Soft tissue injections

doi:10.1016/j.berh.2005.01.003

Best Practice & Research Clinical Rheumatology

Volume 19, Issue 3, June 2005, Pages 503-527

https://doi.org/10.1016/j.berh.2005.01.003 Get rights and content

Soft tissue rheumatism includes a wide spectrum of common lesions of the tendons, enthesis, tendon sheaths, bursae, ligaments and fasciae as well as nerve compression syndromes. Studies on the pathogenesis of these lesions do not support a major role for inflammation, thus questioning the rationale for glucocorticoid injections. This chapter reviews current indications for local glucocorticoid injections and available evidence on its efficacy, as well as contraindications and potential risks. Randomised controlled studies of good methodological quality are rare and there is limited scientific evidence to support the superiority of glucocorticoid injections over alternative treatments.

The basic principles of the glucocorticoid injection method are outlined, together with a description of the practical procedure for the more common conditions.

Section snippets

Context and rationale

Clinically, soft tissue lesions are commonly classified as acute (up to 2 weeks in duration), subacute (2–4 weeks) and chronic (over 6 weeks). Early intervention in soft tissue lesions is based on patient education, aimed at resolving the injury and preventing chronicity and recurrence.1, 2, 3 Proposed measures include correction of aggravating factors, relative rest and appropriate exercise. Initial control of pain may be achieved through analgesics and non-glucocorticoidal anti-inflammatory

Efficacy

Although soft tissue injections are very popular among rheumatologists and have stood the ‘proof of time,’ there is a remarkable paucity of controlled data to support their efficacy. Randomised controlled trials are scarce and their interpretation is frequently hindered by methodological issues, such as poor definition of cases, inclusion of heterogeneous study populations, small sample sizes, unsuitable outcome measures, short term follow up, inadequate blinding and lack of true placebo.1, 4,

Contraindications and risks

There are few contraindications to soft tissue corticoglucocorticoid injections, as shown in Table 2. In addition, they are very safe, as long as the indications, contraindications and technical recommendations are respected. Potential adverse effects are listed in Table 3. Their actual incidence is unknown.

Patients should always be asked about previous allergic reactions to local anaesthetics and glucocorticoids. Moderate pain at the injection site is common. An inflammatory flare,

General technical recommendations

Published recommendations for soft tissue injections are based on personal experience and anecdote more than on evidence. Even for conditions that have been more extensively studied, such as tennis elbow, a systematic review of 12 randomised controlled trials failed to reach any conclusions with respect to the most suitable glucocorticoid, the most adequate dose, injection volume or interval.²⁵ Common practice is remarkably variable between centres and practitioners with respect to almost all

Subacromial space

The following techniques may be used to treat rotator cuff tendinopathy and subacromial bursitis.

Summary

Soft tissue rheumatic disorders are extremely common and result in significant morbidity, loss of productivity and socioeconomic impact.

Early intervention is aimed at resolving the injury and preventing chronicity and recurrence. Soft tissue glucocorticoid injections are commonly reserved for chronic cases. Evidence from histopathological, biochemical and molecular studies do not support a major role for inflammation in soft tissue disorders, undermining the rationale for the use of

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Cited by (12)

