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Joint and Soft-tissue Injections Of The Upper Extremity
INJECTION TECHNIQUES: PRINCIPLES AND PRACTICE 1047-9651/95 $0.00
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JOINT AND SOFT-TISSUE INJECTIONS OF THE UPPER EXTREMITY William F. Micheo, MD, Ricardo A. Rodriguez, MD, and Eduardo Amy, MD
Peripheral joint and soft-tissue injections are potent diagnostic and therapeutic tools that have a role in the treatment of localized inflammation. These injections can be used to differentiate various clinical pain syndromes, and with adequate patient selection as well as proper injection technique morbidity can be reduced below that encountered with nonsteroidal anti-inflammatory Pathologic conditions potentially improved by local corticosteroid injections include articular disorders such as rheumatoid arthritis and osteoarthritis; nonarticular disorders such as bursitis and tendonitis; and myofascial pain syndrome~.'~, 39, 40 Specific clinical entities that are amenable to treatment with local injection include carpal tunnel syndrome (CTS)12,13, 20, 38, 41, 54 and De Quervain's tenosynovitisI4,30, 41, 53, 55 in the wrist; epicondylitis9,23, 33, 34, 42 in the elbow; and impingement syndromes, adhesive capsulitis, and acromioclavicular joint disorders* in the shoulder. The purpose of this article is to review the literature and present the authors' methods of evaluation, treatment, and injection for these upper extremity conditions. PHARMACOLOGY
Since the initial intra-articular corticosteroid therapy used in 1951 by Hollander et a1,'6 local treatment has evolved into using longer-acting steroids in
From the Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico Medical School, San Juan, Puerto Rico PHYSICAL MEDICINE AND REHABILITATION CLINICS OF NORTH AMERICA VOLUME 6 . NUMBER 4 . NOVEMBER 1995
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combination with local anesthetic agents. The use of the anesthetic agents serves a dual purpose: to achieve fast pain relief and to help in the diagnostic process4,l3 Longer-acting preparations (bupivacaine hydrochloride) are now available that give a longer duration of pain relief and may allow progression of the rehabilitation process. When the presence of an inflammatory process makes the use of an anesthetic agent alone insufficient for therapeutic purposes, corticosteroids may be of great benefit. The corticosteroids suppress the initial events of inflammation by inhibiting migration of inflammatory cells, capillary dilatation, and tissue edema. Once the inflammatory process starts, they also inhibit capillary and fibroblast proliferation and collagen synthesis. These latter effects are known to compromise healing and to decrease tensile strength of tendons and ligament^.^', 3h Corticosteroids can be divided into those which are short acting (cortisone, hydrocortisone), intermediate acting (prednisone, prednisolone tebutate, triamcinolone, methylprednisolone acetate), and long acting (dexamethasone sodium, bethamethasone). Although there appears to be a preference in the literature* to use intermediate- and long-acting steroids, no particular agent has been documented as being more advantageous than another. The relative insolubility of some corticosteroids affects their potency and duration of response.'&29 The effect of agents that are water soluble and readily absorbed tends to be of shorter duration.
ADVERSE EFFECTS The most common symptomatic adverse reaction is a postinjection flare that has been reported to occur in 1%to 10% of patients.33,39, 42, 49 This can be lessened with the concomitant administration of lid~caine.~, 23 Other local adverse effects seen less frequently include steroid arthropathy, skin atrophy and depigmentation, and tendon r ~ p t u r e . ~ "52~Systemic ~ , ~ ~ , or distant effects may include facial flushing, hypersensitivity reaction, transient paresis of the injected extremity, and the hyperglycemic effect of the short-acting agents in diabetic patients.39In general, the use of injections is very safe, with studies reporting an incidence of infection of 0.0001% or less if an aseptic technique is used.2h,49
GENERAL GUIDELINES Precautions that should be followed when using corticosteroid treatment include limiting the number of injections to any particular area or joint to three per year. They should not be used in patients who will not follow or are unable to follow a relative rest period postinje~tion.~~ Special care should be taken to use peritendinous injections and never intratendinous or intraneural injection, or injection into subcutaneous fat. In the case of intra-articular injection, trauma to cartilage should be prevented. When using anesthetics and steroids mixed in the same syringe, precipitation and the formation of crystals may result, which may be a source of local flare or may lead to calcification in the area of injection. This may be avoided by using single-dose vials of lidocaine, which lack preservatives; longer-acting bupivacaine; or injecting with separate syrin"References 9, 11-13, 20, 23, 26, 34, 38, 45, 54, 55.
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g e ~The . ~authors ~ consider an overlying infectious process an absolute contraindication to soft tissue injection. An aseptic technique should be followed during infiltration. Once the optimal site for injection has been chosen, the skin is preferably cleansed with an iodine solution or swab at least twice, and then with alcohol. Sterile gloves are not necessary, but syringes and needles should be sterile and disposable. Local injections should only be considered a part of the rehabilitation program. They should be used in combination with other therapeutic modalities such as physical agents and exercise. When stressing tendons after corticosteroid injections, consideration should be given to the fact that there may be a reduction in the tensile strength of the tendons of as much as 40%. This tensile strength reduction may last anywhere from 14 days to 15 weeks, particularly after direct tendon injecti~n.~', 36, 56 THE WRIST Functional Anatomy
In the volar aspect of the wrist, below the skin and the deep fascia, is the tendon of the palmaris longus muscle, which continues as the palmar aponeurosis overlying the flexor retinaculum. Important structures superficial to the transverse carpal ligament are the ulnar nerve and artery radial to the flexor carpi ulnaris tendon and the radial artery radial to the flexor carpi radialis (Fig. 1).The transverse carpal ligament is a 2- to 3-cm-long structure extending from the navicular to the hamate and pisiform. Together with the more dorsal carpal bones, it forms the carpal canal (Fig. 2). The canal houses the flexor digitorium superficialis and profundus, as well as the flexor pollicis longus, with a radially oriented median nerve. The more ulnar arrangement of the flexors of the digits allow for ample room of the median nerve. The flexor carpi radialis splits the flexor retinaculum to continue to its insertion. The extensor retinaculum of the wrist accommodates the nine extensor muscles that cross the wrist in six different compartments. The first dorsal compartment is the one that houses the extensor pollicis brevis and the abductor pollicis longus adjacent to the radial styloid process. The superficial branch of the radial nerve crosses the wrist over the radial styloid in close proximity to the tendons of the first dorsal compartment (Fig. 3). CARPAL TUNNEL SYNDROME Clinical Concepts
The usual history of a patient with CTS is complaint of progressive weakness and clumsiness of the hand, pain in the hand or forearm, and associated hypesthesia or paresthesia in the median nerve distribution. In more severe cases, paralysis of the abductor pollicis brevis with thenar eminence atrophy is observed. Symptoms may be bilateral, worse in the dominant hand, increased with forceful hand activities, and awaken the patient at night. The clinical examination includes sensory evaluation of the hand and manual muscle testing of thenar eminence muscles, as well as thorough neurologic assessment of the upper extremity to rule out proximal pathology such as a cervical radiculopathy.
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Figure 1. Volar wrist anatomy. A = Transverse carpal ligament; B = median nerve; C = flexor pollicis longus; D = flexor carpi radialis; E = radial artery; F = ulnar artery and nerve; G = palmaris longus; and H = flexor carpi ulnaris.
Special tests such as Phalen's and the Tinnel sign may be positive in over 70% of patients; however, their absence does not rule out the ~ o n d i t i o nElectrodiag.~~ nostic studies have been shown to have a high degree of sensitivity and specificity in confirming and establishing the severity of CTS.' Mild cases of CTS can be treated initially with the use of splinting, physical therapy, nonsteroidal anti-inflammatory drugs, and limitation of provocative activities. This activity modification may include work restrictions and job site changes, because CTS has been clearly defined as an occupational d i s ~ r d e r . ~ , If symptoms persist despite the previously mentioned treatment regimen, injection into the carpal tunnel is performed. This injection has the dual role of diagnosis and treatment.13s41It may also play a role in prognosis because a direct correlation has been found between relief of symptoms with injection and relief with surgery.12,13, 24 The effectiveness of treatment with injection has varied in the literature with documented relief seen in 13% to 81% of patient^.'^^'^^^^^^^^^^^ 54 The recurrence rate ranges from 8% to 94%."13,41,54This variability of results is related to the different populations studied, study techniques, diagnostic parameters, follow-up time, and different outcome measures.
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Figure 2. Transverse wrist anatomy. A-G as in Figure 1; I = flexor digitorurn superficialis; and J = flexor digitorurn profundus.
Figure 3. Anatomy relative to de Quervain's tenosynovitis. A = Extensor pollicis longus; B = radius styloid process; C = abductor pollicis longus; D = extensor pollicis brevis; and E = superficial radial nerve.
