Musculoskeletal Injections and Alternative Options

A practical guide to 'what, when and how?'

Maneesh Bhatia

• Publisher: CRC Press
• Year: 2019
• Print ISBN: 9780815355571
• eBook ISBN: 9781351129701
• Edition: 1
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Musculoskeletal injections for joint or tendon problems are performed commonly and their use, which can result in a marked improvement in acute symptoms as well as delay or postpone surgery, is on the rise.

Key features:

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• Provides concise, current and portable information

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• Covers the latest treatment options, supported by scientific evidence and guidelines

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• Discusses alternative injections, non-injection measures and novel treatment modalities

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• Text supported by illustrations and video of injection procedures and physiotherapy

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• Ideal for both the non-specialist seeking an introduction to the subject and the more experienced practitioner

This accessible guide helps doctors from various disciplines including orthopaedics, sports medicine, rheumatology, radiology and primary care as well as allied health care professionals understand the indications and local anatomy to safely perform injections with complication avoidance. In addition, the book provides useful information regarding other alternatives including physiotherapy and novel modalities. The content is supported by current evidence, guidelines and companion videos.

1

Musculoskeletal injections in general

Devendra Mahadevan and Euan Stirling

Introduction

Pain from musculoskeletal problems is an increasing cause for poor quality of life and is putting increased demands on the healthcare system. The chronicity of symptoms may impact on the physical, psychological and socio-economic status of patients (Video 1.1).

Management strategies should focus on the individual needs of these patients (localised versus systemic pain, co-morbidities, physical status and functional requirements). There are a multitude of treatment options employed by healthcare providers. These include non-medicinal treatments (self-management education, physical/exercise therapy, manual therapy and psychosocial interventions), complementary therapies (acupuncture, ultrasound, TENS [transcutaneous electrical nerve stimulation]), pharmacological interventions (analgesics, anti-inflammatories, corticosteroid injections) and surgery. In order to provide optimal care to patients with musculoskeletal pain and ensure efficient use of healthcare resources, evidence-based practice is essential.

This chapter discusses the use of corticosteroid injections in the management of musculoskeletal pain and the practicalities of providing this treatment. Like all other procedures, the efficacy of this treatment depends on appropriate use, i.e. correct indication, selecting the appropriate pharmacological agent and performing the procedure correctly and safely.

What are corticosteroids?

Corticosteroids are steroid hormones that are either naturally produced by the adrenal cortex in vertebrates or synthetically made to mimic the naturally occurring variant. Corticosteroids regulate a wide range of physiologic processes, including stress and immune responses, regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte levels and behaviour [1].

They can be given topically, orally or by injection, and may produce a local or systemic response. Examples of synthetic corticosteroids used as pharmacological agents include betamethasone, prednisone, triamcinolone and dexamethasone.

How do steroid injections work?

Corticosteroids have a combined anti-inflammatory and immunosuppressive effect. When injected into joints, they reduce synovial blood flow and vascular permeability [2], and lower leukocyte and inflammatory mediators including prostaglandins and leukotrienes [3–5]. They also alter local collagen synthesis [6] and increase the hyaluronic acid concentration within the joint [3,4]. The mechanism of action is complex: The steroids act directly on nuclear steroid receptors and interrupt the inflammatory and immune cascade at several levels. The net effect is reduction in pain and inflammation locally.

The esterification (reaction between alcohols and carboxylic acids to make esters) of corticosteroids enhances their pharmacokinetic properties. The alteration of the parent steroid chemical properties can improve metabolic and water solubility and lipophilicity, thus potentially increasing bioavailability and prolonging duration of efficacy [7]. For example, branched esterification reduces the solubility of the drug and enhances its duration of action, as it remains longer at the injection site [2].

What are the indications and contraindications of corticosteroid injections?

Corticosteroid injections play an important role in the management of musculoskeletal conditions. They can be used as a definitive treatment (e.g. trochanteric bursitis, De Quervain’s tenosynovitis); provide a pain-free window for rehabilitation (e.g. subacromial impingement, epicondylitis, plantar fasciitis); or to provide episodic pain and symptom relief (e.g. osteoarthritis).

When used appropriately for the correct indication, corticosteroids will provide good relief (Table 1.1). One must be aware that corticosteroids are contraindicated in several conditions that produce a ‘painful and swollen’ joint (Table 1.2). Physicians need to be astute in establishing the diagnosis prior to instilling corticosteroid injections. If the intra-articular diagnosis is not obvious, a diagnostic aspiration should be performed prior to injecting the joint with corticosteroids. The aspirated fluid may be visually analysed (cloudy synovial fluid or haemarthrosis) and if it looks abnormal, should be sent for microscopy and cultures.

Table 1.1 Indications for corticosteroid injections

Inflammatory art...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• List of videos
• e-Resources
• Foreword by Nicola Maffulli
• Foreword by Bill Ribbans
• Review and endorsements
• Editor
• Editor’s Note
• Contributors
• 1. Musculoskeletal injections in general
• 2. Shoulder and elbow injections
• 3. Hand and wrist injections
• 4. Hip and knee injections
• 5. Foot and ankle injections
• 6. Image-guided injections in orthopaedics
• 7. Platelet-rich plasma injections
• 8. Visco-supplementation injections
• 9. Practical prolotherapy
• 10. Extracorporeal shock wave therapy
• 11. Novel treatments for the management of chronic shoulder, knee and hip joint pain
• Index
• Original Title Page
• Patient’s guide to steroid injection