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Pearls in Injection Therapies for Musculoskeletal
Disorders and Conditions
Frank Caruso MPS, PA-C, EMT-P
Skin, Bones, Hearts & Private
Parts - 2019
Educational Objectives
• Recognize signs, symptoms of musculoskeletal disorders that may require injection therapies– Using evidence based medicine to decide when injection therapy
is indicated
• Understand what materials may be injected safely and where
• Learn the complications and precautions in providing injection therapies
• Understand how to perform a proper physical examination
• Review and reinforce proper technique for joint and soft tissue injections and aspirations
• Understand how to properly dispose and or analyze any aspirations performed to treat musculoskeletal conditions
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Injection Therapy
Tools of the Trade!
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Injection Therapy
• Adjunctive therapy
• Short – intermediate pain/functional relief
• Describe indications and contraindications
• Select equipment/products for injection or
aspiration
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Injection:
• Illustrate pertinent anatomic
landmarks for each
procedure
• Demonstrate safe and
effective technique
• When to refer to a
subspecialist
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Injections/Aspirations
• Diagnostic
• Therapeutic treatment
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Therapeutic Injections
• Crystalloid arthropathies
• Synovitis
• Rheumatoid arthritis
• Osteoarthritis
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Soft Tissue Indications
• Bursitis
• Tendonitis/osis
• Epicondylitis
• Trigger Points
• Ganglion Cysts
• Neuromas
• Nerve entrapment syndromes
• Fasciitis
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• Infected tissue/septic patients
• Critical weight bearing tendons
• Achilles tendon
• True allergy
• Uncooperative patient
• Lack of informed consent
• Prior severe steroid flare
• Joints with arthroplasty
Contraindications to Injection
Therapy
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Contra-Indications Injection
• Fracture site: can delay healing
• Children – injectable lesions that are not
due to systemic arthropathy are very rare
under the age of 18 years
• Reluctant patient – no informed consent
given
• Gut feeling!!
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Relative Contra-indications
• Stay away from arteries, nerves or pleural surfaces
• Brittle diabetes
• History of avascular necrosis
• Immunocompromised states
• Large tendinopathies: e.g. tendo-archilles, infra-patella tendon
• Psychogenic pain
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Safety
• Universal precautions
• Aseptic technique
• Know your landmarks
• Always attempt to aspirate
before injecting anything!
• Don’t inject tendons directly –
inject around the tendon
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Aseptic Technique
• Physical exam: mark injection site – check three times!!
• Clean injection site with appropriate cleanser and allow to dry
• Wash your hands/allow to dry
• Use pre-packed, in-date, sterile, disposable needles and syringes
• Use single-dose ampoules or vials, then discard
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Aseptic Technique
• Change needles after drawing up
• Place on gloves
• Do not touch the skin after marking and cleansing the site
• Do not guide the needle with your finger
• Always aspirate before injecting
• Wipe clean
• Sometimes massage the area
• Apply Band-Aid or pressure dressing
• Post injection instructions (especially diabetics)
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What Does Tissue Types Feel
Like?
• Muscle : soft, spongy
• Tendon or ligament: fibrous and touch
• Capsule: slight resistance to needle as it
penetrates – poking a pin through a
balloon
• Cartilage: sticky
• Bone: hard and hurts when touched
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Complications: Steroid Injection• 1. Systemic
– Vasovagal, lidocaine allergy/toxocity, cardiac arrhythmias, seizures, facial flushing, increased blood sugars in diabetes (impaired diabetic control), adrenal suppression (hypothalamic pituitary axis suppression), and impaired immune response, menstrual irregularity (usually post-menopausal), fall in ESR and CRP levels (see in patients with inflammatory arthritis), anaphylaxis
• 2. Local– Bleeding, post injection flare of pain, soft tissue
infection, ligament/tendon rupture, subcutaneous atrophy , depigmentation, soft-tissue calcification, steroid chalk or paste, steroid arthropathy, joint sepsis
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Rare Local Side Effects
• Nerve damage
• Transient paresis of an
extremity
• Needle fracture
• Delayed soft-tissue
healing
• Fat atrophy
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Corticosteroids
• Commonly used injectable corticosteroids are synthetic analogues of adrenal glucocorticoid hormone cortisol which is secreted by the adrenal cortex.
