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Dr Paul Annett MBBS FACSP Sports Physician Visiting Fellow UNSW Cortisone Injection Historical • Hench & Co-workers 1950 • Hollander 1951 Local use via injection • Use evolved with soft tissue use to sports Cortisone Actions • Inhibit early inflammation – Edema, leukocyte migration, etc • Inhibit late manifestations – Fibroblasts – Collagen deposition – Scar formation Cortisone Injection • Important questions to ask: • What to inject? • When to inject? • Where to inject? • How to inject? • Complications of injection? • Advice to Patients? What to inject? • • • • • • • Joint Bursa Peri-tendinous Synovial sheath Enthesis Ligament Muscle What to inject? • Shoulder - Sub-acromial, AC joint, Glenohumeral joint • • • • • • • • Elbow - CEO, CFO, Elbow joint Wrist - DeQuervains,SL ligament,Ganglion Hand - Tenosynovitis Ankle - Post sprain synovitis, Tendinopathy Foot - Plantar fascial insertion, 1st MTP Knee - Knee joint, Patella tendon Hip - Greater trochanter, Hip Joint Spine - Facet joint, Epidural space When To Inject? • Appropriate diagnosis – History – Examination – Judicious investigation • 4-6 weeks of appropriate pre-injection management – Relative rest & X-train – Ice, NSAIDS, modalities – Well structured rehabilitation program • NEVER in children Advice to Patients • NOT A CURE - Rehab essential! • Will this hurt? • What are the side effects? – – – – Systemic (NB diabetes) Infection - 1:20,000 Crystal flare - ice + paracetamol Skin changes - atrophy & pigment loss – Bleeding – Neuritis • How long to rest? What to Inject? • • • • Cortisone More soluble - short acting Depot preparations Local anaesthetic additive – Dilute cortisone – Reduces initial pain – Confirms diagnosis • Relative volumes How to Inject? • • • • • • • GENERAL PRINCIPLES Informed consent Aseptic no touch technique Avoid skin infection Appropriate needle & syringe size Be confident! Skin anesthesia Failure of Injection • Physician – Wrong diagnosis – Poor injection technique – Inadequate rehabilitation program • Athlete / Patient – – – – Persistent overuse Poor technique Intrinsic factors Advanced degenerative disease How Many Injections? • Repeat at least once if initial failure – Incorrect position – ? Need imaging guidance • Failure of 3 injections Re-think! • Repetition causes collagen weakness • 3 is not set in stone Now - On To Injections Shoulder - Sub-acromial • Overuse or degenerative rotator cuff pathology • Posterolateral approach • 2ml cortisone + 5ml local • Re-examine Shoulder - AC joint • Degenerative pathology • Superior approach • 1ml cortisone + 1ml local Shoulder – Glenohumeral Joint • Capsulitis, GH OA, post traumatic pathology • Posterior approach • 2cm inferior and medial to posterolateral acromial edge • Needle angled superomedial to the coracoid (palpate with other hand) • 2ml cortisone + 5ml local Thank You
