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SIXTH EDITION SILVER’S JOINT AND SOFT TISSUE INJECTION INJECTING WITH CONFIDENCE Trevor Silver (1927–2011) Dr Silver was a general practitioner (GP) with an interest in the management of musculoskeletal conditions, notably injection therapy Throughout his career, he was interested in education and training For many years, he was Regional Adviser to South West Thames Region British Postgraduate Medical Federation and held a number of important roles within the Royal College of General Practitioners, including Chair and Provost of the South West Thames Faculty He chaired many management, education and research committees, including the local division of the BMA and his regional health authority regional research committee He was a GP advisor to the Arthritis and Rheumatism Council and a trainer to the Royal Army Medical Corps (RAMC) He contributed to original research on the regional inequalities of GP training in inner city areas He travelled widely to deliver his highly regarded soft tissue and joint injection workshops and published the successful book, Joint and Soft Tissue Injection (Adapted from BMJ 2011; 343:d7233 with permission from BMJ Publishing Group Ltd.) SIXTH EDITION SILVER’S JOINT AND SOFT TISSUE INJECTION INJECTING WITH CONFIDENCE EDITED BY DAVID SILVER FRCR FRCP Consultant Musculoskeletal Radiologist Royal Devon and Exeter NHS Foundation Trust Past President, British Society of Skeletal Radiologists UK CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2019 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper International Standard Book Number-13: 978-1-138-60417-9 (Paperback) 978-1-138-60420-9 (Hardback) This book contains information obtained from authentic and highly regarded sources Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Contents Preface to the first edition xi Preface to the second edition xiii Preface to the third edition xv Preface to the fourth edition xvii Preface to the fifth edition xix Preface to the sixth edition xxi Introduction xxiii About the author xxv Contributors xxvii Abbreviations xxix Incidence and general principles Frequency of injection Anticoagulation 4 Choice of steroid Contraindications to the use of steroids Local anaesthetic Post-injection advice References 6 Further reading Joint and soft tissue corticosteroid injection: what is the evidence? Introduction 10 Upper limb 10 Shoulder 10 Elbow 11 Hand 11 Lower limb 12 Hip 12 Hip/knee 12 Foot 12 What should we inject? 13 How often we inject? 13 Is it safe to inject in the diabetic patient? 13 What is the role of image-guided injection? 13 References 15 Medico-legal issues, complications and consent 17 Introduction 18 Technique of the procedure 18 Untoward complications of steroid injection 18 Lipodystrophy 18 vi Contents Loss of skin pigment 18 Hyperglycaemia 19 Infection 19 Pain after injection 19 Potential complications from injection 20 Informed consent 20 ‘Prudent doctor/prudent patient’ 20 Implied consent 20 Express consent 21 Injection procedures 21 Written consent 21 Documentation of consent 21 References 22 Further reading 22 The challenge of recognising and managing inflammatory arthritis 23 Introduction 24 Background: the burden of inflammatory disease 24 Challenges to diagnosis 24 How to diagnose 25 Clinical findings 25 Special investigations 25 Management 25 Injecting in inflammatory arthritis 26 Conclusion 27 References 27 The shoulder 29 Introduction 30 Presentation and diagnosis 30 Pitfalls in diagnosis 32 Referred pain to the tip of the shoulder 32 Pain referred to the deltoid insertion 33 Functional anatomy 33 The acromioclavicular joint 33 Examination of the shoulder 34 What the pain means 36 Pain on resisted abduction 36 Resisted external rotation 36 Resisted internal rotation 36 Resisted supination and flexion of the forearm 36 Injection technique 38 Anterior approach 38 Lateral (subacromial) approach 40 Posterior approach 42 