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Corticosteroids
• Suppressing inflammation
• Suppressing inflammatory flares in
degenerative joint disease
• Breaking up the inflammatory damage–
repair-damage cycle
• Possibly a direct chondro-protective effect
on cartilage metabolism
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Properties of Injectable
CorticosteroidsCorticosteroid Relative Anti-
inflammatory potency
Solubility Biological Half-life (hrs)
Hydrocortisone acetate
(Hydrocortone)
1 high 8-12
Triamcinolone
Acetonide (Kenalog)
5 intermediate 12-36
Triamcinolone
hexacetonide
(Artisospan)
5 intermediate 12-36
Methylprednisolone
acetate (Depo-Medrol)
5 intermediate 12-36
Betamethasone acetate
and sodium phosphate
(Celestone Soluspan)
25 low 26-54
Dexamethasone
acetate (Decadron-LA)
25 low 26-54
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Equivalent Dosages of Injectable
CortcosteroidsCorticosteroid Preparation Trade Name Equivalent dose/volume
(mg/ml)
Trimciolone acetonide Kenalog 40
Triamcinolone hexacetonide Aristospan 40
Methylprednisolone acetate Depomedrol 40
Dexamethasone acetate Decadron-LA 8
Betamethasone acetate and
sodium phosphate
Celestone Soluspan 6
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InjectionSyringe
size
Needle
gauge
Needle
length
Anesthetic
(cc)
Knee 5-10 cc 22 1.5 in 3-5 cc
Subacromial bursa 10 cc 21-25 1.5 in 5 cc
Carpal tunnel 5 cc 21-25 1.5 in 2-3 cc
Greater trochanter bursa 5-10 cc 22-25 varies 4 cc
Lateral epicondylitis 5 cc 25 1 in 2-3 cc
1st MTP/CMC 3 cc 25-26 1 in 0.5-1 cc
de Quervain's 5 cc 25 1.5 in 1 cc
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Local Anesthetics
• Analgesic
• Diagnostic
• Dilution
• Distension
• Dispersion
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Commonly Used Local
Anesthesia
Agents
• Lidocaine
• Marcaine (avoid – except soft tissues)
• “Special Agents”
– ie: “the towel”
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Viscosupplementation
• Hyalauronan (sodium hyaluronate) is a natural complex sugar of the glycosaminoglycan family
• Concentration and size of endogenous hyalauronan are reduced in the joint fluid of patients with osteoarthritis
• Commercial replacement agents are high molecular weight derivative of hyalauronanwhich are synthetically derived from rooster combs or produced by bacterial fermentation and extraction
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Viscosupplementation
• Exact mechanism of action unknown
• Physical cushioning?
• Anti-inflammatory action?
• Stimulation of production of endogenous hyaluronan by synoviocytes
• Synvisc (Genzyme), Orthovisc (DepuyMitek), Hyalgan (Sanofi-Aventis), Supartz(Smith and Nephew), and Euflexa(Ferring)
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OK LET’S GET GOING!
So what can we do with a needle? Are you
scared yet?
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Aspiration
• Serous fluid streaked with fresh blood: related to trauma of the aspiration
• Frank blood: usually history of trauma –hemarthrosis of knee due to anterior cruciateligament injury occurs 40 % of the time.