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The two most commonly used approaches for the infiltration of the carpal canal are radial or ulnar to the palmaris l o n g ~ s . " - 38,41,54 ~ ~ ~ ~The , ulnar approach appears to be safer when one takes into consideration the anatomy of the wrist. A radial approach would place the needle in close proximity to the median nerve and make it more susceptible to damage.10,",44A recent cadaver study by Minamikawa et showed that a reproducible delivery of medication into the carpal tunnel could be achieved by using the ulnar approach.32 Severe cases of CTS that do not respond to treatment and show severe paresthesias as well as weakness and atrophy of the thenar muscles require surgical management.
Injection Technique
The wrist is positioned in a neutral or a slightly extended position on the edge of the table. A 23- to 25-gauge 1- to 1.5-in needle is inserted ulnar to the palmaris longus, or in its absence, in line with the fourth ray at the wrist flexion crease. The needle should be directed at a 30-degree angle beneath the transverse carpal ligament and oriented radially until the carpal tunnel is entered. Proper placement can be ascertained by needle movement with digit flexion and extension. If paresthesias are felt by the patient, the needle should be withdrawn and repositioned. Once the proper needle placement is achieved, aspiration to avoid injection into a vessel should be performed. A mixture of 10 to 20 mg triamcinolone or an equivalent corticosteroid preparation, combined with 0.5 to 1 mL 2% lidocaine, is injected slowly into the carpal canal (Fig. 4). Another alternative is to inject the local anesthetic and subsequently inject the steroid by changing the syringe and leaving the needle in place. Minimal resistance should be felt at the time of injection. The patient will feel a gradual onset of numbness in the median nerve distribution if needle localization was adequate. Immediate, severe worsening of symptoms after the procedure may indicate intraneural injection of corticosteroid, and this would require emergent surgical consultation." After the injection the patient is instructed to use a resting splint at night, to limit forceful activities for a period of 2 weeks, and to return for reevaluation in 1 to 2 weeks. DE QUERVAIN'S TENOSYNOVITIS Clinical Concepts
The characteristic signs and symptoms of this condition are pain radiating from the radial styloid process to the thumb and proximally into the forearm. It also presents with increased pain on range of motion at the wrist and thumb with swelling and tenderness on the first dorsal compartment. A positive Finklestein's test result, which consists of positioning the patient's thumb into the palm of the hand under the flexed fingers and passively ulnarly deviating the wrist with reproduction of symptoms, may be elicited. This tendon disorder can be chronic or present acutely and is usually considered idiopathic. However, a strong association between the signs and symptoms of hand and wrist tendonitis and repetitive as well as forceful manual .~ reports have described anatomical work activities has been r e p ~ r t e d Several variations in the first dorsal compartment where the extensor pollicis brevis and
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Figure 4. Injection technique for CTS.
abductor pollicis longus are in separate compartments in patients with De Quervain's tenosyn~vitis.'~ 53, 55 These anatomical variants may be associated with increased failure of conservative treatment. The initial treatment of this condition includes the use of icing, relative rest, and therapeutic modalities such as electrical stimulation and ultrasound. Additional use of a spica splint for 2 to 3 weeks could also be considered. The combination of injection into the first dorsal compartment with splinting is also an alternative treatment. The reported effectiveness of the use of corticosteroid injection ranges from 50% to 90% improvement in symptom^.'^, 30, 41, 53, 55 Injection Technique
Treatment consists of an injection of 20 mg of triamcinolone with 0.5 mL of 2% lidocaine into the first dorsal compartment using a 23- to 25-gauge needle 5/8- to 1-in long. The needle is introduced 1 cm proximal to the tip of the styloid process and angled distally at 45 degrees to the longitudinal axis of the forearm (Fig. 5). Observation of filling of the tendon sheath confirms adequate
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Figure 5. Injection technique for de Que~ain'stenosynovitis.
placement. Because of the close relationship of the superficial radial nerve to the first dorsal compartment, any symptoms of paresthesias in the thumb while placing the needle indicate a need for relocation. THE ELBOW Functional Anatomy
The distal humerus consists of a lateral and medial condyle forming the articular surfaces for the trochlea and capitellum. Located above the condyles, the lateral epicondyle serves as the origin of the extensor-supinator group, and the medial epicondyle is the origin of the forearm pronator-flexor group. The extensor carpi radialis longus originates just below the brachioradialis from the supracondylar ridge and inserts in the base of the second metacarpal. The extensor carpi radialis brevis originates from the inferior lateral epicondyle and inserts in the base of the third metacarpal. The main action of these muscles is wrist extension with radial deviation at the wrist (Fig. 6). The principal nerve found in the lateral aspect of the elbow is the radial nerve. The nerve winds around the posterior aspect of the shaft of the humerus, piercing the lateral intermuscular septum to enter the volar compartment of the forearm. At this point it lies lateral to the brachialis, posteromedial to the extensor carpi radialis longus, and volar to the capitellum in an area known as the radial tunnel. At this level it innervates the brachialis, brachioradialis, and extensor carpi radialis longus. The nerve divides near the arcade of Frohse into superficial and deep branches. The deep branch passes between the two heads of the supinator muscle to continue as the posterior interosseous nerve. Clinical Concepts
Lateral epicondylitis is a syndrome characterized by pain over the lateral epicondyle of the humerus that may radiate to the arm and forearm. It is
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Figure 6. Anatomy relative to lateral epicondylitis of the elbow. A = Humerus lateral epicondyle; B = extensor carpi radialis longus; C = extensor carpi radialis brevis; D = extensor digitorurn cornrnunis; E = extensor digiti minirni; and F = extensor carpi ulnaris.
worsened by extension or supination of the wrist against resistance. Point tenderness localizes the lesion, which most commonly involves the extensor carpi radialis brevis muscle. Symptoms may be reproduced by resisted wrist or third digit extension. This is an overuse syndrome that affects more men than women in the dominant upper extremity. It may be the result of occupational activities that involve repetitive gripping or rotation of the forearm?,23, 25, 35, 46 In tennis players it may be the result of faulty technique, particularly the backhand stroke or incorrect grip size.% The initial treatment should include the use of icing and electrical stimulation. Heating modalities such as ultrasound can be added in the subacute or chronic stages. A flexibility and strengthening program of the wrist extensor muscles emphasizing eccentric exercises should also be incorporated. With failure of early conservative treatment to decrease the signs and symptoms of inflammation within 4 weeks, infiltration of the epicondyle should be considered with a combination of anesthetic and corticosteroid. Some investigators, such as Schnatz and Steiner,46initially treat lateral epicondylitis with a steroid injection,
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and others, such as Brattberg5found other treatment modalities such as acupuncture to be superior to local injection with corticosteroids. A meta-analysis by Labelle et alZ5suggested a positive therapeutic effect for steroid injection; however, conflicting results and methodological problems led to recommendations of further research. Failed treatment with local corticosteroid injection may be caused by the presence of radial tunnel syndrome. In this clinical entity, pain is usually distal to the epicondyle, anterior to the radial head, or the extensor muscle mass. Electrodiagnostic testing that shows involvement of the radial innervated muscles distal to the supinator muscle may confirm the diagnosis.
Injection Technique
A mixture of 20 mg of triamcinolone with 0.5 mL of 2% lidocaine is prepared for injection. The needle is a 23- to 25-gauge, 5/8 to 1 in in length. The patient is seated with the elbow flexed and relaxed resting on the lap. Injection into the most tender area should take away the pain. This may require alternating technique in which the needle is redirected in at least three different orientations (Fig. 7). Aspiration is attempted before injection, and careful observation for paresthesias during needle placement is made, which would lead to needle repositioning. After infiltration, light pressure over the area to ascertain distribution of the injected solution should be performed. Light resisted wrist extension without pain points to an effective injection. A relative rest period after injection is advised for approximately 2 to 3 weeks, and for those patients who need to use their hands for repetitive activities, a wrist cock-up splint to rest the extensor muscles should be prescribed.
Figure 7. Injection technique for lateral epicondylitis.
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THESHOULDER Functional Anatomy
Complete shoulder motion involves the glenohumeral, sternoclavicular, acromioclavicular, and scapulothoracic articulations. Shoulder stability depends on normally functioning muscles, intact ligaments, glenoid labrum, and capsule. The rotator cuff muscles originate from the scapula and insert into the lesser tuberosity, greater tuberosity, and transverse humeral ligament. The rotator cuff is formed by the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, which fuse into a tendon as they insert into the humerus. The long head of the biceps tendon originates intra-articularly from the supraglenoid tubercule and penetrates the rotator cuff between the supraspinatus and subscapularis tendon. The rotator cuff muscles provide stability of the shoulder against the action of the prime movers such as the deltoid. The infraspinatus in particular maintains the center of rotation of the humeral head, minimizing upward migration under the coracoacromial arch as the deltoid pulls the arm into abduction or forward flexion (Fig. 8). The coracoacromial ligament connects the acromion and coracoid process forming an arch under which the cuff tendons pass. Several bursae are present in the shoulder; however, the subacromial bursa is the one that facilitates passage of the rotator cuff under the subacromial arch. In some cases it is considered to be a serosal surface rather than a bursa1 sack.z8
Figure 8. Anatomy relative to the shoulder. A = Acromioclavicular ligament; 6 = acromion; C = subacromial bursa; D = supraspinatus; E = infraspinatus; F = teres minor; G = coracoacromial ligament; H = coracoid; L = tendon long head biceps femoris; J = glenoid labrum; and K = subscapularis.
