Repost: Corticosteroid injections for articular and soft tissue pain

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Corticosteroid injections for articular and soft tissue pain.

Patient Care August 2003;37:39-48.

{Complete paper, with tables & references, can be viewed at:}

http://www.mdlinx.com/RheumatologyLinx/thearts.cfm?artid=682686 & specid=18

Joint and soft tissue injection with corticosteroids is effective for a

variety of clinical conditions. Here is a brief guide to injection

technique at the most common sites, along with a review of indications,

contraindications, and possible complications.

Intra-articular and soft tissue injection therapies have an important

role in the diagnosis and management of rheumatoid arthritis (RA),

degenerative joint disease, crystalline arthritis, bursitis,

tendinopathies, and entrapment neuropathies.1 For several decades,

intra-articular corticosteroid injections have been performed, despite

the paucity of evidence showing their efficacy for various painful

arthropathies and periarthropathies.

In recent years, several controlled studies have examined the

effectiveness of corticosteroid injection. Though some have shown only

temporary benefits, others have found decreased pain, increased range of

motion, and improved joint function in patients with chronic subacromial

impingement syndrome and those with early-stage RA.2-6 Studies have also

substantiated the benefits of intra-articular corticosteroid injection

for joint inflammation control prior to invasive surgical procedures.7

In general, joint and soft tissue injection

* Is cost-effective for subacute and chronic articular and

periarticular disorders

* Allows for point-of-service care that often eliminates the need

for referral to an orthopedic specialist

* Is safe and does not require extensive training.

Mastery of the required techniques may be achieved by attending a

joint-injection workshop or by performing several injections under the

supervision of a physician who is competent in these skills. Once

mastered, these techniques may be performed independently in the office

setting. Third-party reimbursement for joint and soft tissue injections

is more than sufficient to compensate for the time required by these

procedures.

INDICATIONS AND CONTRAINDICATIONS

Joint and soft tissue injection techniques may be used both to confirm a

presumptive diagnosis by injecting a local anesthetic into a symptomatic

tissue region and to treat painful joints and periarticular structures

with analgesic/corticosteroid medications with the aim of decreasing

pain, improving mobility, and improving overall joint function. Joint

aspiration may also be undertaken to relieve painful joint effusions as

well as to analyze joint fluid for crystals, WBCs, and infectious

agents.

COMPLICATIONS

Joint and soft tissue injection has several potential complications.

Localized infections, including septic arthritis, may occur if proper

technique is not used. Even with sterile technique, infections may be a

problem. A postinjection corticosteroid flare, which may occur in up to

20% of patients receiving intra-articular injections, is typified by

tenderness, edema, warmth, and pain with active movement of the affected

joint. Generally occurring 24 to 48 hours after injection, it is

believed to be due to a synovitis from the preservatives in the

corticosteroid suspension. This reaction, which is more common with

short-acting corticosteroids than with longer-acting preparations, is

self-limited and responds readily to NSAIDs and the application of ice.

Skin atrophy and depigmentation are possible when corticosteroids are

injected superficially into soft tissues. These complications may be

avoided by using small doses of corticosteroid for superficial

injections (such as of the epicondyle of the elbow) and by fanning out

the injection over a larger area.

Tendon rupture, though quite rare, has been reported. Caution should be

taken never to inject directly into the tendon itself. Corticosteroid

arthropathy (accelerated degeneration of articular cartilage and

weakening of joint ligaments and tendons) is a theoretical problem that

may result from repeated corticosteroid injections over a short period

or from overuse of potent corticosteroids into the same joint. Systemic

complications such as adrenal suppression and alterations in taste have

occurred rarely.

WILLIAM D. MARTZ, MD, Assistant Professor, Department of Family and

Community Medicine, University of Arizona College of Medicine; and

Medical Director, Family Practice Office, University Physicians, Tucson

Copyright © 2003 and published by Medical Economics Company at Montvale,

NJ 07645-1742. All rights reserved.