Chapter 73. Bursitis and Tendonitis Therapy

Bursitis and tendonitis are frequent complaints evaluated in the Emergency Department. Bursitis represents an acute or chronic inflammation of the bursa. Similarly, tendonitis involves inflammation surrounding the bony insertion sites of the tendons. Typically, these complaints are treated conservatively with reduction of inflammation as the goal. Treatment often includes rest, elevation, application of cold and heat, and the introduction of anti-inflammatory agents. However, joint and soft tissue injections are helpful for both the diagnosis and therapy of a variety of musculoskeletal complaints. Diagnostic goals include a means for fluid aspiration and to provide symptom relief of the affected body part. Therapeutic goals include delivery of local anesthetics for acute pain relief, delivery of corticosteroid for suppression of inflammation, and increased mobility.1 Injection therapy along with the above generalized treatment guidelines are a critical component of a multifaceted treatment regimen that should be considered by the Emergency Physician.

Definitive care can often be easily initiated by the administration of a steroid injection during the patient's earliest presentation. It has been shown that the clinical response to injectable corticosteroids is quite positive.2–5 The techniques of aspiration and injection are easily mastered. These techniques are generally safe and effective when appropriate guidelines are followed.1 While injection therapy can be effective, it must be remembered that this treatment should not replace cessation or modification of the offending activity if identified.

Bursae are round, fluid filled, pad-like sacs or cavities. There are roughly over 160 bursae in the body. They are usually located at sites of friction such as joints, or in 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, inflammatory arthritis such as rheumatoid arthritis, crystal deposition, and infection.

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 inflammation, mucoid degeneration, and fibrinoid degeneration.6

Bursitis and tendonitis are often grouped together because the history, symptomatology, physical examination findings, and the 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 anti-inflammatory effect while minimizing systemic effects.

Injections of corticosteroids should be performed for an inflammatory bursitis or synovitis when systemic therapy is contraindicated and as an adjunct to physical therapy or systemic therapy. Many inflammatory conditions, including articular and nonarticular processes, are improved with local corticosteroid injection therapy.1,7,8 The articular processes that are helped by injection therapy include gout, pseudogout, spondyloarthropathies, rheumatoid arthritis, neuritis, osteoarthritis, and crystalloid arthropathies. The nonarticular processes that are helped by injection therapy include bursitis, periarthritis, adhesive capsulitis, tenosynovitis, epicondylitis, trigger points, ganglion cysts, entrapment syndromes, tendonitis, plantar fasciitis, and neuritis.

Both absolute and relative contraindications should be assessed when corticosteroid injection therapy is contemplated. The absolute contraindications include overlying cellulitis, septic arthritis, adjacent acute fracture, bacteremia, unstable joints, joints containing a prosthesis, and a history of an allergy or anaphylaxis to local anesthetics. 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 greater than three injections annually into a weight-bearing joint. Systemic conditions such as renal failure, cardiac failure, hypertension, diabetes, and other conditions that may be affected by the injection of corticosteroids should also be considered prior to proceeding with any injection therapy.

• Povidine iodine or chlorhexidine solutions
• Sterile gloves
• Sterile drapes and towels
• 18 gauge needles, 1.5 to 2 in. long
• 22 gauge needles, 1.5 to 2 in. long
• 23 gauge needles, 1.5 to 2 in. long
• 25 gauge needles, 1.5 to 2 in. long
• Syringes (1, 5, and 10 mL)
• Injectable steroidal preparation (Table 73-1)
• Licocaine (1% and 2%) without epinephrine
• Bupivacaine (0.25% and 0.50%) without epinephrine
• Mepivacaine (1%) without epinephrine
• Adhesive bandages (to be placed postinjection)

Explain the procedure, its risks, and its benefits to the patient and/or their representative. Obtain a written informed consent to perform the procedure. Position the patient so that they are comfortable and the injection site is easily accessible. Identify the injection site using the appropriate anatomic landmarks. It may be necessary to outline structures with a skin pencil when landmarks are difficult to palpate. Clean any dirt and debris from the skin. Apply povidone iodine or chlorhexidine solutions over the injection site and surrounding skin. Allow it to dry. Generally, sterile drapes and gloves are recommended for the novice but are not absolutely necessary depending upon operator experience.9,12 A no-touch technique is indicated if a sterile field is not created.

