The Shoulder
Shoulder pain and loss of range of movement are among the most common joint problems in the elderly [22, 23]. Approxi- mately 70% of the cases of shoulder pain involve the rotator cuff [23]. However, glenohumeral OA, acromioclavicular
OA, and frozen shoulder are not uncommon. Different approaches are used depending on the indication and the underlying pathology.
Glenohumeral Joint Injection
Glenohumeral joint is a synovial ball-and-socket joint with limited space for injection (Fig. 13.1). However, the aim is to inject into the intra-capsular space and not necessarily inside the intra-articular cavity. Shoulder OA, RA, and frozen shoulder are the main indication of glenohumeral injection.
We recommend injecting from the posterior approach as this has no overlying neurovascular structures.
Technique
1. Prepare 1.5 ml of methylprednisolone 40 mg/mL or equivalent and 2.5 ml of lidocaine (1%) in a 5 ml volume syringe, using 21–23 gauge, 1.5 in. needle.
2. