Transcript ShoulderInjection

Dr Paul Annett MBBS FACSP
Sports Physician
Visiting Fellow UNSW
Cortisone Injection
Historical
• Hench & Co-workers
1950
• Hollander 1951 Local use via injection
• Use evolved with soft
tissue use to sports
Cortisone Actions
• Inhibit early
inflammation
– Edema, leukocyte
migration, etc
• Inhibit late
manifestations
– Fibroblasts
– Collagen deposition
– Scar formation
Cortisone Injection
• Important questions to
ask:
• What to inject?
• When to inject?
• Where to inject?
• How to inject?
• Complications of
injection?
• Advice to Patients?
What to inject?
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Joint
Bursa
Peri-tendinous
Synovial sheath
Enthesis
Ligament
Muscle
What to inject?
• Shoulder - Sub-acromial, AC joint,
Glenohumeral joint
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Elbow - CEO, CFO, Elbow joint
Wrist - DeQuervains,SL ligament,Ganglion
Hand - Tenosynovitis
Ankle - Post sprain synovitis, Tendinopathy
Foot - Plantar fascial insertion, 1st MTP
Knee - Knee joint, Patella tendon
Hip - Greater trochanter, Hip Joint
Spine - Facet joint, Epidural space
When To Inject?
• Appropriate diagnosis
– History
– Examination
– Judicious investigation
• 4-6 weeks of appropriate pre-injection
management
– Relative rest & X-train
– Ice, NSAIDS, modalities
– Well structured rehabilitation program
• NEVER in children
Advice to Patients
• NOT A CURE - Rehab essential!
• Will this hurt?
• What are the side effects?
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Systemic (NB diabetes)
Infection - 1:20,000
Crystal flare - ice + paracetamol
Skin changes - atrophy &
pigment loss
– Bleeding
– Neuritis
• How long to rest?
What to Inject?
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Cortisone
More soluble - short acting
Depot preparations
Local anaesthetic additive
– Dilute cortisone
– Reduces initial pain
– Confirms diagnosis
• Relative volumes
How to Inject?
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GENERAL PRINCIPLES
Informed consent
Aseptic no touch technique
Avoid skin infection
Appropriate needle & syringe size
Be confident!
Skin anesthesia
Failure of Injection
• Physician
– Wrong diagnosis
– Poor injection technique
– Inadequate rehabilitation
program
• Athlete / Patient
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Persistent overuse
Poor technique
Intrinsic factors
Advanced degenerative disease
How Many Injections?
• Repeat at least once if initial failure
– Incorrect position
– ? Need imaging guidance
• Failure of 3 injections Re-think!
• Repetition causes collagen
weakness
• 3 is not set in stone
Now - On To Injections
Shoulder - Sub-acromial
• Overuse or
degenerative rotator
cuff pathology
• Posterolateral
approach
• 2ml cortisone + 5ml
local
• Re-examine
Shoulder - AC joint
• Degenerative
pathology
• Superior approach
• 1ml cortisone + 1ml
local
Shoulder – Glenohumeral Joint
• Capsulitis, GH OA, post
traumatic pathology
• Posterior approach
• 2cm inferior and medial to
posterolateral acromial
edge
• Needle angled
superomedial to the
coracoid (palpate with
other hand)
• 2ml cortisone + 5ml local
Thank You