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THE USE of HYDROCORTISONE LOCALLY in the TREATMENT of SOFT TISSUE LESIONS by C

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THE USE of HYDROCORTISONE LOCALLY in the TREATMENT of SOFT TISSUE LESIONS by C Postgrad Med J: first published as 10.1136/pgmj.32.363.2 on 1 January 1956. Downloaded from THE USE OF HYDROCORTISONE LOCALLY IN THE TREATMENT OF SOFT TISSUE LESIONS By C. E. QUIN, M.D., M.R.C.P. Assistant, Arthur Stanley Institute for Rheumatic Diseases, Middlesex Hospital Hollander et al., (I95I) showed that injection of Extra-articular tennis elbow is easily recognised hydrocortisone into the inflamed knee joint of a by the characteristic symptoms and signs. The patient suffering from rheumatoid arthritis was patient complains of pain on the outer side of the followed by striking relief of pain and stiffness, elbow radiating along the postero-lateral aspect of and a reduction of tenderness and swelling of the the forearm. The pain is made worse by using joint. There was no improvement in symptoms the hand and arm. On examination gripping and or signs in other affected joints. Measurements of dorsiflexion of the wrist against resistance obvi- intra-articular temperature showed a fall of 0.40 to ously increase the pain and there is marked 3.o°C. following injection of hydrocortisone into an tenderness over the antero-lateral aspect of the inflamed knee but no fall in the equally inflamed external epicondyle. Movements of the elbow contralateral knee which had not received hydro- joint are full. In the intra-articular variety of cortisone. These results suggested that improve- tennis elbow symptoms are similar. Examination copyright. ment in the treated joint was due to a local action of however, reveals tenderness over the radio- hydrocortisone; especially as the amount of drug humeral joint usually posteriorly but sometimes injected, namely a single injection of 25 mg., was anteriorly. Extension of the elbow is slightly too small to exert a recognisable systemic effect in restricted or there is a distinct feeling of resistance rheumatoid arthritis. This evidence of a local on attempting full extension. action of hydrocortisone on inflammatory processes Tennis elbow recovers spontaneously in periods has led to the trial ofthe drug in a variety of painful varying from 2 to 20 months from the onset. It lesions of connective tissue in the past four years. usually causes such pain and inconvenience that Local injection of hydrocortisone has been found not many patients are content to await natural http://pmj.bmj.com/ to be particularly valuable in the treatment of recovery. In the intra-articular type manipulation ennis elbow, bursitis, including subacromial by Mill's method often relieves the symptoms. bursitis, and tenosynovitis. Extra-articular tennis elbow can be cured by operation. In the operation usually performed, Tennis Elbow the common extensor tendon is cut away from the Intra-articular and extra-articular forms of lateral epicondyle with or without the periosteum. tennis elbow have been described. In the former The operation is however undertaken reluctantly the lesion responsible for the symptoms is in a for a minor disability which will eventually recover on October 2, 2021 by guest. Protected fringe of synovial membrane interposed between spontaneously. Other forms of treatment such the radial head and capitellum. This synovial as rest in a cock-up splint, manipulation, physio- fringe_ becomes thickened as a result of repeated therapy and X-ray therapy have been used minor trauma or torn in a single traumatic extensively but the results have been disappointing. incident. In the extra-articular variety the lesion There is now no doubt that local injection of is in the common extensor tendon at its attachment hydrocortisone is an effective remedy for tennis to the external epicondyle. The lesion is generally elbow. Murley (i954) treated i9 patients with supposed to be due to a partial or complete tear of hydrocortisone and i8 patients with procaine and the' fibres of the common extensor tendon but was able to show that hydrocortisone caused relief histological appearances suggest a degenerative of symptoms in a high proportion of cases. rather than a traumatic lesion. Inflammation of The method of giving the injection is simple. the radio-humeral bursa (Osgood's bursa) is a rare All that is necessary is to inject 25 mg. hydro- cause of tennis elbow. The majority of cases are cortisone acetate suspension into the tender area extra-articular. in the region of the lateral epicondyle. An Postgrad Med J: first published as 10.1136/pgmj.32.363.2 on 1 January 1956. Downloaded from January i956 QUIN: Hydrocortisone Locally in Treatment of Sof: Tissue Lesions 3 injection of hydrocortisone into such a tender area cause is peri-articular. Degenerative changes in the can: however be extremely painful and it is there- rotator cuff, and particularly in the supraspinatus fore a good plan to inject a small amount of tendon, with or