Bicipital tendinosis 44 Injection technique 44 Contents vii Acromioclavicular joint arthritis 46 Injection technique 46 Physiotherapy: the shoulder 48 Summary 48 Shoulder impingement 48 ‘Frozen’ shoulder/shoulder capsulitis 48 Acromioclavicular joint arthritis 48 References 49 The wrist and hand 51 Incidence 52 Common problems treated with steroid injections 52 The first carpometacarpal joint 53 Presentation and diagnosis 53 Functional anatomy 53 Injection technique 54 Metacarpal and interphalangeal joints 56 Functional anatomy 56 Injection technique 56 Carpal tunnel syndrome 56 Presentation and diagnosis 56 Tinel’s test 57 Phelan’s test 57 Functional anatomy 57 Injection technique 58 De Quervain’s tenosynovitis 60 Presentation and diagnosis 60 Functional anatomy 60 Injection technique 60 Post-injection advice 60 Trigger finger 62 Presentation and diagnosis 62 Functional anatomy 62 Injection technique 62 Physiotherapy: wrist and hand 64 First carpometacarpal, metacarpal and interphalangeal joint osteoarthritis 64 Carpal tunnel syndrome 64 De Quervain’s tenosynovitis 64 Trigger finger 64 References 65 The elbow 67 Introduction 68 Tennis elbow 68 Presentation and diagnosis 68 Functional anatomy 68 Injection technique 68 viii Contents Golfer’s elbow 71 Presentation and diagnosis 71 Functional anatomy 71 Injection technique 72 Post-injection advice 72 Lipodystrophy 72 Physiotherapy: tennis and golfer’s elbow 72 Olecranon bursitis 74 Elbow joint 76 Presentation 76 Functional anatomy 76 Injection technique 76 Physiotherapy: elbow joint 76 Conditions around the hip and thigh 79 The hip 80 Trochanteric bursitis 80 Injection technique 80 Ischiogluteal bursitis (hamstring tendinopathy) 82 Injection technique 82 Meralgia paraesthetica 84 Injection technique 84 Iliotibial band friction syndrome 86 Presentation and diagnosis 86 Functional anatomy 86 Injection technique 86 Physiotherapy: conditions around the hip and thigh 88 Trochanteric bursitis 88 Ischiogluteal bursitis 88 Meralgia paraesthetica 88 Iliotibial band friction syndrome 89 Reference 89 The knee joint 91 Introduction 92 Presentation and diagnosis 92 Functional anatomy 92 Aspiration and injection therapy 93 Technique of aspiration and injection 94 Aspiration 94 Injection 94 Physiotherapy: the knee 96 References 96 Further reading 96 10 The ankle and foot 97 Introduction 98 Functional anatomy 98 Contents ix Presentation of some common problems 98 Injection technique 100 Ankle sprains 100 Achilles tendon 100 Plantar fasciitis: the painful heel 102 Injection technique 102 Tarsal tunnel syndrome 102 The ankle joint 104 Injection technique 104 Tibialis posterior tendinosis 104 Functional anatomy 104 Injection technique 104 Physiotherapy: the ankle and foot 106 Ankle sprains 106 Plantar fasciitis 106 Tarsal tunnel 106 Ankle arthritis 107 Tibialis posterior tendinosis 107 References 107 11 Musculoskeletal imaging and therapeutic options in soft tissue disorders 109 Introduction 110 Pathophysiology 110 When to image 112 Imaging modalities 112 Radiography 112 Magnetic resonance imaging 114 Ultrasound 114 Relative merits for different imaging modalities 114 Imaging of joints 116 General principles 116 The shoulder 116 Achilles tendon 120 The ankle 122 Plantar fascia 124 The knee 124 Ultrasound in inflammatory disease 126 Ultrasound-guided injection 126 Calcific tendinosis 126 Shockwave therapy 128 Educational aspects of reporting 128 Resource implications 128 Summary 129 Further reading 129 Index 131 124 Silver’s Joint and Soft Tissue Injection Plantar fascia Inferior heel pain is a common clinical presentation and is usually due to plantar fasciitis Inferior calcaneal bone spurs are common, but are not a cause of plantar fasciitis Ultrasound is an objective method for confirming the diagnosis The plantar fascia will become thickened, measuring more than 0.4 cm, with decreased reflectivity from oedema and thickening of the paratenon (see Figure 11.20) The paratenonitis