-inflammatory agents may be injection. In: Pfenninger JL, Fowler GC, eds. Proce- used, especially for the first 24 to 48 hours.
dures for primary care physicians. St. Louis: Mosby,1994:1036-54.
The affected area should be rested from stren- 12. Scott W. Injection techniques and use in the treat- uous activity for several days after the injec- ment of sports injuries. Sports Med 1996;22:406-16.
SCARABS prairie dog towns, or from infected wild Don’t Catch That -or- Disease Risk Reduction & Rodent Pets can also contract plague, and plague WITHIN THIS Inquiline Collecting can be transmitted from mammal to mammal via inhalation (hence the term It has been four days since you filled kill jars with rare, inquiline Aphodius and “epizootic”) will course through