How soon between injections?

[jonnylingo]

What is your comfort level with frequency?

I have a lady with diffuse shoulder pain with exam pointing to possible subacromial bursitis, bicipital tendinitis, and GH arthritis. First injection doesn't work (done by PA in another practice), so now she's begging me to do a bicipital tendon injection with US. Would you wait 4 weeks if there is complete failure with first, but patient is eagerly waiting for next?

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[drf]

If you're worried about steroid load do separate SASD bursa, biceps tendon sheath, and IA injections with local. Then re inject the area that helped the most with steroid.

Most likely the IA, if it helps, will more or less spread to all the areas.

 

[Aether2000]

Saw a new patient last week....multiple fractures of the pelvis, sacrum, metatarsals, 5 vertebral fractures, and a humerus fracture with osteoporosis. Still has her ovaries, takes premarin, went through menopause 2 years before. No trauma. Did not have asthma, RA, SLE, or any condition requiring chronic steroids. She had never taken a medrol dose pack or oral prednisone nor had IM injections of steroids for an allergic reaction or asthma. Never had any spinal injections. I am scratching my head, and as she was leaving she mentioned casually she was having her shoulder injected by an orthopedic surgeon. When I told her this is not a good idea due to the multiple fractures and osteoporosis, she said she gets them every 3-4 weeks. And her family doc injects her knees once a month. I told her that was why she has osteoporosis and is fracturing multiple bones at age 46. She will not be coming back as she said her orthopedist and family doctor know what they are doing and that I was wrong for questioning them. So in this N of 1, we know every 2 weeks steroid injections are not good.....

 

[pmrmd]

Frequency depends on the injected steroid. The half-life of dex is 5 hours. The half-life of kenalog is considerably more. Dex suppresses the adrenals for about a day. Kenalog does so for a month.

 

[Aether2000]

True. Dex is much shorter in adrenal suppression. The maximum suppression occurs at 24 hours and recovers the next day. http://www.ncbi.nlm.nih.gov/pubmed/23977910

 

[freddydpt]

So I might be old fashioned, but can't you just stick the probe on and localize the site of pain? Bursitis = fluid in bursa... Bicipital tenosynovitis = fluid around biceps tendon... if it's OA, a bursitis injection isn't going to help much. If none of those findings are helpful, I'd localize with local injections like "drf" said, except an intraarticular injection won't help a bursitis (unless there is a full thickness rotator cuff tear).

 

[jj337]

Johnny Lingo - Mahana you ugly!! One of my favorite movies as a kid.

 

[Taus]

So I might be old fashioned, but can't you just stick the probe on and localize the site of pain? Bursitis = fluid in bursa... Bicipital tenosynovitis = fluid around biceps tendon... if it's OA, a bursitis injection isn't going to help much. If none of those findings are helpful, I'd localize with local injections like "drf" said, except an intraarticular injection won't help a bursitis (unless there is a full thickness rotator cuff tear).

If you're worried about steroid load do separate SASD bursa, biceps tendon sheath, and IA injections with local. Then re inject the area that helped the most with steroid.
Most likely the IA, if it helps, will more or less spread to all the areas.

Sorry, but I can't help saying it... how about a history and physical exam to guide you......

 

[jonnylingo]

Thanks for responses.

Still... What do you do if this pt approaches you "Doc, that injection last week didn't work (Subacromial with Kenalog by PA). I'm taking Vicodin so I can work at the day care (opiate naive), can you inject my biceps ASAP? (diagnosed by Ortho as having biceps tendinitis)"

Assuming you do a H&P, feel it's biceps tendinitis, and no osteoperosis or other red flags, do you wait, what...4 weeks to do the next injection? Or inject now and hopefully get them back to work?

 

[pmrmd]

There is probably no right or wrong answer. If its me, I'm injecting with dex to whatever my exam tells me is the pain generator. Doing one injection so soon after the other won't hurt the person in the long run. It's more important to keep the person functional and back to work IMO.

 

[drf]

Sorry, but I can't help saying it... how about a history and physical exam to guide you......

Sometimes patients hurt at all locations.

 

[Taus]

Sometimes patients hurt at all locations.

True, though in that situation I'd strongly question whether an injection should play a role at all...

 

[jesspt]

True, though in that situation I'd strongly question whether an injection should play a role at all...

Let me plug PT here - If her pain is that diffuse, and your physical exam essentially points to almost any of the potential pain generators in the shoulder, why not try PT vs an injection that at this point sounds like a shot in the dark?

 

[drf]

True, though in that situation I'd strongly question whether an injection should play a role at all...

Fair enuff. My practice is to ask the patient to pick one spot that hurts the worst.

My point was just to the original question. If HnP and imaging aren't enough to decide what to inject, and one worries about steroid load, simply don't use the steroid for the diagnostic aspect.

 

[normalforce]

Fair enuff. My practice is to ask the patient to pick one spot that hurts the worst.

My point was just to the original question. If HnP and imaging aren't enough to decide what to inject, and one worries about steroid load, simply don't use the steroid for the diagnostic aspect.

How about trying a transdermal with 8% diclofenac and 1% bupivacaine +/- ketamine. I have had so much success with transdermal compounding for shoulder issues its just sick. Try it. I use focused pain relief out of new York.