R H E U M A T I S M D I S O R D E R S A N D A L L E R G I E S

SOFT TISSUE AND JOINT INJECTION TECHNIQUES FOR FAMILY PHYSICIANS Dr Humeira Badsha

Non-articular musculoskeletal pain can arise as iatrogenic infection or tendon rupture, are rare. a result of tendinitis, , nerve entrapment Surgery may be required for patients who refuse syndromes,myofascial pain and fibromyalgia. infiltrations or in whom infiltrations fail. It is important to differentiate soft-tissue rheumatism from other causes of pain arising from DE QUERVAIN‘S the joint. The location of pain and inflammation, Clinical appearance and presence of pain only on active range of motion This condition is characterized by disabling pain may help to differentiate a soft-tissue problem from in the radial aspect of the wrist at the base of the a joint problem. X-rays may be helpful by revealing thumb. There is swelling and tenderness of the joint problems although it must be pointed out common sheath of the abductor pollicis longus that problems can be the cause of pain and extensor pollicis brevis. De Quervain’s and disability even when there is an underlying tenosynovitis is particularly common in two joint pathology. settings: in mothers who repeatedly lift infants and young children and in people who use their hands in repetitive activities, such as knitting, sewing, and Clinical appearance gardening. A positive Finkelstein’s test is A trigger finger is the locking of one or several characteristic of the condition. The correct way to fingers in flexion. The patient may have to pull perform this test is to position the hand in the the finger to straighten it. The cause is cartilaginous following manner: In the painful hand, (a) the fully metaplasia at the first retaining pulley (at the flexed thumb rests on the palm (b) the fingers are palmar aspect of the metacarpophalangeal joint) curled over the thumb and (c) the wrist is very which normally becomes taut during finger flexion. gently deviated to the ulnar side. Acute pain along When 3 or more digits are affected, conditions the tendon is diagnostic of de Quervain’s such as diabetes and hypothyroidism should be tenosynovitis. Additional findings can include a considered. diffusely swollen and tender sheath or loculated tenosynovial effusions near the radial styloid. Treatment Spontaneous improvement occurs only in 20% of Treatment cases. If untreated, the process can lead to an Corticosteroid infiltrations are very effective in de inability to straighten the finger and permanent Quervain’s tenosynovitis, although the success rate . Trigger finger is treated with is slightly less than in trigger finger. Surgery is corticosteroid infiltrations. With appropriate indicated in the event of treatment failures. treatment, including up to 3 infiltrations, the success rate is over 95%. Complications, including GANGLIA

Clinical appearance HUMEIRA BADSHA, MBBS, FAMS, FACR Ganglia are ubiquitous uni- or multilocular cystic Consultant, Department of Rheumatology, Allergy & lesions that arise in paratendinous, pararticular, or Immunology, Tan Tock Seng Hospital intraosseous locations. Ganglia can be confidently

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diagnosed in most cases on the basis of location, distal to the epicondyle, plus pain reproduction typical increase in size and symptoms caused by by resisted dorsiflexion of the wrist. Passive elbow joint use, and palpatory findings (cystic). flexion and extension are normal. Medial Aspiration, which must be made with a large-bore epicondylitis (golfer’s elbow) represents the mirror needle, yields a thick jelly-like material. image of lateral epicondylitis. Echography, computer tomography (CT) and Treatment magnetic resonance imaging (MRI) facilitate the resolves spontaneously with time diagnosis of ganglia that occur in deep and atypical and rest of the affected arm. Patients should be locations. given isometric and range of motion exercises An imaging procedure should be performed for the entire upper extremity, including the whenever there is doubt about the diagnosis. shoulder, elbow, wrist, and fingers. Exercises Because of its low cost and excellent resolution, should not create prolonged (more than two echography is a useful imaging procedure to hours) post-exercise pain. In tennis players, investigate soft tissue lesions. alteration of technique and revision of Treatment equipment may be essential for good long-term Surprisingly, little research has been done on results. Medical therapy includes topical and ganglia. There are no published controlled trials systemic analgesics. Nonsteroidal anti- comparing different forms of treatment. inflammatory drugs (NSAIDs) can be used Aspiration followed by injection of a long-acting often, just prior to the offending exercise. corticosteroid is an appropriate treatment. Corticosteroid infiltrations are frequently used Technical details can be found in the in tennis elbow, and at least 50% of patients accompanying article. Surgery is generally find immediate relief. However, recurrence is required for lesions greater than 3 cm in seen in 30% of these patients. About 10% of diameter, for anterior wrist ganglia, and for patients have chronic symptoms despite medical intraosseous ganglia, as well as in cases where treatment, and repeated corticosteroid injections there is nerve compression. have been implicated in chronicity. Therefore, more than one injection is ill advised.

