Common Injections of the Knee

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Common Injections of the Knee Foot/Ankle
General Principles and Specific Techniques

• Jeff Leggit, MD

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Objectives

• Review the general indications,
  contraindications, benefits, and risks of
  injections
• Discuss consent, equipment, anesthesia,
  corticosteroid choice and technique
• Discuss specific anatomic injections detailing
  indications, clinical landmarks, technique,
  needle size and dosage

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Indications
Risks/Complications

• Therapeutic
• Remove tense effusions
• Remove blood or pus
• Therapeutic lavage
• Injection of steroids or other intra-articular
  therapies
• Diagnostic
• Synovial fluid analysis
• Therapeutic trial
• Imaging studies
• Synovial biopsy

• Tendon rupture
• Post-injection flare
• Cartilage degeneration
• Local trauma/pain
• Infection 1/20,000 - 50,000 injections
• Atrophy/hypo or hyperpigmentation
• Hyperglycemia

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Risks/Complications

• Tendon rupture
• Post-injection flare
• Cartilage degeneration
• Local trauma/pain
• Infection 1/20,000 - 50,000 injections
• Atrophy/hypo or hyperpigmentation
• Hyperglycemia

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Contraindications

• Cellulitis or broken skin over needle entry site
• Anticoagulation or a coagulopathy (relative)
• Intra-articular fractures (for steroids)
• Septic effusion (for steroids)
• Lack of response to prior injections
• More than 3 prior injections in the last year to
  a weight bearing joint
• Inaccessible joints joint prostheses

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Evidence-Based Medicine

• There is currently insufficient quality data to
  provide a definitive answer on the efficacy of
  steroid injections.

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General Principles

• Consent
• Equipment
• Anesthesia
• Corticosteroids
• Alternate Compounds
• Technique
• Post-Procedure Care

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Consent

• Consent should be obtained on all diagnostic and
  therapeutic injections!
• A detailed discussion of benefits, risks and the
  expected results should be covered.
• Consent should be witnessed and documented.

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Equipment

• Controversies
• sterile prep vs. alcohol prep
• sterile gloves vs. nonsterile
• Injections 21 - 27 gauge 1-10cc syringes
• Aspirations 18 - 20 gauge 3 - 50cc syringes
• Anesthesia1-2 lidocaine, 0.5 bupivicaine?
  and/or topical (Ethyl Chloride, EMLA, TAC)
• Steroid Celeston 6mg/cc, Triamcinolone 40mg/cc
• Sponges, Band-Aids
• Access to equipment for allergy/anaphylaxis

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Anesthesia

• Aids in providing pain relief, assisting in
  diagnosis, and providing a volume for the
  steroid.
• Lidocaine 0.5 to 2 amide 1 - 5 min onset of
  action duration 1 hr.
• Bupivicaine 0.25 - 0.5 amide 30 min onset of
  action duration 8 hr.
• Ethyl chloride, EMLA, TAC

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Anesthesia

• Anesthetics work by causing a reversible block to
  impulse conduction along nerve fibers.

Loss of Pain Sensation
Loss of All Sensation
Loss of Motor Power
As Dose of Local Anesthetic Increases
Max Dose of Lidocaine 4/mg/kg
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Corticosteroids

• Treats the local inflammatory response (if
  present)- not the clinical problem.
• Modify Pain Receptors
• Goal is to maximize glucocorticoid effects
  minimize mineralocorticoid effects.
• Increased solubility shorter duration lower
  risk for post-injection steroid flare lower
  risk for local atrophy.