without: calcification are often i per cent. Procaine solution first. found at operation in these cases of periarthritis. In successful cases pain becomes less within Inflammation of the subacromial bursa is also a 24;to 48 hours and usually within one week there common finding and is probably secondary to the are no symptoms or signs apart from slight local rotator cuff lesion. The use of the terms supra- tenderness. A few patients have increased pain spinatus tendinitis, subacromial bursitis and and occasionally there is slight swelling at the site capsulitis of the shoulder arises from an attempt to of !the injection. This' local reaction to the define the site and extent of the periarticular lesion injection usually disappears in 48 hours though more accurately but it is not always easy to make occasionally it lasts up to five days. The im- these distinctions. In practice the cases of painful mediate results of treatment are extremely shoulder fall into three groups: (I) Acute peri- satisfactory. Thus 45 out of 57 patients treated arthritis, (2) Simple chronic periarthritis (without at the Middlesex Hospital had relief of symptoms. much limitation of movement), (3) Chronic Some patients however noticed aching after heavy periarthritis with adhesions. Where there is a work though they had no pain in ordinary everyday definite history of injury it is important to bear in activities. The relief followed one injection in 41 mind the possibility of rupture ofthe supraspinatus" patients but the remaining four required a second tendon for the treatment of this lesion is surgical. injection. A reduction in the severity ofsymptoms The characteristic feature of this condition is occurred in eight patients and'in four there was no immediate weakness of the arm following the benefit. Follow up over a period of one year has injury, the patient being unable to perform the shown that about half the cases relapse. 'The first I5° of abduction. If, however, he is assisted symptoms on relapse are not usually so severe as with the initial phase of abduction he can complete they'were originally and they respond to a further the movement. In addition the tuberosity of the injection of hydrocortisone. In spite of the humerus may appear unduly prominent on the occurrence of relapses and the occasional failure affected side and a sulcus be seen or felt near may copyright. even with several injections, the local injection of the tuberosity where the tendon should be. hydrocortisone is a most valuable remedy for tennis elbow comparing very favourably with other Acute Periarthritis forms of treatment. There may be a history of injury to the shoulder or of a fall on the outstretched hand but this is not Golfer's Elbow always so. The patient develops intense pain in Golfer's elbow or medial epicondylalgia is a the shoulder. The pain is present at rest often condition very similar to extra-articular tennis preventing sleep, and it is aggravated by the elbow but it is not so common. Examination movement of the arm.' Movement of slightest http://pmj.bmj.com/ reveals tenderness over the anterior aspect of the the shoulder is restricted because of the pain. medial epicondyle. Symptoms are relieved by Marked tenderness is present over the anterior injection of hydrocortisone into the tender area. aspect of the shoulder in the region of the greater tuberosity and between it and the acromion Periarthritis of Shoulder process. It is in these acute cases that hydro- Various cervical, thoracic and abdominal lesions cortisone is extremely beneficial. Hydrocortisone may giva rise to pain referred to the shoulder. is injected into the subacromial bursa. The Although stiffness of the shoulder may occasionally needle attached to a syringe containing 2 per cent. on October 2, 2021 by guest. Protected arise from disuse in such cases, movement of the Procaine is directed towards the superior facet of joint is usually full and painless. Arthritic or trau- the greater tuberosity of the humerus and advanced matic lesions of the sternoclavicular or acromio- until the point of the needle strikes bone. It is clavicular joints can cause pain in the shoulder then withdrawn about Imm. The procaine aggravated by movement but are easily recognized solution should flow easily after this slight with- by the presence of tenderness and often by swelling drawal of the needle. The piston of the syringe of the affected joint. Pain in the shoulder with should be Withdrawn and occasionally chalky limitation of movement of thejoint may result from material will be aspirated; 25 to 50 mg. of hydro. lesions such as primary or secondary neoplasm or cortisone should then be injected. Within 24 to Paget's disease in the upper end of the humerus, 48 hours of the injection there is usually relief of and from tuberculous arthritis, rheumatoid arth- the constant severe pain though movement may ritis or osteoarthritis of the gleno-humeral joint. still be painful. In the ensuing week a steady In about 8o per cent.
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