TENNIS ELBOW SHOULDER PAIN Clinical appearance Particular emphasis should be placed on Tennis elbow, or lateral epicondylitis , is common determining whether paresthesias are present. in middle-aged people, most of whom are not The common shoulder pain syndromes include tennis players. Tennis elbow results from overuse rotator cuff tendinitis, subacromial of the extensor carpi radialis brevis, a muscle that impingement, frozen shoulder and acromial- spans the lateral epicondyle, and the base of the claricular joint disease. third metacarpal, a wrist dorsiflexor. The diagnosis is suggested by the lateral location of the pain, Rotator cuff tendinitis which characteristically affects the soft tissues just Inflammation of the common tendon of the

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subscapularis, supraspinatus, infraspinatus, and Differential diagnosis teres minor may result from microcrystalline The single feature that best assists in the diagnosis deposits (apatites), overuse, impingement on the of shoulder pain is its location. The pain may be tendon from above or below, or degenerative located at the top, side, front, back, or axillary sides changes that occur with aging. Specific shoulder of the joint. Lateral pain is characteristic of rotator motions are painful, particularly abduction when cuff or glenohumeral disease. Superior pain suggest combined with rotations. Range of passive motion acromial-claricular or sternoclavicular conditions. is typically normal. Calcific rotator cuff tendinitis Anterior pain may be caused by bicipital tendinitis occurs when a pre-existing calcium deposit and early frozen shoulder. Posterior pain can be undergoes resorption, resulting in acute caused by tears in labrum glenoidale and inflammation, extreme pain and loss of shoulder suprascapular neuropathy, and axillary pain of motion. various neural causes. An important maneuver in

Subacromial impingement The rotator cuff tendon, which courses through a narrow space between the acromion and the proximal humerus, may be impinged upon from above or below. Increased tendon bulk acts as a tight-fitting wedge between the two bony boundaries. Impingement symptoms are largely due to the tendinitis. In some cases, there are also symptoms related to the condition that causes the impingement, such as tenderness at an osteoarthritic acromial-claricular joint.

Frozen shoulder It is important to remember that acromial- claricular frozen shoulder may occur in diabetic fibrosis, paraneoplastic syndrome and occasionally Figure 1: The arc of elevation maneuver. Because the in scleroderma. Frozen shoulder should be greater tuberosity of the humerus has to clear under the distinguished from such as that seen in acromion/coracoacromial ligament during abduction, rheumatoid arthritis and ankylosing spondylitis, patients with subacromial impingement hurt during arc A. reduced motion caused by inactivity, rotator cuff Once the greater tuberosity has cleared, pain ceases in arc B. A similar phenomenon occurs as the arm is brought tendinitis, and posttraumatic and postsurgical down: no pain in arc B, pain in arc A, then no pain in full capsular retraction with limited joint motion. dependency. Because the acromioclavicular (AC) joint has Because the joint capsule encircles the joint, passive its greatest motion in terminal elevation, patients with AC and active shoulder motions are equally lost in all arthritis hurt in arc B. Finally, when the AC joint causes impingement, e.g., in osteoarthritis, there will be pain in directions. arc A from impingement, plus pain in arc B from stress on the diseased joint.

