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  • 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

    + +

    +

    =

    http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=OexEOQMwpsHZJM&tbnid=qq7F329ohzGGKM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.ehow.com%2Fhow_7382654_inject-kenalog-scar.html&ei=wtorUreJA4zD4APF_IHwDQ&psig=AFQjCNE-FNjgkuk4tWnKKRgvgC8VQ31muA&ust=1378692124676771

  • 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 (

  • 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

    http://www.cdc.gov/hai/outbreaks/meningitis-map-large.html

  • 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.

    http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=zuTGOcfOT2CBcM&tbnid=n8QR3Ct3PqCazM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.zimmer.com%2Fen-US%2Fhcp%2Fcommon%2Fproduct%2Fgel-one.jspx%3Fcate%3Dbiologics&ei=Mks-UoG3Is_54APnqoGoCQ&bvm=bv.52434380,d.dmg&psig=AFQjCNGUgiIwikZkkrc5z9QnX6pkKyAjeQ&ust=1379900583493980

  • 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

    http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=Q0YQ8SpPghz65M&tbnid=yurqGIP_MFCSXM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.jointreconstruction.com%2Fkneearthritis%2Fabknarth.htm&ei=Fk8-UqSZDNSq4APpl4CoCw&bvm=bv.52434380,d.dmg&psig=AFQjCNE6-iMkKMzBfnr56qOwrKCHMxA2Sg&ust=1379901539783635

  • 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 Glenohumera