Indications for Musculoskeletal Injections:

Focus on Corticosteroid Injections

Erica Martin, M.D.

PGY4, University of Michigan Sports Medicine Fellow

2018 Sports Medicine for the Primary Care Physician & Fall Update in Family Medicine

October 3rd, 2018

History of corticosteroid injections

• Early 1900s- Janet Travell, MD

• 1951- Joseph Hollander, MD

Risks/Aims of Corticosteroid Injections

Risks• Damage to underlying structures

• Skin depigmentation

• Muscle atrophy

• Tendon rupture

• Infection

• Bleeding

• Hyperglycemia

Potential Benefits• Improved pain

• Improved function

Where are we headed?

• Shoulder

• Elbow

• Hand

• Hip

• Knee

Shoulder

Indications: Shoulder corticosteroid injection

•Adhesive capsulitis

• Impingement syndrome

•Glenohumeral osteoarthritis (OA)

https://orthoinfo.aaos.org/en/diseases--conditions/shoulder-pain-and-common-shoulder-problems/

Indications: Shoulder corticosteroid injectionAdhesive capsulitis

• What is adhesive capsulitis?

• Presentation?

• Evidence:• Injected steroid versus oral steroids, PT, NSAIDs?

• Intra-articular versus subacromial?

• Duration of effectiveness?

• Bottom line?

Steroid injections for AC are generally effective in the short term given in either the subacromial space or in the glenohumeral joint. May not provide

better outcomes than PT, but may be helpful for pain relief and QOL.

Indications: Shoulder corticosteroid injectionImpingement Syndrome

• What is impingement syndrome?

• Presentation?

• Evidence:• Injection approach?

• Injected steroid versus other treatment modalities?

• Bottom line?

Try conservative measures for impingement syndrome first, then consider subacromial injection.

Indications: Shoulder corticosteroid injectionGlenohumeral Osteoarthritis

• What is glenohumeral osteoarthritis?

• Presentation?

• Evidence:• Only one study at this point looking at corticosteroid injection

• Bottom line?

For glenohumeral OA, there is no great evidence for CS injection at this time. Could try in cases of refractory pain.

Ultrasound-guided injections versus landmark-based injections in the shoulder?

• Glenohumeral joint?

• Ultrasound ideal

• Subacromial space?

Elbow

Indications: Elbow corticosteroid injection

• Lateral epicondylitis

• Medial epicondylitis

http://www.nationmultimedia.com/img/news/2016/07/07/30290013/30290013-01.jpg

Indications: Elbow corticosteroid injectionLateral epicondylitis

• What is it?

• Presentation?

• Evidence:• Duration of effect?

• Recurrence rate?

• Bottom line?

For lateral epicondylitis, there is high recurrence rate with injection, and improvements are short-term.

Indications: Elbow corticosteroid injectionMedial Epicondylitis

• What is it?

• Presentation?

• Evidence:• Improvement in pain?

• Duration of effect?

• Bottom line?

CSI for medial epicondylitis shows short term decreases in pain levels, but long term pain relief is not consistently seen.

Ultrasound-guided injections versus landmark-based injections in the elbow?

• Studies only done for intra-articular injections, no studies for lateral or medial epicondylitis.

• Lack of evidence to give concrete recommendation.

Hand/Wrist

Indications: Hand/wrist corticosteroid injection

• Carpal tunnel syndrome

• DeQuervain’s tenosynovitis

• Trigger finger

• Osteoarthritis

https://www.google.com/

Indications: Hand/wrist corticosteroid injectionCarpal Tunnel Syndrome

• What is it?

• Presentation?

• Evidence:• Improvement in symptoms?• Versus systemic corticosteroid?• Duration of benefit?• Rates of surgical intervention?

• Bottom line?

CS injection for CTS can help with symptoms in short term and may increase time before surgery is required, but high recurrence rate and many patients end up

needing carpal tunnel release.

Indications: Hand/wrist corticosteroid injectionDeQuervain’s tenosynovitis

• What is it?

• Presentation?

• Evidence:• Somewhat difficult injection• Efficacy?

• Bottom line?For DeQuervain’s tenosynovitis, consider CS injection. Refer if no improvement

in symptoms with injection as there may be anatomic variation in first dorsal compartment affecting injection efficacy.

Indications: Hand/wrist corticosteroid injectionTrigger Finger

• What is it?

• Presentation?

• Evidence:• Duration of pain symptom relief?• Repeat injections?• Surgery?

• Bottom line?

Physicians should offer steroid injection for trigger finger.

Indications: Hand/wrist corticosteroid injectionHand/wrist osteoarthritis

• What is it?

• Presentation?

• Evidence:• Very little

• Bottom line?There is insufficient evidence to recommend corticosteroid injection for

hand/wrist OA. Refer to subspecialist if you feel may be beneficial for patient as technically difficult area.