is probably responsible for the pain, so it is logical to inject this area, rather than the tendon itself, which would run the risk of r upture Ultrasound is an effective method for injecting the paratenon with steroid (which is difficult without image guidance as it is a very thin structure lying just superficial to the tendon) (see Figure 11.21) The knee MRI has an established role in, and is highly sensitive to, detecting meniscal and cruciate injury Ultrasound is more limited, mainly because of the depth of structures However, it is useful in diagnosing meniscal and parameniscal abnormality and is an effective tool in examining the patellar tendon In some cases of patellar tendinosis there is cystic change, which is unlikely to settle with conservative management; therefore, appropriate orthopaedic referral should be considered Musculoskeletal imaging and therapeutic options in soft tissue disorders 125 Figure 11.20 Plantar fasciitis demonstrating objective changes on ultrasound Tip of needle Figure 11.21 Ultrasound-guided injection of the paratenon around the plantar fascia 126 Silver’s Joint and Soft Tissue Injection ULTRASOUND IN INFLAMMATORY DISEASE Ultrasound has been described as ‘the rheumatologist’s extended finger’, emphasising its extended role in the clinical examination of musculoskeletal injury or disease As there is no associated radiation, there is no limit to the number of examinations that can be performed It has also been demonstrated to detect erosive changes earlier than conventional radiographs Although proven to be as effective in this regard and capable of imaging areas that are inaccessible to ultrasound (e.g the spine and sacroiliac joints), MRI is limited in terms of availability and cost The potential applications of ultrasound include: • The examination of deep joints (i.e the hip and shoulder) • The detection of mild synovitis where clinical signs are absent • Distinction from synovitis and other causes of swelling, including tenosynovitis and subcutaneous oedema • Quantitative assessment of synovitis • Differentiation between synovial hypertrophy and effusion, allowing decisions regarding aspiration to be made • Needle placement for therapeutic injection, aspiration and biopsy Ultrasound-guided injection Ultrasound-guided injection allows accurate injection into proven areas of abnormality The needle tip is visible throughout the course of the examination, which allows a single and accurate passage into a bursa, small joint or paratenon As the non-distended subacromial space measures less than 2 mm in width, accurate injection without guidance is difficult Scanning during blind injections often shows the needle located within muscle or a tendon, with little resistance to injection The advantages of ultrasound-guided injection include quick and easy injection, the avoidance of multiple injections where there is lack of response and the certainty of accurate placement There is little evidence to suggest that either a blind or guided injection confers any advantage, but this is the subject of current research Calcific tendinosis Calcific tendinosis is a painful condition that can affect any tendon, although the supraspinatus tendon of the rotator cuff is the most commonly involved The aetiology is unclear, although repetitive trauma, a genetic predisposition or biochemical disorder have all been implicated Calcific deposits are common incidental findings and are thought to be painful during periods of formation and resorption Patients often present with severe pain affecting all movements, which does not respond to local injection or anti-inflammatory drugs While the diagnosis is commonly overlooked, once suspected, it can be confirmed with radiography or ultrasound Ultrasound is useful in confirming that the pain is attributable Musculoskeletal imaging and therapeutic options in soft tissue disorders 127 Figure 11.22 Calcific tendinosis: barbotage to the deposit and not impingement