Rick Pope MPAS, PA-C, DFAAPA, CPAAPA

Maine NP2017

Annual Conference

Joint injections

1:45-3:45 PM

Friday April 28th

Disclosures

Rick Pope PA-C, MPAS, DFAAPA, CPAAPA

No conflicts of Interest

Do any of you know what the CPAAPA

designation stands for?

What is the most common diagnosis for which joint injections are performed?

1. Trigger finger

2. Shoulder impingement syndrome

3. Trochanter bursitis

4. Low back pain (facet arthritis/disc disease)

5. Osteoarthritis knee

What is the most common diagnosis for which joint injections are performed?

1. Trigger finger

2. Shoulder impingement syndrome

3. Trochanter bursitis

4. Low back pain (facet arthritis/disc disease)

5. Osteoarthritis knee

What is the most important Dx not to miss when you see an effusion?

1. Acute Gout

2. Acute Pseudogout

3. Osteoarthritis

4. Septic arthritis

5. Lyme arthritis

What is the most important Dx not to miss when you see an effusion?

1. Acute Gout

2. Acute Pseudogout

3. Osteoarthritis

4. Septic arthritis

5. Lyme arthritis

Practice Type?

1. Are any of you in Primary Care/Family Practice?

2. Orthopedics?

3. Occupational Med?

4. Emergency/Urgent Care?

5. OPD subspecialty clinic?

6. Hospital based?

7. Others?

GOALS for participants

1. Review the disease states and conditions for which injections are appropriate.

2. Provide rationale for use of specific types of corticosteroid injectables with anesthetic mixture.

3. Review the indications and side effects of corticosteroids.

4. Demonstrate injection techniques both orthopedic and rheumatologic.

5. Be able to perform mock procedures on shoulder, elbow, hip, knee and trigger points on each other.

MY GOAL AS AN INSTRUCTOR

provide a safe participant oriented environment

U.S. Prevalence* of Rheumatic Disorders1

2007, 2008, *2010 (ACR)

Reference: 1. Lawrence RC, et al. Arthritis Rheum. 1998;41:778-799. 2. Lawrence RC et all. Arthritis Rheum 2008;58:26-35

27

51.3 1.1

0

5

10

15

20

25

Cases(millions)

*Calculated by the National Arthritis Data Workgroup based on available surveys, such as the National Health and Nutrition

Examination Survey.

Inflammatory

Mildly inflammatory

*8.0

Arthritis and Rheumatism Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part II 28

December 2007

Treatment of Knee OA

• Pt education

• Reach ideal body weight in those who are overweight

– Weight loss can result in significant decrease in symptoms

• Alter lifestyle behaviors, eg, overuse syndromes

• Mostly palliative to decrease pain, leading ideally to improved health-related quality of life

.

Treatment of Knee OA

• Analgesics/anti-inflammatory therapies

• Assistive devices to “unload” joints

• Cognitive behavior therapy

• Physical therapy and exercise therapy

• No proven structure-modifying therapies

• Recent data regarding metalloproteinase inhibitors suggests some benefit in patients with progressive disease

Principles for Knee Osteoarthritis management

• National guidelines from AAOS, ACR, and AGS1,3,4

–Exercise, weight loss relieve symptoms and

maintain function

–NSAIDs and tramadol preferred for most

patients

–Acetaminophen may be preferred for older

patients because of better safety profile

1. Hochberg MC, et al. Arthritis Care Res (Hoboken). 2012;64:465-474; 2. Centers for Disease Control and Prevention.

http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Updated May 16, 2014. Accessed July 11, 2014;

3. AAOS. Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline. Rosemont, IL: AAOS; 2013;.

2. 4. AGS. J Am Geriatr Soc. 2009;57:1331-1346.

AAOS: American Academy of Orthopedic Surgeons

AGS: American Geriatric society

Treatment of OsteoarthritisPharmacolgic

Topical agentsLidocaine

Methylsalicylate (Ben Gay etc)

Bio-freeze™

Diclofenac gel/patch/lotion

Local InjectionsCorticosteroid Injections

Hyaluronic Injections (knee)

Injectables

Benefits of local corticosteroid injections

• Reduce inflammation

• Rapid reduction in pain

• Improve range of motion

• Prevent contracture

*In inflammatory conditions chondroprotective and may prevent or inhibit erosion of cartilage and bone

Benefits of aspirations and intra-articular steroid injection include:

Steroid Duration/Potency Dose/site

Hydrocortisone acetate Low/Short 10-25 mg for soft tissue and small

joints/ 50 mg for large joints

Methylprednisolone acetate

(Depo Medrol) Intermediate/Intermediate

2-10 mg for soft tissue and small

joints / 10-80 mg for large joints

Triamcinolone acetonide

(Aristocort, Kenalog)

