Steve Provost(SCU) Leigh Mellish (UNSW) Jacquelyn Cranney(UNSW)
Dr Paul Annett MBBS FACSP Sports Physician Visiting Fellow UNSW.
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Transcript of Dr Paul Annett MBBS FACSP Sports Physician Visiting Fellow UNSW.
Dr Paul Annett MBBS FACSP
Sports Physician
Visiting Fellow UNSW
Cortisone Injection
Historical
• Hench & Co-workers 1950
• Hollander 1951 - Local use via injection
• Use evolved with soft tissue use to sports
Cortisone Actions
• Inhibit early inflammation– Edema, leukocyte
migration, etc
• Inhibit late manifestations– Fibroblasts
– Collagen deposition
– Scar formation
Cortisone Injection
• Important questions to ask:
• What to inject?• When to inject?• Where to inject?• How to inject?• Complications of
injection?• Advice to Patients?
What to inject?
• Joint• Bursa• Peri-tendinous• Synovial sheath• Enthesis• Ligament• Muscle
What to inject?• Shoulder - Sub-acromial, AC joint, Glenohumeral
joint
• Elbow - CEO, CFO, Elbow joint• Wrist - DeQuervains,SL ligament,Ganglion• Hand - Tenosynovitis• Ankle - Post sprain synovitis, Tendinopathy• Foot - Plantar fascial insertion, 1st MTP• Knee - Knee joint, Patella tendon• Hip - Greater trochanter, Hip Joint• Spine - Facet joint, Epidural space
When To Inject?• Appropriate diagnosis
– History– Examination– Judicious investigation
• 4-6 weeks of appropriate pre-injection management– Relative rest & X-train– Ice, NSAIDS, modalities– Well structured rehabilitation program
• NEVER in children
Advice to Patients• NOT A CURE - Rehab essential!
• Will this hurt?
• What are the side effects?– Systemic (NB diabetes)
– Infection - 1:20,000
– Crystal flare - ice + paracetamol
– Skin changes - atrophy & pigment loss
– Bleeding
– Neuritis
• How long to rest?
What to Inject?
• Cortisone• More soluble - short acting• Depot preparations• Local anaesthetic additive
– Dilute cortisone– Reduces initial pain– Confirms diagnosis
• Relative volumes
How to Inject?
• GENERAL PRINCIPLES
• Informed consent
• Aseptic no touch technique
• Avoid skin infection
• Appropriate needle & syringe size
• Be confident!
• Skin anesthesia
Failure of Injection• Physician
– Wrong diagnosis– Poor injection technique– Inadequate rehabilitation program
• Athlete / Patient– Persistent overuse– Poor technique– Intrinsic factors– Advanced degenerative disease
How Many Injections?
• Repeat at least once if initial failure– Incorrect position – ? Need imaging guidance
• Failure of 3 injections - Re-think!
• Repetition causes collagen weakness
• 3 is not set in stone
Now - On To Injections
Shoulder - Sub-acromial
• Overuse or degenerative rotator cuff pathology
• Posterolateral approach
• 2ml cortisone + 5ml local
• Re-examine
Shoulder - AC joint
• Degenerative pathology
• Superior approach• 1ml cortisone + 1ml
local
Shoulder – Glenohumeral Joint
• Capsulitis, GH OA, post traumatic pathology
• Posterior approach• 2cm inferior and medial to
posterolateral acromial edge
• Needle angled superomedial to the coracoid (palpate with other hand)
• 2ml cortisone + 5ml local
Thank You