or a cuff tear While the condition is often self-limiting, a significant number of patients will have a protracted course and further therapy should be considered Arthroscopic excision is a proven treatment, but it does carry all the attendant risks of surgery and anaesthesia, together with a long recovery period A percutaneous treatment is available (barbotage), which involves puncturing the deposit with two 20G needles inserted under ultrasound or fluoroscopic guidance The procedure is performed under local anaesthesia and is well tolerated Following multiple punctures, saline is washed through the deposit to remove some of the broken particles Following the procedure, both steroid and Marcaine® are instilled before needle removal The procedure takes about 15 minutes to perform and is sometimes followed by a 24-hour period of exacerbation of symptoms, with a marked improvement over the next few days The procedure is thought to produce local hyperaemia, which aids resorption of the calcific deposits Success has been reported in up to 90% of patients who have been recalcitrant to other methods of treatment, and where symptoms have lasted for many months (see Figure 11.22) 128 Silver’s Joint and Soft Tissue Injection SHOCKWAVE THERAPY Extracorporeal shockwave therapy (ESWT), previously known as extracorporeal shockwave lithotripsy (ESWL), has been available for some time and is a well-established and effective method for treating renal calculi It also has an established role in treating bony and soft tissue disorders, with clinical improvement of symptoms in the following areas: • Bony non-union • Calcific tendinosis • Tennis and golfer’s elbow • Trochanteric bursitis • Patella tendinosis • Achilles tendinosis • Plantar fasciitis • Peyronie’s disease of the penis ESWT directs shockwaves directly onto the affected tendon through ultrasound or radiographic guidance, and uses high-energy, accurately-focused beams of ultrasound waves The mechanism of action is not entirely clear, but it can induce a local hyperaemic response, have an effect on cell membranes, alter the threshold of pain receptors or release negative ions, all of which are claimed to be responsible for its therapeutic response ESWT is not widely available in the UK; there is greater experience of its use in the USA and mainland Europe It has clear advantages in that it has no significant side effects, is non-invasive and does not involve the use of steroids Results from those centres with wide experience of its use are encouraging and are the subject of ongoing research Current European guidelines suggest its use in refractory tendinopathy, where there has been ineffective first-line therapy, including anti-inflammatory drugs, local steroid injection and physiotherapy EDUCATIONAL ASPECTS OF REPORTING It will be difficult for practising clinicians to familiarise themselves with all the complex imaging and interventional techniques now available, but as requests are made and feedback is obtained, individual referrers will begin to develop a deeper understanding of the pathology and biomechanics of common soft tissue disorders Through this process, clinicians will become more confident in their clinical management and recognise that there may be a reason why a problem has not improved with conservative management or injection Imaging is also a useful tool for the practitioner, allowing prompt diagnosis and effective management, leading to patient and doctor satisfaction RESOURCE IMPLICATIONS The availability of imaging modalities and therapeutic options varies geographically, so it is up to the clinical practitioner to make the most of what is available Musculoskeletal imaging and therapeutic options in soft tissue disorders 129 locally Clinicians should develop a good relationship with providers in secondary care, who can then adapt their facilities to provide the best possible service to both patients and their doctors SUMMARY Ultrasound and