1. Introduction

Ian Reilly FCPodS DMS

Consultant Podiatric Surgeon

� Injection therapy (IT) for the

treatment of joint pain has been

performed for many years using

different substances� Compounds such as sodium bicarbonate,

potassium phosphate and procaine have been used

from the first half of the twentieth century▪ Miller JH, White J, Norton TH. The value of intra-articular injections in osteoarthritis of

the knee. Journal of Bone and Joint Surgery 1958; 40B: 636-643)

� Hollander et al reported the use of

hydrocortisone and cortisone in 1951 with

further reports produced by Bornstein

and Fallet, and Lambelet (cited by Miller

et al)� Hollander JL, Brown EM Jr, Jessar R, Brown C. Hydrocortisone and cortisone

injected into arthritic joints; comparative effects of and use of hydrocortisone as

a local antiarthritic agent. J Am Med Assoc. 1951; 147: 1629-35.

� Even though injectable steroids have

been around for more than 50 years,

there is a paucity of (good) evidence

regarding their use� The challenge is to apply what evidence is

available appropriately in a safe and effective

manner

� Hyaluronate, alcohol, prolotherapy, needling

“The right medicine,in the right quantity,

in the right place,at the right time”.

David Lannik MD, 2005.

1. Introduction

� Diagnostic value� Pain relief� Aspiration

� Therapeutic value� Definitive treatment� To provide a pain-free window for some

other (curative) therapy)� To provide episodic pain and symptom

relief

Reduce pain

Improve mobility

Improve function

First, Do No Harm

Intra-articular

Peri-articular

Soft tissue (ST)

1. Introduction

� Chemically, they are derived from

cholesterol and all the molecules share a

common chemical structure

� Physiologically, the glucocorticoids have a

wide range of actions as glucocorticoid

receptors are found in a wide range of tissues

� As well as anti-inflammatory and

immunosuppressive actions, they affect

carbohydrate, protein and lipid metabolism, the

cardiovascular and the central nervous systems

� Corticosteroids are injected locally for an

anti-inflammatory effect

Phospholipids

Arachidonic Acid

Thromboxane A2Prostaglandins

Endoperoxides

Prostacyclins

Leukotrienes

COX I/II

Phospholipase A2

NSAIDsNSAIDs

Steroids

Cell Injury

� Triamcinolone acetonide � Adcortyl 10mg/ml

� Kenalog 40mg/ml � Net price 1ml vial = £1.49

� Methylprednisolone acetate� Depo-Medrone 40mg/ml

� Net price 1ml = £2.87

� (also 2/3mL) � Net price with lidocaine = £3.28

� Betamethasone phosphate� Betnesol 4mg/ml

� Net price 1ml amp = £1.17 � Hydrocortisone acetate

� Hydrocortistab 25mg/ml

� Net price 1ml amp = £5.72

�Diagnostic

�Therapeutic ?

�Both?Explain to your patient in advance of the possible outcomes and your subsequent strategy

�Plantar fasciitis

�Morton's neuroma

�Hallux limitus

1. Introduction

Injections will

not benefit

everyone!

Diagnosis

Knowledge of anatomy

Treatment algorithms

Technique

Drug choice

Dosage

� Diagnosis� An inaccurate diagnosis is

made

� Knowledge of anatomy� The drug is put into the wrong

tissue

� Treatment algorithms� Steroid therapy is used

inappropriately

� Treatment is aimed at

alleviating the symptoms without addressing the

underlying cause

� Technique� Poor technique allows the

spread of drugs into adjacent

tissues

� Injections are given too

frequently

� Little regard is given to

aftercare

� Drug choice� An inappropriate drug is

chosen

� Dosage � Too little or too large a dose is

given

� Soft tissue injection� If the patient is pregnant or breastfeeding

� Overlying soft tissue infection, cellulitis or dermatitis

� A viral infection or TB

� Bacteremia

� A known hypersensitivity to any of the constituent agent

� Lack of response after two injections

� Severe coagulopathy

� Anticoagulant therapy (relative contraindication)

� Intra-articular injections

� As for soft tissue, and:

� No more than 3 injections per year in

weightbearing joint

� Unstable joints

� Inaccessible joints

� Joint prosthesis

� Osteochondral fracture

1. Select the patient

2. Prepare the injection site

3. Prepare the injection

4. Give the injection

5. Record drugs/dose/batch No’s

6. Give aftercare advice

1. Introduction

� Do you have a clear diagnosis?

� Is injection therapy the best treatment?

… at this point in the treatment pathway

� Discuss all the options

� Are there any contraindications?

