Musculoskeletal complaints are frequently lumped into the wastebasket
diagnoses of bursitis and tendonitis. Patients are often begun on
nonsteroidal anti-inflammatory drugs with orthopedic follow-up in
a few days. However, joint and soft tissue injections are diagnostically
and therapeutically powerful interventions that are effective for
patients with musculoskeletal complaints. These injections are a
critical component of a multifaceted treatment regimen that should
be in the arsenal of the trained Emergency Physician.
The techniques of aspiration and injection are easily mastered.
These injections are both safe and effective if appropriate guidelines
are followed.1 The effectiveness of injection therapy is
dependent upon “hitting the target structure,” followed by
a comprehensive rehabilitation program. In selected patients, the
Emergency Physician may begin definitive care by administration
of a steroid injection. The clinical response to injectable corticosteroids
is generally quite positive.2–5
Bursae are round, flat, pad-like sacs or cavities in connective
tissue. They are usually found in the vicinity of joints, at areas
of friction, or in areas of possible impingement. Bursae are lined
with a synovial membrane and contain synovial fluid. They act to
reduce friction. There are approximately 160 bursae in the body.
Tendons are fibrous connective tissue bands attaching muscles to bones.
A synovial sheath containing synovial fluid surrounds most tendons.
Tendonitis and bursitis are inflammations of these respective
structures. They are grouped together because the patient’s
history, symptomatology, physical examination findings, and the treatment
for these two inflammatory processes often overlap.
Corticosteroid injections serve to decrease inflammation, provide
pain control, and promote healing. The goal of injection into joints,
tendon sheaths, and bursae is to attain concentrated synovial fluid
steroid levels to maximize the local anti-inflammatory effect while
minimizing systemic effects.
Injections of corticosteroids should be performed for an inflammatory
bursitis or synovitis when systemic therapy is contraindicated (renal
failure, cardiac failure, hypertension, or diabetes) and as an adjunct
to physical therapy or systemic therapy. Many conditions, including
articular and nonarticular processes, are improved with local corticosteroid
injection therapy.1,6,7 The articular processes that are
helped by injection therapy include rheumatoid arthritis, spondyloarthropathy,
ankylosing spondylitis, osteoarthritis, gout, and pseudogout. Joint
injection in patients with these conditions should usually be deferred
to the patient’s Family Practitioner, Internist, or Rheumatologist.
The nonarticular processes that are helped by injection therapy include
bursitis, periarthritis, adhesive capsulitis, tenosynovitis, tendonitis,
lateral and medial epicondylitis, plantar fasciitis, and neuritis.
There are absolute and relative contraindications to corticosteroid
injection therapy. The absolute contraindications include overlying
cellulitis, septic arthritis, bacteremia, unstable joints, and joints
containing prostheses. The relative contraindications include inaccessibility
of the joint, joints requiring radiographic guidance to ensure proper
needle placement, meniscal or labral tears as a cause of symptoms,
joints with loose bodies as a cause of symptoms, coagulopathy, anticoagulant
therapy, or more than three injections annually into a weight-bearing
- Povidone iodine solution or swabs
- Sterile gloves...
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