MRI can be used effectively to diagnose and treat a wide range of musculoskeletal conditions The examples in this chapter are not exhaustive but have been chosen to illustrate the role of imaging and guided therapy in some of the more common soft tissue disorders Imaging can be used to complement clinical diagnosis and injection techniques, allowing the practitioner to become more confident in his/her diagnosis and management of soft tissue disorders FURTHER READING Blei CL et al (1986) Achilles tendon: ultrasound diagnosis of pathological conditions Radiology 159: 765–767 Bunker TD and Schranz PJ (1988) Clinical Challenges in Orthopaedics: The Shoulder Oxford University Press, Oxford, UK Cunnane G et al (1996) Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound Semin Arthritis Rheum 25: 383–389 Da Cruz DJ et al (1988) Achilles paratenonitis: An evaluation of steroid injection Br J Sports Med 22 (2): 64–65 Farin PU and Jaroma H (1995) Acute traumatic tears of the rotator cuff: Value of sonography Radiology 197 (1): 269–273 Farin PU et al (1995) Rotator cuff calcifications: treatment with US-guided technique Radiology 195: 841–843 Farin PU et al (1996) Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavage Skeletal Radiol 25: 551–554 Gibbon WW et al (1999) Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis Br J Sports Med 33 (2): 129–130 Green S et al (2001) Interventions for shoulder pain Cochrane Database Syst Rev 2: CD001156 Hollister MS et al (1995) Association of sonographically detected subacromial/subdeltoid bursal effusion and intra-articular fluid with rotator cuff tear Am J Roentgenol 165: 605–608 Kane D et al (1998) Ultrasound guided injection of recalcitrant plantar fasciitis Ann Rheum Dis 57 (12): 749–750 Loew M et al (1999) Shock-wave therapy is effective for chronic tendinosis of the shoulder J Bone Joint Surg Br 81 (5): 863–867 Manger B and Kalden J (1995) Joint and connective tissue ultrasonography: a rheumatological bedside procedure? Arthritis Rheum 38: 736–742 130 Silver’s Joint and Soft Tissue Injection Rompe JD et al (1995) Extracorporal shock wave therapy for calcifying tendinitis of the shoulder Clin Orthop Relat Res 321: 196–201 Rompe JD et al (1998) Shoulder function after extracorporal shock wave therapy for calcific tendinitis J Shoulder Elbow Surg 7: 505–509 Index abductor pollicis longus tendon 52, 60 accuracy of injection placement 14 Achilles tendon injection 100 rupture 2–3, 19, 98, 120–1 tendinosis 98, 110–11 ultrasound 120–1 acromioclavicular joint functional anatomy 33–4 injection technique 46–7 osteoarthritis 36, 46, 48 physiotherapy 48 acromion process 2, 33, 38, 39, 40, 41, 42, 43, 47 acupuncture 72, 88 adhesive capsulitis, see frozen shoulder age of patient, shoulder pain 2, 30–1 anatomical snuffbox 53 ankle joint functional anatomy 98 imaging 122 injection technique 100, 101, 104 physiotherapy 106 ankle sprains 98, 100, 106 ankylosing spondylitis 102 anti-citrullinated c-peptide (anti-CCP) 25 antibiotics, and Achilles tendinosis 98 anticoagulants Aristospan® arm movements, shoulder pathology 36–7 aseptic technique 3, 18 aspiration knee effusions 93, 94 olecranon bursa 74 back pain Baker’s cyst 92 barbotage 30, 127 biceps tendon, long head 33 bicipital tendinosis 34, 44–5 bicipital tendon 45 blood glucose levels 13, 19 body mass index (BMI) 106 bone, imaging 112–13, 115 brachioradialis 68 bronchogenic carcinoma 32 bupivacaine bursitis ischiogluteal 82–3 knee joint 92 olecranon 74–5 subacromial 31, 40, 116 trochanteric 12, 80–1 C-reactive protein 26 calcaneal (heel) spur 98–9 radiography 112–13 calcific tendinosis 30 aetiology 126 imaging 126–7 percutaneous treatment 127 capsaicin 96 carpal tunnel syndrome 52, 56–60 evidence for injections 11 functional anatomy 57 injection technique 58–60 physiotherapy 64 pregnancy presentation and diagnosis 56–7 carpometacarpal joint, first 53 injection 54–5 osteoarthritis 53 physiotherapy 64 131 132 Index cervical spine