Medication dosing in bursae and soft tissue injections is influenced by the bursa size, the presence or absence of synovial fluid, the presence or absence of edema, the severity of synovitis, and the steroid preparation selected. Table 73-1 summarizes the characteristics of commonly available corticosteroid preparations. The duration of action is chiefly dependent on the solubility of the preparation. For example, a dose of 20 to 30 mg of methylprednisolone acetate or equivalent is appropriate for large spaces such as the subacromial, olecranon, and the trochanteric bursae. This can be increased to a 30 to 40 mg dose if a large amount of synovial fluid is present. A dose of 10 to 20 mg is appropriate for intermediate size bursae present in the wrists, knees, and heels. A dose of 5 to 15 mg is appropriate for tendon sheaths. Triamcinolone hexacetonide and acetonide are the least soluble preparations available. The local effects of these steroid preparations may take several days for effects to be noticed initially, but these effects will ultimately last weeks or months. More soluble preparations such as hydrocortisone acetate have effects that last a few days. Many physicians prefer triamcinolone due to its prolonged duration of action. Corticosteroids are often mixed with a local anesthetic solution prior to injection. The local anesthetic solution provides immediate pain relief for the patient. It also confirms for the physician that the injection was placed at the appropriate anatomic site. If less volume is needed for the injection, consider using higher concentrations of local anesthetics such as 2% lidocaine instead of 1%.

Injection techniques for pediatric patients are not different than those for adults. However, smaller injected volumes maybe required depending on the age and size of the child. Soft tissue corticosteroid injections should be performed by a Rheumatologist or an Orthopedic Surgeon as these injections can affect bone growth, cartilage growth, and damage growth plates.

The sites for joint injections are typically based on anatomic landmarks. When superficial bursitis, tendonitis, and large effusions are involved, ultrasound may be helpful if available and depending upon physician experience. When deep bursae are involved or the target structure is difficult to reach, ultrasound can be helpful.6,10,11 The deep injections requiring ultrasonographic guidance may require a specialist. The procedure can be time consuming and difficult to perform for the Emergency Physician who does not possess the skills and experience with ultrasound-guided procedures.6,10,11

Subacromial Bursitis

The subacromial bursa lies between the rotator cuff muscles inferiorly (i.e., supraspinatus, infraspinatus, teres minor, and subscapularis muscles) and the overlying acromion, teres major muscle, and deltoid muscle. It cushions the coracoacromial ligament from the supraspinatus muscle. The subacromial space contains the long head of the biceps, the rotator cuff tendons, and the subacromial bursa. The syndromes of calcific tendonitis, supraspinatus tendonitis, and subacromial bursitis are so similar that the signs of each are difficult to distinguish. Anatomic proximity may cause associated irritative inflammation of adjacent structures, so that these conditions often overlap and coexist. Pain from these syndromes is elicited by shoulder abduction.

Patients often present holding the affected arm in a protective fashion against the chest wall. The classic sign of subacromial bursitis is tenderness over the greater trochanter that disappears with arm adduction. The “subacromial painful arc” is painful active abduction of the shoulder with maximal pain occurring between 70° and 100° of abduction. This differs from acromioclavicular joint inflammation, which results in a painful arc from 120° to 180° of shoulder abduction.

Three techniques are described to inject the subacromial bursa: the lateral approach, the anterior approach, and the posterior approach. The lateral approach is the most commonly used technique. Some prefer the anterior (or subcoracoid) approach provided that the practitioner has good familiarity with the anatomic landmarks. However, the anterior approach is more difficult for the less experienced to perform.

Place the patient seated upright or supine on a gurney. Palpate the indentation under the acromion process of the scapula for the lateral approach. This indentation is located between the acromion process and the greater tuberosity of the humerus. Fill a syringe with 1 mL of local anesthetic solution and 1 mL of a selected corticosteroid such as dexamethasone. Apply a 22 to 25 gauge needle to the syringe. Insert the needle into the indentation and direct it superomedially. Advance the needle until the tip touches the inferior surface of the acromion (Figure 73-1). Inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage.

Alternative approaches include the anterior and posterior approaches. Position the patient as above for the anterior approach. Identify the coracoid process of the scapula. Insert the needle 1.5 cm lateral to the coracoid process. Direct the needle horizontally and posteriorly. Advance the needle approximately 2.5 cm to gain direct access to the subacromial space. Inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage.

