Jason Rand PA-C, PT Boston Sports and Shoulder Center

Boston Celtics Medical Team

New England Baptist Hospital – Sports Medicine Service

Corticosteroid An Aqueous Suspension a practically white,

odorless, crystalline powder

Suppress inflammation by decreasing collagenase and prostaglandin formation

But also…. Catabolic promoter that block glucose

uptake in tissues, and decrease new protein synthesis

Indications Arthritis flair

Synovitis

Adhesive capsulitis

Tendonopathy/tendonitis (NWB Tendon)

Crystal-Induced Arthritis

Rheumatoid arthritis

Corticosteroid

“I heard you can only have….”

Depends on diagnosis

End stage oa vs. Tendonitis

“Will the arthritis worsen”

Intra-articular cortisone injections do not lead to the progression of osteoarthritis 1

1) Raynauld JP, Buckland-Wright C Ward R et al. Safety and efficacy of long-term

intraarticular steroid injections in oa of the knee: a randomized , double-blinded

placebo-controled trial Arthritis Rhum. 2003;2005 13(1):37-46

Single injections of the 4 most commonly injected

corticosteroids do not appear to have significant

chondrotoxic properties when studied in a bioreactor

perfusion model over the average residence time of

each medication post injection.

- A0SSM 2010 Podium Presentation

Corticosteroid

Medication Onset Duration Cortisol Fast Short

Depo-Medrol

(Methylprednisone acetate) Slow Intermediate

Kenalog

(Trimcinolone acetonide) Moderate Intermediate

Celestone

(Beatmethasone) Fast Long

In general, ↓ solubility, ↑ duration of action, ↑ incidence of cutaneous side effects

Dosage Size of Joint Examples Range of Dosage

Large Knees Ankles Shoulders

20 to 80 mg

Medium Elbows Wrists

10 to 40 mg

Small

Metacarpophalangeal Interphalangeal Sternoclavicular Acromioclavicular

4 to 10 mg

+ +

+

=

Corticosteroid Injection Contraindications

Acute trauma

Suspicion of a septic joint

Injection through superficial infection

Upcoming surgery to region

Prosthetic Joint (relative)

Corticosteroid Injection Adverse reactions

Hypothalamic-pituitary adrenal (HPA) axis suppression.

Transient hyperglycemia

Sodium Retention

Joint infection rare ( 1 in 13,000)1 ( 1 in 15,000)2 (<1 in 78,000)3

Local Effects: Lipodystrophy

Loss of skin pigmentation

Tendon rupture

Post – Injection Flair 2-10%

1: Charalambous CP, Tryfonidis M, Sadiq S et al. Septic arthritis following intra-

articular steriod injection of the knee: a survey of current practice

regarding antiseptic technique used during intra-articular steroid injection

of the knee Clin Rheumatol. 2003 Dec;22(6):386-390. 2: Essentials of Musculoskeletal Care 3

3. Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Bet

practice and reaserch in clinical rheumatology 23 (2009) 161-192.

Cortisone – Skin Blanching

Increased risk in African American Population

Dec. Risk by attempting to avoid peri-dermal

injection

Cortisone – Fat Atrophy

Corticosteroid Injection Post- injection education

Avoid heavy activity for next 48 hours

Site of injection may be sore

Ice, NSAIDS, Tylenol

Benefits may take hours or days

May get worse before it gets better

Cortisone and Physical Therapy Match made in heaven

Adhesive Capsulitis/ Arthrofibrosis

RC inpingment

Osteoarthritis

Precautions

Post injection pain: Hold or modify PT

Steroid Contamination! New England Compounding Center (Framingham, MA)

323 Cases of fungal meningitis

5 Peripheral infections

24 Deaths

Hylauronic Acid (HA)

Polysaccharide chain with repeating disaccharide units Glucuronic acid and N-acetyl-

glucosamine

Present in both synovial fluid and articular cartilage Synovial Fluid: viscoelastic

properties: lubricant, shock absorber

Articular Cartilage: Binds aggrecan molecules via a link protean to create a negatively charged aggregate and migration pathway

May promote chondrocyte proliferation and diferentiation

Hylauronic Acid (HA) Endrogenous HA

Produced by Synovioum (Type B synoviocytes, Fibroblasts)

In the arthritic joint:

Reduction in HA concentration and molecular weight by 33 – 50%.

Inflammatory effusion, molecular fragmentation, abnormal synoviocyte production

Mechanism of Action: Unknown, thought to exert anti-inflammatory, analgesic and

possibly chondroprotective effects on the joint synovium and cartilage.

Six Synthetic HA injections approved for use.

Physical Properties of Viscosupplements

Molecular Weight (kDa)

Elasticity (Pa at 2.5 Hz)

Viscosity (Pa at 2.5 Hz)

Healthy, Young Synovial Fluid 8 6 (age 21-45) 117 (age 18-27) 45 (age 18-27)

Osteoarthritis Synovial Fluid Not Available 1.9 1.4

Synvisc® (hylan G-F 20) 5000-6000 111 25

Hyalagan ® (Sodium hyaluronate) 500-720 0.6 3

Supartz ® (Sodium hyaluronate) 620-1200 9 16

Orthovisc ® (High molecular weight

hyaluronan)

1000-2900 60 46

Euflexa TM (1% sodium hyaluronate) 2400-3600 92 37

Synvisc vs Steroid

(Aristospan, Triamcinolone Hexacetonide)

Prospective, multicenter, randomized, blinded 26 week trial Synvisc took longer to work but worked for a longer duration

then steroid Carborn D, Rush J, Lanzar W, Parenti D, Murry C. Synvisc study group: A randomized, single blinded comparison of the efficacy and tolerability of hylan G-F 20 and triancinolone hexacetonide in patients with

