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 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 is easily recognised hydrocortisone into the inflamed knee joint of a by the characteristic symptoms and signs. The patient suffering from rheumatoid 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 . 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, , including subacromial by Mill's method often relieves the symptoms. bursitis, and . 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 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. 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- , 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 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 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 of the gleno-humeral joint. still be painful. In the ensuing week a steady In about 8o per cent. of cases presenting with pain increase in the range of painless movement may and limitation of movement of the shoulder the be noted and as long as this improvement continues Postgrad Med J: first published as 10.1136/pgmj.32.363.2 on 1 January 1956. Downloaded from 4- POSTGRADUATE MEDICAL JOURNAL January 1956 no further injection need be given. Often only shoulder' adhesions in the subacromial bursa one injection ensures uninterrupted recovery, but limit gleno-humeral movement. In a severe case if observation shows that improvement has ceased movement at the shoulder may be almost entirely or is tardy there should be no hesitation in giving due to rotation ofthe scapula on the chest wall, and one or more further injections. The patient this can be appreciated by inspection and palpation should be encouraged to increase the range of of the scapula during active and passive shoulder movement of the shoulder each day provided that movement. These patients complain of pain in the. attempt to do so is not followed by a return of the shoulder but often stiffness is the principal rest pain. A useful measure to overcome residual symptom. Tenderness is less intense and not so stiffness is the performance of pendulum exercises. localized in contrast to the findings in acute and With the trunk bent forward the patient swings the simple chronic periarthritis. Hydrocortisone in- arm in antero-posterior and medio-lateral direc- jection rarely produces much benefit in this type tions. These exercises are comparatively painless of case. If pain is a marked feature of the case as there is no pinching ofthe inflamed tissues of the however, it may be relieved by an injection, and subacromial bursa between the greater tuberosity this aids mobilization of the shoulder by exercises of the humerus and the acromion such as occurs in which are an essential part of the treatment. abduction of the shoulder. Relief of acute rest Many cases will recover after a period of a few pain occurs in about 75 per cent. of cases (Robecchi months to one year, but if improvement is not and Capra, I953; Overton, I954). In the occurring as shown by the failure to increase the remainder partial relief occurs in the majority but range of movement, the question of manipulation a few experience no benefit. Recovery occurs under anaesthesia must be considered. Ramsey eventually in the natural course ofacute periarthritis and Key (1953) consider that local injection of and is then permanent. The same applies when hydrocortisone at the time of the manipulation recovery is accelerated by the use of hydrocortisone. makes the post-operative course less painful and thus it is easier to maintain the restored range of Simple Chronic Periarthritis movement. The complains of pain in the shoulder patient copyright. region particularly near the insertion of the deltoid Bursitis muscle. Pain on movement is the outstanding There is no doubt that cases of traumatic pre- symptom, it being most severe on abduction at the patella and respond favourably moment when the greater tuberosity passes under to hydrocortisone. Aspiration followed by in- the acromion process. There may be some pain jection of I2.5 mg. of hydrocortisone into the at rest, especially at night when it may be aggra- bursa relieves the pain and residual swelling vated by lying on the affected side. Examination disappears in 7 to o days. In the series treated reveals tenderness over the greater tuberosity. by Young et al., (I954) 88 per cent. had complete There be no limitation of movement or and apparently lasting remission, and Ramsey and may slight