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establishing the presence of rotator cuff tendinitis hip joint! To the presenting compliant “My hip and acromial-claricular joint is the arc hurts,” ask “Where in the hip?” The patient may of elevation test (Figure 1). point to the anterior, the lateral, or the posterior aspect of the joint. Treatment Differential diagnosis Physical therapy Broad physical therapy principles apply to shoulder Anterior pain pain treatment. Shoulder physical therapy should Pain originating in the hip joint is experienced begin with pendular exercises during the acute and anteriorly, mainly in the groin and anteromedial subacute phases, followed by stretching and thigh. Hip joint disease is usually associated with strengthening exercises later in the course of the limitation of motion and endpoint pain. disease. Heating the area with warm packs (or Additional causes of anterior hip pain include ultrasound) is particularly helpful prior to iliopsoas tendinitis, capsular stretching and exercising because it facilitates stretching and iliopsoas bursitis. Both tendinitis and capsular provides analgesia. stretching feature pain on traction, whereas tendinitis also causes pain on resisted motion. Medications Nonsteroidal anti-inflammatory drugs are helpful Lateral pain in rotator cuff tendinitis, including cases of Diagnosis of lateral hip pain may be difficult. Hip impingement and . arthritis seldom cause lateral pain alone. Corticosteroid infiltrations is a very useful Trochanteric bursitis affects the bursa between the treatment in rotator cuff tendinitis, the initial fascia lata and the greater trochanter. Bursal inflammation of the bursae underlying the gluteus phases of frozen shoulder, and AC osteoarthritis. medius or minimus has also been described. Surgery Radiating pain from the lumbar spine is dull and Surgery can relieve structural subacromial is associated with lumbar/gluteal pain. impingement, which is generally resistant to Neuropathies affecting the subcostal, physical and anti-inflammatory therapy. iliohypogastric and lateral cutaneous nerve of the thigh (meralgia paresthetica) cause lateral pain,

HIP PAIN paresthesias, and hypoesthesia in the corresponding territories near the iliac crest, the area just below Clinical appearance it, and the lateral thigh respectively. Bone Pain in the hip region may originate in tendinous, pathology in the femoral neck, such as a bone bursal, articular, osseus structures or other soft insufficiency fracture, and occasionally aseptic tissues. It may also be due to radiculopathy or necrosis of the femoral head may cause peripheral nerve injury, or be referred from predominantly trochanteric pain. Also, soft tissue elsewhere. The initial assessment should be based or bone malignancy may affect the trochanteric on the actual location of pain. Never take for region, and their presence should be suspected granted that “hip pain” actually originates in the whenever a bulge is felt. Radiographic studies are

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negative in routine cases of trochanteric bursitis disease can be safely ruled out. Knee examination but are very helpful in defining bone lesions. should include inspection, range of passive motion, Echography and MRI effectively detect soft tissue patellofemoral function, stressing of the medial and tumors and trochanteric bursitis. Bone scans can lateral compartments, and an assessment of joint detect intraosseus or intraarticular disease. stability. Inspection may reveal swelling at the suprapatellar pouch and parapatellar gutters Posterior pain indicative of a synovial effusion, prepatellar Posterior hip pain is less common than anterior swelling from , and patellar and lateral pain. Pain may originate in the lumbar tendon region swelling caused by pretendinous spine, occasionally in the sacroiliac joint, and in bursitis, tendon inflammation, fat pad hyperplasia/ some cases in the hip joint, although hip joint inflammation , or . Swelling disease almost always has coexistent anterior pain. at the medial or lateral articular lines usually Pain that originates in the ischial tuberosity (ischial represents a meniscal cyst. A bulge in the popliteal bursitis) is aggravated by sitting. fossa may be caused by a Baker’s cyst, but other Treatment soft tissue lesions should be excluded. The treatment of trochanteric pain caused by Palpation is used to confirm or refute the above trochanteric bursitis involves identification of findings, because fat and synovial proliferation can underlying factors, such as a 2.5 cm leg length cause bulges around the knee joint. Identification discrepancy in favor of the affected side plus of focal tenderness may be critical for diagnosis. ipsilateral iliotibial band contracture, and is key Classic findings include tenderness at the medial to a successful long-term treatment. In such a or lateral articular lines in meniscal disease; patellar patient, a 1.25 cm heel lift should be provided for or tibial insertion of the patellar tendon in calcific the short limb, and the patient should be referred and patellar tendon , to physical therapy for instruction on iliotibial respectively; tibial insertion of the pes anserinus band stretching exercises. Corticosteroid in the anserine bursitis syndrome; and lateral infiltration is an effective mode of therapy. Patients femoral condyle in patients with the iliotibial band refractory to medical therapy should be evaluated syndrome. Valgus and varus stress while flexing by an orthopedist. A longitudinal split of the and extending the joint will identify iliotibial band, which relieves pressure on the unicompartmental abnormalities, such as lateral and underlying trochanteric bursae, often alleviates the medial meniscal lesions. The Lachman test, which pain. can be described as a drawer sign elicited by pulling forward the upper tibia with the knee flexed 20 degrees, is positive in anterior cruciate ligament tears. Clinical appearance Differential diagnosis Knee pain may be intrinsic or it may radiate from a proximal structure such as the hip or the lumbar Anterior pain plexus. If knee motion is free and painless while Pain in the anterior knee may be caused by many the patient is lying on the contralateral side, knee problems including patellofemoral syndrome