OA of knee. J Rheumatology 2004;31:333-343

Viscosupplementation Indications:

Patient with Osteoarthritis who has failed or is unable to participate in basic conservative treatment

Only approved for the knee joint (US)

Precautions With Physical Therapy

Avoid repetitive “high level activity” for first 24 – 48 hours

AAOS guidelines for knee osteoarthritis Recommendation against the use of intraarticular

hyaluronic acid for symptomatic OA

Result of review of literature - Meta-analysis

Many individual studies demonstrated effectiveness

Platelet-Rich Plasma Autologus blood fraction rich in platelets

Injected to region of poor or delayed heeling

Theory: Platelets are first to arrive at site of tissue injury, release growth factors that are critical to the heeling

process

Whole Blood Platelet Rich Blood: 2.5-8.0 x whole blood platelet concentration PDGF TGF-B VEGF Cell proliferation/ signal –transduction/angiogenesis Bfgf EGF IFG Tissue heeling

Numerous

Systems

Achilles Tendinopathy One year follow up of PRP for chronic Achilles

Tendonapathy: Double blinded Placebo-controlled trial (de Jonge et al, 2011):

No statistical difference at one year follow up Recover platelet seperation system

Epicondylitis Chronic Tennis Elbow; Double blinded, prospective

trial of 230 patients (Mishra et al; 2013): Greater improvement (VAS) in PRP group at 4, 8, 12, 24 weeks

Biomet system

12 Weeks

24 Weeks

PRP Group 55.1% 83.9%

Control - Needling 47% 68.3%

Osteoarthritis

Platelet Rich Plasma Office Procedure for tendon or soft tissue injury Blood is spun down in office separating cells and plasma The plasma portion contains numerous biologic factors that have been

shown to enhance healing in animal and human studies. Platelet derived growth factors: PDGF AB and BB,TGF beta 1 and

beta 2,IGF,EGF,VEGF

Prolotherapy Injection of non-phamacological irritant solution

(Dextrose)

Theory: Decreasing pain and repairing tissue by reinitiating the inflammatory process

Mechanism of Action: Unknown

May involve multiple treatment sessions each costing 200-1000$

Shoulder Injection Subacromial

Shoulder Injection Subacromial Common injection issues

Encounter bone

Redirect needle in a downward fashion, around prominent acromian or superiorly if the humerous is the obstruction.

Post-injection care

Pain may worsen 24-48 hours after injection

Post-injection examination (diagnostic portion)

TLC Physical Therapy or hold off a few days

Shoulder Injection Glenohumeral Indications

Adhesive capsulitis

Osteoarthritis

Aspiration to rule out infection

Risks

Infection

Cartilage Injury

Anatomy Review

Shoulder Injection Glenohumeral Structures to avoid

Axillary Nerve

Articular cartillage

Fluoroscopic GH injection (Use of Isovue – 200)

Glenohumeral Injection (fluroscopic assist)

Glenohumeral Injection (fluroscopic assist)

Glenohumeral Injection (fluroscopic assist)

Acromioclavicular Joint

Acromioclavicular Joint

Common Injections Elbow joint – OA/RA

Olecranon Bursitis

Medial and Lateral Epicondyles

Aspiration: Fracture, gout

Triangle of safety for IA elbow Inj. Mark landmarks of lateral

triangle Lateral olecranon Lateral epicondyle Radial head

Medial and Lateral Epicondylitis

Injection for epicondylitis (opathy) Used in conjunction with Physical Therapy

Procedure as well as an injection

Mobilize needle within tendon during injection

Ouch! Pain prescription ?

Olecranon Bursitis Injection with patient lying flat

Inject right into bursal sac

Stop when you encounter, bursal fluid

Aspirate vs. Aspirate/culture vs Cortisone Inj.

Ankle Joint Injection Indications for Injection

Diagnostic Suspected septic arthritis

Evaluation of joint effusion

Identification of intra-articular fracture

Identification of crystal arthropathy

Therapeutic Relief of pain by aspirating effusion or

blood

Injection of medications (eg, corticosteroids, anesthetics)

Patient Position Supine

Relaxed

Patient comfortable

Sitting up

Benefit of gravity

Maintain ankle in a plantarflexed position

Injection Location Avoid Dorsalis Pedis Artery and Deep Peroneal nerve

Maintained lateral the EHL

Hip Injection

Indications

OA

RA

Labral Tear

Anterior Technique

Patient supine with hip slightly flexed and IR

Femoral artery is palpated

Point of entry: 2 cm inferior to the inguinal ligament

Hip Injection Best done under fluoroscopy

Hard to confirm placement

Most get fluid back to confirm placement

Shown to be very challenging as in office procedure 1

Anterior approach was successful in only 60% of injections,

The needle pierced or contacted the femoral nerve in 27% of anterior injections and was within 5 mm of the femoral nerve in 60% of anterior attempts

Leopold SS, Battista V, Oliverio JA. Safety and efficacy if intraaticular hip injection using

anatomical landmarks. Arthritis Rheum 2001; 44: 2449-50.

Trochanteric Bursitis

Knee joint Injection

CT Arthrogram

One Big Capsule!!!

Approaches to the knee Anteriolateral/ medial

Fat pad

Cartilage

Superiolateral

Mid-Patella Patella cartilage

Thank You! Jason Rand PA-C, PT RandPA@gmail.com

Jason Rand PA-C, PT

Boston Sports and Shoulder Center

Boston Celtics Medical Team

New England Baptist Hospital – Sports Medicine

Service