assessment 34 incidence of problems ciprofloxacin 98 clergyman’s knee 92 Cobra trial 24 colour flow Doppler 123 complications of injections 2–3, 18–20, 72 informing patients 20–2 consent, see informed consent contraindications to injections 5–6 corticosteroids adverse effects 2–3, 18–20, 72 choice of agents 4–5, 13 contraindications 5–6 evidence for 10–13 solubility 13, 19 and tendon rupture 3, 18–19, 111 cost analysis, image-guided injections 14 crepitus Achilles tendon 98 De Quervain’s tenosynovitis 60 knee 92 shoulder 35 tibialis posterior tendon 104 cyclists 82, 86, 89 Cyriax, James 34 DAS-28 score 26 De Quervain’s tenosynovitis 60–1 functional anatomy 60 injection 60–1 physiotherapy 64 presentation and diagnosis 60 degenerative joint disease, see osteoarthritis deltoid insertion, referred pain 33 Depo-Medrone® 5, 86 diabetes mellitus frozen shoulder 31, 32 safety of injections 13, 19 diagnosis disease modifying anti-rheumatic drugs (DMARDs) 25–6 diuretics 58 dynamic examination 115 effusions aspiration 93, 94 knee 92 elbow joint functional anatomy 76, 77 injection technique 76 painful 11, 76 physiotherapy 76 see also golfer’s elbow; tennis elbow erythrocyte sedimentation rate (ESR) 2, 26 evidence of care 18 evidence for injections lower limb problems 12–13 ultrasound-guidance 14 upper limb problems 10–12 exercise knee disorders 96 reduced/non-weight-bearing 96, 107 express consent 21 extensor carpi radialis 68 extensor carpi ulnaris 68 extensor digitorum 68 extensor pollicis brevis tendon 60 extracorporeal shockwave therapy 128 flexor carpi radialis 59, 71 flexor carpi ulnaris 71 flexor digitorum superficialis 71 flexor retinaculum 57, 59 foam roller 89 foot deformities 122 foot movements 98 foot pain forefoot 98, 99 see also plantar fasciitis foot posture 89, 106, 107 footwear 89, 106, 107 Index 133 forearm extensor muscles 68 flexor muscles 71 resisted movements 36–7 forefoot pain 98, 99 frequency of injection 4, 13 frozen shoulder 2, 10, 117 associated conditions 31, 32 clinical phases 31 imaging 117 injections 46 physiotherapy 48 shoulder examination 35 treatment options 117 General Medical Council (GMC) 21 general practice consultations back pain shoulder complaints 2, 110 general practitioner (GP), diagnosis of joint/soft tissue disorders Gerdy’s tubercle 86 glenohumeral joint 2, 33 MRI 119 osteoarthritis 30 gluteal muscles 82, 88, 89 golfer’s elbow 11, 71–4 functional anatomy 71 injection technique 72, 72–3 physiotherapy 72, 74 post-injection advice 72 presentation and diagnosis 71 gout 40, 99 synovial fluid analysis 93 greater trochanteric pain syndrome 12, 80–1 injection technique 80–1 physiotherapy 88 presentation 80 Haglund’s disease 120 hallux rigidus 99 hamstring tendinopathy 82–3, 88 hand washing hand and wrist common problems treated with injections 52 incidence of pain 52 osteoarthritis 11, 52, 53–5, 56, 64 rheumatoid arthritis 52, 56 Heberden’s nodes 52 heel (calcaneal) spur 98–9 imaging 112–13 heel pain 98–9, 124 see also plantar fasciitis hip joint anatomy 80 muscle weakness 89 hip and thigh pain evidence for injections 12 iliotibial band syndrome 86–7 ischiogluteal bursitis 82–3 meralgia paraesthetica 84–5 physiotherapy 88–9 trochanteric bursitis 12, 80–1 history taking housemaid’s knee 92 hyaluronic acid 93–4, 96, 104 hydroxyapatite crystals 40 hyperaemia, imaging 123 hyperglycaemia 13, 19 hypertension hyperthyroidism iliac spine, anterior superior 84, 85 iliotibial band 86 iliotibial band friction syndrome 86–7 injection technique 86–7 physiotherapy 89 presentation and diagnosis 86 image-guided injections 13–14 benefits 13–14, 114–15 drawbacks 14 evidence for 14 plantar fasciitis 124–5 shoulder problems 14, 115 trigger finger 62 134 Index imaging 110 ankle 122 educational feedback 128 MRI 114 radiography 112–13 relative merits of modalities 115 resource implications 128–9 shoulder 116–20 timing of 112 ultrasound 111, 113 impingement syndrome 2, 31–2, 48 implied consent 20 infection 3, 