Management of localized Tender Points

Vinod Naneria

Classification – According to Pathology

Stenosing Tenosynovitis De Quervain’s Trigger thumb and fingers Bicep’s tenosynovitis Tibialis Posterior and Peroneal tendon

tenosynovitis

Classification – cont….

Traumatic and/or degenerative Tendenous avascular origin/insertion

Tennis / Golfer’s elbow Planter fasciitis Bursitis

Retrocalcaneal bursitis Periarthritis shoulder Trochanteric bursitis Olecranon bursitis

Classification – cont….

Trigger zones Supra and periscapular Costochondritis / Titze’s disease Gluteus maximums origin

Intra Articular CMC joint Knee Joint TM joint

Classification – cont…. Synovitis

Flexor tendons at wrist Extensor tendons at wrist

Miscellaneous Accessory Navicular Os trigonum Ganglions Osteitis Pubis Coccygodynia

Management Counseling

Self limiting conditions No long term disability Treatment may fail quite often Nothing to worry about

Drug Therapy Indomethacin 75mg H.S., with milk for 3

weeks and gradual withdrawal by alternate day / substitute by mild NSAID

Caution: Hypertension

Rule out Hypertension No anti inflammatory long term drug in

Hypertension Better to inject than drug therapy. Always ask for – serum creatinine and

urine for albumin

Management – cont…

Physiotherapy Local ultrasound heating Stretching exercises Corrective orthosis ( scooped heel) Wrist Band Elbow immobilizer

Management – Local Steroid Triamcinolone Acetonide – 10mg No Xylocain / Hylase 2cc syringe, 22 gauge needle, 1.5” long Lying down patient Multiple puncture for spread of drug Post injection massage Local band-aid dressing NSAID for two days Informed consent

Management – cont…

Injection – Intra lesional Planter fasciitis Tennis and Golfer’s elbow All trigger points All joints All bursitis

Injection – Peri lesional Into Sheath – all tenosynovitis

Instructions to patients

To come prepared after cleaning the part to be injected.

Especially the heel or coccyx Always ask the patient to bring an

attendant for inadvertent Drug reaction Vaso-vagal reaction or sudden hypotension

Caution: Diabetes

Avoid injection in cases of high blood glucose level.

Predispose to infection Affect serum glucose management Better skin preparation

Management – cont… PrecautionsAvoid All weight bearing joint Avoid hitting the tendon directlyAvoid hitting the nerves directlyAvoid injecting directly in to artery or veinWatch for allergic reactions for an hour

Instructions to patient after local steroid injection

Inform about post injection flair Inform about skin and local soft tissue

atrophy Watch for infection Avoid repeating injection at the same

site for at least 6 weeks

Cortisone induced Leucoderma of the wrist

A word of caution:

To avoid possible depigmentation and subcutaneous atrophy, intra-lesional doses should not be placed too superficially in easily visible sites in deeply pigmented patients

Soft tissue necrosis

Tips….. Planter fasciitis:

Hit directly from the planter surface on the medial calcaneal tuberosity.

Feel the medial calcaneal tuberosity with the tip of the needle and push it distally so that it can slip over the calcaneum. This the place.

Inject the drug and make multiple punctures in the planter apponeurosis.

Massage the site after the injection

Tips….. De Quervains disease

Start just proximal to the nodule Inject the drug into the sheath See the filling of the sheath up to the base

of thumb Do not inject in to the tendons A tight sheath will give the same resistance

as the injection into the tendon – you have to differentiate.

Tips…..

Coccygodynia Feel maximum tender point The place for injection is the junction

between the two mobile parts. So do not

inject over the bone but inject into the space between two pieces of coccyx.

Tips…..

Tennis Elbow Always just anterior to the epicondyle Occasionally over the lateral epicondyle Inject into the soft tissue over the

epicondyle anteriorly and not over the bone.

With the needle hit the bone and then withdraw it before injection

Make multiple punctures

Caution :Temporaryskin de-pigmentation.Local subcutaneous tissue necrosis.

Contraindications for use Hypersensitivity to ingredients of triamcinolone Preparation Systemic infections or local infections Infected joints Where previous injections have produced local atrophy Active peptic ulcer, myasthenia gravis, osteoporosis, acute

glomerular nephritis, fresh intestinal anastamoses, diverticulitis, thrombophlebitis,

Psychic disturbances, pregnancy, diabetes mellitus, hyperthyroidism,

Acute coronary artery disease, hypertension, limited cardiac reserve,

Triamcinolone is crystalline suspention

The duration of effect is inversely related to the solubility of the preparation: the less soluble an agent, the longer it remains in the joint and the more prolonged the effect. Consequently, suspensions are longer acting.

Crystals of Triamcinolone can be detected in joint fluid even after 6 months after injection

DISCLAIMER

Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 30 years.

It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal

opinion. Depending upon the x-rays and clinical presentations, viewers can

make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best

suited to him. I am not responsible for any controversies arise out of this presentation.

For any correction or suggestion please contact naneria@yahoo.com