The posterior approach may also be used. The distance from the coracoacromial ligamentous arch in this approach is great and may limit efficacy. Place the patient sitting upright with the effected forearm resting in their lap. Palpate the most lateral point of the acromion process posteriorly. Insert the needle at this landmark. Aim the needle toward the center of the humeral head and at an upward angle of 10° (Figure 73-2). Advance the needle 3 to 5 cm until the bursa is entered. Inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage.

Shoulder Impingement Syndrome

A shoulder impingement syndrome results from rotator cuff, particularly the supraspinatus muscle, compression between the humerus and the coracoacromial arch. This is part of a pathophysiologic continuum with an endpoint of complete rotator cuff rupture in some cases. A history of overhead activities such as painting a ceiling is common. The clinical hallmark is a painful arch of abduction from 60° to 120°. Pain typically begins at 60° to 70° of abduction and is maximal from 100° to 120°. Tenderness at the tendon insertion site over the greater tuberosity of the humerus may be present.

The impingement injection test may separate the pain of impingement from other causes of shoulder pain. First, the examiner prevents scapular rotation by holding the patients scapula against their rib cage. Extend the patient's affected arm in forced forward elevation. Pain with this movement may signify a number of inflammatory shoulder conditions. Repeat this maneuver after injecting 10 mL of local anesthetic solution beneath the anterior acromion process. The absence of pain after local anesthetic injection defines an impingement syndrome.

Place the patient sitting upright or supine on a gurney. Identify the coracoacromial ligament, which is found by palpating the coracoid process and the tip of acromion process. The coracoacromial ligament connects these two bony points (Figure 73-3). This ligament is a thick, dense, fibrous band. Fill a syringe with 80 mg of triamcinolone and 2 mL of bupivacaine or mepivacaine. Apply a 22 to 25 gauge needle to the syringe.12 Insert the needle under the coracoacromial arch and inject the steroid–anesthetic mixture (Figure 73-3). The plunger should depress easily and without resistance. Forceful injection indicates that the tip of the needle is within the rotator cuff tendons. Advance the needle another 0.5 cm and reattempt the injection, seeking minimal resistance. Withdraw the needle and apply a bandage.

Bicipital Tendonitis

The long head of the biceps tendon passes through the bicipital groove of the humerus (Figure 73-4). In this condition, the inflamed tendon is tender to palpation along the anterior humerus. Yergason's test is a clinical indicator of bicipital tendonitis. Flex the patient's elbow 90°. Grasp the patient's affected arm as if shaking hands. A positive test is the elicitation of pain in the biceps muscle while the examiner provides resisted supination to the patient's hand. Lipman's test is another clinical indicator of bicipital tendonitis. Tenderness of the bicipital tendon as it is rolled or plucked within the bicipital groove is considered a positive test. In general, pain causes restricted motion. Shoulder elevation will aggravate the patient's symptoms.

Place the patient seated with the affected arm externally rotated 20°. The bicipital groove and tendon are now pointing directly anterior. Fill a syringe with 10 to 15 mg of triamcinolone and 2 mL of local anesthetic solution. Apply a 22 to 25 gauge needle to the syringe. Palpate the bicipital tendon and identify the point of maximal tenderness. Insert and direct the needle into the tendon sheath and aim toward the border of the bicipital groove at the site of maximal tenderness (Figure 73-4). Inject one-third of the dose into the peritendinous space (Figure 73-4(1)). Confirmation of the needle placement within the tendon sheath is made by free flow of the steroid–anesthetic mixture with minimal resistance. Difficulty depressing the plunger indicates that the tip of the needle is within the tendon. If resistance to injection occurs, withdraw the needle slightly and aim more parallel to the tendon to allow penetration of the sheath and not the tendon substance. Withdraw the needle to just under the skin and redirect it 2.5 cm superiorly, touching the border of the bicipital groove, and inject another one-third of the dose (Figure 73-4(2)). The final one-third of the dose is deposited by again withdrawing the needle to the subcutaneous area and redirecting the tip 2.5 cm inferiorly to the first injection site and touching the border of the bicipital groove (Figure 73-4(3)). Withdraw the needle and apply a bandage.