Ultrasound-guided injections versus landmark-based injections in the wrist/hand?

• Carpal tunnel syndrome?• 1 study, 46 median nerves

• Improvements in symptom severity scores greater and average time to symptom relief shorter in US guided group.

• DeQuervain’s?• Can have multiple subcompartments which can affect efficacy

• Trigger finger?• Study done by Cecen et al. in 2014→no significant difference in US versus

landmark-guided injection.

• Hand/wrist osteoarthritis?• Multiple studies show increased injection accuracy with US guidance.

Ultrasound-guided injections versus landmark-based injections in the wrist/hand?

Hip

Indications: Hip corticosteroid injection

• Greater trochanteric pain syndrome

• Osteoarthritis

https://www.google.com/

Indications: Hip corticosteroid injectionGreater trochanteric pain syndrome

• What is it?• Change in nomenclature based on histologic changes

• Presentation?

• Evidence?• Injection versus “usual care”?• Pain relief/”recovery”• Duration?

• Bottom line?

For greater trochanteric pain syndrome, can consider injection if patients desire quicker relief of pain.

Indications: Hip corticosteroid injectionOsteoarthritis

• What is it?

• Presentation?

• Evidence?• Numbing agent +/- steroid• Duration of efficacy?

• Bottom line?

Steroid injections can be helpful for relief of pain in hip OA; however, this is an anatomically difficult area to inject without imaging guidance and would

recommend referral for this procedure.

Ultrasound-guided injections versus landmark-based injections in the hip?

• Trochanteric pain syndrome• Mitchell et al., RCT of 40 patients→more improvement in pain scores in US

guided group at 6 months.

• Hip osteoarthritis• 2 studies looking at accuracy of landmark-guided injections. Between 67 and

78% accuracy.

• Case series done by Pourbagher et al. showed 80% with improvements in function and pain after US guided injection

• No comparative studies to date

Knee

Indications: Knee corticosteroid injection

• Osteoarthritis

https://www.nuffieldhealth.com/local/4b/72/7a13c6f249d2bc477e0ecf3bc73f/happyknees500x300.jpg

Indications: Knee corticosteroid injectionOsteoarthritis

• What is it?

• Presentation?

• Evidence?• Duration of pain relief?

• Bottom line?

For knee osteoarthritis, CS injection can be used prior to referral for surgical evaluation.

Ultrasound-guided injections versus landmark-based injections in the knee?

• Osteoarthritis• Landmark-based injections

• Accuracy depends on approach taken, ranges between 67-91%

• Superolateral approach most accurate

• Landmark versus US guided injections• Accuracy of injection ranging from 63-100% with ultrasound versus landmark accuracy

between 39 and 100% based on 2012 review

• Study done by Sibbitt et al. suggestive of cost benefit for US guided injection versus landmark

Okay, but what kind of steroid do I use? And how much?

Injection location Steroid type Steroid Dose

Glenohumeral joint TA may be better than MPA for adhesive capsulitis

40 mg no better than 20 mg for adhesive capsulitis

Subacromial space MPA may be better than TA for pain

80 mg similar to 40 mg, but 40 mg better than 20 mg

Hip joint Similar efficacy for MPA or TA Longer duration of improvement in 80 mg compared to 40 mg

Knee joint TH better than TA, MP, and B 40 mg equivalent to 80 mg

TA= triamcinolone acetate; MPA=methylprednisolone acetate; TH=triamcinolone hexacetonide; B=betamethasone

Table adapted from Table 1 in Cushman, Daniel M., et al. “Efficacy of Injected Corticosteroid Type, Dose, and Volume for Pain in Large Joints: A Narrative Review.” PM&R, vol. 10, no. 7, 2018, pp. 748–757

Parting thoughts…

• Biomechanics are key for long term outcomes!

https://www.verywellfit.com/

Works Cited• Amin, Nirav H., et al. “Medial Epicondylitis.” Journal of the American Academy of Orthopaedic Surgeons, vol. 23, no. 6, 2015,

pp. 348–355., doi:10.5435/jaaos-d-14-00145.

• Block, J., B., & M. (2012). Clinical utility of ultrasound guidance for intra-articular knee injections: A review. Clinical Interventions in Aging, 89. doi:10.2147/cia.s29265

• Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care. Ann Fam Med. 2011;9(3): 226-234.

• Buchbinder, Rachelle, et al. “Corticosteroid Injections for Shoulder Pain.” Cochrane Database of Systematic Reviews, 2003, doi:10.1002/14651858.cd004016.

• Cecen, G.S., Gulabi, D., Saglam, F. et al. Arch Orthop Trauma Surg (2015) 135: 125. https://doi-org.proxy.lib.umich.edu/10.1007/s00402-014-2110-9

• Colen, S., et al. “Intra-Articular Infiltration Therapy for Patients with Glenohumeral Osteoarthritis. a Systematic Review of the Literature.” Osteoarthritis and Cartilage, vol. 22, Oct. 2014, doi:10.1016/j.joca.2014.02.748.