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(chondromalacia patella); tender, inflamed medial meniscal tears and cysts, as well as the biceps plica (a vestigial synovial fold that has become femoris tenosynovitis in which there is tenderness swollen by inflammation and fibrosis) which will in the posterolateral corner of the joint. jump under the examining finger in a medial Posterior pain parapatellar location during flexion and extension Pain in the posterior knee may be caused by movements of the joint; prepatellar bursitis evident popliteal (Baker’s) cysts, various lesions affecting as a tender, soft tissue lump in front of the patella. the popliteal artery, venous thrombosis, Osgood-Schlatter’s disease in pediatric cases results hematomas, ganglia, and soft tissue tumors in a tender, hard lump at the tibial tuberosity. including sarcomas. Foucher’s maneuver is very Medial pain useful in distinguishing popliteal cysts from other Pain over the medial aspect of the knee is usually mass lesions. When the knee is flexed 30-40 caused by a meniscal tear in a younger patient and degrees, Baker’s cysts become soft or undetectable medial compartment osteoarthritis in patients past (a positive Foucher’s sign) while other popliteal the age of 50 years. However, there are other masses remain unchanged. Echography, with considerations. Anserine bursitis (not truly a Doppler, is particularly helpful in the analysis of bursitis in most instances) hurts on pressure 3-5 posterior knee pain. Venous disease, popliteal cm distal to the medial articular line. Medial artery aneurysms, solid tumors, and ganglia can collateral ligament bursitis, which overlaps the be reliably identified by this method. articular line, hurts more on pressure in flexion when the bursa is exposed than in extension when Treatment the sac gets covered by the medial collateral In addition to specific measures for the diagnosed ligament. Meniscal cysts characteristically soften condition, all patients with a painful knee should and may become undetectable in full flexion and be instructed on isometric quadriceps exercises. full extension, while they are hard and prominent The use of a cane on the opposite side helps relieve when the knee is flexed 30-40 degrees. pain and provides stability and safety while the Lateral pain condition improves. Depending on the cause of Pain in the lateral knee is seen in the iliotibial band the pain, local or systemic analgesics or NSAIDs syndrome, a condition that results from the may be used. Both warm packs and cold excessive friction of a tight iliotibial band on the compresses are analgesic, the effect varying with lateral femoral condyle. Patients with this the individual patient. Prepatellar bursitis is treated syndrome report lateral knee pain while running, in a similar fashion as , although going up or downstairs, and bicycling. On it is generally more problematic. Septic cases often examination with the knee in semiflexion, a tender require hospitalization, catheter or surgical spot is found on the lateral femoral condyle drainage, and parenteral antibiotics for a few days anterior to the band. Tenderness decreases or until the process is controlled. At this point, oral disappears when the knee is fully extended. Other antibiotics may be started and continued to conditions affecting the lateral knee include complete 2-3 weeks of therapy.

