joint injections

[topwise]

What is the highest frequency with which you've been taught to do corticosteroid injections in a joint (e.g. the shoulder)? Once a month? Once every three months? More frequent than that?

(Sorry in advance if this is off-topic, but I was given an answer to this question by an attending that just isn't sitting well with me.)

 

[SSdoc33]

ask your attending where he/she got their info.

here's a good review by todd stitik from UMDNJ on the subject

Am J Phys Med Rehabil. 2006 Nov;85(11 Suppl):S51-65;

 

[SSdoc33]

btw, you are probably not injecting the shoulder "joint", rather the subacromial space. i know you used that as an example, but still.

 

[topwise]

btw, you are probably not injecting the shoulder "joint", rather the subacromial space. i know you used that as an example, but still.

Well, either one. I think he was probably referring to the subacromial space, but I'd be interested in hearing the answer about intra-articular injections as well.

The link you sent doesn't work.... (I don't have a subscription to that journal)

 

[SOUNDMAN]

When we were doing injections, my physician and I would usually not do anymore than 3 a year in anyone location.

Another key was how much relief they actually obtained from the injection. Since most mix their injections with some sort of local anesthetic, the injection works as a diagnostic as well as therapeutic tool. If the patient obtained significant relief of their pain with say a subacromial injection, then it allowed us to know that

A. we got it in the right place, and
B.confirmed the possible diagnosis.

If they didn't get relief before they left, then one of the two criteria above may be incorrect.

In addition if someone received great relief from the anesthetic portion, but then after the anesthetic effect wore off received essentially no relief from the mixed in steroid, we found the many times a second injection was more likely NOT to be therapeutic and other treatments were initiated.

We wouldn't usually do them closer than a month apart either, we preferred 3 months between injections ideally.

 

[topwise]

From what I've read, you're not supposed to do steroid injections less than a month apart and in most clinics they say 3 months. And I recently did a SAE question where the answer was 6 weeks. But this attending told me he'll do them once a week for 3 or 4 weeks, which really surprised me.

 

[mehul_25]

btw, you are probably not injecting the shoulder "joint", rather the subacromial space. i know you used that as an example, but still.

You can inject and aspirate the glenohumeral joint. Probably easier under fluoro. During fellowship I once aspirated >80 ml of fluid from this dude's shoulder.

 

[SSdoc33]

topwise, that wasnt a link, it was a reference. its from the blue journal (american journal of PM&R).

 

[topwise]

topwise, that wasnt a link, it was a reference. its from the blue journal (american journal of PM&R).

Thank you for the reference, although I'd be interested to hear your thoughts on the subject or a link, since I don't have ready access to the journal at this moment.

 

[PMR 4 MSK]

I like to think of it in terms of blood flow, systemic effects and local tissues:

In a relatively avascular area, such as intra-articular, you should theroretically get a particulate steroid to stick around for a long time. Therefore, I try not to do it more often than q 3 months. I will do it closer together on a rare patient who has no other option while we work on other things - meds, PT, etc., or while waiting for surgery.

In a more vascular area, such as the subacromial space, around tendons, nerves, etc, you may be able to get away with it a little more frequently, but look at the steroid load you are giving them. The more vascular the area is, the more systemic a response you will get, along with it's many side effects, including bone metabolism, GI ulcers, weight gain and risk of avascular necrosis of hips, e.g. Also local steroid effects such as local tissue breakdown and risk of infection.

If you limit any injection to no more than 3 - 4 per year, and use the minimal amount of steroid neccesary (another debatable subject), you should be ok. Go above that and you had better have some literature or a good expert witness to back you up in the case of a serious adverse event.

An even more debatable subject is what to do with the patient in need of multiple injections for multiple locations - shoulder impingment + lumbar stenosis with radiculopathy + knee OA + hip bursitis. There's no real studies on this kind of patient. (And yes, I knoe there's other things you can do - NSAID's, PT, etc. I'm just talking about the patient that's tried them and could benefit from local steroid injections.)

When consenting patients, I tell them I use the minimal amount of steroid with the minimal frequency and minimal # repeat injections to bring their problem under control. If their pain problems cannot be controlled well enough or long enough by that, we need to look at other options.

 

[topwise]

I like to think of it in terms of blood flow, systemic effects and local tissues:

In a relatively avascular area, such as intra-articular, you should theroretically get a particulate steroid to stick around for a long time. Therefore, I try not to do it more often than q 3 months. I will do it closer together on a rare patient who has no other option while we work on other things - meds, PT, etc., or while waiting for surgery.