• Cushman, Daniel M., et al. “Efficacy of Injected Corticosteroid Type, Dose, and Volume for Pain in Large Joints: A Narrative Review.” Pm&r, vol. 10, no. 7, 2018, pp. 748–757., doi:10.1016/j.pmrj.2018.01.002.

• Dardas, Agnes Z., et al. “Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger.” The Journal of Hand Surgery, vol. 42, no. 4, 2017, pp. 227–235., doi:10.1016/j.jhsa.2017.02.001.

• Hepper, C. Tate, et al. “The Efficacy and Duration of Intra-Articular Corticosteroid Injection for Knee Osteoarthritis: A Systematic Review of Level I Studies.” Journal of the American Academy of Orthopaedic Surgeons, vol. 17, no. 10, 2009, pp. 638–646., doi:10.5435/00124635-200910000-00006.

• Ilyas, Asif M., et al. “De Quervain Tenosynovitis of the Wrist.” Journal of the American Academy of Orthopaedic Surgeons, vol. 15, no. 12, 2007, pp. 757–764., doi:10.5435/00124635-200712000-00009.

• Krogh, Thøger Persson, et al. “Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis.” The American Journal of Sports Medicine, vol. 41, no. 6, Dec. 2012, pp. 1435–1446., doi:10.1177/0363546512458237.

Works Cited continued

• Lambert RG, Hutchings EJ, Grave MG, et al. Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2007; 56(7): 2278-2287.

• Mcauliffe, Matthew B., et al. “Evidence for Accuracy and Effectiveness of Musculoskeletal Ultrasound-Guided Compared with Landmark-Guided Procedures.” Current Physical Medicine and Rehabilitation Reports, vol. 4, no. 1, Dec. 2016, pp. 5–11., doi:10.1007/s40141-016-0103-z.

• Mcdermott, James D., et al. “Ultrasound-Guided Injections for De Quervain’s Tenosynovitis.” Clinical Orthopaedics and Related Research®, vol. 470, no. 7, Mar. 2012, pp. 1925–1931., doi:10.1007/s11999-012-2369-5.

• Mitchell, W.G., Kettwich, S.C., Sibbitt, W.L. et al. Rheumatol Int (2018) 38: 393. https://doi-org.proxy.lib.umich.edu/10.1007/s00296-018-3938-z

• Peters-Veluthamaningal, Cyriac, et al. “Corticosteroid Injection for Trigger Finger in Adults.” Cochrane Database of Systematic Reviews, 2009 doi:10.1002/14651858.cd005617.pub2.

• Simone, John (1993) The Principles of Corticosteroid Injection Therapy in Musculoskeletal Medicine, Journal of Orthopaedic Medicine, 15:3, 56-58, DOI: 10.1080/1355297X.1993.11719726

• Stahl, Shalom, and Teddy Kaufman. “The Efficacy of an Injection of Steroids for Medial Epicondylitis.” The Journal of Bone and Joint Surgery (American Volume), vol. 79, no. 11, 1997, pp. 1648–1652., doi:10.2106/00004623-199711000-00006.

• Sussman, Walter I., et al. “Ultrasound-Guided Elbow Procedures.” Physical Medicine and Rehabilitation Clinics of North America, vol. 27, no. 3, 2016, pp. 573–587., doi:10.1016/j.pmr.2016.04.002.

• Üstün, Nilgün, et al. “Ultrasound-Guided vs. Blind Steroid Injections in Carpal Tunnel Syndrome.” American Journal of Physical Medicine & Rehabilitation, vol. 92, no. 11, 2013, pp. 999–1004., doi:10.1097/phm.0b013e31829b4d72.

• Wallen, Margaret M, and Donna Gillies. “Intra-Articular Steroids and Splints/Rest for Children with Juvenile Idiopathic Arthritis and Adults with Rheumatoid Arthritis.” Cochrane Database of Systematic Reviews, 2006, doi:10.1002/14651858.cd002824.pub2.

• Wilson VP. Janet G. Travell, MD: A Daughter’s Recollection. Texas Heart Institute Journal. 2003;30(1):8-12.

• Wojahn, Robert D, et al. “Long-Term Outcomes Following a Single Corticosteroid Injection for Trigger Finger.” THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED, vol. 96, no. 22, 19 Nov. 2014, pp. 1849–1854. A, doi:http://dx.doi.org/10.2106/JBJS.N.00004.

• Xiao, Ryan C., et al. “Corticosteroid Injections for Adhesive Capsulitis.” Clinical Journal of Sport Medicine, vol. 27, no. 3 , May 2017, pp. 308–320., doi:10.1097/jsm.0000000000000358.