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In some of the regional syndromes, one or be diagnosed clinically. A lateral x-ray of the heel more corticosteroid infiltrations will eventually may show an intrabursal effusion characteristic be required. Anserine bursitis, medial collateral of . ligament bursitis, and the respond particularly well to Treatment corticosteroid infiltrations. Technical aspects of Superficial bursitis requires better shoes in the long this procedure are discussed in the run, but NSAIDs may be used temporarily. accompanying article. On the other hand, the Noninsertional tendinitis patients should be medial , tight lateral retinaculum, referred to an orthopedist with broad experience and meniscal pathology including ruptured in foot pathology, as tendon debridement or repair menisci and meniscal cysts are amenable to may be indicated. Insertional tendinitis in the arthroscopic surgery. Baker’s cysts almost always spondylarthropathies usually responds to systemic reflect intraarticular pathology that results in treatment. Refractory cases may be treated with a excess synovial fluid production and distention walking cast. Corticosteroid infiltrations in the of a pre-existent communicating gastrocnemius- retrocalcaneal bursa are very effective treatment but semimembranous bursa. They are best treated care must be taken not to infiltrate the tendon, by addressing the knee problem that causes the which could lead to tendon rupture. Ancillary bursal distention. Provided that infection has measures for all types of posterior heel pain include been ruled out, knee drainage followed by the use of heel lifts to decrease traction on the intraarticular corticosteroids is an effective Achilles tendon and gently performed tendon method to reduce a symptomatic Baker’s cyst stretching exercises. Also, the use of a night splint and avert the risk of rupture. Long-term that holds the foot at 90 degrees has been treatment is aimed at the underlying knee recommended for pain relief. process. PLANTAR HEEL PAIN

POSTERIOR HEEL PAIN Clinical appearance An enlarged superficial bursa can be readily The pain is maximal when the patient first stands identified superficial to the Achilles tendon, in the morning and tends to decrease with walking. which is best determined while the tendon is There are 4 clinical contexts in which the symptom tense. Thickening and tenderness may be felt at develops. Fat pad failure is seen in obese patients the insertional or noninsertional Achilles with attrition of the plantar fat pad, in patients tendon. The presence of nodules at the with a thin and flabby plantar pad, and as an noninsertional area (in the absence of nodular iatrogenic condition in patients who sustained rheumatoid arthritis and tophaceous gout) multiple plantar corticosteroid infiltrations for heel suggests partial rupture and is therefore a spurs. “Plantar ” is seen in runners with warning sign for a complete rupture. The extent interstitial fascial rupture, in patients with flat, and severity of the lesion can be fully disclosed pronated feet in whom a collapsed longitudinal by echography or MRI. Insertional tendinitis can arch stretches the fascia, and in patients with

