steroid injectionOct 31, Steroids injection meaning First popularized by Janet Travell, MD, muscle injections are a remarkably effective adjunct to pharmacologic and physical therapies and are safe and easy to perform. Joint injections, while technically more difficult to perform, also can be of great benefit in the patient's recovery. The purpose human growth hormone sydney this article is to introduce the basic principles of muscle steroids injection meaning joint injections. Inflammation is one of the body's first reactions to injury.
Steroid Injections | Cleveland Clinic
Oct 31, Author: First popularized by Janet Travell, MD, muscle injections are a remarkably effective adjunct to pharmacologic and physical therapies and are safe and easy to perform.
Joint injections, while technically more difficult to perform, also can be of great benefit in the patient's recovery. The purpose of this article is to introduce the basic principles of muscle and joint injections.
Inflammation is one of the body's first reactions to injury. Release of damaged cells and tissue debris occurs upon injury. These expelled particles act as antigens to stimulate a nonspecific immune response and to cause the proliferation of leukocytes. Local blood flow increases to transport the polymorphonuclear leukocytes, macrophages, and plasma proteins to the injured area.
A redistribution of arteriolar flow produces stasis and hypoxia at the injury site. The resulting infiltration of tissues by the leukocytes, plasma proteins, and fluid causes the redness, swelling, and pain that are characteristic of inflammation.
Initially, the inflammatory reaction serves several important purposes. The influx of leukocytes facilitates the process of phagocytosis and the removal of damaged cells and other particulate matter. Pain and tenderness remind the patient to protect the injured area; however, the inflammatory reaction eventually becomes counterproductive.
The extravascular pressure exerted by the edema may retard blood flow into the area and delay healing. The mechanism of corticosteroid action includes a reduction of the inflammatory reaction by limiting the capillary dilatation and permeability of the vascular structures.
These compounds restrict the accumulation of polymorphonuclear leukocytes and macrophages and reduce the release of vasoactive kinins. Additionally, new research suggests that corticosteroids may inhibit the release of arachidonic acid from phospholipids, thereby reducing the formation of prostaglandins, which contribute to the inflammatory process.
Finally, the clinician should appreciate the importance of introducing a needle into the injured area. The needle itself may provide drainage and a release of pressure, and it may also mechanically disrupt the scar tissue in the muscle. As with the treatment of any disorder, a carefully taken patient history and a carefully made physical examination are of paramount importance.
Sharp, severe, intense pain suggests the presence of a more acute, traumatic reaction with marked inflammation.
Dull, low-grade, chronic pain indicates the existence of a mild inflammatory reaction, a chronic overuse injury, or arthritis. Radiation of pain or additional neurologic symptoms eg, tingling, burning, numbness imply additional neurologic involvement.
Medication history is important because discontinuation of anti-inflammatory medications often precipitates a reaction. Dietary changes also may precipitate reactions, such as an attack of gout. The physical examination is performed to assess the location and severity of the reaction.
Determination of whether the inflammation is in the muscle, tendon, or joint is of paramount importance. Trigger points in muscles can be easily identified if the clinician uses the appropriate palpation skills. Many clinicians ask their patients to identify the site of greatest discomfort. Patients often know exactly where the source of their pain is, having spent hours localizing it. Radiographic studies may or may not be beneficial, because it takes a significant amount of effusion for the injury to appear on a routine radiograph.
Usually, clinical symptoms are present and treatable long before a radiographic abnormality may be identified. On the other hand, radiographs are important in evaluating for fracture or determining acuity. If joint and cartilage damage exists, the clinician knows that a long-standing process is involved.
Electromyograms EMGs are extremely beneficial in determining whether there is a significant neurologic component to the patient's symptoms. This determination is important in targeting injection sites.
Blood work can include blood counts and chemistry series. An elevated leukocyte or white blood cell count may indicate infection. An elevated erythrocyte sedimentation rate suggests that a significant myopathic or arthritic process has developed. Elevated rheumatoid factor implies chronic arthritic conditions, such as rheumatoid arthritis. Elevated uric acid levels are sometimes observed in patients with gout. Treatment of the patient with an inflammatory condition involves a multidisciplinary approach.
Anti-inflammatory medications eg, aspirins, nonsteroidal anti-inflammatory drugs [NSAIDs], oral prednisone are indicated in patients with acute and chronic inflammation. It should be remembered that a full therapeutic dose should initially be used. Many patients discontinue their medication after they have begun to feel better, leaving a low-lying inflammatory reaction.
This author recommends first prescribing the NSAID for a to day period, with instructions to use up the medication as long as side effects do not develop. This should be followed up with an as-needed prn prescription. Nonnarcotic pain medications, such as Elavil, may be beneficial in reducing the pain associated with inflammatory reactions.
Although this is an area of some controversy, the use of narcotic medications is dependent on the severity of the pain, and these drugs should be used only for a limited duration. In acute situations, rest, ice, heat, splinting, and bracing are important elements of care. With time, physical therapy, massage therapy, and general rehabilitation management become increasingly effective. While injection therapy is relatively safe, there are inherent dangers in any procedure where the skin is pierced, including infection, bleeding, joint ruptures, and perforation of vital structures.