Fascial Manipulation method as a treatment for pain, atrophy and skin depigmentation after pes anserine bursa corticosteroid injection: A case report
2020, Journal of Bodywork and Movement Therapies
Citation Excerpt :
Extra-articular glucocorticoid injections are used for disorders of the tendons, enthesis, tendon sheaths, bursa, ligaments and fascia (Brinks et al., 2010). Despite the use of extra-articular steroid injections, there is a small amount of controlled data to support their efficacy (Brinks et al., 2010; Ines and da Silva, 2005). Extra-articular glucocorticoid injections may cause minor complications including pain, paresthesias, mild discoloration of the skin, transient sympathetic reaction and ecchymosis, as well as major complications which include infection, skin depigmentation and subcutaneous atrophy.
Ultrasound-guided versus palpation-guided local corticosteroid injection therapy for treatment of plantar fasciitis
2016, Egyptian Rheumatologist
Citation Excerpt :
Triamcinolone acetonide is one of the intermediates to long acting glucocorticoids. It was recommended for soft tissue injections [34]. However, it was considered by some authors to be inadequate for periarticular injection [35].
This study aimed to assess the efficacy of ultrasound-guided versus palpation-guided local corticosteroid injection therapy for the treatment of plantar fasciitis (PF).
The present study included 21 female patients with unilateral chronic idiopathic PF. The study included 10 female healthy volunteers (20 feet) as a control group. The participants were randomly assigned to receive ultrasound-guided (10 patients) or palpation-guided (11 patients) local corticosteroid injection once. The corticosteroid drug was 0.5 ml of triamcinolone acetonide (40 mg/ml). Patients were evaluated before injection and 2 weeks and 4 weeks following injection. Clinical evaluation was done by using the visual analog scale (VAS) for heel pain assessment and Plantar Fasciitis Pain/Disability Scale. Ultrasonographic evaluation was done by assessing plantar fascia thickness and echogenicity.
There was a statistically significant reduction in VAS, Plantar Fasciitis Pain/Disability Scale, plantar fascia thickness and improvement in plantar fascia echogenicity after treatment in both patient groups; however, there were no statistically significant differences between both groups. The plantar fascia thickness was statistically significantly thicker in both groups in relation to control group before injection and after it by 2 weeks and 4 weeks. The plantar fascia hypoechogenicity was found exclusively among patients groups before injection. At 4 weeks after injection, the hypoechogenicity disappeared in all patients of both groups.
Ultrasound-guided and palpation-guided local corticosteroid injections were effective and successful in treatment of PF. Both techniques improved PF clinically and ultrasonographically without statistically significant superior results for the ultrasound-guided injection.
The role of ultrasound guided peri-tendinous injection in the treatment of non-calcific tendinopathy
2015, Egyptian Journal of Radiology and Nuclear Medicine
Citation Excerpt :
Although soft tissue injections are very popular there is remarkable paucity of controlled data to support their efficacy. That is because the randomized controlled trials were scarce and their interpretation was frequently hindered by methodological issues, such as poor definition of cases, inclusion of heterogeneous study populations, small sample sizes, unsuitable outcome measures, short term follow up, inadequate blinding and lack of true placebo (9). Most of the studies regarding the role of steroid injection in tendinopathy showed that they are well tolerated and more effective for tendinosis in the short-term than other injection treatment, with lack of benefit at long term therapy (10,11).
To evaluate the effectiveness of the percutaneous ultrasound guided peri-tendinous injection in improving or treating non-calcific tendinopathy.
Between January 2012 and March 2014, 25 patients with non calcific tendinosis were treated by ultrasound guided corticosteroid injection. All patients underwent pre-treatment diagnostic ultrasound, as well as assessment of the pain and disability of the affected area through a self-answered questionnaire. Reevaluation of the ultrasound changes and clinical response as regard the pain and disability score on regular follow up visits, were done at the 1st, 3rd and 6th month posttreatment.
According to the results of this study, there was statistically marked reduction in patients pain and disability score, with reduction of the mean pain score from maximum 3 points pre-treatment to 0.5 post-treatment, and mean disability score form 1.5 point pre-treatment to 0 point at the 6th month follow up visit. The clinical success rate was 87%, with a technical success rate of 100%.
Ultrasound is a non invasive imaging technique that allows real time guidance for interventional therapy of non-calcific tendinopathy improving the result of peri-tendinous corticosteroid injection.
Injection Techniques in Musculoskeletal Medicine (with PAGEBURST Access): A Practical Manual for Clinicians in Primary and Secondary Care, Fourth Edition
2011, Injection Techniques in Musculoskeletal Medicine (with PAGEBURST Access): A Practical Manual for Clinicians in Primary and Secondary Care, Fourth Edition
Glucocorticoids and sport's performance
2006, Revista Clinica Espanola
Además de los glucocorticoides endógenos tenemos los sintéticos, cuyas propiedades hormonales derivan de la hidrocortisona. Los efectos fisiológicos y farmacológicos de los glucocorticoides son fundamentalmente antiinflamatorios e inmunosupresores. Como cualquier medicamento no están exentos de efectos secundarios; sin embargo, cuando la prescripción es correcta, y bajo la supervision médica, éstos se minimizan. Aunque en los corticoides se han descrito efectos antiinflamatorios, antiálgicos, ansiolíticos, antiasténicos, todos estos efectos se han visto en pacientes en reposo y no existe ningún estudio concerniente al comportamiento de los mismos con el ejercicio. Aquellos trabajos tendentes a analizar los efectos de los corticoides sobre el rendimiento deportivo no han constatado ninguna mejoría.
There are endogen and exogenous glucocorticoids whose hormonal properties are derived from hydrocortisone. The physiological and pharmacological effects of the glucocorticoids are antiinflammatory and immunosupressor, basically. As other drugs, they have secondary effects, which are minimum when the prescription is correct and controlled by a medical doctor. Although antiinflammatory, antialgic, anxiolytic, and antiasthenic effects have been described in corticosteriods, all these effects have been seen at patients at rest and there is no study to confirm these effects in subjects that do exercise. These studies that tend to analyze the effects of corticosteroids on sport’s performance have concluded that there is not any improvement of performance.
Treatment of Persistent Cutaneous Atrophy After Corticosteroid Injection With Fat Graft
2019, Reumatologia Clinica
Subcutaneous fat atrophy and hypopigmentation are potential adverse side effects of local corticosteroid injection that may resolve spontaneously within 1–2 years. This report shows that fat grafting provides a simple, effective and safe correction of corticosteroid induced cutaneous atrophy with very satisfying esthetic and functional results.
La atrofia de la grasa subcutánea y la despigmentación de la piel son efectos secundarios adversos potenciales de la inyección local de corticosteroides que pueden resolverse espontáneamente en 1-2 años. Este caso muestra que el injerto de grasa proporciona una corrección simple, eficaz y segura de estas complicaciones con resultados estéticos y funcionales muy satisfactorios.