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spondylarthropathy and enthesitis at the calcaneal Injection techniques: insertion. The tarsal tunnel syndrome results in K Infection is a very rare complication of plantar pain and paresthesias. It is due to a pressure corticosteroid infiltrations. Hollander has neuropathy of the calcaneal branches of the reported an overall rate of infection of 1/14,000 posterior tibial nerve or the first branch of the infiltrations. Sterile technique is reccomended. lateral plantar nerve. Both are more likely to occur K Tendon rupture following corticosteroid in patients with flat, pronated feet from excessive infiltrations may occur from collagenous pressure on the medial edge of the heel. Stress weakening caused by the glucocorticoid, fractures of the calcaneus and calcaneal cysts can especially if the preparation is injected directly also cause plantar heel pain. into the tendon rather than the tendon sheath. Skin atrophy, hypopigmentation, fat pad Treatment atrophy, and tendon rupture are generally Plantar heel pain should be treated with related to poor technique (too large a volume nonspecific measures, along with treatment aimed or dose, incorrect needle placement) with at the underlying condition. A heel cup, a firm leakage of corticosteroid into the subcutaneous plastic device that squeezes the plantar fat pad at tissue or direct injection into the tendon. its edges and increases its thickness, helps most Multiple injections (>3) in the same site should patients. Anti-inflammatory drugs help, be avoided. It is prudent to have a 4-week gap particularly in patients with spondylarthropathy. between injections in the same site. Achilles tendon and stretching K Fainting is uncommon and is related to exercises are useful once the condition becomes apprehension and pain! Excessively anxious inactive and may help prevent recurrences. patients should be injected while lying down Corticosteroid infiltrations can be quite helpful even if the target is the upper extremity. A rare, in patients with an inflammatory cause. Because but potentially severe, lethal systemic effect of the procedure is technically difficult and very corticosteroid infiltrations is anaphylaxis (6). painful, it is generally reserved for those patients Therefore, epinephrine should be at hand when who have not benefited from a more performing an infiltration. conservative program including NSAIDs in full K The most common (seen in up to 40% of doses for 6 weeks. Additional measures that have patients) systemic effect is facial flushing. This been reported to be useful include a night splint is a benign transient symptom that can last for that holds the ankle at 90 degrees and a few hours but may be quite distressing for dexamethasone iontophoresis. Laser therapy was the uninformed patient. found ineffective in a well-designed controlled trial. Because spurs do not cause the pain in Shoulder joint injection noninflammatory cases, they should not be K Posterior approach: The anterior landmark surgically removed. Plantar fasciotomy is a is the tip of the coracoid process, which can salvage procedure for severe, long-standing cases. be identified 2 cm medial to the AC joint and There is a partial collapse of the longitudinal 2 cm distal to the clavicle. The posterolateral arch following this procedure. landmark is 1 cm below and 1 cm medial to

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the posterior angle of the acromion. needle is Knee injection advanced from the posterolateral landmark K The needle is inserted horizontally under the toward the coracoid. The needle should be felt patella between the midpoint and upper pole. to slip into the joint space in which it can move Once the needle is intraarticular, which can be about freely. ascertained by aspirating synovial fluid, the corticosteroid or corticosteroid/lidocaine Subacromial bursa mixture is instilled. K Entry is posterolateral, aiming the needle anteromedially under the acromion with the Anserine bursa tip directed to the undersurface of the K Infiltrate the area of tenderness by introducing acromion. the needle directly into bursa at the medial aspect of the tibia 5 cm below joint line. Trigger finger

K The entry should be 5 mm distal to the proximal palmar skin crease for the index, O GENERAL RULES: Dosage of triamcinolone and 5 mm distal to the distal palmar skin for O Large joint: 20-40 mg 1-2 cc lignocaine the long and ring fingers. The nodule should O Small joint: 10-20 mg 1/2-1 cc lignocaine be palpable. The needle is then withdrawn O Tendons/bursae: 5-20 mg 1/2 cc lignocaine 2-3 mm, and the patient is asked to very gently flex and extend the distal phalanx practiced prior to the (this should be procedure) to REFERENCES 1. Canoso JJ. Rheumatology in primary care. Philadelphia: ascertain lack of tendon engagement. WB Saunders; 1997. 2. Van der Heijden GJMG, van der Windt DAWM, de Trochanteric bursa Winter AF. Physiotherapy for patients with soft tissue K First, the tender spot at the posterior corner of shoulder disorders: a systematic review of randomised clinical the greater trochanter is identified by ascending trials. BMJ 1997; 315:25-30. 3. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman palpation along the femur. The 1½ inch or JD. Efficacy of injections of corticosteroids for subacromial longer #21 or #22 needle is inserted vertically impingement syndrome. J Bone Joint Surg Am 1996; 78:1685-9. down to periosteum. Larger volume of 4. Schbeeb MI, O’Duffy JD, Michet CJ Jr, O’Fallon WM, lignocaine and steroid required. Matteson EL. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol 1996; 23:2104-6. 5. Schepsis AA, Leach RE, Gorzyca J. : etiology, treatment, surgical results, and review of the literature. Clin Orthop 1991; 266:185-96.

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