The Use of Corticosteroid Preparations: Intra-Articular and Soft Tissue Injections
The Use of Corticosteroid Preparations: Intra-Articular and Soft Tissue Injections
Jennifer Kwan-Morley
Joan M. Von Feldt
A 69-year-old man who has a history of hypertension, diabetes, and hyperlipidemia presents with a 7-year history of bilateral knee pain. He notes that his pain is worse after physical activity and prolonged standing. He denies morning stiffness. He describes minimally warm knees with significant fluid. He has had only minimal relief with a physical therapy regimen, nonsteroidal antiinflammatory drugs (NSAIDs), and knee braces. He needs further management because the pain is starting to impair his activities of daily living.
Intra-articular corticosteroid injections are the mainstay of many orthopaedic and rheumatology clinics and have been extensively used to treat various musculoskeletal conditions since the 1950s. The discovery of corticosteroids in 1949, for which Hench and Kendall won the Nobel Prize in 1950, opened the door for treatment of inflammatory diseases and states. In 1951, Hollander et al.1 described the use of intraarticular corticosteroids for arthritic joints, and since then, their continued popularity is in part due to efficacy in pain relief, promptness of action, safety, and relative lack of systemic side effects. Since its discovery, the use of long-acting depot corticosteroids has found several niches.2,3 Table 66-1 lists the many diseases that have been shown to benefit from steroid injections.
CORTICOSTEROID PREPARATIONS IN THE UNITED STATES
One of the biggest challenges facing practitioners is determining the ideal preparation of corticosteroid for use, the dosage and volume of corticosteroid needed, and whether or not to add lidocaine to the steroid mixture. A study of members of the American College of Rheumatology (ACR) showed that the type of intra-articular steroids used and whether or not the physician added lidocaine to the steroid were in part due to geographic location (type of steroid) and time of training (younger physicians tend to use lidocaine). In general, fluorinated compounds are less soluble and therefore tend to be longer acting, which is preferable for intra-articular injections. However, given those characteristics, fluorinated compounds are less desirable for soft tissue injections, as their use can lead to more adverse reactions.4Table 66-2 lists commonly used preparations available in the United States.
TABLE 66-1 Diseases that Benefit from Steroid Injection
Location
Disease
Intra-articular
Rheumatoid arthritis
Systemic lupus erythematosus
Crystal deposition
Osteoarthritis
Spondyloarthropathies
Bursa
Bursitis
Tendon
Overuse syndromes
Tendinitis
Epicondylitis
Trigger finger
Never inject the Achilles tendon
Soft tissue
Myofascial/Trigger points
Tietze syndrome
Entrapment neuropathies
Carpal tunnel syndrome
Cubital tunnel syndrome
Tarsal tunnel syndrome
Intra-Articular Injections
The most important aspect of intra-articular injections is choosing the optimal dose of corticosteroids. This is in part determined by the size of the joint involved, the degree of inflammation, and the concentration of steroid used.5 In general, joints are subdivided into small, medium, and large categories. The maximum volume that can be injected into the joints without overdistension of the surrounding capsule is listed in Table 66-3. Note that the values listed are for total volume into the joint. The ACR recommends maximal drainage of the joint prior to corticosteroid injection for maximal effect and to avoid overdistension of the joint capsule.
TABLE 66-2 Commonly Used Preparations in the United States