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Aspiration
• Serous fluid of variable
viscosity: normal or
non-inflammatory
synovial fluid is
colorless or straw-
colored, contains few
cells (less than 500),
mainly mononuclear
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Aspiration
• Xanthochromic fluid: old blood that has broken down – appears orange in color –implies old trauma
• Turbid fluid: inflammatory fluid appears less viscous than normal joint flood –looks darker and more turbid due to the increase in debris, cells and fibrin, and clots may form – do not inject, await results of culture
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Aspiration
• Frank pus: aspirate
has a foul smell – true
emergency – appears
usually appear very ill
• Other: chemical
reactions, etc.
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Injection Preparation Protocol
• Prepare patient – get
permission~!
• Prepare equipment
• Prepare site
• Assemble equipment
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What Do You Do With The
Stuff Once You Aspirate??
When indicated culture, glucose, gram
stain, cell count, crystal analysis!
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Synovial Fluid Analysis
• String sign
• Cell count
• Glucose
• Gram stain
• Crystals
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Diagnosis Appearance WBCs Glucose %
blood level
Crystals Culture
Normal Clear <200 95+ None ---
DJD Clear <4000 95+ None ---
Traumatic
Arthritis
Straw, bloody,
xanthochromic
<4000 95+ None ---
Acute
Gout
Turbid 2000-
50,000
80-100 Needle
like
---
Pseudogo
ut
Turbid 2000-
50,000
80-100 Rhomboi
d like
---
Septic
Arthritis
Purulent/turbid 5000-
>50000
<50 None +
usually
Non-
traumatic
Arthritis
Turbid 2000-
50,000
75 None ---
Synovial Fluid Interpretation
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Lab Analysis of Fluid
• White blood cell count
– <50,000 inflammatory
– >50,000 infectious
• Polymorphonucleocyte percentage
• Crystals
• If fluid cloudy, culture
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Septic Arthritis
• Early diagnosis essential:
– Growth impairment
– Articular destruction
– Osteomyelitis
– Soft tissue expansion
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Injection Therapies: Problems
That May Arise
• An inappropriate drug is chosen
• Too large a dose or volume is given in the wrong area of the musculoskeletal system
• The drug is put into the wrong tissue
• Poor technique causes skin complications or possible tendon/nerve/none injuries
• Injections are given too frequently
• Folks don’t pay attention to what is causing the condition
• Little or no aftercare is provided
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Stuff You Need: Keep Your
Supplies Well Localized• A dedicated cabinet
• An injection tray
• An injection cart
• Plastic toolbox
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Items
• Gloves
• Blue Chuck Pads
• Alcohol pads
• Povidone-iodine pads
• Bandages
• Hemostat surgical clamp – for
those needle change outs!
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Items
• Syringes (3, 5, 10, 20 and 60cc)
• Needles (20 gauge, 1 inch – drawing up meds and aspiration of small joints), 18 gauge 1 ½ in for aspiration of large joints and bursa, 23 gauge ½, 1, and 1 ½ for injections)
• PainEase or Ethyl chloride
• Anesthetic of choice
• Steroid of choice
• Viscosupplementation of choice – always pre-authorize
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Ready?? Will focus on shoulder/knee today!
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Shoulder: Glenohumeral
Acute or Chronic Capsulitis
• Anatomy: shoulder joint
surrounded by large
capsule – easiest
approach is posterior.
• Coracoid process –
landmark
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Glenohumeral Joint • Uncommon injection
• Difficult, especially with adhesive capsulitis
• Posterior approach usually preferred
• Landmark: lateral edge of acromion, coracoid process
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Shoulder
Sub-Acromial Bursa
• Landmark: lateral edge of
acromion or posterior
• Allow arm to “dangle”
along side
• Don’t inject if you have
tremendous resistance -
reposition
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Acromio-Clavicular joint
AC joint superficial
Be careful – common
place for skin atrophy
and hypopigmentation!
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Shoulder
(Long Head of the Biceps)
• Anatomy: lies in a
sheath in the bicipital
groove between the
greater and lesser
tuberosities
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Scapulothoracic Syndrome
• Anatomy: bursitis
medial superior
border of the
scapula
• Be careful of the
long thoracic nerve
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Knee Joint
• Very common to aspirate and inject
• Anatomy: Suprapatellarapproach is probably the easiest (extra-articularbut still within the joint space.