http://pmj.bmj.com/ limitation of abduction and rotation. Calcium Key (I953) report similar results. Crisp and deposits in the rotator cuff will be revealed by Kendall (I955) had a favourable response in X-ray in about half the cases. An injection of 70 per cent. of cases but relapse occurred within hydrocortisone into the subacromial bursa pro- two months and further injections again gave only duces excellent results in about half the cases, a few temporary relief. Ramsey and Key (I953) have obtain partial relief of symptoms, and some no also treated which were inflamed but not benefit whatever. The greater the severity of the septic. Hydrocortisone I2.5 mg. was injected into pain the more likelihood there is of a successful the bursa and relief of pain followed, this lasting on October 2, 2021 by guest. Protected result. Relief of symptoms becomes less likely in for from I to 6 months. limitation of movement rather than pain is the predominant feature of the case. Plantar In this group should be included those patients This is a common cause of painful heel. The who complain of pain over the anterior aspect of patient complains of pain in the ball of the heel on the shoulder, made worse by elevating the arm, standing and walking. Tenderness is present on and with tenderness over the bicipital groove. the plantar aspect of the heel and especially on the The source of the pain is a tendinitis of the long inner side near the attachment of the head of the biceps or tenosynovitis of its sheath. to the medial process of the tuberosity of the os An injection of hydrocortisone into the bicipital calcis. In these cases I have injected hydro- groove relieves the symptoms in these cases. cortisone into the heel pad, the needle being inserted into the inner aspect of the heel and Chronic Periarthritis with Adhesions directed towards the site of attachment of the In this condition, also known as 'the frozen plantar fascia. Relief of symptoms has occurred January 1956 QUIN: Hydrocortisone Locally in Treatment of Soft Tissue Lesions Postgrad Med J: first published as 10.1136/pgmj.32.363.2 on 1 January 1956. Downloaded from in about half the cases. Crisp and Kendall (i955) 25 mg. hydrocortisone into the tendon sheath report success in about 40 per cent. of cases relieves the symptoms, often permanently, but Failure may occur because the hydrocortisone does relapses may occur requiring further injections. not reach the lesion, which may be quite small as in Tennis Elbow. In view of the ineffectiveness of other methods of treatment however, hydro- This is a condition in which movement of the cortisone injections are certainly worth a trial. finger is hindered by thickening of the flexor tendon or its sheath usually at the level of the Lesions of Tendons and Tendon Sheaths metacarpophalangeal joint. The finger tends to Stenosing tenosynovitis or De Quervain's stick in flexion, and extension is only possible with disease is frequently responsible for pain in the assistance, a distinct jerk occurring as the obstruc- region of the wrist joint. The synovial sheath tion is overcome. An injection of I2.5 mg. of containing the tendons of abductor pollicis longus hydrocortisone into the tendon sheath results in and entensor pollicis brevis is most often affected, relief of symptoms within a week. but analogous stenosis has been described in other tendon sheaths at the wrist and ankle. When the Simple Ganglion sheath of abductor pollicis longus is involved the Reports on the treatment of simple ganglion patient complains of pain in the region of the with hydrocortisone are conflicting and I have no radial styloid. The pain is felt on active abduction personal experience of it. Howard et al., (1953) and extension of the thumb, and it may radiate state that no improvement occurred in five cases upwards towards the elbow or downwards into the following injection of hydrocortisone into ganglia. thumb. Intense pain is caused by flexing the Becker (I953)' gives some interesting figures on thumb into the palm followed by forced ulnar the treatment of simple ganglion. Before hydro- flexion of the wrist. Thickening of the sheath is cortisone became available 47 patients were sometimes so marked as to be clearly visible in the treated conservatively, and in a third of the cases region of the radial styloid, and in most cases it is the ganglia disappeared. Fifty-four patients were palpable. Tenderness is present over the sheath treated surgically but the