Ideally, the comprehensive interdisciplinary pain center would combat the scourge of fragmented musculoskeletal care. Chronic musculoskeletal pain is prevalent in 50% of adults and is the leading cause of disability in the United States [1=Burden MSK dz].1 Systemic corticosteroid treatment of musculoskeletal pain began soon after the discovery and synthesis of cortisone in the 1940s.2 Intraarticular steroid injections followed shortly thereafter, and in 1951, Hollander published the results of a large series of patients treated with corticosteroid joint injections.3 Corticosteroid injections continue to play an important role in the diagnosis and management of acute and chronic musculoskeletal pain. Pain physicians who recognize joint pain versus spine pain and who are proficient in multimodal management of both are well suited to coordinate reasonable utilization of intraarticular injections.
The spectrum of treatment options for painful joints includes tincture of time, education and counseling, activity and physical treatments, orthoses, medications, imaging, injections, and surgery. This chapter covers indications, techniques and anatomic details, sensitivity, specificity, outcomes, and associated adverse events of the most common intraarticular injections, as well as information on less frequently performed injections. Spine joint (facet and sacroiliac) intraarticular and certain nonarticular musculoskeletal injections are included. This chapter does not cover ultrasound-guided injections, a topic unto itself; please refer to the ultrasound chapter for more detail.
INDICATIONS AND CONTRAINDICATIONS
General principles favored by the authors are highlighted in the rules of Table 82-1. Indications for joint injections include (1) treatment of the painful joint, (2) for diagnosis to assess response to blockade of the joint, (3) for diagnosis to obtain joint fluid, or (4) for treatment to drain excess joint fluid causing pain. Corticosteroid injections are used for osteoarthritis (OA), rheumatoid arthritis (RA), psoriatic arthritis, lupus, crystalline arthritis (gout and pseudogout), reactive arthritis (Reiter's syndrome), and more. Other conditions include bursitis, tendonitis, and enthesopathy. Contraindications may include (1) infection, localized or systemic, or other immunity issues; (2) allergy or adverse reaction potential to substances involved; and (3) pregnancy or breastfeeding because of safety profiles of medications and radiation exposure. Infection in a joint may itself be a reason to access the joint with a needle to obtain fluid, but placing steroid there would not be done. Surgical implants give pause; truly consider the risk-to-benefit ratio. Pain in a joint that has been replaced is not likely to be cured with an injection. Anticoagulation is not a contraindication (see later discussion).
Rules for Joint Injections
||Download (.pdf) TABLE 82-1
Rules for Joint Injections
Any joint can be injected (but should it be?).
Search literature and texts for previously described techniques.
Indicated for diagnostic (clinical response and joint fluid sample) and therapeutic purpose
Contraindicated in my clinic:
Active or very recent illness, infections
Allergy, adverse drug reactions (ADRs) (but can use ...