… absolute or relative

� Warn about side effects

� Record that this has been done

� Information to be given to the patient should

include:� The diagnosis and nature of their condition

� The details of proposed treatment and the alternatives

� The nature and effects of drugs to be given

� The most likely possible side effects and incidence

� The likely benefits

� Your plans for follow-up and after care

� Position the patient

� Mark the site

� Swab the skin and

allow to dry

� Iodine for joint

injections

� Cotton wool and

plaster at hand

MARK A CROSS CLEANSE THE CENTRE

Mark the site

� Decide the dose and volume

� Wash and dry hands

� Open vials/swab bungs

� Draw up the steroid

� Dilute with local anesthetic: 50/50, depending

on local guidelines

� Change the needle after drawing up

solution(s)

Hand washing and skin

disinfection is important –

do it in front of the patient

Simon AC (2004) Hand

hygiene, the crusade of the infection control specialist.

Alcohol-based handrub: the solution! : Acta Clin Belg. 2004

Jul-Aug;59(4):189-93.

1. Introduction

� White 19g

� Green 21g

� Blue 23g

� Orange 25g

� Grey 27g

1. Introduction

�Clinician preference (strength/dose)

� Soft tissue:

▪Methylprednisolone

▪ Hydrocortisone

� Joints:

▪ Triamcinolone

40mg triamcinolone

40mg methyl-prednisolone

6mg beta-methasone

4 mg dexa-methasone

�Diagnosis

�Analgesia

�Dilution

�Distension

� Diagnosis: this helps confirm the placement of the solution and the diagnosis

� Analgesia: although temporary, a reduction in pain will make the whole process less painful for the patient, may help break the pain cycle and may reduce the post-injection flare

� Dilution: an increased volume of solution helps spread the active drug where a larger joint is being injected

� Distension: large volumes of injected solution may help break down adhesions

� Patient consent – can be oral or written, but must be informed� Use (non-sterile) gloves; gowns are not required

� Keep talking to the patient – let them know what to expect

� Apply strong skin traction using a non-touch technique� Insert the needle rapidly and perpendicularly to the skin

� Attempt to aspirate

� Inject joints and bursae as a bolus; entheses with a peppering technique� Withdraw needle gently and keep the plunger depressed to prevent

suction of the steroid back into the syringe

� Compress the site with cotton wool to prevent capillary leakage along the needle tract

� Dispose of sharps safely

� Apply a dressing

1. Introduction

� The injection can

be painful – we

are often

injecting into a

hot spot (PMT)

� Be aware of

patient

apprehension

� Technique used

� Aseptic

� Drugs

� Name of drug

� Dose

� Batch number

� Expiry date

� Information sheet

� Warnings given

� “You should try and rest for

the first 2-3 days after the

injection and avoid any

activities that normally

make your symptoms

worse”

�... Treatment

�... Surgery

�... Injection

�... Etc...!

1. Introduction

Bugger!

You will see complications!� Use:

� 2.5 mL syringe

� 23/25 g needle (to inject with)

� 20-40 mg of methyl-pred or hydrocortisone

� Palpate the hot spot and mark

� Inject from a medial approach (… or plantar)

� Work the needle progressively deeper

� Look for needle paraesthesia – and go gently

� Aspirate

� Inject – peppering technique

1. Introduction

Patient education, PT, OT, BMI, exercise, etc

Surgery

Paracetamol

OTC NSAIDs

Rx NSAIDs

Creamer P et al, Lancet 1997;350:503-508

Joint

Injections

Fre

qu

ency

Difficu

lty

� Use:

� 2.5 mL syringe

� 21g needle (to draw up with) / 23/25g needle (to inject with)

� 20-40 mg of triamcinolone (or methyl-prednisolone)

� Palpate the joint line� Distract and plantarflex the toe – the joint line may pucker (if there

minimal dorsal arthrosis)

� You may be able to palpate this

� Start dorso-medially (DM): insert the needle away from EHL

� Medial and dorso-lateral (DL) approaches can be tried if the DM approach is difficult

� If you do go DL, remember the EHB tendon

� Ensure you are in the joint (given the length of the needle)

� Remember the curvature of the joint: damage from the needle tip can aggravate the pain

1. Introduction

1. Introduction

� Use:

� 2.5 mL syringe

� 23/25 g needle (to inject with)

� 20-40 mg of methyl-pred or hydrocortisone� Palpate the IM space� Mark up or visualise the MPJs� Hold the needle lightly at 90 degrees to the skin� Look for needle paraesthesia – deep – and go gently� Inject in-between and distal to the MPJs� Remember the plantar surface of the skin… the patient may

feel pin-prick sensation plantarly and falsely think this is from the neuroma (causing lipo-hypotrophy)

� Talk to the patient… they may JUMP!

1. An accurate diagnosis

2. Good judgement

3. Technical skills

As a basis, sound (3D) anatomical

knowledge is crucial

� …… is just the

beginning !

� "Education is a

progressive

discovery of our

own ignorance."

▪ Will Durant

� Foot and Ankle

Injection

Techniques: A

Practical Guide

� Stuart Metcalfe, Ian

Reilly. 2010

1. Introduction

FIN

Questions???