Thank you very much for that detailed answer. I was just perplexed when I was told by an attending that it was OK to do weekly subacromial steroid injections. On my admittedly brief search on the topic, I didn't see anything to support that, and I've always been taught that there is a risk of tendon rupture in that situation. However, I was wondering if there was anyone out there who does more frequent injections.

 

[AviatorDoc]

My understanding is that it is all purely theoretical. Very few adverse events have been reported with the large number of corticosteroid injections that are performed every day (excluding spine -- different story). You could probably get away with injection into the subacromial space qweek for a period of time, but if a tendon rupture were to occur, or some other systemic side-effect, you would be challenged to uphold your practice, as it is outside the scope of current standard-of-care. (Again, conceding that there is very little to no evidence driving this standard.)

Now... should doctors be afraid to go outside standard-of-care in situations where their clinical accumen deems an intervention is more beneficial than the current standard? That's a completely different question, and I certainly don't want to hijack this thread. 🙂

 

[tchoupdoc]

Thank you very much for that detailed answer. I was just perplexed when I was told by an attending that it was OK to do weekly subacromial steroid injections. On my admittedly brief search on the topic, I didn't see anything to support that, and I've always been taught that there is a risk of tendon rupture in that situation. However, I was wondering if there was anyone out there who does more frequent injections.

Hi there. I am PMR employed by an academic ortho practice. The ortho surgeons define the standard of care for this. Possibly oversimplified, but nonetheless the standard:

--Knees and shoulders: no more than four injections per year.

Yes, you can do more, and plenty do. But infect a joint and then explain why you did one every month! Keep in mind: all articular cartilage in a septic knee can be destroyed in 24 hours.

 

[drusso]

I remember once seeing a rheumatology article somewhere that said no more than 1 mg/kg/year of cortisone for joint injections...I can't remember the citation, maybe others can.

I generally limit it to 4-5 per year for neuraxial steroids and 3-4 per year for joint/soft tissues/TPI's. My general rule of thumb is that if I'm injecting something, somewhere on your body more than every 2-3 months it's time to step back and ask "is this a good long-term solution for a long-term problem..."

 

[lobelsteve]

I remember once seeing a rheumatology article somewhere that said no more than 1 mg/kg/year of cortisone for joint injections...I can't remember the citation, maybe others can.

I generally limit it to 4-5 per year for neuraxial steroids and 3-4 per year for joint/soft tissues/TPI's. My general rule of thumb is that if I'm injecting something, somewhere on your body more than every 2-3 months it's time to step back and ask "is this a good long-term solution for a long-term problem..."

Does this mean you put steroids in your trigger point injections?

 

[PMR 4 MSK]

Does this mean you put steroids in your trigger point injections?

I see so many physiatrists and anesthesiologists who still do. It's like the thought process is, if I'm not putting steroid in an injection, it doesn't count, and/or it won't help.

I just use 0.25% bupivicaine and a 25 g needle.

 

[dc2md]

"I just use 0.25% bupivicaine and a 25 g needle."

25 gauge? We use 27g usually (meaning most attendings). Do you find 27g is too small...too much resistance to injection?

 

[ampaphb]

"I just use 0.25% bupivicaine and a 25 g needle."

25 gauge? We use 27g usually (meaning most attendings). Do you find 27g is too small...too much resistance to injection?

Chris, most practices don't typically stock 27g needles, and the truth of the matter is, you reach into the drawer, and grab whatever it is you can find

FYI, Charity never had 27g needles anywhere, and 27s were only the 1/2" variety, even at the VA. Now imagine, if you will, the typical VA and New Orleans-sized patient, and you will realize a 1/2" needle was truly inadequate for almost anything other than raising a skin wheal

 

[dc2md]

Chris, most practices don't typically stock 27g needles, and the truth of the matter is, you reach into the drawer, and grab whatever it is you can find

FYI, Charity never had 27g needles anywhere, and 27s were only the 1/2" variety, even at the VA. Now imagine, if you will, the typical VA and New Orleans-sized patient, and you will realize a 1/2" needle was truly inadequate for almost anything other than raising a skin wheal

good points...the general population down here isn't lacking in girth.
i haven't done a VA rotation yet (and of course charity is down and out since Katrina) and so my only experience is at Ochsner. i think we typically only use 18g (to draw meds) and 27g (to inject). and the 27g are 1.5inch i believe so they suffice.

 

[ampaphb]

good points...the general population down here is lacking in girth.
i haven't done a VA rotation yet (and of course charity is down and out since Katrina) and so my only experience is at Ochsner. i think we typically only use 18g (to draw meds) and 27g (to inject). and the 27g are 1.5inch i believe so they suffice.

New Orleneans lacking in girth? That's hysterical!!!