Lateral Epicondylitis (Tennis Elbow)

Lateral epicondylitis, or tennis elbow, is pain at the origin of the wrist and finger extensor muscles. Pain is elicited on palpation of the lateral epicondyle of the humerus. It is also elicited during resisted wrist extension. A history of playing racquet sports or doing manual labor is common.

Locate the injection site by palpating the base of the lateral epicondyle with the elbow flexed 90°. Fill a syringe with 1 mL of local anesthetic solution, 1 mL of methylprednisolone, and 0.5 mL of dexamethasone. Apply a 22 to 25 gauge needle to the syringe. Alternatively, mix the local anesthetic solution with 40 mg of triamcinolone. A total volume of 2 mL is required. Insert the needle in the indentation between the lateral epicondyle and the radial head, beginning at the radial head (Figure 73-5A). Slowly advance the needle toward the lateral epicondyle. The radial nerve runs in this area, and care must be taken not to penetrate and inject the nerve. Paresthesias and pain will be felt if the needle enters the nerve.

Inject 0.5 mL of the steroid–anesthetic mixture into the tenoperiosteum at the base of the lateral epicondyle. Withdraw the needle until the tip is at the level of the radial head while simultaneously infiltrating with 0.25 mL of the steroid–anesthetic mixture. Infiltrate 0.5 mL of the steroid–anesthetic mixture when the tip of the needle reaches the level of the radial head. Redirect the needle over the proximal extensor muscle bellies (Figure 73-5B). Inject the remaining steroid–anesthetic mixture in a fan-like pattern over the extensor muscle bellies (Figure 73-5B). Withdraw the needle and apply a bandage.

Medial Epicondylitis (Golfer's Elbow)

Patients affected with medial epicondylitis, or golfer's elbow, are most commonly Little League pitchers, golfers, and bowlers. Pain is felt in the medial aspect of the elbow upon flexion and supination of the wrist. Tenderness is elicited on palpation just distal to the medial epicondyle. It is important to exclude an avulsion fracture of the medial epicondyle or a compression fracture of the subchondral bone of the lateral condyle or radial head in children with nonfused epiphyses. Radiographs are suggested to exclude these causes.

Place the patient supine on a gurney. Place the arm in 90° of external rotation and abducted 90°. Flex the elbow 90°. Prepare a steroid–anesthetic mixture similar to that used for lateral epicondylitis. Identify by palpation the volar surface of the medial epicondyle. Insert the needle 2 cm proximal to the medial epicondyle and advance it distally to the tenoperiosteal region (Figure 73-6). The ulnar nerve is better protected than the radial nerve, as it runs posterior to the epicondyle. Proximal needle insertion prevents striking the ulnar nerve. Paresthesias and pain are indicators of nerve penetration. Inject 1.5 mL of the steroid–anesthetic mixture over the medial epicondyle while withdrawing the needle. Withdraw the needle and apply a bandage.

Olecranon Bursitis

Olecranon bursitis is usually sterile even though the olecranon bursa is the most frequent site of a septic bursitis. The bursa is located subcutaneously overlying the olecranon process of the ulna. Olecranon bursitis is not very painful except for the discomfort due to bursal expansion. An enlarged olecranon bursa may limit elbow extension. Studies have demonstrated that corticosteroid injection is superior to oral regimens for resolution of bursal inflammation.13 Simple aspiration without corticosteroid injection is often followed by reoccurrence. Since the olecranon bursa is the most common site of a septic bursitis, aspiration with fluid analysis is recommended before corticosteroid injection unless infection can be ruled out clinically.

Seat the patient upright with their elbow flexed 90°. Fill a syringe with 30 to 40 mg of triamcinolone and 1 mL of local anesthetic solution. Insert an 18 gauge needle on an empty syringe into the most dependent aspect of the bursal sac. Aspirate the bursal fluid to drain it completely. The bursa may be “milked” by palpation and compression of the tissues toward the draining needle. Hold the needle securely. Remove the syringe while the tip of the needle remains within the bursa. Attach the syringe containing the steroid–anesthetic mixture. Inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage. Wrap the elbow region with an elastic compression bandage (Jones compression dressing) for 7 to 10 days. Instruct the patient to limit elbow movement for 7 to 10 days to prevent reaccumulation of the fluid.14

DeQuervain's Tenosynovitis

DeQuervain's tenosynovitis is an inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis muscles as they cross the wrist (Figure 73-7A). The precise cause is unknown. Excessive friction from overusing the thumb and wrist such as repetitive and excessive gripping and grasping may be a possible etiology. Cases have been seen in bricklayers, golfers, those who sew, and piano players. Pain is elicited by the classic Finkelstein test, in which the patient deviates the wrist ulnarly while holding the thumb between the palms and fingers (Figure 73-7B). Palpation along the course of the tendon will also cause pain.

