Dr Paul Annett MBBS FACSP

Sports Physician

Visiting Fellow UNSW

Cortisone Injection

Historical

• Hench & Co-workers 1950

• Hollander 1951 - Local use via injection

• Use evolved with soft tissue use to sports

Cortisone Actions

• Inhibit early inflammation– Edema, leukocyte

migration, etc

• Inhibit late manifestations– Fibroblasts

– Collagen deposition

– Scar formation

Cortisone Injection

• Important questions to ask:

• What to inject?• When to inject?• Where to inject?• How to inject?• Complications of

injection?• Advice to Patients?

What to inject?

• Joint• Bursa• Peri-tendinous• Synovial sheath• Enthesis• Ligament• Muscle

What to inject?• Shoulder - Sub-acromial, AC joint, Glenohumeral

joint

• Elbow - CEO, CFO, Elbow joint• Wrist - DeQuervains,SL ligament,Ganglion• Hand - Tenosynovitis• Ankle - Post sprain synovitis, Tendinopathy• Foot - Plantar fascial insertion, 1st MTP• Knee - Knee joint, Patella tendon• Hip - Greater trochanter, Hip Joint• Spine - Facet joint, Epidural space

When To Inject?• Appropriate diagnosis

– History– Examination– Judicious investigation

• 4-6 weeks of appropriate pre-injection management– Relative rest & X-train– Ice, NSAIDS, modalities– Well structured rehabilitation program

• NEVER in children

Advice to Patients• NOT A CURE - Rehab essential!

• Will this hurt?

• What are the side effects?– Systemic (NB diabetes)

– Infection - 1:20,000

– Crystal flare - ice + paracetamol

– Skin changes - atrophy & pigment loss

– Bleeding

– Neuritis

• How long to rest?

What to Inject?

• Cortisone• More soluble - short acting• Depot preparations• Local anaesthetic additive

– Dilute cortisone– Reduces initial pain– Confirms diagnosis

• Relative volumes

How to Inject?

• GENERAL PRINCIPLES

• Informed consent

• Aseptic no touch technique

• Avoid skin infection

• Appropriate needle & syringe size

• Be confident!

• Skin anesthesia

Failure of Injection• Physician

– Wrong diagnosis– Poor injection technique– Inadequate rehabilitation program

• Athlete / Patient– Persistent overuse– Poor technique– Intrinsic factors– Advanced degenerative disease

How Many Injections?

• Repeat at least once if initial failure– Incorrect position – ? Need imaging guidance

• Failure of 3 injections - Re-think!

• Repetition causes collagen weakness

• 3 is not set in stone

Now - On To Injections

Shoulder - Sub-acromial

• Overuse or degenerative rotator cuff pathology

• Posterolateral approach

• 2ml cortisone + 5ml local

• Re-examine

Shoulder - AC joint

• Degenerative pathology

• Superior approach• 1ml cortisone + 1ml

local

Shoulder – Glenohumeral Joint

• Capsulitis, GH OA, post traumatic pathology

• Posterior approach• 2cm inferior and medial to

posterolateral acromial edge

• Needle angled superomedial to the coracoid (palpate with other hand)

• 2ml cortisone + 5ml local

Thank You