View all citing articles on Scopus

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10Soft tissue injections

Section snippets

Context and rationale

Efficacy

Contraindications and risks

General technical recommendations

Subacromial space

Summary

Physical Medicine and Rehabilitation Clinics of North America

Journal of Hand Surgery

Journal of Hand Surgery

Seminars on Arthritis and Rheumatism

Best Practice and Research Clinical Rheumatology

Journal of Hand Surgery (Am)

The pathogenesis of tendinopathy. A molecular perspective

Rheumatology

Corticoglucocorticoid injections in tendon lesions

British Medical Journal

Overuse injuries of tendons

Cell matrix response in tendon injury

Clinical Sports Medicine

The aetiology and treatment of tendinitis

Treatment principles in tendon injuries and other tendon disoders

Corticoglucocorticoid injections for shoulder pain

Cochrane Database Systematic Reviews

Long- or short-acting anesthetic with corticoglucocorticoid in local injections of overuse injuries? A prospective, randomised, double-blind study

International Journal of Sports Medicine

Aspiration and injection of joints and periarticular tissues

Local corticoglucocorticoid injection for carpal tunnel syndrome

Cochrane Database Systematic Reviews

Comparison of the accuracy of glucocorticoid placement with clinical outcome in patients with shoulder symptoms

Annals of the Rheumatic Diseases

Musculoskeletal ultrasound imaging: a new diagnostic tool for the rheumatologist?

British Journal of Rheumatology

Ultrasound guided injections in rheumatology

Journal of Rheumatology

Percutaneous ultrasound-guided injections in the musculoskeletal system

Ultrasound Quarterly

A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticoglucocorticoids in patients with painful shoulder

Journal of Rheumatology

A prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac in patients with rotator cuff tendonitis

Journal of Rheumatology

Efficacy of injections of corticoglucocorticoids for subacromial impingement syndrome

Journal of Bone and Joint Surgery

10
Soft tissue injections