Treatment with local steroids in MSK disease

Gabrielle KingsleyLewisham and Greenwich NHS

Trust and Kings College London

Educational Objectives

• Why are injectable steroids used in MSK disease?

• Preparations and doses• Indications and benefits• Adverse events

• What if I want to start doing injections?

To review the use and abuse of local steroids in musculoskeletal disease

Why are injectable steroids used in MSK disease?

• Reducing joint inflammation− Inflamed joints eg rheumatoid arthritis− Joints damaged by osteoarthritis with possible

inflammation

• Reducing soft tissue inflammation or swelling− Inflamed soft tissue eg epicondylitis−Reduction in tendon swelling eg shoulder tendinitis−Reduction in nerve swelling eg compressive

neuropathies like carpal tunnel syndrome

Preparations and dosesDepomedrone-depot methylprednisolone• Crystal suspension, commonly used and fairly cheap

Triamcinolone (kenalog)• More expensive but some studies suggest longer-

lasting especially the hexacetonide preparation• Interaction with ritonavir (also interacts with systemic

and inhaled steroids)

Hydrocortisone• Aqueous preparation with no crystals• Cheap but currently not easily available; effect short-

lived

Dose varies with agent and size of site injected; can add local anaesthetic

Indications and benefits:Soft Tissue• Soft tissue inflammatory lesions

−epicondylitis (elbows)−bursitis (shoulders, olecranon, greater trochanter, knees)−Steroids, usually with local anaesthetic, injected into

relevant bursa/site leading to reduced pain and swelling−To avoid recurrence, activity change/use a

support/physio

• Inflamed tendons−Rotator cuff tendons eg supraspinatus (shoulder)−De Quervain’s tenosynovitis (wrist)/hands−NOT Achilles tendon−Steroids, with local anaesthetic, between tendon and

tendon sheath to reduce swelling of tendon; reduces pain but also allows tendon to move through small spaces

Indications and benefits:Soft Tissue

• Trigger fingers and thumbs−Inject between tendon and tendon sheath−Restores free tendon movement

• Compression neuropathy−Carpal tunnel syndrome−Rarely other sites eg tarsal tunnel−Inject non-crystalline steroid without local anaesthetic

into space around nerve (eg carpal tunnel)−Reduces swelling of nerve avoiding its compression in

the carpal tunnel; neurological function improves

Indications and benefits:Joints - OA• Osteoarthritis (OA)

− Inject into joint (ensure no infection)− Improves pain and thus function−Most commonly used for

OA base of thumb (where effect may be prolonged) OA where degeneration associated with inflammation eg knee

• NICE Guidance: intra-articular therapy in OA• 1.5.12 Intra-articular corticosteroid injections should be

considered as an adjunct to core treatments for the relief of moderate to severe pain in people with OA. [2008]

• 1.5.13 Do not offer intra-articular hyaluronan injections for the management of osteoarthritis. [2014]

Indications and benefits:Joints – Inflammatory arthritis

• Inflammatory arthritis−Rheumatoid arthritis, spondyloarthropathy, crystal

arthritis (gout and pseudogout)− If multiple joints are involved consider systemic steroids

(intra-muscular or possibly oral)−Must be certain that joint is not infected!− If there is significant fluid, may need to aspirate joint

first before injecting steroid into synovial space−Reduces synovitis (pain and swelling) improving

function−Not usually a long term effect - in general, improvement

will not be sustained unless other treatment is amended (except where underlying problem is self-limiting eg gout)

Adverse events

• What is the link with infection?• Other adverse events

−Injections, especially into small spaces, can be painful (finger joints, epicondyles)

−Soft tissue injections (especially into small spaces like epicondylitis) may lead to tissue atrophy and loss of pigmentation (problematic in ethnic minorities)

−Tendon injections can cause tendon rupture (don’t inject into the tendon itself and avoid more than two injections)

−Injection of crystal preparations can lead to flares (eg crystal synovitis)

−Repeated intra-articular steroid may worsen joint damage

Summary• Why are injectable steroids used in

MSK disease?• Preparations and doses• Indications and benefits• Adverse events

What if I want to start doing injections?

• Learn from someone already competent

• Know your anatomy• Preferably use plastic models

and/or cadavers before real patients

Treatment with local steroids in MSK disease