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IMPINGEMENT SYNDROME Clinical Concepts
Impingement has been described as the encroachment of the acromion, coracoacromial ligament, coracoid process, and acromioclavicular joint on the rotator cuff mechanism that passes beneath them as the glenohumeral joint is moved.28Impingement syndrome resulting in shoulder pain can be caused by acute or chronic overload and may be the final end point of a variety of glenohumeral and scapulothoracic abnormalities. Repetitive overhead activities are thought to be the cause of symptoms in the younger athlete."" In the older patient, degenerative changes within the tendon and bony changes within the coracoacromial arch may be the etiologic factors.152R,31 Structures that may be affected include the rotator cuff tendons, biceps tendon, and the subacromial bursa. The patient may present with complaints of pain after overhead activities. As the condition progresses, pain may interfere with throwing activities, activities of daily living, and may be present at night, leaving the patient unable to sleep on the affected shoulder. This pain may be associated with a catch, aggravated at midranges of shoulder motion, and may radiate to the anterolatera1 aspect of the shoulder. In chronic stages the patient may also complain of weakness and loss of muscle mass. On physical examination, inspection may show atrophy of the deltoid and other shoulder girdle muscles. Palpation may show subacromial, biceps tendon, and acromioclavicular tenderness. Passive range of motion testing may show limited internal rotation secondary to a tight posterior capsule. Active range of motion shows crepitus and pain particularly in the 60- to 120-degree range of abduction or flexion. Manual muscle testing may show weakness of the external rotators while testing with the arm at the side and the supraspinatus while testing resisted abduction in the scapular plane with internal rotation in the "empty can position." Reproduction of symptoms with the impingement maneuver of maximally internally rotating the shoulder with flexion to 90 degrees may aid in the diagnosis. Patients with bicipital tendinitis show localized pain to palpation of the biceps tendon and reproduction of symptoms on resisted forward shoulder flexion as well as elbow flexion. When pain and guarding interfere with the examination, a subacromial injection of local anesthetic is useful in identifying the structures of the subacromial zone as the source of the patient's di~comfort.~, 15, 28, 31 It is important to identify within the spectrum of impingement syndrome a patient that may have a rotator cuff tear. This patient may show residual weakness despite improvement in pain after anesthetic injection. Specialized diagnostic testing as well as surgical treatment may be needed in these cases. Initial management of patients with impingement includes rest from overhead activities that produce pain and modalities such as ice, electrical stimulation, and ultrasound. Therapeutic exercises include posterior capsule stretching and strengthening of the rotator cuff and other scapular muscle^.'^ If pain interferes with the rehabilitation program after 3 to 4 weeks of treatment, an injection with corticosteroids may be ~onsidered.~, 15, 17, 22, 31, 40, 47 These injections are used to allow progression in the rehabilitation program, particularly with strengthening exercises. Subacromial injections are frequently used and found to be clinically effective; however, scientific data supporting their use is sparse.
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Injection Technique
Using a 21- to 23-gauge 1.5-in needle, 40 mg of triamcinolone and 3 to 5 mL of 2% xylocaine are injected into the subacromial space. The patient is placed in a sitting position, traction is applied to the upper extremity, and the subacromial space is entered using a lateral approach under the palpable tip of the acromion (Fig. 9). Once the subacromial space is entered, minimal resistance should be felt on injection. If resistance is felt, this may indicate injection into the tendon or acromion, and retraction and repositioning of the needle may be needed. An alternative technique is to use a posterolateral approach under the easily palpable acromial tip. This approach is helpful in older patients with osteophyte formation3 and when difficulty is encountered entering the subacromial space on lateral approach. For biceps tendon sheath injection, the patient is placed in a sitting position with the elbow flexed and the forearm supinated. The biceps tendon is localized and injected using a 25-gauge 1-in needle with 20 mg triamcinolone and 1 mL of 2% xylocaine in a plane parallel to the bicipital groove along the sheath and not into the tendon itself (see Fig. 9). After injection the patient is instructed to use ice for 48 hours, to limit forceful overhead shoulder activities for a period of 2 weeks, and to continue in the rehabilitation program. ADHESIVE CAPSULlTlS Clinical Concepts
Clinically, adhesive capsulitis is defined as a progressive painful limitation of shoulder motion.47The patient usually complains of stiffness, pain with
Figure 9. Injection technique for subacromial bursa and biceps tendon in impingement syndrome and adhesive capsulitis.
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attempted motion, and pain at night. A history of precipitating events or associated conditions such as trauma, immobility, bursitis, or diabetes mellitus may be present; however, in many instances no causative factors are identified. On physical examination the patient may show diffuse shoulder tenderness as well as restricted passive and active motion. This loss of motion is usually more significant in external and internal rotation. In this patient group a subacromial injection of anesthetic may eliminate pain, but restriction of motion will persist? l8 The natural history of adhesive capsulitis has been widely studied. In some patients it appears to be a self-limited condition; however, in others symptoms are seen as long as 2 to 3 years after the initial onset.1R43,50 Multiple therapeutic interventions that include physical therapy, oral medications, manipulation under general anesthesia, and local corticosteroid injections have been studied and Local injections found to have variable results in shortening the recovery time.8,47 with corticosteroids, particularly if used early in the treatment course, have been found to be of benefit in pain relief; however, no definite improvement in the range of motion has been shown after periarticular or intra-articular injections.43, The patient is initially managed with superficial heat, electrical stimulation, and ultrasound in combination with pendulum as well as active assistive motion exercises. Gentle stretching and light strengthening may be added with increased patient tolerance to the rehabilitation program. If the pain interferes with the exercise program or with sleep, the addition of local corticosteroids 4 to 6 weeks into the treatment course should be considered. Injection Technique
With the patient in a sitting position, the subacromial space and bicipital tendon are injected using the same technique as previously described for impingement syndrome. If myofascial trigger points are present over the posterior muscle area, an injection with 1 mL of 2% xylocaine using a 5/8- to 1-in, 25gauge needle may be considered. In addition to the periarticular injection, an intra-articular injection may be attempted. The approach used at our center, based on anatomic dissection, is an anterior-superior approach (Fig. 10). Using the anterior aspect of the acromioclavicular joint as a landmark, a 22-gauge 1.5-in needle is directed inferiorly into the joint. When resistance is felt at the tip of the needle, perform a gentle passive internal external rotation of the shoulder. If this is accompanied by movement at the tip of the needle, slightly retract the needle, aspirate, and inject. A combination of 20 to 40 mg of triamcinolone with 1 to 2 mL of 2% lidocaine may be injected. It is important to note that if the capsule is contracted it may be difficult to enter the joint space and the contents may be injected periarticularly. In this setting fluoroscopically guided intra-articular injections may be an alternative to assure injection into the glenohumeral joint. After the injection the patient is given instructions to use icing for the next 48 hours and to continue in his or her rehabilitation program. The patient should be re-evaluated the week after infiltration. ACROMIOCLAVICULAR JOINT DISORDERS Clinical Concepts
Pain related to the acromioclavicular joint could be the result of trauma, overuse, or degenerative changes. A young weight lifter may present with pain
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Figure 10. Injection technique for adhesive capsulitis. Intra-articular approach.
secondary to osteolysis of the distal clavicle, whereas an older tennis player may 2', 27, 51 present with pain secondary to o~teoarthritis.~, On physical examination, the hallmark finding is tenderness over the joint. Symptoms may also be reproduced by horizontal adduction and extreme forward flexion. Conservative treatment is similar to the other shoulder conditions already discussed and includes therapeutic modalities as well as exercise. Local injections should be reserved for patients who are not progressing in the rehabili27 tation program and considered as an alternative before surgical interventi~n.~, Injection Technique
Palpate the plane of the joint to identify the site of injection. Using a 23- to 25-gauge 1- to 1.5-in needle, inject 20 mg of triamcinolone and 0.5 to 1 mL of 2% lidocaine. The needle is inserted through a superior approach in an anterior direction into the joint. Minimal resistance to injection should be felt if the needle is in place. Fluoroscopically guided needle placement to confirm intraarticular location can be considered if exact diagnostic information is required as well as to maximize beneficial effects. Postinjection instructions are similar to the ones previously described.
