Joint Injections. AJ Durfee PA-C. Course Objectives. Jerry Hizon,MD, FAAFP,CAQSM

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for Dr Hizon to cover the Chargers Medical coverage for USA Rugby 7 s Winter and Summer X-Games Medical coverage Clinical Staff Point Loma Nazarene University

1 Jerry Hizon,MD, FAAFP,CAQSM Joint Injections OUCH Sports Med Ctr Team Doctor, SD Chargers (NFL) Temecula Valley High School Assist. Clinical Professor, University of California, San Diego Mayor of Temecula AJ Durfee PA-C Oasis sports medicine group Western University of Health Sciences Works for Dr Hizon to cover the Chargers Medical coverage for USA Rugby 7 s Winter and Summer X-Games Medical coverage Clinical Staff Point Loma Nazarene University Course Objectives Review the important anatomy needed to perform joint injections Discuss the various pharmacologic agents used in joint injections Corticosteroids Lidocaine/Marcaine Hyluronic Acid 1

2 Course Objectives-continued List the various joints that are commonly injected in the geriatric patient. State the risks and contraindications to performing joint injections. General Introduction s are safe and effective Helpful tool to treat musculoskeletal problems Anatomy- Bone is your friend Pharmacology/Aseptic technique Procedure Principles of Injection Local problem tx. With local solution Steroids injections safer than NSAIA? NSAIA: GI bleeds- minor vs. life threatening Renal - ARF (interstitial nephritis) Liver toxicity- cytochrome P450 Steroids Injections: Complications (Grey, Clin. Ortho., 1983) 2

(consider frozen peas) Raider s Javelin Injection Technique?

3 Steroid Injections Techniques to minimize pain Prepare Patient, Position Patient Ethyl Chloride- spray until skin turns white Mix steroid with caine brothers Ice for 10 to 15 minutes after injection Have them ice the area at home 15 min x 3 per day (consider frozen peas) Raider s Javelin Injection Technique? Risks from Injections Bleeding Infection Scarring Nerve Damage Tendon Weakening Vaso-vagal reaction Pharmacology Corticosteroids Local Analgesics Lidocaine Marcaine Bupivicaine Levobupivacaine Ropivacaine 3

4 Types of Injectable Steroids Short Acting Depomedrol Long Acting Triamcinalone (Aristospan) Dexamethasone Betamethasone Viscosupplementation Hyluronic acid level decreases with OA Series of weekly injections Synvisc, Orthovisc, Supartz, Hyalgan, Synvisc One Repeat Injections Maximum 3 injections to same joint per year Specialist sometimes reinject more often, but not recommended in PC Lower patient expectations on repeat injections!!!! (down regulation) Procedure Explain/consent patient Dress/position patient Glove/goggle/mark site with lollypop prep with betadine x 3, Ethyl Chloride Inject Clean/Dress/Ice x 15 min Aftercare/follow up 4

5 Post Injection Care/Follow Up Avoid full activity x 4 days Repeat injections after six weeks Failure to improve Re-think diagnosis/image study Modify activity Surgical intervention? Anatomy Shoulder Knee Elbow Wrist/Hand Ankle/Foot Spine- lumbar/cervical Bone- ribs, AC joint Muscles- Hamstring/Gastrox Pathology Impingement Syndrome of Shoulder AC Joint Separation Knee- DJD/OA, bursitis Hip Greater Trochanteric Bursitis Elbow - DJD/OA, epicondolitis (Lat/Med) Ankle/Foot - plantar fasciitis Wrist/Hand - MCP. Metacarpal-carpal joint Ganglion, Trigger fingers, de Quervain s Back SI joint Shoulder Impingement Syndrome History Pain with abduction, sleep, overhead activity Symptoms Popping, clicking, weakness, Physical Signs-Impingement Signs Neers, Hawkins, Scarf Treatment Options 5

Shoulder (Subacromial) Injection 1 cc Aristospan 1cc Dexamethasone 6cc Marcain 0.

