1 SIMPLE MSK INJECTION TECHNIQUES-Dr Masiiwa M. Njawaya B.Med, PGDip SportsMedicine ASCEP Senior Registrar South East Sydney Sports Medicine & Orthopaedics (SESMO), Double Bay, Sydney, NSW Nepean Specialist Sports Medicine (NSSM), Penrith, NSW

2 PICTURE THE ANATOMY OR…VISUALISE IT ! PICTURE THE ANATOMY OR… THROW A DART

3 PREPARE

4 Overview Injection basics Preparation Practical LL injectionsIndications. CI. Complications. Recommendations Preparation Consent. Equipment. Patient position. Landmarks. Techniques. Post-injection care. Follow Up Practical LL injections Hip (GTB), Knee, Practical UL injections Shoulder (SAB), [Elbow (CEO) – if time],

5 Injection Basics Uses CIDiagnostic – infection (septic joint), trauma (haemarthrosis), crystal arthropathy (gout, ps.gout) Therapeutic – aspirate effusion, pain-relief (OA, inflammatory arthropathy) General Practice - CSI, Hyaluronic acid Sports Medicine - PRP, prolotherapy CI Infection, bleeding diathesis, h/o AVN, previous flare, uncontrolled DM, Uses: Pus, blood, or crystals Always aspirate: Csi effect fast last 4 weeks V HA effect 6 weeks >3 months effect. Pre ski.

6 Injection Basics Complications (IA)Trauma – neurovascular, cartilage (direct, steroid arthropathy, LA chondropathy) Infection -1 in 10,000. No touch technique. Hospital. Flare – <5% CSI – 24-48hrs, steroid crystals, ice, analgesia HA- 72hrs aseptic acute arthritis with subsequent inj. Aspirate-? Infection or crystals Diabetes- worsen sugar control ( up to 5 days) Failure (hit & miss, wrong diagnosis) Local-pigmentation, soft tissue atrophy, AVN Allergy Complications (EA) – tendon rupture (*link) Infection rates vary 1’3000-1’50000 ( gen uncommon) Csi crystals = pro-inflammatory ( irritant) ”flare”. Crystals x rxn w methylparabens(bacteriostaic) inLA. Less bioavail.

7 Injection Basics Recommendations Number Medication choice≤3 injections/year (especially weight bearing joints) Rheumatologists. Surgeons - caution pre joint replacement Medication choice LA – Reduce/Avoid IA – subcutaneous only! Ropivacaine (naropin) better than lignocaine/bupivacaine ( marcain) Steroid choice – betamethasone(celestone) V methylprednisolone (depo-medrol) V triamcinolone (kenacort) HA – synvisc (avian), durolane. Knees. Placement …Honesty. Peritendinous (consider U/S or experienced) EA (If in doubt,take it out. Repeat (U/S) No resistance #: rheu,atologists: Ra 1/ month for 3 months => 4/yr V Oa q 3m 3/yr. None 12mths Pre TKR some surgeons Med: Personal pref! PLACEMENT: Look (site, patient). Feel (resistance). Move (During:aspirate, reposition, Post: clinical signs/test)

8 LA options Lignocaine rapid onset <5 mins <2 hrs effect V Ropiva 1-15mins 2-6h V Bupivacaine slower 5-10mins 6-8h Ropivacaine less chondrotoxic than ligno (no preservs). Less cardiotoxic than bupiv (cardiac arrest)!

9 CSI Options Kenacort & depo less post injection flare

10 Preparation Consent – verbal or written Equipment Patient Position Landmarks Techniques - NO TOUCH STERILE Post-injection care Paperwork – clear documentation of above. Patient Effect: Today – Gd. Tomorrow -sore. Day aft tomorrow –better. 2wks –best. 4wks – beat. 6wks -repeat Exercise: Today-rest. 1 week later – Exercise Follow Up – 2 weeks, 6 weeks Tomorrow : 24-48hrs Monitor ?Flare ( ice, analgesia) V Scare (infection)- tracking cellulitis, pain/stiff, fevers (hospital- aspirate, washout) Effect I tell my pts: “ Sore tomorrow. Better day after tomorrow. Best at 2 weeks. Beat at 4weeks. Repeat at 6 weeks”

12 Hip(Trochanteric bursitis)Presentation Chronic overuse > Acute (trauma) Lateral hip/thigh pain. Can’t lie laterally. Test: Tender over GT. Resisted hip abduction –pain & weak. Preparation 1 amp betamethasone(5.7mg/ml) + *lignocaine 1% (50mg/5ml). 5ml syringe. 21G (green) x 1.5-2in(4-5cm) Female middle aged, SUDDEN increase in walk( hills stairs)or gym to fight the many moons. Usu assoc tendinopathy main issue,

13 Visualise the anatomy! Patient position Palpate & MarkLying lateral Palpate & Mark GT-quadrangular shape. (Bursa btw GT & Glut max tendon). Palpate superolateral GT for tender spot. Mark tender spot (golf). NO TOUCH Technique Needle perpendicular. Touch bone, withdraw slightly. Visualise the anatomy!

