Bursitis and tendonitis are frequent complaints evaluated in the Emergency Department. Bursitis represents an acute or chronic inflammation of a bursa. Tendonitis involves inflammation surrounding the bony insertion sites of the tendons. These complaints are usually treated conservatively with the goal of reducing inflammation. Treatment often includes anti-inflammatory agents, application of cold and heat, elevation, and rest. Joint injections (Chapter 97) and soft tissue injections are helpful for the diagnosis and therapy of a variety of musculoskeletal complaints. The goal of aspirating fluid from a joint is to help make a diagnosis or to relieve pressure within a swollen joint. The therapeutic goal of putting a needle into a joint or soft tissue is to deliver local anesthetics and corticosteroid medications for acute pain relief, suppression of inflammation, and increased mobility.1,2 Injection therapy along with generalized treatment is a component of a multifaceted treatment regimen that should be considered by the Emergency Physician.
Definitive care can be initiated by the administration of a steroid injection during the patient’s presentation. The clinical response to injectable corticosteroids is quite positive.3-6 The techniques of aspiration and injection are easily mastered. These techniques are generally safe and effective when appropriate guidelines are followed.1 Injection treatment does not replace cessation or modification of the offending activity if identified.
Injection therapies are frequently performed based on anatomic landmarks. Ultrasound (US) can be used to guide injections. US-guided injections are safer and allow the Emergency Physician to visualize the needle during the procedure when done in the long axis and ensure delivery of the medication to the appropriate area. The use of US decreases complications and increases patient satisfaction.7 This chapter uses landmarks and US-guided injections to provide relief of the patient’s symptoms.
ANATOMY AND PATHOPHYSIOLOGY
Bursae are round, fluid-filled, pad-like sacs or cavities. There are approximately 160 bursae in the body. They are usually located at sites of friction (e.g., over joints or areas where tendons pass over bony prominences). Bursae are lined with a synovial membrane and contain synovial fluid. Their primary purpose is to reduce friction when movement occurs and to provide a mechanical advantage for tendon function. Bursitis often results from trauma, chronic overuse, and inflammatory arthritis (e.g., crystal deposition, infection, and rheumatoid arthritis).
Tendons are fibrous connective tissue bands attaching muscles to bones. A synovial sheath containing synovial fluid surrounds most tendons. Tendons mainly transmit forces from muscle to the skeleton. Pathologic findings are typified by fibrinoid degeneration, inflammation, and mucoid degeneration.8
Bursitis and tendonitis are often grouped together because the history, symptomatology, physical examination findings, and treatment for these two inflammatory processes often coincide. Corticosteroid injections serve to decrease inflammation, provide pain control, and promote healing. The goal of injection into tendon sheaths and bursae is to attain concentrated steroid levels to maximize the local ...