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SUMMARY
Joint and soft tissue injections play an important role in the management of upper extremity pathologic conditions such as shoulder impingement syndrome, lateral epicondylitis, De Quervain's tenosynovitis, and carpal tunnel syndrome. These injections should become one of the physiatric treatment alternatives. With knowledge of the specific anatomy and the use of appropriate injection techniques, the morbidity for these procedures is low. Corticosteroid injections should be considered a part of the complete rehabilitation program and used in conjunction with other therapeutic interventions such as physical modalities and exercise. References 1. American Association of Electrodiagnostic Medicine: Practice parameters for electrodiagnostic studies in carpal tunnel syndrome. Rochester, MN, October 1993 2. Armstrong TJ, Fine LJ, Goldstein SA, et al: Ergonomics considerations in the hand and wrist tendinitis. J Hand Surg 12A:830-837, 1987 3. Bach BR, Bush-Joseph C: Subacromial space injections a tool for evaluating shoulder pain. Physician and Sports Medicine 20:93-97, 1992 4. Birrer RB: Aspiration and corticosteroid injection. Practical pointers for safe relief. Physician and Sports Medicine 20:57-71, 1992 5. Brattberg G: Acupuncture therapy for tennis elbow. Pain 16:285-288, 1983 6. Cahill BR: Atraumatic osteolysis of the distal clavicle. A review. Sports Med 13:214222, 1992 7. Cannon LS, Bemacki EJ, Walter SD: Factors associated with carpal tunnel syndrome. J Occup Med 23:255-258, 1981 8. Dacre JE, Beeney N, Scott DL: Injections and physiotherapy for the painhl stiff shoulder. Ann Rheum Dis 48:322-325, 1989 9. Day BH, Govindasamy N, Patnaik R: Corticosteroid injections in the treatment of tennis elbow. Practitioner 220:459462, 1978 10. Foster JB: Hydrocortisone and the carpal tunnel syndrome. Lancet 1:454-456, 1960 11. Frederick HA, Carter PR: Injection injuries to the median and ulnar nerves at the wrist. J Hand Surg 17A645-647,1992 12. Gelberman RH, Aronson D, Weisman MH: Carpal tunnel syndrome results of a prospective trial. J Bone Joint Surg 62A:1181-1184,1980 13. Green DP: Diagnostic and therapeutic value of carpal tunnel injection. J Hand Surg 9A:850-854, 1984 14. Harvey FJ, Harvey PM, Horsley MW. De Quervain's disease: Surgical non-surgical treatment. J Hand Surg 15A:83-87, 1990 15. Hawkins RJ, Mohtadi N: Rotator cuff problems in athletes. In DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Principles and Practice. Philadelphia, PA, Saunders, 1994, pp 623-656 16. Hollander JE, Brown EM, Jessar RA, et al: Hydrocortisone and cortisone injected into arthritic ioints. Comparative effects of and use of hydrocortisone as a local antiarthritic agent. JAMA 147:1629-1635, 1951 17. Hollander TE: Arthritis and Allied Conditions. In McCarthy DJ (ed): A Textbook of ~ h e u m a t o l b Philadelphia, ~~. PA, Lea and Febiger, 1985, pp'541-553 18. Hulstyn MJ, Weiss A-P: Adhesive capsulitis of the shoulder. Orthop Rev 22:425433, 1993 19. Kamkar A, Irrgang JJ, Whitney SL: Nonoperative management of secondary shoulder impingement syndrome. J Orthop Sports Phys Ther 17:212-224, 1993 20. Kay NR, Marshall PD: A safe, reliable method of carpal tunnel injection. J Hand Surg 17A1160-1161, 1992 21. Kennedy JC, Willis RB: The effects of local steroid injections on the tendons: A biomechanical and microscopic correlative study. Am J Sports Med 411-21, 1976
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22. Kerlan RK, Glousman RE: Injection techniques in athletic medicine. Clin Sports Med 8:541-560, 1989 23. Kivi P: The etiology and conservative treatment of humeral epicondylitis. Scan J Rehabil Med 15:3741,1982 24. Kulick MI, Gordillo G, Javidi T, et al: Long term analysis of patients having surgical treatment for carpal tunnel syndrome. J Hand Surg 11A:5946,1986 25. Labelle H, Guibert R, Joncas J, et al: Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg [Br] 74:646-651, 1992 26. Leadbetter WB: The use of corticosteroid injection in athletic injury. Presented at The Society of Tennis Medicine and Science 1994 RCA Championship Sports Sciences Symposium. Indianapolis, August 20-21, 1994 27. Lyons FR, Rockwood CA: Osteolysis of the clavicle. In DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Principles and Practice. Philadelphia, PA, Saunders, 1994, pp 541-559 28. Matsen FA, Amtz CT: Subacromial impingement. In Rockwood CA, Matsen FA (eds): The Shoulder. Philadelphia, PA, Saunders, 1990, pp 62%646 29. McGrath MH: Local steroid therapy in the hand. J Hand Surg 9A:850-854, 1984 30. McKenzie MM: Conservative treatment of de Quervain's disease. Br Med J 4:659-660, 1972 31. Meyers JF: Arthroscopic management of impingement syndrome and rotator cuff tears. In Grana WA, Lombardo JA, Sharkey BJ, et al (eds): Advances in Sports Medicine and Fitness, vol2. Chicago, IL, Year Book Medical Publishers, 1989, pp 243-259 32. Minamikawa Y, Peimer CA, Kambe K, et al: Tenosynovial injection for carpal tunnel syndrome. J Hand Surg 17A:178-181,1992 33. Nevelos AB: The treatment of tennis elbow with triamcinolone acetonide. Curr Med Res Opin 6:507-509,1980 34. Nirschl RP, Sobel J: Conservative treatment of tennis elbow. Phys Sportsmed 9:43-54, 1981 35. Noteboom T, Cruver R, Keller J, et al: Tennis elbow: A Review. J Orthop Sports Phys Ther 19:357-366, 1994 36. Noyes FR, Grood ES, Nussbaum NS, et al: Effect of intra-articular corticosteroids on ligament properties. Clin Orthop 123:197-209, 1977 37. Owens DS, Irby R: Intra-articular and soft tissue aspiration and injection. Clin Rheum Pract 452-63, 1986 38. Ozdogan H, Yazici H: The efficacy of local steroid injections in the idiopathic carpal tunnel syndrome: A double blind study. Br J Rheumatol23:272-275, 1984 39. Pfenninger JL: Injections of joints and soft tissue: Part I. General guidelines. Am Fam Physician 44:1196-1202, 1991 40. Pfenninger JL: Injections of joints and soft tissue: Part 11. Guidelines for specific joints. Am Fam Physician 441690-1701, 1991 41. Phalen GS: The carpal tunnel syndrome, sixteen-year's experience. J Bone Joint Surg 48A:211-228, 1966 42. Price R, Heinrich SI, Gibson T: Local injection treatment of tennis elbow. Hydrocortisone, triamcinolone, and lignocaine compared. Br J Rheumatol30:39-44, 1991 43. Rizk TE, Pinals RS, Talaiver AS: Corticosteroid injections in adhesive capsulitis: Investigation of their value and site. Arch Phys Med Rehabil 72:20-22, 1991 44. Robbins H: Anatomical study of the median nerve in the carpal tunnel syndrome. J Bone Joint Surg 45A:953-966, 1963 45. Roy S, Oldham R: Management of the painful shoulder. Lancet 1:1322-1324, 1976 46. Schnatz P, Steiner C: Tennis elbow: A biomechanical and therapeutic approach. Journal of American Osteopathic Association 93778-788, 1993 47. Smith DL, Campbell SM: Painful shoulder syndromes: Diagnosis and management. J Gen Intern Med 7:328-339, 1992 48. Stannard JP, Bucknell AL: Rupture of the triceps tendon associated with steroid injections. Am J Sports Med 21:482485, 1993 49. Stefanish RJ: Intra-articular corticosteroids in the treatment of osteoarthritis. Orthop Rev 1565-71,1986
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50. Steinbrocker 0, Argyros TG: Frozen shoulder: Treatment by local injections of depot corticosteroids. Arch Phys Med Rehabil55:209-213, 1974 51. Stenlund B: Shoulder tendinitis and osteoarthrosis of the acromioclavicular joint and their relation to sports. Br J Sports Med 27:125-130, 1993 52. Watson M: Major ruptures of the rotator cuff. The results of surgical repair in 89 patients. J Bone Joint Surg 67B:618-624, 1985 53. Weiss A-P, Akelman E, Tabatabai M: Treatment of De Quervain's disease. J Hand Surg 19A:595-598, 1994 54. Weiss A-P, Sachar K, Gendream M: Consewative management of carpal tunnel syndrome: A re-examination of steroid injection and splinting. J Hand Surg 19A:410-415, 1994 -
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55. Witt J, Press G, Gelberman R: Treatment of De Quervain's tenosynovitis. J Bone Joint Surg 73A.219-222, 1991 56. Wrem RN, Goldner JL, Markee JL: An experimental study of the effect of cortisone on the healing process and tensile strength of tendons. J Bone Joint Surg 36A:588-601,1954
Address reprint requests to William F. Micheo. MD Department of Physical Medicine, Rehabilitation and Sports Medicine UPR School of Medicine P.O. Box 365067 San Juan, PR 00936-5067
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JOINT AND SOFT-TISSUE INJECTIONS OF THE UPPER EXTREMITY William F. Micheo, MD, Ricardo A. Rodriguez, MD, and Eduardo Amy, MD
Peripheral joint and soft-tissue injections are potent diagnostic and therapeutic tools that have a role in the treatment of localized inflammation. These injections can be used to differentiate various clinical pain syndromes, and with adequate patient selection as well as proper injection technique morbidity can be reduced below that encountered with nonsteroidal anti-inflammatory Pathologic conditions potentially improved by local corticosteroid injections include articular disorders such as rheumatoid arthritis and osteoarthritis; nonarticular disorders such as bursitis and tendonitis; and myofascial pain syndrome~.'~, 39, 40 Specific clinical entities that are amenable to treatment with local injection include carpal tunnel syndrome (CTS)12,13, 20, 38, 41, 54 and De Quervain's tenosynovitisI4,30, 41, 53, 55 in the wrist; epicondylitis9,23, 33, 34, 42 in the elbow; and impingement syndromes, adhesive capsulitis, and acromioclavicular joint disorders* in the shoulder. The purpose of this article is to review the literature and present the authors' methods of evaluation, treatment, and injection for these upper extremity conditions. PHARMACOLOGY
