2. Dr Paul Annett MBBS FACSP Sports Physician Visiting Fellow UNSW

3. Cortisone Injection

4. Historical Hench & Co-workers 1950 Hollander 1951 - Local use via injection Use evolved with soft tissue use to sports

5. Cortisone Actions Inhibit early inflammation –Edema, leukocyte migration, etc Inhibit late manifestations –Fibroblasts –Collagen deposition –Scar formation

6. Cortisone Injection Important questions to ask: What to inject? When to inject? Where to inject? How to inject? Complications of injection? Advice to Patients?

7. What to inject? Joint Bursa Peri-tendinous Synovial sheath Enthesis Ligament Muscle

8. What to inject? Shoulder - Sub-acromial, AC joint, Glenohumeral joint 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

9. 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

10. Advice to Patients NOT A CURE - Rehab essential! Will this hurt? What are the side effects? –Systemic (NB diabetes) –Infection - 1:20,000 –Crystal flare - ice + paracetamol –Skin changes - atrophy & pigment loss –Bleeding –Neuritis How long to rest?

11. What to Inject? Cortisone More soluble - short acting Depot preparations Local anaesthetic additive –Dilute cortisone –Reduces initial pain –Confirms diagnosis Relative volumes

12. How to Inject? GENERAL PRINCIPLES Informed consent Aseptic no touch technique Avoid skin infection Appropriate needle & syringe size Be confident! Skin anesthesia

13. Failure of Injection Physician –Wrong diagnosis –Poor injection technique –Inadequate rehabilitation program Athlete / Patient –Persistent overuse –Poor technique –Intrinsic factors –Advanced degenerative disease

14. 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

15. Now - On To Injections

16. Shoulder - Sub-acromial Overuse or degenerative rotator cuff pathology Posterolateral approach 2ml cortisone + 5ml local Re-examine

17. Shoulder - AC joint Degenerative pathology Superior approach 1ml cortisone + 1ml local

18. 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

19. Thank You