5, 19 inflammatory arthritis 24–7 see also rheumatoid arthritis informed consent 20–2 documentation 21–2 express 21 implied 20 written 21 infrapatellar bursae 92 infraspinatus 33, 34 infraspinatus tendinosis 36 injections international normalized ratio (INR) interphalangeal joints arthritis 52 injection 56 ischiogluteal bursitis (hamstring tendinopathy) 82–3, 88 joint infection 3, 5, 19 synovial fluid analysis 93 Kenalog® knee joint aspiration and injection techniques 94–5 effusions 92 evidence for injections 12 functional anatomy 92 imaging 124 indications for injection/aspiration 93 osteoarthritis 93–4, 96 physiotherapy 96 lateral cutaneous nerve of thigh 84, 85 lateral epicondylitis, see tennis elbow lidocaine 5, 6, 33, 38, 40, 42, 44, 54, 60, 62, 68, 76, 82, 86, 94, 102, 104, lipodystrophy 18, 72 litigation, see medico-legal issues local anaesthetic long-lasting tennis elbow injection 68 long head of biceps tendon 33 lumbosacral spine problems magnetic resonance imaging (MRI) 110, 114 arthrogram 119 knee 124 relative merits 115 rotator cuff tears 115, 119 Marcaine® March fracture 99 medial epicondylitis, see golfer’s elbow median nerve compression 11, 56 functional anatomy 57 medico-legal issues 18–20 informed consent 20–2 Mental Capacity Act 2005 21 meralgia paraesthetica 84–5 causes 84 injection technique 84–5 physiotherapy 88 metacarpal joints, injection 56 metatarsalgia 98, 99 methotrexate 25–6 methylprednisolone acetate 5, 86 mid-tarsal joint 98, 99 Morton’s neurofibroma 99 National Institute for Health and Care Excellence (NICE) 26, 94, 96 nerve entrapment syndromes carpal tunnel syndrome 11, 56–60 meralgia paraesthetica 84–5 tarsal tunnel syndrome 99, 102 Index 135 non-steroidal anti-inflammatory drugs (NSAIDs) elbow pain 11, 72 hand osteoarthritis 64 hip/thigh pain 88 knee pain 96 shoulder pain 10, 46 novel oral anticoagulants (NOACs) olecranon bursitis 74–5 osteoarthritis acromioclavicular joint 34, 46, 48 ankle 107 incidence 52 knee 93–4, 96 synovial fluid analysis 93 wrist and hand 11, 52, 53–5, 56, 64 osteochondritis dissecans 92 osteoporosis pain following injection 19 reduction in ultrasound-guided injection 14 referred 32, 33 ‘painful arc’ 33, 34 palmaris longus tendon 57, 58, 59, 71 Pancoast tumour 32 paraesthesia carpal tunnel syndrome 56, 58 thigh (meralgia paraesthetica) 84–5 paratenon 110 paratenonitis 110, 124 patella, palpation 92 patellar tendinosis 124 patellar tendon rupture 18–19 patient advice, post-injection patient information 21–2 patient safety 2–3 diabetic patient 13, 19 repeat injections 18–19 ‘pepper pot’ injection technique 70 pes cavus 99 pes planus 122 Phelan’s test 57 physiotherapy ankle and foot 106–7 elbow joint 76 frozen shoulder 48 hip and thigh 88–9 knee joint 96 shoulder 48 tennis and golfer’s elbow 72 wrist and hand 64 pigment loss 18 plantar fascia 106, 113 plantar fasciitis evidence for injections 12–13 image-guided injection 124–5 imaging 112–13 injection techniques 102, 103 physiotherapy 106 predisposing factors 106 presentation 98–9 POLICE (mnemonic) 106 polymyalgia rheumatica 32 post-injection advice posterior tibial nerve, compression 99, 102 posture elbow pain 74 foot 89, 106, 107 meralgia paraesthetica 84 and shoulder pain 48 pregnancy prepatellar bursae 92 prudent doctor principle 20 prudent patient 20 pseudogout 93 pulmonary function tests, rheumatoid arthritis 26 quadriceps relaxation 94 wasting 92 quality of life (QOL) scores 12 quinolone antibiotics 98 radiography 112–13 plantar fasciitis 112–13 136 Index radiography (continued) relative merits 115 shoulder problems 30 referred pain tip of shoulder 32 to deltoid insertion 33 Reiter’s syndrome 40, 93, 99, 102, 113 repeat injections 13 safety 18–19 rheumatoid arthritis 24 ankle/foot 99 clinical diagnosis 24–5 disease activity score 26 disease burden 24 epidemiology 24, 52 hand/wrist 52, 56 injections 26–7 knee 93 medical management 25 shoulder 113 special investigations 25 synovial fluid analysis 93 