Since the initial intra-articular corticosteroid therapy used in 1951 by Hollander et a1,'6 local treatment has evolved into using longer-acting steroids in
From the Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico Medical School, San Juan, Puerto Rico PHYSICAL MEDICINE AND REHABILITATION CLINICS OF NORTH AMERICA VOLUME 6 . NUMBER 4 . NOVEMBER 1995
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combination with local anesthetic agents. The use of the anesthetic agents serves a dual purpose: to achieve fast pain relief and to help in the diagnostic process4,l3 Longer-acting preparations (bupivacaine hydrochloride) are now available that give a longer duration of pain relief and may allow progression of the rehabilitation process. When the presence of an inflammatory process makes the use of an anesthetic agent alone insufficient for therapeutic purposes, corticosteroids may be of great benefit. The corticosteroids suppress the initial events of inflammation by inhibiting migration of inflammatory cells, capillary dilatation, and tissue edema. Once the inflammatory process starts, they also inhibit capillary and fibroblast proliferation and collagen synthesis. These latter effects are known to compromise healing and to decrease tensile strength of tendons and ligament^.^', 3h Corticosteroids can be divided into those which are short acting (cortisone, hydrocortisone), intermediate acting (prednisone, prednisolone tebutate, triamcinolone, methylprednisolone acetate), and long acting (dexamethasone sodium, bethamethasone). Although there appears to be a preference in the literature* to use intermediate- and long-acting steroids, no particular agent has been documented as being more advantageous than another. The relative insolubility of some corticosteroids affects their potency and duration of response.'&29 The effect of agents that are water soluble and readily absorbed tends to be of shorter duration.
ADVERSE EFFECTS The most common symptomatic adverse reaction is a postinjection flare that has been reported to occur in 1%to 10% of patients.33,39, 42, 49 This can be lessened with the concomitant administration of lid~caine.~, 23 Other local adverse effects seen less frequently include steroid arthropathy, skin atrophy and depigmentation, and tendon r ~ p t u r e . ~ "52~Systemic ~ , ~ ~ , or distant effects may include facial flushing, hypersensitivity reaction, transient paresis of the injected extremity, and the hyperglycemic effect of the short-acting agents in diabetic patients.39In general, the use of injections is very safe, with studies reporting an incidence of infection of 0.0001% or less if an aseptic technique is used.2h,49
GENERAL GUIDELINES Precautions that should be followed when using corticosteroid treatment include limiting the number of injections to any particular area or joint to three per year. They should not be used in patients who will not follow or are unable to follow a relative rest period postinje~tion.~~ Special care should be taken to use peritendinous injections and never intratendinous or intraneural injection, or injection into subcutaneous fat. In the case of intra-articular injection, trauma to cartilage should be prevented. When using anesthetics and steroids mixed in the same syringe, precipitation and the formation of crystals may result, which may be a source of local flare or may lead to calcification in the area of injection. This may be avoided by using single-dose vials of lidocaine, which lack preservatives; longer-acting bupivacaine; or injecting with separate syrin"References 9, 11-13, 20, 23, 26, 34, 38, 45, 54, 55.
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g e ~The . ~authors ~ consider an overlying infectious process an absolute contraindication to soft tissue injection. An aseptic technique should be followed during infiltration. Once the optimal site for injection has been chosen, the skin is preferably cleansed with an iodine solution or swab at least twice, and then with alcohol. Sterile gloves are not necessary, but syringes and needles should be sterile and disposable. Local injections should only be considered a part of the rehabilitation program. They should be used in combination with other therapeutic modalities such as physical agents and exercise. When stressing tendons after corticosteroid injections, consideration should be given to the fact that there may be a reduction in the tensile strength of the tendons of as much as 40%. This tensile strength reduction may last anywhere from 14 days to 15 weeks, particularly after direct tendon injecti~n.~', 36, 56 THE WRIST Functional Anatomy
In the volar aspect of the wrist, below the skin and the deep fascia, is the tendon of the palmaris longus muscle, which continues as the palmar aponeurosis overlying the flexor retinaculum. Important structures superficial to the transverse carpal ligament are the ulnar nerve and artery radial to the flexor carpi ulnaris tendon and the radial artery radial to the flexor carpi radialis (Fig. 1).The transverse carpal ligament is a 2- to 3-cm-long structure extending from the navicular to the hamate and pisiform. Together with the more dorsal carpal bones, it forms the carpal canal (Fig. 2). The canal houses the flexor digitorium superficialis and profundus, as well as the flexor pollicis longus, with a radially oriented median nerve. The more ulnar arrangement of the flexors of the digits allow for ample room of the median nerve. The flexor carpi radialis splits the flexor retinaculum to continue to its insertion. The extensor retinaculum of the wrist accommodates the nine extensor muscles that cross the wrist in six different compartments. The first dorsal compartment is the one that houses the extensor pollicis brevis and the abductor pollicis longus adjacent to the radial styloid process. The superficial branch of the radial nerve crosses the wrist over the radial styloid in close proximity to the tendons of the first dorsal compartment (Fig. 3). CARPAL TUNNEL SYNDROME Clinical Concepts
The usual history of a patient with CTS is complaint of progressive weakness and clumsiness of the hand, pain in the hand or forearm, and associated hypesthesia or paresthesia in the median nerve distribution. In more severe cases, paralysis of the abductor pollicis brevis with thenar eminence atrophy is observed. Symptoms may be bilateral, worse in the dominant hand, increased with forceful hand activities, and awaken the patient at night. The clinical examination includes sensory evaluation of the hand and manual muscle testing of thenar eminence muscles, as well as thorough neurologic assessment of the upper extremity to rule out proximal pathology such as a cervical radiculopathy.
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Figure 1. Volar wrist anatomy. A = Transverse carpal ligament; B = median nerve; C = flexor pollicis longus; D = flexor carpi radialis; E = radial artery; F = ulnar artery and nerve; G = palmaris longus; and H = flexor carpi ulnaris.
Special tests such as Phalen's and the Tinnel sign may be positive in over 70% of patients; however, their absence does not rule out the ~ o n d i t i o nElectrodiag.~~ nostic studies have been shown to have a high degree of sensitivity and specificity in confirming and establishing the severity of CTS.' Mild cases of CTS can be treated initially with the use of splinting, physical therapy, nonsteroidal anti-inflammatory drugs, and limitation of provocative activities. This activity modification may include work restrictions and job site changes, because CTS has been clearly defined as an occupational d i s ~ r d e r . ~ , If symptoms persist despite the previously mentioned treatment regimen, injection into the carpal tunnel is performed. This injection has the dual role of diagnosis and treatment.13s41It may also play a role in prognosis because a direct correlation has been found between relief of symptoms with injection and relief with surgery.12,13, 24 The effectiveness of treatment with injection has varied in the literature with documented relief seen in 13% to 81% of patient^.'^^'^^^^^^^^^^^ 54 The recurrence rate ranges from 8% to 94%."13,41,54This variability of results is related to the different populations studied, study techniques, diagnostic parameters, follow-up time, and different outcome measures.
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Figure 2. Transverse wrist anatomy. A-G as in Figure 1; I = flexor digitorurn superficialis; and J = flexor digitorurn profundus.
Figure 3. Anatomy relative to de Quervain's tenosynovitis. A = Extensor pollicis longus; B = radius styloid process; C = abductor pollicis longus; D = extensor pollicis brevis; and E = superficial radial nerve.