ganglia later reappeared at the radial styloid. This condition can be in a third of the cases. In 26 out of 30 patients copyright. satisfactorily treated by making an incision into the receiving local hydrocortisone the ganglia disap- thickened sheath, and until recently other methods peared and there was no recurrence. of treatment have usually been unsuccessful. Christie (I955) in a controlled trial showed that one Miscellaneous Soft Tissue Lesions injection of hydrocortisone relieved the symptoms Following an injury painful tender areas in in 70 per cent. of cases for periods exceeding three musclo-tendinous regions, tendon insertions and months. In the remaining 30 per cent. of cases ligaments are frequently found. An injection of relief was obtained but relapses occurred a few hydrocortisone into such tender areas often weeks after the injection. Relief could be obtained produces a striking relief of symptoms. In a http://pmj.bmj.com/ again by further injections but when relapses were few patients chronic pain in the hip region is observed repeatedly surgical treatment was con- associated with an acutely tender area near the sidered advisable. The following injection great trochanter. This may be due to calcareous technique has been found satisfactory. The tendinitis similar to supraspinatus tendinitis or to needle, attached to a syringe containing 2 per cent. gluteal bursitis. Treatment of this lesion with procaine, is inserted into the skin about I cm. distal hydrocortisone locally is often successful. It to the of the radial styloid in the line of the must be borne in mind however, that tip gluteal on October 2, 2021 by guest. Protected tendon of abductor pollicis longus, and is directed bursitis may be tuberculous and hydrocortisone upwards over the radial styloid so as to enter the would then be contra-indicated. Patients com- tendon sheath. The contents of the syringe are plaining of pain in the knee are occasionally found then discharged, this producing a longitudinal to have an acutely tender area in the periarticular swelling which indicates that the fluid has entered soft tissues especially near the internal lateral the sheath. The syringe containing procaine is ligament. Injection of hydrocortisone into,such then replaced by one containing hydrocortisone tender areas is worth a trial and quite often results and 25 mg. of the latter is injected. in complete relief of symptoms. I have injected tender areas in the lumbo-sacral region in cases of Traumatic Tenosynovitis low back pain but the results have been This is seen frequently in the tendon sheaths disappointing. near the wrist and ankle. The patient complains Dupuytren's has been treated with of pain over the affected sheath and examination hydrocortisone injections. Coste (I953) treated reveals crepitus on movement. An injection on ten patients and considered that slight improvement 6 POSTGRADUATE MEDICAL JOURNAL January i956 Postgrad Med J: first published as 10.1136/pgmj.32.363.2 on 1 January 1956. Downloaded from occurred in early cases. Howard et al., (I953) ment of tennis elbow, periarthritis of the shoulder considered that it was of some value as an adjunct and tenosynovitis including De Quervain's disease. to surgery in the treatment of Dupuytren's BIBLIOGRAPHY contracture. BECKER, IV. F. (1953), Indust. Med. and Surg., 22, 555. Badner et al., have BADNER, Hi., HOWARD, A. H. and KAPLAN, J. H. ('953), (I953) injected hydro- Trans. West. Sect. Am. Urol. Ass., 20, 32. cortisone into the fibrous plaques in the penis in CHRISTIE, I. G. B. (x955), Brit. med. J., i, I5oI. COSTE, F. uad WEISSENBACH, R. (I953), Rev. Rhum., 12, 863. Peyronie's disease and noted improvement in x6 CRISP, E. J. and KENDALL, P. H. (955s), Lancet, i, 476. out of so treated. HOLLANDER r. L., BROWVN, E. M., JESSAR, R. A. and I7 patients BROWN, C. Y. (I95I), . Amer. Med. Ass., 147, I629. HOWARD, L. D., PRATT, 0. R. and BUNNELL, S. ('953), .. Bone .t. Surg., 35a, 994. Conclusion MURLEY, A. H. G. (I954), Lancet, ii, 223. often relieves OVERTON, L. M. (xs94), Clinical Orthopaedics, 4, II5. Hydrocortisone injected locally RAMSEY R. H. and KEY, J. A., (I953), . Mo. Med. Ass., 50o, 604. symptoms in a variety of painful soft tissue lesions. ROBECCHI, A. and CAPRA, R. (i953), Rev. Rhum., 11, 757. YOUNG, HI. H., WARD, L. E. and HENDERSON, E. D. (x9S4), The drug is particularly valuable in the manage- Y. Bone. Pt. Surg., 36a, 6o2.

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