Chapter 62

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 joint.

• Povidone iodine solution or swabs
• Sterile gloves
• ...

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