A study by Ellegaard et al indicated that in patients with subacromial pain syndrome, the effectiveness of steroid injections is not improved by exercise therapy in the affected shoulder. The study included 99 patients, all of whom received injections, with no significant difference found in the visual analogue score for pain between the exercise intervention and control groups. Indications for injection therapy may include any of the following inflammatory conditions [ 7 ]:.
A study by Rhon et al indicated that corticosteroid injections and physical therapy are equally effective in the treatment of shoulder impingement syndrome, although patients receiving corticosteroids may require more medical visits related to their condition.
The study, a randomized, single-blind, comparative-effectiveness, parallel-group trial, involved adult patients aged years with unilateral shoulder impingement syndrome.
One group of patients received a subacromial corticosteroid injection of 40 mg of triamcinolone acetonide, while a second group underwent six manual physical therapy sessions. Patient outcomes were evaluated using the Shoulder Pain and Disability Index, the Global Rating of Change, and the Numeric Rating Scale for pain and by assessing the extent of patient health-care use related to shoulder impingement syndrome over the course of a year.
A prospective study by Althoff et al indicated that the pain and symptoms of active sacroiliitis can be sufficiently relieved for 6 months through computed tomography CT scan-guided corticosteroid injection of the sacroiliac joints. A prospective study by Earp et al indicated that a single corticosteroid injection can alleviate the symptoms of de Quervain tendinopathy for at least a year.
A study by Sarifakioglu et al indicated that both physical therapy and corticosteroid injections in the pes anserine area are effective treatments for patients with a combination of knee osteoarthritis and pes anserine tenindobursitis.
Patients with these concurrent conditions who were treated with one therapy or the other showed, after 8 weeks, significant improvements in their Western Ontario and McMaster Universities Osteoarthritis Index WOMAC scores and three-meter timed up-and-go scores. No significant differences were found between improvements associated with either treatment. However, a randomized, placebo-controlled, double-blind study by McAlindon et al found that in patients with knee osteoarthritis, intra-articular corticosteroid injections 40 mg of triamcinolone acetonide, administered quarterly over 2 years led to an increase in cartilage loss and was associated with less pain reduction than placebo injections.
The study determined that the mean change in index compartment cartilage thickness in the corticosteroid patients was about twice that of the placebo subjects. The investigators stated, though, that due to the timing of pain measurements, the study could have missed transient pain reductions in the corticosteroid group.
The packing insert for corticosteroids lists additional significant precautions and contraindications. The physician should be familiar with all of these restrictions before considering injection therapy.
Potential local side effects of corticosteroid injections include infection, subcutaneous atrophy, skin depigmentation, and tendon rupture. A study by Suh-Burgmann and Liu found a link between corticosteroid injections for joint or back pain and abnormal vaginal bleeding in postmenopausal women.
Regarding injections for myofascial pain, some clinicians prefer to perform trigger point injections of corticosteroid, while others prefer to perform trigger point injections containing only local anesthetics or no medication at all "dry needling".
The procedure for injection therapy is uncomplicated and well established. The object is to inject the corticosteroid preparation with as little pain and as few complications as possible. The technique is similar for muscle, periarticular, or articular injections. Selection of the site and careful attention to surface and deep anatomy are of paramount importance. For example, a lateral epicondyle injection is relatively easy. An injection into at the medial epicondyle near the ulnar nerve carries greater risk, and extra care must be taken to identify the nerve, outline its course, and avoid it.
Sterile technique is recommended when performing injections. This added care is needed to minimize the risk of iatrogenic infection and is especially important for intra-articular injections.
Opinions abound regarding whether to give a separate injection with just a local anesthetic eg, lidocaine prior to the corticosteroid injection. Some physicians prefer to give 1 injection the corticosteroid preparation, perhaps mixed with a local anesthetic.
Their rationale is that 1 needle is less painful than 2; however, the cortisone injection involves a thicker material, and therefore, a larger-gauge needle is used. Thus, this author prefers a 2-needle technique, feeling that this method is better tolerated by patients.
The 2-needle technique starts with the physician anesthetizing the area with a small, gauge needle and waiting minutes for the anesthesia to take full effect; a larger-bore needle gauge is then used for the corticosteroid injection.
It should be remembered that the povidone-iodine solution should dry on the skin to have its full antibacterial effect. Just swabbing on the disinfectant and injecting increases the risk of infection. Another important tip is to consider changing the needle used to aspirate the medication into the syringe with the one used to do the injection, especially when using multidose vials. Finally, gentle distraction of the joint being injected may improve accessibility.
The material used for the injection is left to the discretion of the physician. Numerous philosophies and theories exist regarding the use of the different materials that are available. This author prefers a cocktail consisting of equal parts of the following:.
For muscle trigger point injections, the needle is inserted directly into the trigger point. The plunger should always be withdrawn to confirm that a blood vessel has not been penetrated before injecting the cortisone. The needle may remain in place but can be moved up and down and turned without withdrawing it from the skin. The needle should be angled into areas of the trigger point.
It should be remembered that some of the benefit of the injection is the mechanical disruption of scar tissue. For periarticular injections, the injection should not be made directly into the tendon, lest the patient develop mechanical disruption or weakening of the tendon.
Injection of the cortisone is accomplished in small droplets around the area of inflammation.