Fill a syringe with 40 mg of triamcinolone and 1 to 2 mL of mepivacaine or bupivacaine. Apply a 25 gauge needle to the syringe. Bending the needle approximately 30° at its base makes it easier to negotiate the area and insert the needle alongside the tendon.14 Introduce the needle through the skin overlying the point of maximal tenderness. This is usually just distal to the radial styloid process (Figure 73-8). Inject the steroid–anesthetic mixture into the tendon sheath. Resistance to injection signifies that the tip of the needle is within the tendon. Withdraw the needle slightly and reinject, feeling for the loss of resistance. Withdraw the needle and apply a bandage. Apply a light thumb splint for approximately 10 days. The splint is especially useful at night or when there is significant activity.

Trochanteric Bursitis

Trochanteric bursitis typically affects women in the fourth to sixth decades of life. It also occurs in runners, ballet dancers, and as a form of overuse or trauma to the hip. Hip pain often prevents the patient from sleeping on the affected side. Pain is also severe with walking, especially up stairs. The deep trochanteric bursa lies between the tendon of the gluteus maximus and the greater trochanter of the femur. Another lies between the gluteus medius and the greater trochanter (Figure 73-9). Pain is elicited on palpation of the greater trochanter of the femur. Pain can be reproduced by hip adduction in superficial bursitis or on a resisted active abduction in deep bursitis.

The principal bursa lies between the gluteus maximus and the posterolateral prominence of the greater trochanter. Pain may radiate from the greater trochanter down the lateral or posterior thigh, mimicking sciatica or hip joint disease. In contrast to these syndromes, passive range of motion of the hip is nearly painless in the trochanteric bursitis. However, active abduction of the affected hip while the patient is lying on the unaffected side increases symptoms. Pain is also elicited by abduction and external rotation of the hip.

Place the patient prone on a gurney. Fill a syringe with 80 mg of triamcinolone and 3 to 10 mL of local anesthetic solution. Apply a 22 to 23 gauge needle on the syringe. Insert the needle at the point of maximal tenderness and aimed toward the greater trochanter. Advance the needle until the tip strikes the greater trochanter. Withdraw the needle 1 to 2 mm and inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage.

Ischial Bursitis

The ischial bursa lies between the ischial tuberosity and the overlying gluteus maximus (Figure 73-9). It becomes inflamed from trauma or prolonged sitting on a hard surface. Pain may radiate down the back of the thigh and mimic sciatica. Pain can be elicited by applying pressure over the ischial tuberosity.

Place the patient prone on a gurney. Fill a syringe with 30 to 40 mg of triamcinolone and 5 to 10 mL of local anesthetic solution. Apply a 22 to 23 gauge needle to the syringe. Insert the needle over the most prominent section of the ischium. Hip flexion may facilitate palpation of the ischium in obese patients. Care must be taken not to injure the sciatic nerve. Striking the nerve will cause paresthesias across the buttocks and down the leg. Advance the needle until it contacts the ischial tuberosity. Withdraw the needle 2 to 3 mm and inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage.

Iliotibial Band Syndrome

Patients with iliotibial band syndrome present with lateral knee pain. This condition is commonly seen in cyclists, dancers, long-distance runners or walkers, and football players. These patients have a painful limp that is exacerbated with walking or running. Climbing stairs or walking up an incline will increase their pain. Tenderness is elicited with the patient lying supine and knee flexed 90°. Instruct the patient to extend their knee as you press over the lateral femoral condyle. Pain will be localized to the lateral femoral condyle. The patient will have pain at 30° of flexion as the iliotibial band slides over the condyle. A positive Rinne test occurs when the patient stands with their weight on the affected leg and flexes their knee. Pain at 30° of flexion is considered in a positive test.