Dislocations Beware the frozen shoulder Be sure not missing posterior dislocation Physical Exam Pearl Even

Acromioclavicular (AC) Separations of the Shoulder Fall on to tip of shoulder, adducted arm Very painful

6 Shoulder (Subacromial) Injection 1 cc Aristospan 1cc Dexamethasone 6cc Marcain 0.25% Location Posterior 1 cm medial / 1cm inferior to posterior tubercle Lateral Posterior Shoulder Dislocations Beware the frozen shoulder Be sure not missing posterior dislocation Physical Exam Pearl Even full rotator cuff tears can externally rotate Dislocated shoulders cannot externally rotate! Acromioclavicular (AC) Separations of the Shoulder Fall on to tip of shoulder, adducted arm Very painful Consider early injection Prevents natural course of Pain, Bleeding, Inflammation, Disuse Atrophy Turns a 8 week injury into 1 week Need to do within 24 hours 6

Location Superior/Lateral aspect- soft spot

7 AC Joint (Shoulder Separation) 1/2 cc Aristospan 1/2 cc Dexamethasone 2 cc Marcaine 0.25% plain Perform as soon as possible after injury Knee Injections (DJD) 1 cc Aristospan 1 cc Dexamethasone 2 cc Marcaine 0.25% Location Superior/Lateral aspect- soft spot Lateral Anterior (don t recommend) Superior Lateral Approach Superior Lateral Apporoach 7

Anterior Approach Hip- Greater Trochanteric

25% plain Elbow- Lateral Epicondolitis 1/2

8 Anterior Approach Hip- Greater Trochanteric Bursitis Common in geriatric Good results from injection 1cc Aristospan 1cc Dexamethasone 4cc Marcaine 0.25% plain Elbow- Lateral Epicondolitis 1/2 cc Aristospan 1/2 cc Dexamethasone 1 cc Marcaine 0.25% plain BE CAREFUL OF SKIN ATROPHY Deeper is better in regards to this injection Olecranon Bursitis of Elbow 1/2 cc Dexamethasone 1/2 cc Aristospan 1cc 0.5% Marcaine Compression/Padding Sleeve 8

DeQuervain Tenosynovitis Carpal-MC Joint of the

1/4cc Dexamethasone (1cc/4mg) 1/4cc Aristospan

5%) Ganglions Aspirate Use Needle Holders to

9 DeQuervain Tenosynovitis Carpal-MC Joint of the Thumb 1/4 cc Aristospan 1/4cc Dexamethasone 1/2 cc Marcaine 0.25% plain BE CAREFUL OF SKIN ATROPHY! 1/4cc Dexamethasone (1cc/4mg) 1/4cc Aristospan (1cc/20mg) 1/2cc Marcaine (0.5%) Ganglions Aspirate Use Needle Holders to change syringes 1/4cc Dexamethasone (1cc/4mg) 1/4cc Aristospan (1cc/20mg) 1/2cc Marcaine (0.5%) Trigger Finger - A1 pulley stenosis 1/4cc Dexamethasone (1cc/4mg) 1/4cc Aristospan (1cc/20mg) 1/2cc Marcaine (0.5%) 9

Plantar Fasciitis 1/2 cc Aristospan 1/2 cc

25% plain BE CAREFUL OF HEEL FAT PAD ATROPHY!

(1cc/4mg) 1/4cc Aristospan (1cc/20mg) 1/2cc

5%) Sacroiliac Joint 1/2cc Dexamethasone

Final Comments Patients may artificially feel

10 Plantar Fasciitis 1/2 cc Aristospan 1/2 cc Dexamethasone 1 cc Marcaine 0.25% plain BE CAREFUL OF HEEL FAT PAD ATROPHY!!!!!! Morton s Neuroma 1/4cc Dexamethasone (1cc/4mg) 1/4cc Aristospan (1cc/20mg) 1/2cc Marcaine (0.5%) Sacroiliac Joint 1/2cc Dexamethasone (1cc/4mg) 1/2cc Aristospan (1cc/20mg) 2 cc Marcaine (0.5%) Final Comments Patients may artificially feel better for 4days ROM helpful s should be view as one aspect of the treatment to compliment physical therapy. 10

11 Pearls Bone is your friend If you can put a finger on the pain you can put a needle in it Don t let the skin get in the way of the cure 11

JOINT INJECTIONS AJ DURFEE PA-C CHRIS MAYBERRY PA-C

JOINT INJECTIONS AJ DURFEE PA-C Worked with sports group in San Diego for 7 ½ years Worked for Kaiser Orthopedics since 2011 I grew up in San Diego CHRIS MAYBERRY PA-C 1 XAVIER VALDEZ Grew up in Texas