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The two most commonly used approaches for the infiltration of the carpal canal are radial or ulnar to the palmaris l o n g ~ s . " - 38,41,54 ~ ~ ~ ~The , ulnar approach appears to be safer when one takes into consideration the anatomy of the wrist. A radial approach would place the needle in close proximity to the median nerve and make it more susceptible to damage.10,",44A recent cadaver study by Minamikawa et showed that a reproducible delivery of medication into the carpal tunnel could be achieved by using the ulnar approach.32 Severe cases of CTS that do not respond to treatment and show severe paresthesias as well as weakness and atrophy of the thenar muscles require surgical management.
Injection Technique
The wrist is positioned in a neutral or a slightly extended position on the edge of the table. A 23- to 25-gauge 1- to 1.5-in needle is inserted ulnar to the palmaris longus, or in its absence, in line with the fourth ray at the wrist flexion crease. The needle should be directed at a 30-degree angle beneath the transverse carpal ligament and oriented radially until the carpal tunnel is entered. Proper placement can be ascertained by needle movement with digit flexion and extension. If paresthesias are felt by the patient, the needle should be withdrawn and repositioned. Once the proper needle placement is achieved, aspiration to avoid injection into a vessel should be performed. A mixture of 10 to 20 mg triamcinolone or an equivalent corticosteroid preparation, combined with 0.5 to 1 mL 2% lidocaine, is injected slowly into the carpal canal (Fig. 4). Another alternative is to inject the local anesthetic and subsequently inject the steroid by changing the syringe and leaving the needle in place. Minimal resistance should be felt at the time of injection. The patient will feel a gradual onset of numbness in the median nerve distribution if needle localization was adequate. Immediate, severe worsening of symptoms after the procedure may indicate intraneural injection of corticosteroid, and this would require emergent surgical consultation." After the injection the patient is instructed to use a resting splint at night, to limit forceful activities for a period of 2 weeks, and to return for reevaluation in 1 to 2 weeks. DE QUERVAIN'S TENOSYNOVITIS Clinical Concepts
The characteristic signs and symptoms of this condition are pain radiating from the radial styloid process to the thumb and proximally into the forearm. It also presents with increased pain on range of motion at the wrist and thumb with swelling and tenderness on the first dorsal compartment. A positive Finklestein's test result, which consists of positioning the patient's thumb into the palm of the hand under the flexed fingers and passively ulnarly deviating the wrist with reproduction of symptoms, may be elicited. This tendon disorder can be chronic or present acutely and is usually considered idiopathic. However, a strong association between the signs and symptoms of hand and wrist tendonitis and repetitive as well as forceful manual .~ reports have described anatomical work activities has been r e p ~ r t e d Several variations in the first dorsal compartment where the extensor pollicis brevis and
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Figure 4. Injection technique for CTS.
abductor pollicis longus are in separate compartments in patients with De Quervain's tenosyn~vitis.'~ 53, 55 These anatomical variants may be associated with increased failure of conservative treatment. The initial treatment of this condition includes the use of icing, relative rest, and therapeutic modalities such as electrical stimulation and ultrasound. Additional use of a spica splint for 2 to 3 weeks could also be considered. The combination of injection into the first dorsal compartment with splinting is also an alternative treatment. The reported effectiveness of the use of corticosteroid injection ranges from 50% to 90% improvement in symptom^.'^, 30, 41, 53, 55 Injection Technique
Treatment consists of an injection of 20 mg of triamcinolone with 0.5 mL of 2% lidocaine into the first dorsal compartment using a 23- to 25-gauge needle 5/8- to 1-in long. The needle is introduced 1 cm proximal to the tip of the styloid process and angled distally at 45 degrees to the longitudinal axis of the forearm (Fig. 5). Observation of filling of the tendon sheath confirms adequate
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Figure 5. Injection technique for de Que~ain'stenosynovitis.
placement. Because of the close relationship of the superficial radial nerve to the first dorsal compartment, any symptoms of paresthesias in the thumb while placing the needle indicate a need for relocation. THE ELBOW Functional Anatomy
The distal humerus consists of a lateral and medial condyle forming the articular surfaces for the trochlea and capitellum. Located above the condyles, the lateral epicondyle serves as the origin of the extensor-supinator group, and the medial epicondyle is the origin of the forearm pronator-flexor group. The extensor carpi radialis longus originates just below the brachioradialis from the supracondylar ridge and inserts in the base of the second metacarpal. The extensor carpi radialis brevis originates from the inferior lateral epicondyle and inserts in the base of the third metacarpal. The main action of these muscles is wrist extension with radial deviation at the wrist (Fig. 6). The principal nerve found in the lateral aspect of the elbow is the radial nerve. The nerve winds around the posterior aspect of the shaft of the humerus, piercing the lateral intermuscular septum to enter the volar compartment of the forearm. At this point it lies lateral to the brachialis, posteromedial to the extensor carpi radialis longus, and volar to the capitellum in an area known as the radial tunnel. At this level it innervates the brachialis, brachioradialis, and extensor carpi radialis longus. The nerve divides near the arcade of Frohse into superficial and deep branches. The deep branch passes between the two heads of the supinator muscle to continue as the posterior interosseous nerve. Clinical Concepts
Lateral epicondylitis is a syndrome characterized by pain over the lateral epicondyle of the humerus that may radiate to the arm and forearm. It is
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Figure 6. Anatomy relative to lateral epicondylitis of the elbow. A = Humerus lateral epicondyle; B = extensor carpi radialis longus; C = extensor carpi radialis brevis; D = extensor digitorurn cornrnunis; E = extensor digiti minirni; and F = extensor carpi ulnaris.
worsened by extension or supination of the wrist against resistance. Point tenderness localizes the lesion, which most commonly involves the extensor carpi radialis brevis muscle. Symptoms may be reproduced by resisted wrist or third digit extension. This is an overuse syndrome that affects more men than women in the dominant upper extremity. It may be the result of occupational activities that involve repetitive gripping or rotation of the forearm?,23, 25, 35, 46 In tennis players it may be the result of faulty technique, particularly the backhand stroke or incorrect grip size.% The initial treatment should include the use of icing and electrical stimulation. Heating modalities such as ultrasound can be added in the subacute or chronic stages. A flexibility and strengthening program of the wrist extensor muscles emphasizing eccentric exercises should also be incorporated. With failure of early conservative treatment to decrease the signs and symptoms of inflammation within 4 weeks, infiltration of the epicondyle should be considered with a combination of anesthetic and corticosteroid. Some investigators, such as Schnatz and Steiner,46initially treat lateral epicondylitis with a steroid injection,
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and others, such as Brattberg5found other treatment modalities such as acupuncture to be superior to local injection with corticosteroids. A meta-analysis by Labelle et alZ5suggested a positive therapeutic effect for steroid injection; however, conflicting results and methodological problems led to recommendations of further research. Failed treatment with local corticosteroid injection may be caused by the presence of radial tunnel syndrome. In this clinical entity, pain is usually distal to the epicondyle, anterior to the radial head, or the extensor muscle mass. Electrodiagnostic testing that shows involvement of the radial innervated muscles distal to the supinator muscle may confirm the diagnosis.
Injection Technique
A mixture of 20 mg of triamcinolone with 0.5 mL of 2% lidocaine is prepared for injection. The needle is a 23- to 25-gauge, 5/8 to 1 in in length. The patient is seated with the elbow flexed and relaxed resting on the lap. Injection into the most tender area should take away the pain. This may require alternating technique in which the needle is redirected in at least three different orientations (Fig. 7). Aspiration is attempted before injection, and careful observation for paresthesias during needle placement is made, which would lead to needle repositioning. After infiltration, light pressure over the area to ascertain distribution of the injected solution should be performed. Light resisted wrist extension without pain points to an effective injection. A relative rest period after injection is advised for approximately 2 to 3 weeks, and for those patients who need to use their hands for repetitive activities, a wrist cock-up splint to rest the extensor muscles should be prescribed.
Figure 7. Injection technique for lateral epicondylitis.
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THESHOULDER Functional Anatomy
Complete shoulder motion involves the glenohumeral, sternoclavicular, acromioclavicular, and scapulothoracic articulations. Shoulder stability depends on normally functioning muscles, intact ligaments, glenoid labrum, and capsule. The rotator cuff muscles originate from the scapula and insert into the lesser tuberosity, greater tuberosity, and transverse humeral ligament. The rotator cuff is formed by the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, which fuse into a tendon as they insert into the humerus. The long head of the biceps tendon originates intra-articularly from the supraglenoid tubercule and penetrates the rotator cuff between the supraspinatus and subscapularis tendon. The rotator cuff muscles provide stability of the shoulder against the action of the prime movers such as the deltoid. The infraspinatus in particular maintains the center of rotation of the humeral head, minimizing upward migration under the coracoacromial arch as the deltoid pulls the arm into abduction or forward flexion (Fig. 8). The coracoacromial ligament connects the acromion and coracoid process forming an arch under which the cuff tendons pass. Several bursae are present in the shoulder; however, the subacromial bursa is the one that facilitates passage of the rotator cuff under the subacromial arch. In some cases it is considered to be a serosal surface rather than a bursa1 sack.z8
Figure 8. Anatomy relative to the shoulder. A = Acromioclavicular ligament; 6 = acromion; C = subacromial bursa; D = supraspinatus; E = infraspinatus; F = teres minor; G = coracoacromial ligament; H = coracoid; L = tendon long head biceps femoris; J = glenoid labrum; and K = subscapularis.
