1. Spire Tunbridge Wells- TALK
Joint injection
Dr Amit Saha
Consultant Rheumatologist & Clinical Lead for Rheumatology- Maidstone and Tunbridge Wells NHS Trust
Spire Tunbridge Wells- TALK

2. Introduction course-
Focus on 90% of injections- knee, wrists shoulder
When to inject and aspirate – need diagnosis first
Safety

3. Shoulder Frozen shoulder (adhesive capsulitis)
Subacromial impingement syndromes

4. Frozen Shoulder
Stiffened gleno-humeral joint that has lost significant range of motion (abduction and rotation).
40-60s
Dis-use – sling, recent operation, pre-existing shoulder complaint
50% reduction in all movements (especially external rotation)

5. Frozen Shoulder
In SAI – though active movement reduced, passively you can push full movement.
Patients with frozen shoulder have varying degrees of pain early in the disease course, but complain primarily of joint stiffness. Symptoms generally develop over the course of weeks to months.
No X-rays generally needed (exception if you think there is gleno-humeral OA)

6. Treatment Acute (first 8 weeks)- NSAIDs and avoid excessive activities
Gentle exercises- Pendular exercises (evidence weak) plus stretching exercises.
Revaluate in 8 weeks – Continue or inject

7. Randomized trial of 109 patients.
At seven weeks, 40 of 52 patients randomly assigned to glucocorticoid injection were considered to have a treatment success compared with 26 of 56 patients (46 percent) treated with physiotherapy.
van der Windt DA et al. BMJ. 1998;317(7168):1292.

8. Glucocorticoid injection may hasten recovery, and the addition of supervised physical therapy following glucocorticoid injection may result in more rapid improvement than injection alone. However, the long-term outcome of adhesive capsulitis may not be much affected by either intervention.

9. Four groups: steroid plus supervised physiotherapy (PT), glucocorticoid injection alone, saline injection plus supervised PT, or saline injection alone.
Those who received a glucocorticoid injection and supervised PT improved significantly more, and more rapidly, than any other group at six weeks; those who received glucocorticoid injections were better than those who did not at three months.
But by one year there was no discernible difference in improvement among the four groups.
Carette et al. Arthritis Rheum. 2003;48(3):829.

10. Injection Approach - posterior approach

11. Subacromial impingement syndromes
Rotator cuff may be compressed during glenohumeral movement
Painful daily activities may include putting on a shirt or brushing hair.
Patients may localize the pain to the lateral deltoid and often describe pain at night, especially when lying on the affected shoulder.

13. Inspection – Rotator cuff atrophy
Palpation- focal subacromial tenderness at the lateral or posterior-lateral border of the acromion.
Painful ROM that occurs between 60 and 120 degrees of active abduction marks a positive arc test

14. Normal passive range of movement and power
Beyond 150 degrees possible acromio-clavicular OA

15. Treatment X-rays generally not needed Simple things first
Injections- evidence weak. Systematic review poor trials.

16. Knee OA knees Aspirate- gout/pseudogout/infection
Works – can be up to 6 months
Certain patients better to use than others

17. Carpal Tunnel syndrome
Median nerve entrapment
Classically 1-31/2 fingers
Classic symptoms
Tinel’s and phalens
Splints first
Surgery if severe damage
Inject if splints fail

18. Injections Discussed benefits already
Risks – Bleeding and infection – less than 1 in 10,000
Aseptic
INR less than 3 for large joints
Post-injection flare- last few hours usually within hours.
Tendon damage – Tendon rupture is most commonly encountered when undiluted glucocorticoid is given very near or into tendon
Nerve damage
Skin depigmentation
Do not inject prosthetic joints
Avoid general exertion for 24 hours.

19. Shoulder – 40mg (1ml) Depo-medrone (methylprednisolone acetate) plus approximately1-2mls of 1% lidocaine
Knee - 80mg (2ml) Depo-medrone (methylprednisolone) plus approximately 2mls of 1% lidocaine
Wrist 20mg (0.5ml) Depo-medrone plus 0.5ml 1% lidocaine

20. Frequency- evidence limited
Inject very active large joints affected by rheumatoid arthritis as often as 3 injections per year for any given joint.
For joints affected by osteoarthritis, can inject glucocorticoids as often as once every six months only if no other therapy is effective.

21. Green needle – 21 gauge (knee and shoulder)
Orange needle – 25 gauge (wrist)
10ml syringe for knee and shoulder
1ml syringe for wrist
Universal container
Alcohol swabs (with 70% isopropyl alcohol)

22. Knee injection
Superior
Lateral
Medial
Inferior