Common Injections in Sports Medicine: General Principles and Specific Techniques



Common Injections in Sports Medicine: General Principles and Specific Techniques


Christopher J. Lutrzykowski

Francis G. O’Connor

Thad Barkdull



INTRODUCTION



  • Injections are a common intervention provided by sports clinicians. Injections can be both diagnostic and therapeutic. If delivered properly and with sound indications, injections can be very rewarding for both the patient and the provider.


  • This chapter details the indications, benefits, risks, and technique for administering common injections in sports medicine. These injections, while in most cases simple to administer, should be done only after proper training and appropriate supervision. Most injections are simple to learn (see one, do one, teach one); judgment on their use, however, takes time and effort to acquire.




CONTRAINDICATIONS (54)



  • Cellulitis or broken skin over the needle entry site would increase the risk for infection.








    Table 74.2 Common Adverse Outcomes






































    Complication


    Estimated Incidence (%)


    Postinjection flare


    2-10


    Steroid arthropathy


    0.8


    Tendon rupture


    < 1


    Facial flushing


    < 1


    Skin atrophy, depigmentation


    < 1


    Iatrogenic infectious arthritis


    < 0.001-0.072


    Transient paresis of injected extremity


    Rare


    Hypersensitivity reaction


    Rare


    Asymptomatic pericapsular calcification


    43


    Acceleration of cartilage attrition


    Unknown


    SOURCE: Gray RG, Gottleib NL. Intra-articular corticosteroids. An updated assessment. Clin Orthop Relat Res. 1983;(177):253-63.



  • Unstable coagulopathy


  • Intra-articular fractures are a contraindication to a corticosteroid injection.


  • Septic effusion of a bursa or a periarticular structure


  • Lack of response to prior injections


  • More than three prior injections in the last year to a weight-bearing joint


  • Inaccessible joints, e.g., hip, spine, sternoclavicular (62), and sacroiliac joints


  • Joint prostheses — relative contraindication


  • Known hypersensitivity to any component of the injection


GENERAL PRINCIPLES (38,63)



  • Consent: Because there are inherent risks and complications associated with corticosteroid injections, informed consent should be obtained, witnessed, and documented.


  • Equipment: Most injections are performed using an alcohol, chlorhexidine, or povidone-iodine wipe; some authors recommend a sterile scrub before injecting into a large joint (9,54). Sterile versus nonsterile gloves are another area of controversy; as a rule, the authors teach that sterile gloves are used for joints and nonsterile gloves may be used for soft tissue structures. Some advocate sterile gloves for all injections, whereas others prefer using the one sterile glove technique. In this technique, the physician wears the sterile glove on the noninjecting hand to ensure proper positioning after the local preparation. Finally, the “sterile no touch” technique may be employed as well, with only the needle touching the patient after preparation. Other equipment includes the following:



    • Povidone-iodine wipes and/or alcohol wipes


    • Sterile or nonsterile gloves


    • Sterile drapes: optional


    • 21- to 27-gauge 1.5-inches needles for injection


    • 18- to 20-gauge needles for aspirations



    • 1- to 10-cc syringes for injections


    • 3- to 50-cc syringes for aspirations


    • Ethyl chloride surface coolant


    • 1% lidocaine


    • 0.5% bupivacaine


    • 2 × 2 gauze sponges


    • Small dressings such as Band-Aids


    • Access to equipment to treat severe allergic reactions: oxygen; epinephrine 1:1,000; Benadryl 25-50 mg intramural (IM); advanced cardiac life support (ACLS) equipment


  • Anesthesia: The three main uses of anesthesia include diminishing pain, aiding in diagnosis, and providing a volume for corticosteroid injections. Although there are many local anesthetics, the two most commonly used are the amide compounds lidocaine and bupivacaine.


  • Recent studies have indicated evidence of chondrolysis in postoperative patients treated with continuous intraarticular bupivacaine (3,47). Because no minimum volume has been described, cautious use of intra-articular anesthetic is recommended until this risk has been clearly defined.



    • Lidocaine (Xylocaine) is available commercially as a 0.5%-2% concentration. The most commonly used concentration is 1%; 2% may be used in small areas where a small volume is required. Time from injection to onset of effect is 1-2 minutes, with duration of action of approximately 1-2 hours. The upper limit of dosing is 10 mL for 2% and 20 mL for 1%; above these levels, side effects can be expected.


    • Bupivacaine (Marcaine) is available commercially in 0.25%-0.5% concentrations. Time from injection to onset of effect is 5-30 minutes, with duration of action of approximately 8 hours. The upper limit of dosing is 30 mL for 0.5% and 60 mL for 0.25%; above these levels, side effects can be expected.