14 Trochanteric bursitisRe-examine Hip ROM/ massage area Advice Relative rest 2 weeks Avoid Hill/stair/repetitive exercise. Walk flat instead. Crossing leg over Pillow between legs nocte ?ITB stretches PHYSIO.

15 Knee Presentation Preparation Diffuse knee swelling – atraumaticAnterior +/- posterior pain –Arthropathy: OA/Inflammatory/Crystal Reduced ROM. Unable to squat. Test (L,F,M,ST) ROM. Swipe Test. Preparation Aspirate: 10ml syringe + 21G needle or 20ml syringe + 18G. Yellow jar –M/C/S. Lavendar tube-cell count & crystals. 1 amp betamethasone(5.7mg/ml) + *lignocaine 1% (50mg/5ml). 5ml syringe. 21G (green) x 1.5(4cm)

17 Knee NO TOUCH Techniques (6) Don’t approach too close to patellaBevel up Aspirate 1st & check! Suprapatellar (2) Mid Patella (2) Inferior Patella (Anterior) (2) Re-examine! –ROM (flexion/squat) Knee Distributes fluid. Checks effect LA / aspiration effect.

18 Suprapatellar approachSuprapatellar (2) – Easiest! Lateral suprapatellar approach 1 cm above superior pole patella + 1cm lateral to patella Medial suprapatellar approach 1 cm above superior pole patella + 1cm medial to patella Soft spot Needle 45° angle towards middle of patella Suprapatellar approach

21 Knee Advice No exercise 1 week. NWB exercise 2nd weekGraduated Return to previous exercise Topical NSAIDS/panadol/ice prn PHYSIO

22 Practical UL Injections

23 Shoulder (SAB) Presentation PreparationAcute (trauma) or chronic (biomechanics) impingement Deltoid pain - reaching at shoulder height, lying lateral, pushing. Analgesia. Test: Painful arc (~70-120° abduction) Preparation 1 amp betamethasone(5.7mg/ml) + lignocaine 1% (50mg/5ml). 5ml syringe. 23G (blue) x 1.5in(4cm) Presentation : NSAIDs, ice Prognosis: Self limiting acute 1- 6 wks. Address biomechanics

25 SAB NO TOUCH Techniques (Aspirate 1st) Re-Examine!✔Posterior – just below (1- 2cm) posterior angle acromion. Needle 30° to skin (up). Aim AL corner acromion ✓Lateral – mid-acromion, ‘soft-spot’ (groove btw acromion & humeral head). Angle needle slightly upwards. ✗Anterior –most accurate BUT NV bundle Re-Examine! Painful arc Advice -Avoid above shoulder activity. PHYSIO. SAB

26 CEO (Tennis elbow) PresentationChronic (overuse), repeated gripping/supination & pronation, tools Pain lateral elbow (radiate forearm), grip pain & weak Test in elbow extension + FA pronation, while palpating at lateral epicondyle: Resisted extension of- middle finger (ED/ECRB-Maudsley’s T), wrist. Passive full wrist flexion (Mill’s Test) Chair lift - 3 finger pinch ECRB

27 Tennis elbow (CEO) Preparation1ml betamethasone(5.7mg/ml) + 1ml *lignocaine 1% (20mg/2ml). 2ml syringe. 25G (orange) x 5/8in(16mm) May only need 1 ml total

29 CEO NO TOUCH Technique (Aspirate 1st, Peritendinous!)If Pronated position – tender spot, needle 90° OR If Supinated –i/o needle from anterior, perpendicular to anterior facet LE Pull back 1-2 mm from bone Bolus or multiple, (Peppering with PRP only) Avoid subcutaneous or intratendinous injection Re-examine – wrist extension Advice Relative rest 2 weeks Palm up grip/hold Avoid repetitive wrist & elbow motions -grip/extension/twist. Bigger grip size. Workstation. Counterforce brace Wrist splint PHYSIO CEO Counterforce brace 1 thumb breath below tender point. Comfortable Not too tight.

30 TAKE HOME MESSAGES PATIENT POSITION VISUALISE THE ANATOMYPRACTICE ….Just Do It ✓! THANK-YOU! Practice makes Perfect!

31 References Hollander JL, Jessar RA, Brown EM Jr. Intra-synovial corticosteroid therapy: a decade of use. Bull Rheum Dis. 1961;11: Raynauld JP et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48(2):370–377. Askari A et al. Hyaluronic acid compared with corticosteroid injections for the treatment of osteoarthritis of the knee: a randomized control trial. SpringerPlus. 2016;5:442. He, Wei-wei et al. Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis.International Journal of Surgery 2017, Volume 39 , 95 – 103 Bellamy, et al. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. The Cochrane Library, Issue 4, 2006. McNabb, James. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2 nd Ed.LWW; Pfenninger, JL Procedures in Primary Care 2 nd Ed. 2003