Place the patient supine on a gurney. Fill a syringe with 80 mg of triamcinolone and 2 mL of local anesthetic solution. Apply a 22 to 25 gauge needle to the syringe. Typically, at 30° of flexion, the iliotibial band is at the midpoint of the lateral femoral condyle (Figure 73-10). Support the patient's leg in this position to bring the tendon to its most superficial point. Identify the point of maximal tenderness as the patient flexes their knee. Insert the needle perpendicular to the skin and 1 cm inferior to the point of maximal tenderness. Aim the needle superiorly. Inject the steroid–anesthetic mixture in an arc from anterior to posterior. The goal is to deposit corticosteroid in the tendon sheath and the surrounding inflamed tissues. Resistance to injection indicates that the tip of the needle is within the tendon. Withdraw the needle slightly and reinject, feeling for the loss of resistance. Withdraw the needle and apply a bandage.

Anserine Bursitis

Anserine or pes anserine bursitis is an inflammation of the bursa located 5 cm below the medial joint line of the knee at the tibial insertion of the gracilis, sartorious, and semitendinosus muscles (Figure 73-11). The anserine bursa is superficial to the tibial insertion of the medial collateral ligament. The syndrome occurs predominately in overweight women with osteoarthritis of the knees. It may also be found in equestrians. The anserine bursa will be tender to palpation.

Place the patient supine with the affected leg externally rotated. Identify the anteromedial joint line of the knee. The bursa is located inferior to the joint line at the insertion of the sartorius, gracilis, and semitendinosus tendons (Figure 73-11). Palpate the area of maximal tenderness at this site. Fill a syringe with 40 mg of triamcinolone and 2 to 4 mL of local anesthetic solution. Apply a 23 to 25 gauge needle to the syringe. Insert the needle and direct its tip into the bursa at the point of maximal tenderness. Inject the steroid–anesthetic mixture into the bursa. Withdraw the needle and apply a bandage.

Prepatellar Bursitis

Prepatellar bursitis is caused by direct pressure, such as when a person is kneeling on a firm surface. It is also known as nun's, rug cutter's, or housemaid's knee. Tenderness and/or crepitance is elicited by direct palpation overlying the patella. Extreme knee flexion causes pain. There is often a fluctuant, well-circumscribed, and warm bursal pouch overlying the patella. The prepatellar space is a common site for septic bursitis. Aspiration with fluid analysis is recommended to rule out an infection before any corticosteroid injection is considered.

Place the patient supine on a gurney with the affected knee slightly flexed. Note that the bursa is very superficial and may be entered by passing the needle just through the skin and subcuticular tissues (Figure 73-11). Fill a syringe with 30 to 40 mg triamcinolone and 1 to 2 mL of local anesthetic solution. Apply a 23 to 25 gauge needle to the syringe.14 Insert the needle into the bursa at the point of maximal fluctuance. Inject the steroid–anesthetic mixture into the bursa. Withdraw the needle and apply a bandage.

Infrapatellar Bursitis

The infrapatellar bursa has two components (Figure 73-11). The superficial infrapatellar bursa lies between the patellar ligament and the skin. The deep infrapatellar bursa lies between the patellar ligament and the anterior tibia. Inflammation of the superficial bursa occurs due to friction from the overlying skin. Clinically, there is no pain with passive flexion. Active knee flexion and extension causes pain in the deep infrapatellar bursa. Edema and tenderness may be found on both sides of the patellar tendon.

Place the patient supine on a gurney with the affected leg and knee extended. Palpate the patellar tendon. Identify the superficial inflamed bursa. Fill a syringe with 20 mg of triamcinolone and 1 mL of local anesthetic solution. Apply a 23 to 25 gauge needle to the syringe. Insert the needle into the superficial bursa and inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage.

Patients with deep infrapatellar bursitis have maximal tenderness and swelling both medially and laterally to the patellar tendon. Fill a syringe with 30 mg of triamcinolone and 1 to 2 mL of local anesthetic solution. Apply a 23 to 25 gauge needle on the syringe. Insert the needle into the infrapatellar bursa, either medially or laterally to the patellar tendon. Attempt to aspirate, although fluid accumulation is minimal and usually no return will be found. Inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage.