      Table 74.3 Relative Potencies and Solubilities of Corticosteroids











































































      Corticosteroid


      Relative Anti-Inflammatory Potency


      Equivalent Dose(mg)


      Solubility


      Concentration (mg · mL−1)


      Short-acting



      Cortisone


      0.8


      25


      NA


      25, 50



      Hydrocortisone


      1


      20


      0.002


      25


      Intermediate-acting



      Triamcinolone


      5


      4


      0.0002


      20



      Hexacetonide







      Methylprednisolone


      5


      4


      0.001


      20, 40, 80


      Long-acting



      Dexamethasone


      25


      0.6


      0.01


      4, 8



      Sodium phosphate







      Betamethasone


      25


      0.6


      NA


      6


      NA, not applicable.


      SOURCE: Genovese MC. Joint and soft tissue injection: a useful adjuvant to systemic and local treatment. Postgrad Med. 1998;103(2):125-34.



    • Side effects including anaphylaxis can occur; resuscitation equipment should be available.


    • An alternative to a local anesthetic injection is topical ethyl chloride. When used, however, spray lightly to avoid cold injury and secondary skin changes.


    • It is recommended to draw the anesthetic prior to the corticosteroid with multiuse vials to limit anesthetic contamination by the steroid (“clear to cloudy”).


  • Corticosteroids (54): Corticosteroids are commonly used in musculoskeletal medicine. The corticosteroid treats the local inflammatory response and not the clinical problem. Steroids have both mineralocorticoid and glucocorticoid effects. The mineralocorticoid effects modify salt and water balance, while the glucocorticoid effect suppresses the inflammatory response. The ideal choice is to use a medication that maximizes the anti-inflammatory effect. Steroids also differ in their solubilities, potencies, and duration of action (Table 74.3). The duration of the effect is thought to vary inversely with the drug’s solubility. Shorter acting agents tend to have a lower incidence of postinjection flare. In general, higher solubility agents (e.g., betamethasone [Celestone], dexamethasone, and methylprednisolone) tend to be better for soft tissues, whereas lower solubility agents (e.g., triamcinolone hexacetonide) tend to favor joint injections. Selected dosing is found in Table 74.4.


  • Alternative injections such as platelet-rich plasma, autologous blood, and prolotherapy are discussed elsewhere in this text.


  • Technique



    • Patient: The patient should be in a comfortable position, preferably sitting or lying down. The most important
      aspect of the patient’s position, however, is that the physician injecting is comfortable and can easily identify anatomic landmarks and administer the injection.








      Table 74.4 Recommended Corticosteroid and Lidocaine Dosages for Injections























































































      Site of Injection


      Dose of 1% Lidocaine (mL)


      Dose of Triamcinolone (mg)


      Dose of Betamethasone (mg)


      de Quervain


      1-2


      40


      6


      Carpal tunnel


      0.5-1


      40


      6


      Trigger finger


      1


      20


      3


      Tennis elbow


      0.5-1


      40


      6


      Subacromial space


      6-8


      40


      6


      Glenohumeral


      6-8


      40-60


      6-9


      Acromioclavicular


      1-2


      40


      6


      Plantar fascia


      1-2


      40


      6


      Anserine bursa


      2-3


      40


      6


      Trochanteric bursa


      4-5


      40-60


      6-9


      Intra-articular knee


      4-6


      40-60


      6-9


      Morton neuroma


      1-2


      20-40


      3-6


      Myofascial


      1-2


      NA


      NA


      Iliotibial band


      1-2


      20-40


      3-6


      Ankle


      2-3


      40


      6


      NA, not applicable.


      SOURCE: Stankus SJ. Inflammation and the role of anti-inflammatory medications. In: Lillegard WA, Butcher JD, Rucker KS, editors. Handbook of Sports Medicine. 2nd ed. Boston (MA): Butterworth-Heinemann; 1999.



    • Be prepared: Have all your equipment ready so that you can move quickly. Have your combination of steroid and anesthetic already drawn up and ready to go. Remember to use separate needles for drawing up different agents.


    • Identify structure: Put the skin under traction and identify anatomic landmarks. If needed, the skin can be marked with a fingernail, a retracted end of a ballpoint pen, or ink.


    • Aseptic technique: The area may be cleansed with alcohol, povidone, or betadine using nonsterile gloves. When entering a joint, a sterile prep may be used, but swabbing with betadine or other suitable antimicrobial prep is common practice.

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May 22, 2016 | Posted by in SPORT MEDICINE | Comments Off on Common Injections in Sports Medicine: General Principles and Specific Techniques
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