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IMPINGEMENT SYNDROME Clinical Concepts
Impingement has been described as the encroachment of the acromion, coracoacromial ligament, coracoid process, and acromioclavicular joint on the rotator cuff mechanism that passes beneath them as the glenohumeral joint is moved.28Impingement syndrome resulting in shoulder pain can be caused by acute or chronic overload and may be the final end point of a variety of glenohumeral and scapulothoracic abnormalities. Repetitive overhead activities are thought to be the cause of symptoms in the younger athlete."" In the older patient, degenerative changes within the tendon and bony changes within the coracoacromial arch may be the etiologic factors.152R,31 Structures that may be affected include the rotator cuff tendons, biceps tendon, and the subacromial bursa. The patient may present with complaints of pain after overhead activities. As the condition progresses, pain may interfere with throwing activities, activities of daily living, and may be present at night, leaving the patient unable to sleep on the affected shoulder. This pain may be associated with a catch, aggravated at midranges of shoulder motion, and may radiate to the anterolatera1 aspect of the shoulder. In chronic stages the patient may also complain of weakness and loss of muscle mass. On physical examination, inspection may show atrophy of the deltoid and other shoulder girdle muscles. Palpation may show subacromial, biceps tendon, and acromioclavicular tenderness. Passive range of motion testing may show limited internal rotation secondary to a tight posterior capsule. Active range of motion shows crepitus and pain particularly in the 60- to 120-degree range of abduction or flexion. Manual muscle testing may show weakness of the external rotators while testing with the arm at the side and the supraspinatus while testing resisted abduction in the scapular plane with internal rotation in the "empty can position." Reproduction of symptoms with the impingement maneuver of maximally internally rotating the shoulder with flexion to 90 degrees may aid in the diagnosis. Patients with bicipital tendinitis show localized pain to palpation of the biceps tendon and reproduction of symptoms on resisted forward shoulder flexion as well as elbow flexion. When pain and guarding interfere with the examination, a subacromial injection of local anesthetic is useful in identifying the structures of the subacromial zone as the source of the patient's di~comfort.~, 15, 28, 31 It is important to identify within the spectrum of impingement syndrome a patient that may have a rotator cuff tear. This patient may show residual weakness despite improvement in pain after anesthetic injection. Specialized diagnostic testing as well as surgical treatment may be needed in these cases. Initial management of patients with impingement includes rest from overhead activities that produce pain and modalities such as ice, electrical stimulation, and ultrasound. Therapeutic exercises include posterior capsule stretching and strengthening of the rotator cuff and other scapular muscle^.'^ If pain interferes with the rehabilitation program after 3 to 4 weeks of treatment, an injection with corticosteroids may be ~onsidered.~, 15, 17, 22, 31, 40, 47 These injections are used to allow progression in the rehabilitation program, particularly with strengthening exercises. Subacromial injections are frequently used and found to be clinically effective; however, scientific data supporting their use is sparse.
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Injection Technique
Using a 21- to 23-gauge 1.5-in needle, 40 mg of triamcinolone and 3 to 5 mL of 2% xylocaine are injected into the subacromial space. The patient is placed in a sitting position, traction is applied to the upper extremity, and the subacromial space is entered using a lateral approach under the palpable tip of the acromion (Fig. 9). Once the subacromial space is entered, minimal resistance should be felt on injection. If resistance is felt, this may indicate injection into the tendon or acromion, and retraction and repositioning of the needle may be needed. An alternative technique is to use a posterolateral approach under the easily palpable acromial tip. This approach is helpful in older patients with osteophyte formation3 and when difficulty is encountered entering the subacromial space on lateral approach. For biceps tendon sheath injection, the patient is placed in a sitting position with the elbow flexed and the forearm supinated. The biceps tendon is localized and injected using a 25-gauge 1-in needle with 20 mg triamcinolone and 1 mL of 2% xylocaine in a plane parallel to the bicipital groove along the sheath and not into the tendon itself (see Fig. 9). After injection the patient is instructed to use ice for 48 hours, to limit forceful overhead shoulder activities for a period of 2 weeks, and to continue in the rehabilitation program. ADHESIVE CAPSULlTlS Clinical Concepts
Clinically, adhesive capsulitis is defined as a progressive painful limitation of shoulder motion.47The patient usually complains of stiffness, pain with
Figure 9. Injection technique for subacromial bursa and biceps tendon in impingement syndrome and adhesive capsulitis.
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attempted motion, and pain at night. A history of precipitating events or associated conditions such as trauma, immobility, bursitis, or diabetes mellitus may be present; however, in many instances no causative factors are identified. On physical examination the patient may show diffuse shoulder tenderness as well as restricted passive and active motion. This loss of motion is usually more significant in external and internal rotation. In this patient group a subacromial injection of anesthetic may eliminate pain, but restriction of motion will persist? l8 The natural history of adhesive capsulitis has been widely studied. In some patients it appears to be a self-limited condition; however, in others symptoms are seen as long as 2 to 3 years after the initial onset.1R43,50 Multiple therapeutic interventions that include physical therapy, oral medications, manipulation under general anesthesia, and local corticosteroid injections have been studied and Local injections found to have variable results in shortening the recovery time.8,47 with corticosteroids, particularly if used early in the treatment course, have been found to be of benefit in pain relief; however, no definite improvement in the range of motion has been shown after periarticular or intra-articular injections.43, The patient is initially managed with superficial heat, electrical stimulation, and ultrasound in combination with pendulum as well as active assistive motion exercises. Gentle stretching and light strengthening may be added with increased patient tolerance to the rehabilitation program. If the pain interferes with the exercise program or with sleep, the addition of local corticosteroids 4 to 6 weeks into the treatment course should be considered. Injection Technique
With the patient in a sitting position, the subacromial space and bicipital tendon are injected using the same technique as previously described for impingement syndrome. If myofascial trigger points are present over the posterior muscle area, an injection with 1 mL of 2% xylocaine using a 5/8- to 1-in, 25gauge needle may be considered. In addition to the periarticular injection, an intra-articular injection may be attempted. The approach used at our center, based on anatomic dissection, is an anterior-superior approach (Fig. 10). Using the anterior aspect of the acromioclavicular joint as a landmark, a 22-gauge 1.5-in needle is directed inferiorly into the joint. When resistance is felt at the tip of the needle, perform a gentle passive internal external rotation of the shoulder. If this is accompanied by movement at the tip of the needle, slightly retract the needle, aspirate, and inject. A combination of 20 to 40 mg of triamcinolone with 1 to 2 mL of 2% lidocaine may be injected. It is important to note that if the capsule is contracted it may be difficult to enter the joint space and the contents may be injected periarticularly. In this setting fluoroscopically guided intra-articular injections may be an alternative to assure injection into the glenohumeral joint. After the injection the patient is given instructions to use icing for the next 48 hours and to continue in his or her rehabilitation program. The patient should be re-evaluated the week after infiltration. ACROMIOCLAVICULAR JOINT DISORDERS Clinical Concepts
Pain related to the acromioclavicular joint could be the result of trauma, overuse, or degenerative changes. A young weight lifter may present with pain
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Figure 10. Injection technique for adhesive capsulitis. Intra-articular approach.
secondary to osteolysis of the distal clavicle, whereas an older tennis player may 2', 27, 51 present with pain secondary to o~teoarthritis.~, On physical examination, the hallmark finding is tenderness over the joint. Symptoms may also be reproduced by horizontal adduction and extreme forward flexion. Conservative treatment is similar to the other shoulder conditions already discussed and includes therapeutic modalities as well as exercise. Local injections should be reserved for patients who are not progressing in the rehabili27 tation program and considered as an alternative before surgical interventi~n.~, Injection Technique
Palpate the plane of the joint to identify the site of injection. Using a 23- to 25-gauge 1- to 1.5-in needle, inject 20 mg of triamcinolone and 0.5 to 1 mL of 2% lidocaine. The needle is inserted through a superior approach in an anterior direction into the joint. Minimal resistance to injection should be felt if the needle is in place. Fluoroscopically guided needle placement to confirm intraarticular location can be considered if exact diagnostic information is required as well as to maximize beneficial effects. Postinjection instructions are similar to the ones previously described.