Achilles Tendonitis

Achilles tendonitis causes tightness and pain in the heel region upon first awaking. This discomfort improves with ambulation. The Achilles tendon will be tender to palpation and may be visually swollen. Corticosteroid injection around the Achilles tendon has been associated with tendon rupture.15 Therefore, this injection is reserved for the Podiatrist, Rheumatologist, or the Orthopedic surgeon.15

Plantar Fasciitis

Plantar fasciitis is a common problem presenting to the Emergency Department and the primary care physician. Patients typically complain of medial heel pain, particularly after standing for a long period of time. These patients have minimal to no swelling but feel acute tenderness to palpation over the calcaneal insertion of the plantar fascia. Maximum tenderness is palpated just beneath the spring ligament at the insertion of the plantar fascia on the calcaneous. Radiographs may demonstrate a calcaneal spur. However, the presence of a spur does not correlate with plantar fasciitis. Patients may have plantar fasciitis with or without a calcaneal spur. The optimal therapy for these patients is to elevate the heel with a felt heel pad inserted in the shoe. In addition, they may begin stretching exercises that are designed to stretch the plantar fascia. This often relieves the condition without an injection. In significant cases where conservative therapy is unsuccessful, injection of the calcaneal insertion of the plantar fascia with a steroid–anesthetic mixture is advocated.

Place the patient supine on a gurney with the affected leg externally rotated. Fill a syringe with 20 mg of triamcinolone and 1 mL of local anesthetic solution. Apply a 25 gauge needle on the syringe. Insert the needle into the medial aspect of the foot and aimed just anterior to the base of the calcaneous (Figure 73-12). Advance the needle 1.5 cm and inject the steroid–anesthetic mixture. Withdraw the needle and apply a bandage. The patient should avoid weight bearing for 3 to 4 days and immediately begin oral nonsteroidal anti-inflammatory drugs.

The patient must be observed for several minutes after the injection. Reexamine the patient to compare pre- and postinjection tenderness and mobility. The patient's symptoms should abate within a few minutes from the local anesthetic. Lack of relief indicates deposition of the steroid–anesthetic mixture away from the target structure. In these cases, a second attempt may be performed if the injection site can be properly identified. Otherwise, refer the patient to their primary care physician, a Rheumatologist, or an Orthopedic Surgeon for reevaluation and reassessment.

Instruct the patient to limit movement and/or weight bearing of the affected area after a corticosteroid injection. The duration of rest is dependent on the injection site. Larger and weight-bearing joints may require up to 2 to 3 weeks of rest, with range-of-motion exercises encouraged. Immobilization with splints or bandages may be necessary to prevent weight-bearing. A rehabilitation program including range-of-motion exercises, stretching, and strengthening may be recommended depending upon the chronicity and severity of the presenting condition.

Local infection is rare after corticosteroid joint injection and occurs from 1 in 17,000 to 50,000 injections.1,8,16,17 A local reaction consisting of swelling, tenderness, and warmth may occur a few hours postinjection and last up to 2 days. This is known as the “postinjection flare” or “steroid flare.”9 It is self-limited, and responds to ice packs and nonsteroidal anti-inflammatory drugs. The etiology of the steroid flare is attributed to preservatives in the steroid suspension inducing a local synovitis. Steroid flares occur in approximately 2% of patients injected with corticosteroids.1

Tendon rupture is a theoretical complication thought to be due to corticosteroids weakening the collagen matrix. Tendon ruptures after corticosteroid injections have been reported, but direct causality has not been established.15,18–21 Rupture is more likely if the injection is made into the tendon matrix rather than the synovial sheath, if the patient does not rest the tendon appropriately after the injection, or with multiple repeat injections.

Subcutaneous fat atrophy and atrophy of the overlying skin may develop if the steroid is injected less than 5 mm beneath the skin surface. A depigmentation in darker-skinned individuals may also occur due to superficial steroid injections. The depigmentation typically resolves spontaneously over a period of 6 months to 1 year.

Local corticosteroid injections are useful diagnostic and therapeutic adjuncts for the Emergency Physician. Many patients with an inflammatory bursitis or tendonitis will benefit greatly from these simple and effective injections. Mastery of the techniques is quite easy. They require a familiarity with the indications, the local anatomy, and the injectable corticosteroid preparations. Complications associated with the injection of a steroid–anesthetic mixture are minimal if it is not injected into an infected space.