• Easy to aspirate
• Supine positioning of the patient
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Knee
Pes Anseurine Bursa
• Anatomy: combined
tendon of insertion of
the sartorius, gracilis
and semi-tendinosus –
bursa lies under the
tendon
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Elbow
(Olecranon Bursitis)
• Anatomy:
olecranon bursa
• Aspiration (send
aspirate)
• Injection
• Side approach –
direct long axis
approach
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Elbow:
Common Extensor Tendon
• Anatomy: lateral
epicondyle, find
maximum point of
tenderness –
adjacent to lateral
epicondyle.
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Elbow
Medial Epicondylitis
• Anatomy: medial
epicondyle
• Be careful of ulnar
nerve – travels just
posterior and inferior
to the medial
epicondyle.
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Hip
(Trochanteric Bursa)
• Anatomy:
bursa lies
over the
greater
trochanter of
the femur.
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Ankle Joint
Chronic Capsulitis
• Anatomy:
inflammation of
the joint
capsule
• Similar to
adhesive
capsulitis of the
shoulder
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Toe Joints
Capsulitis• Anatomy: typically
around second toe,
sometimes third of
fourth –
• Abnormal foot
mechanics
• Pain ball of foot
(especially when
walking barefootCaruso 101
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Foot
Plantar Fasciitis
• Anatomy:
origin of the
plantar
aponeurosis at
the medial
tubercle of the
calcaneus
• Excessive foot
pronationCaruso 103
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Hallux Rigidus
• Common joint
first MTP,
osteoarthrits
and gout
• Inject directly
over the first
MTP
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Foot
(Neuroma)
• Most common
between third
and fourth toes
• Anatomy:
inflammation of
interdigital
nerve by
compression
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Wrist Joint
• Anatomy: wrist joint
capsule is not
continuous and has
septa dividing it into
separate
compartments
• Common injection in
patients with RA
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Thumb and Finger Joints
• Anatomy: The
first metacarpal
articulates with
the trapezium
• Rx: OA CMC
• Very painful
injection!
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Thumb Tendon
deQuervain’s tenosynovitis
• Anatomy:
abductor pollicis
longus and
extensor pollicis
brevis – run
together in a
single sheath of
the radial side of
the wrist.
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Flexor Tendon Nodule
(Trigger Finger)
• Anatomy:
• nodule base of
finger (stenosing
tenosynovitis
• Nodule A-1
pulley of the
tendon sheath –
becomes
entrapped
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Recommendations
• Consent for needle aspiration and or
injection – include possible risks,
complications and benefits
• Give patient aspiration and injection
aftercare handout
• Medical record documentation
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Billing and Coding
• 20526 -Injection, therapeutic, carpal tunnel
• 20550- Injection, single tendon sheath, or
ligament, aponeurosis (plantar fascia)
• 20551 – Injection –single tendon origin
/insertion
• 20552 – Injection, single or multiple trigger
point in one to two muscles
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• 20553 Injection, trigger point in
three or more muscles
• 20600 – Arthrocentesis, aspiration,
and /or injection , small joint or
bursa
• 20605 – Arthrocentesis, aspiration
and /or injection intermediate joint
or bursa
• 20610 – Arthrocentesis, aspiration
and/or injection, major joint
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• 20612 – Aspiration and/or injection
of ganglion cyst (s), any location
• 64450 – Injection, nerve block,
therapeutic, other peripheral nerve
or branch.
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Resources:
• James W. McNabb: A Practical Guide to Joint
and Soft Tissue Injection and Aspiration –
Second Edition. Wolters, Kluwer.Lippincott
Williams and Wilkins 2010
• Stephanie Saunders; Steve Longworth:
injection Techniques in Orthopaedics and
Sports Medicine- Third Edition. Elsevier
2006
• Myriad of online sources
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