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SUMMARY
Joint and soft tissue injections play an important role in the management of upper extremity pathologic conditions such as shoulder impingement syndrome, lateral epicondylitis, De Quervain's tenosynovitis, and carpal tunnel syndrome. These injections should become one of the physiatric treatment alternatives. With knowledge of the specific anatomy and the use of appropriate injection techniques, the morbidity for these procedures is low. Corticosteroid injections should be considered a part of the complete rehabilitation program and used in conjunction with other therapeutic interventions such as physical modalities and exercise. References 1. American Association of Electrodiagnostic Medicine: Practice parameters for electrodiagnostic studies in carpal tunnel syndrome. Rochester, MN, October 1993 2. Armstrong TJ, Fine LJ, Goldstein SA, et al: Ergonomics considerations in the hand and wrist tendinitis. J Hand Surg 12A:830-837, 1987 3. Bach BR, Bush-Joseph C: Subacromial space injections a tool for evaluating shoulder pain. Physician and Sports Medicine 20:93-97, 1992 4. Birrer RB: Aspiration and corticosteroid injection. Practical pointers for safe relief. Physician and Sports Medicine 20:57-71, 1992 5. Brattberg G: Acupuncture therapy for tennis elbow. Pain 16:285-288, 1983 6. Cahill BR: Atraumatic osteolysis of the distal clavicle. A review. Sports Med 13:214222, 1992 7. Cannon LS, Bemacki EJ, Walter SD: Factors associated with carpal tunnel syndrome. J Occup Med 23:255-258, 1981 8. Dacre JE, Beeney N, Scott DL: Injections and physiotherapy for the painhl stiff shoulder. Ann Rheum Dis 48:322-325, 1989 9. Day BH, Govindasamy N, Patnaik R: Corticosteroid injections in the treatment of tennis elbow. Practitioner 220:459462, 1978 10. Foster JB: Hydrocortisone and the carpal tunnel syndrome. Lancet 1:454-456, 1960 11. Frederick HA, Carter PR: Injection injuries to the median and ulnar nerves at the wrist. J Hand Surg 17A645-647,1992 12. Gelberman RH, Aronson D, Weisman MH: Carpal tunnel syndrome results of a prospective trial. J Bone Joint Surg 62A:1181-1184,1980 13. Green DP: Diagnostic and therapeutic value of carpal tunnel injection. J Hand Surg 9A:850-854, 1984 14. Harvey FJ, Harvey PM, Horsley MW. De Quervain's disease: Surgical non-surgical treatment. J Hand Surg 15A:83-87, 1990 15. Hawkins RJ, Mohtadi N: Rotator cuff problems in athletes. In DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Principles and Practice. Philadelphia, PA, Saunders, 1994, pp 623-656 16. Hollander JE, Brown EM, Jessar RA, et al: Hydrocortisone and cortisone injected into arthritic ioints. Comparative effects of and use of hydrocortisone as a local antiarthritic agent. JAMA 147:1629-1635, 1951 17. Hollander TE: Arthritis and Allied Conditions. In McCarthy DJ (ed): A Textbook of ~ h e u m a t o l b Philadelphia, ~~. PA, Lea and Febiger, 1985, pp'541-553 18. Hulstyn MJ, Weiss A-P: Adhesive capsulitis of the shoulder. Orthop Rev 22:425433, 1993 19. Kamkar A, Irrgang JJ, Whitney SL: Nonoperative management of secondary shoulder impingement syndrome. J Orthop Sports Phys Ther 17:212-224, 1993 20. Kay NR, Marshall PD: A safe, reliable method of carpal tunnel injection. J Hand Surg 17A1160-1161, 1992 21. Kennedy JC, Willis RB: The effects of local steroid injections on the tendons: A biomechanical and microscopic correlative study. Am J Sports Med 411-21, 1976
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22. Kerlan RK, Glousman RE: Injection techniques in athletic medicine. Clin Sports Med 8:541-560, 1989 23. Kivi P: The etiology and conservative treatment of humeral epicondylitis. Scan J Rehabil Med 15:3741,1982 24. Kulick MI, Gordillo G, Javidi T, et al: Long term analysis of patients having surgical treatment for carpal tunnel syndrome. J Hand Surg 11A:5946,1986 25. Labelle H, Guibert R, Joncas J, et al: Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow. An attempted meta-analysis. J Bone Joint Surg [Br] 74:646-651, 1992 26. Leadbetter WB: The use of corticosteroid injection in athletic injury. Presented at The Society of Tennis Medicine and Science 1994 RCA Championship Sports Sciences Symposium. Indianapolis, August 20-21, 1994 27. Lyons FR, Rockwood CA: Osteolysis of the clavicle. In DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Principles and Practice. Philadelphia, PA, Saunders, 1994, pp 541-559 28. Matsen FA, Amtz CT: Subacromial impingement. In Rockwood CA, Matsen FA (eds): The Shoulder. Philadelphia, PA, Saunders, 1990, pp 62%646 29. McGrath MH: Local steroid therapy in the hand. J Hand Surg 9A:850-854, 1984 30. McKenzie MM: Conservative treatment of de Quervain's disease. Br Med J 4:659-660, 1972 31. Meyers JF: Arthroscopic management of impingement syndrome and rotator cuff tears. In Grana WA, Lombardo JA, Sharkey BJ, et al (eds): Advances in Sports Medicine and Fitness, vol2. Chicago, IL, Year Book Medical Publishers, 1989, pp 243-259 32. Minamikawa Y, Peimer CA, Kambe K, et al: Tenosynovial injection for carpal tunnel syndrome. J Hand Surg 17A:178-181,1992 33. Nevelos AB: The treatment of tennis elbow with triamcinolone acetonide. Curr Med Res Opin 6:507-509,1980 34. Nirschl RP, Sobel J: Conservative treatment of tennis elbow. Phys Sportsmed 9:43-54, 1981 35. Noteboom T, Cruver R, Keller J, et al: Tennis elbow: A Review. J Orthop Sports Phys Ther 19:357-366, 1994 36. Noyes FR, Grood ES, Nussbaum NS, et al: Effect of intra-articular corticosteroids on ligament properties. Clin Orthop 123:197-209, 1977 37. Owens DS, Irby R: Intra-articular and soft tissue aspiration and injection. Clin Rheum Pract 452-63, 1986 38. Ozdogan H, Yazici H: The efficacy of local steroid injections in the idiopathic carpal tunnel syndrome: A double blind study. Br J Rheumatol23:272-275, 1984 39. Pfenninger JL: Injections of joints and soft tissue: Part I. General guidelines. Am Fam Physician 44:1196-1202, 1991 40. Pfenninger JL: Injections of joints and soft tissue: Part 11. Guidelines for specific joints. Am Fam Physician 441690-1701, 1991 41. Phalen GS: The carpal tunnel syndrome, sixteen-year's experience. J Bone Joint Surg 48A:211-228, 1966 42. Price R, Heinrich SI, Gibson T: Local injection treatment of tennis elbow. Hydrocortisone, triamcinolone, and lignocaine compared. Br J Rheumatol30:39-44, 1991 43. Rizk TE, Pinals RS, Talaiver AS: Corticosteroid injections in adhesive capsulitis: Investigation of their value and site. Arch Phys Med Rehabil 72:20-22, 1991 44. Robbins H: Anatomical study of the median nerve in the carpal tunnel syndrome. J Bone Joint Surg 45A:953-966, 1963 45. Roy S, Oldham R: Management of the painful shoulder. Lancet 1:1322-1324, 1976 46. Schnatz P, Steiner C: Tennis elbow: A biomechanical and therapeutic approach. Journal of American Osteopathic Association 93778-788, 1993 47. Smith DL, Campbell SM: Painful shoulder syndromes: Diagnosis and management. J Gen Intern Med 7:328-339, 1992 48. Stannard JP, Bucknell AL: Rupture of the triceps tendon associated with steroid injections. Am J Sports Med 21:482485, 1993 49. Stefanish RJ: Intra-articular corticosteroids in the treatment of osteoarthritis. Orthop Rev 1565-71,1986
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50. Steinbrocker 0, Argyros TG: Frozen shoulder: Treatment by local injections of depot corticosteroids. Arch Phys Med Rehabil55:209-213, 1974 51. Stenlund B: Shoulder tendinitis and osteoarthrosis of the acromioclavicular joint and their relation to sports. Br J Sports Med 27:125-130, 1993 52. Watson M: Major ruptures of the rotator cuff. The results of surgical repair in 89 patients. J Bone Joint Surg 67B:618-624, 1985 53. Weiss A-P, Akelman E, Tabatabai M: Treatment of De Quervain's disease. J Hand Surg 19A:595-598, 1994 54. Weiss A-P, Sachar K, Gendream M: Consewative management of carpal tunnel syndrome: A re-examination of steroid injection and splinting. J Hand Surg 19A:410-415, 1994 -
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55. Witt J, Press G, Gelberman R: Treatment of De Quervain's tenosynovitis. J Bone Joint Surg 73A.219-222, 1991 56. Wrem RN, Goldner JL, Markee JL: An experimental study of the effect of cortisone on the healing process and tensile strength of tendons. J Bone Joint Surg 36A:588-601,1954
Address reprint requests to William F. Micheo. MD Department of Physical Medicine, Rehabilitation and Sports Medicine UPR School of Medicine P.O. Box 365067 San Juan, PR 00936-5067