Triamcinilone

Hexacetonide (Aristospan)

Intermediate/Intermediate

Long/High

2-10 mg for soft tissue and small

joints / 10-80 mg for large joints

Dexamethasone sodium

phosphate (Decadron) High/Long

0.5-3.0 mg for soft tissue and

small joints / 2-4 mg for large

joints

Betamethasone (Celestone

Soluspan) High/Long

1-3 mg for soft tissue and small

joints, 2-6 mg for large joints

Overview of steroid types

Duration , doses and site

Am Fam Physician 2002; 66: 283-8

Mechanism of action:Corticosteroid Injections

Purported to be a local anti-inflammatory?

Steroids locally in the joint have effects on:

edema

lymphocytes

macrophages

mast cells

Side Effects:Corticosteroid Injections

Infection (1 in 50,000 injections)¹

Post injection flare (2% crystal induced synovitis)¹

Skin hypopigmentation, subcutaneous atrophy¹

Vasovagal syncope (procedure related)¹

Tendon rupture (rare)¹

Osteonecrosis (rare)¹1. West, S Rheumatology Secrets 2rd edition 2002

Relative contraindications to injections

• superficial infection or broken skin

• unstable coagulopathy

• prosthetic joint (hemiarthroplasty can be injected)

Aspiration should be performed if

sepsis is suspected

Hyaluronic Acid Injections

Synovial Fluid

Acts as lubricant

Serves as shock absorber

Relieves pain

Retards inflammation

May support the synthesis of normal hyaluronic acid

Hyaluronic Acid Injectables(Knee Only)

EUFLEXXA™ 3

SYNVISC™ 3 or 1

HYALGAN ™ 5

SUPARTZ ™ 3

ORTHOVISC ™ 3

GEL ONE ™ 3

Once weekly forBranded names™

Why is HA usedto treat pain in O/A?

Cannot take NSAIDs

Will not take corticosteroid injections

Too young for total knee replacement

Not ready for total knee replacement

“nothing else has worked”

Early chondral problems in young patients

Common

injection sites

for corticosteroid injections

•Shoulder

•Trochanteric bursa

•Knee

•Trigger points

Uncommon

sites•HIP (guided)

•SIJ (guided)

•Achilles Tendon

•Infra-patellar Bursa

•TMJ

•Flexor Tendons

•Small joints of hands or feet

Tips for good procedures I•Beginners’ main problem;

Finding the right spot.

•Anatomy picture

for joints and think of referred patterns

Trigger points:

In general stick the needle where it hurts.

•Difficult to cause real

Damage except side of neck

or chest wall.

length vs. gauge

•The longer and thinner the needle,

The more flexible

•The shorter and larger the bore,

The more rigid

Larger needles for larger joints

Smaller needles for smaller joints

Needle choices

Tips for good procedures II

•Relaxed Patient

•Relaxed Operator

Tips for good procedures III

•Right hand injects

•Left hand supports

•Patient is foundation

•Left hand must be

anchored to patient

Tips for good procedures IV

•Pain caused by

rapid tissue invasion

•Introduce needle slowly

•Use smallest needle

possible

•Use smallest injectate

volume possible

•Pain should be no worse

than venipuncture

X-RAY view of the shoulder

Shoulder Anatomy

Posterior Shoulder Approach

Anterior Shoulder Approach

Lateral Epicondyle

Greater trochanterspinal needle

large volume

Hip jointGreater Trochanter

Posterior view right hip

Posterior trochanter

large area

Kneesuperior lateral approach

note knee extension

Kneemedial approach

aspiration or injection

Osteoarthritic fluid

Knee outline patella, patellar tendon, medial and

lateral tibial plateau

Courtesy of Michael Rudzinski

Lateral flexed knee approach Pt supine

Courtesy of Michael Rudzinski

Medial approach 90° flexed

Courtesy of Michael Rudzinski

Trigger Point Injections

Both lidocaine and saline injections result in clinical reductions in pain for headaches

Does dry needling

Help for soft tissue

and why?

White et al. Presented at: ACR; 2004. PECK; FMS

Fibromyalgia

PECK;FMS

Thank youQuestions?

Richard S. Pope MPAS, PA-C, DFAAPA, CPAAPA

If you would like the ppt

E-mail me at:

pop5rjhjc@aol.com

Questions for the audience

1. Do you participate in the process of quality review of your care with patient's?

2. Do you perform procedures in your practice?

3. What are the 3 most commonly perform procedures you do?

4. What are 3 procedures you would like to learn how to perform ?

5. Is your compensation from your employer

salary; productivity; or combination of both ?