• Celestone (6mg/ml)- Has Short Long Acting
  Properties may be best all around agent (hard to
  find and keep)
• Triamcinolone (10/ml 40mg/ml) Low Solubility
  so last longer and may be better for Joint
  Injections

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Alternate Compounds-Prolotherapy

• Theory of strengthening tendons or ligaments by
  injecting a noxious stimulus that cause a
  proliferation of new cells, but avoids the
  possible catabolism of steroids
• Dextrose
• Saline
• Phenol
• Calcium Gluconate
• Autologus Blood
• Aprotinin
• Heparin

Poorly studied, but gaining interest. May be
worth a try
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Technique

• Be prepared!
• Landmarks
• Aseptic vs. Sterile technique
• Local anesthesia
• Needle insertion
• Delivering the volume
• bolus vs. peppering

This is gonna hurt a lot
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Post-Procedure Care

• Evaluation of relief in the office (gt50
  improvement efficacious)
• Discussion of steroid effects/expectations (48
  rule)
• Afterpain treatment
• Ice vs. short course NSAID
• Activity Recommendations
• Follow-up visit!

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Pain Relief and Injection Therapy
Corticosteroid
Anesthetic
Pain
Pain Threshold
48hrs
Time
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Evidence-Based Medicine

• There is currently insufficient quality data to
  provide a definitive answer on the efficacy of
  steroid injections.

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Specific Injections

• Knee joint
• Pes-Anserine Bursitis
• Iliotibial Friction Syndrome

• Plantar Fascia Pain
• Mortons Neuroma
• Tarsal Tunnel Syndrome
• Ankle Joint

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Knee Joint

• Indications
• Degenerative, Inflammatory, Crystal Induced
  Arthropathy
• Diagnostic
• Aspiration
• Needle size and dosage
• 22 to 25 gauge 11/2 inch needle
• 3-5 ml of Anesthesia w/ 1 ml of Celestone 6mg/ml
  or Kenalog 40mg/cc

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Pes Anserine Bursitis(Sartorious, Gracilis,
Semitendinosus)

• Indications
• Diagnostic evaluation of medial knee pain
• Recalcitrant pes anserine bursitis
• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 0.5 ml of Anesthesia w/ 0.5 ml of Celestone
  6mg/ml or Kenalog 40mg/cc

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Iliotibial Band Friction Syndrome

• Indications
• Diagnostic evaluation of lateral knee pain
• Recalcitrant Itb friction syndrome
• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 0.5 ml of Anesthesia w/ 0.5 ml of Celestone
  6mg/ml or Kenalog 40mg/cc

Site of injection
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Plantar Fascia

• Indications
• Recalcitrant plantar fascial pain
• Diagnostic
• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 1ml of Anesthesia w/ 1 ml of Celestone 6mg/ml or
  Kenalog 40mg/cc

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Mortons Neuroma (perineural fibrosis of an
interdigital nerve)

• Indications
• Pain refractory to conventional treatment
• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 0.5ml of Anesthesia w/ 0.5 ml of Celestone
  6mg/ml or Kenalog 40mg/cc

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Tarsal Tunnel Syndrome

• Indications
• Diagnostic
• Persistent Pain
• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 0.5ml of Anesthesia w/ 0.5 ml of Celestone 6mg/ml
  or Kenalog 40mg/cc

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Ankle Joint

• Indications
• Persistent pain from OA or posttraumatic
  arthritis
• Needle size and dosage
• 25 to 27 gauge 1 ½ needle
• 1-2 ml of Anesthesia w/ 1 ml of Celestone
  6mg/ml or Kenalog 40mg/cc

Anterior Tibial Tendon
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1st MTP
Sinus Tarsi Syndrome

• Indications
• Aspiration- Confirmation of crystal induced
  arthropathy
• Injection-Acute treatment of above and OA and
  traumatic arthritis
• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 0.5ml of Anesthesia w/ 0.5 ml of
  Celestone 6mg/ml or Kenalog 40mg/cc

• Indications
• Persistent Pain in Sinus Tarsi
• Needle size and dosage
• 25 to 27 gauge 1 ½ needle
• 1-2 ml of Anesthesia w/ 1 ml of Celestone
  6mg/ml or Kenalog 40mg/cc

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Conclusion

• Injections are very satisfying and rewarding for
  both the patient and the Family Physician.
• Indications and Contraindications must be known.
• An appreciation for the mostly anecdotal evidence
  must be kept in mind.