ultrasound 126 rheumatoid factor (RF) 25 RICE (mnemonic) 100 rotator cuff anatomy 33 evidence for injections 10 examination 34–5 failure (cuff arthropathy) 113 imaging 113, 116–19 pain on examination 36–7 tears 116–19 tendinosis 36, 37 runners 86–7, 88, 89 self-management, knee disorders 96 septic arthritis 3, 19 synovial fluid analysis 93 seronegative arthropathies 93, 98, 113 shockwave therapy 128 shoulder 10–11 examination 34–7 functional anatomy 33–4 movements 34–5 shoulder (continued) painful movements 36–7 referred pain 32–3 rheumatoid arthritis 113 shoulder injections 38–43 anterior approach 38–9 image-guided 14 lateral approach 40–1 posterior approach 42–3 shoulder problems age of patient 2, 30–1 bicipital tendinosis 44–5 causes 30 diagnosis 30–3 evidence for injections 10–11 frozen (adhesive capsulitis) 2, 10, 31, 117 impingement syndrome 2, 31–2, 48 patient consultations 2, 110 physiotherapy 48 presentation 30 terminology 30, 31 skin crease, injection into 58 skin pigment loss 18 spinal problems splints foot 106 hand and wrist 12, 58, 64 sprains, ankle 98, 100, 106 sterilisation technique 3, 18 stiffness, in rheumatoid arthritis 25 student’s elbow (olecranon bursitis) 74–5 subacromial bursa, fluid-filled 119 subacromial bursitis 30–1, 40, 116 subacromial injection 14, 40–1 subcutaneous injection 18, 72 subdeltoid bursa ultrasound 117 ultrasound-guided injection 115 subscapularis 33 tendinosis 34, 36–7 supraspinatus 33, 34 calcific tendinosis 30, 126–7 degeneration 31–2 imaging 115, 119 Index 137 supraspinatus (continued) normal ultrasound 117 tears 31, 115, 118 tendinosis 36, 37 synovial fluid analysis 93 synovitis 110 tarsal tunnel syndrome cause and presentation 99 injection 102 physiotherapy 106 tendinopathy 110 tendinosis definition 30, 110 diagnosis 35 imaging 112 pathophysiology 110–11 tendon rupture corticosteroid injection 2–3, 18–19, 111 hereditary factors 2–3 tendons, ultrasound imaging 116 tennis elbow 11, 68–70 functional anatomy 68 injection technique 68–70 physiotherapy 72, 74 presentation and diagnosis 68 tenosynovitis de Quervain’s 60–1 pathophysiology 110, 111 ultrasound imaging 111 teres minor 33 terminology shoulder disorders 30, 31 tendon disorders 110 thigh, meralgia paraesthetica 84–5 thumb carpometacarpal joint arthritis 53–5 De Quervain’s tenosynovitis 60–1 thumb spica 12 tibialis posterior anatomy 104 imaging 122–3 tendinosis 104, 122–3 tendon sheath injection 104–6 Tinel’s test 57 toe deformities 99 trapeziometacarpal osteoarthritis 11 trauma 31 synovial fluid analysis 93 triamcinolone acetonide 5, 46, 54, 56, 58, 93, 94, 102, 104 triamcinolone hexacetonide 5, 86 trigger finger 52, 62–3 efficacy of injections 11–12 functional anatomy 62 injection technique 62–3 physiotherapy 64 presentation and diagnosis 62 trochanteric bursitis 12, 80–1 evidence for injections 12 injection technique 80–1 physiotherapy 88 presentation 80 tuberculosis 3, synovial fluid analysis 93 Tubigrip 74, 94 ulnar nerve 56 ultrasound 110, 113 Achilles tendon 111, 120 general principles 116 guided injections, see image-guided injections inflammatory disease 126–7 relative merits 115 tibialis posterior 122–3 viscosupplementation 93, 104 visual analogue scale (VAS) 12 ‘washerwoman’s thumb’ 53–5 weights, carrying 74 working habits, tennis and golfer’s elbow 74 wrist pain 11–12 X-rays, see radiography Yergason’s test 44 ... He travelled widely to deliver his highly regarded soft tissue and joint injection workshops and published the successful book, Joint and Soft Tissue Injection (Adapted from BMJ 2011; 343:d7233... live patients Models of the shoulder, wrist and hand, knee joint and elbow joint are available These are marketed by Limbs and Things Ltd of Bristol and I acted as their consultant in the development... will gain much stimulation and satisfaction from treating patients with such a variety of soft tissue and joint conditions Patients will benefit from receiving prompt and efficient therapy, thus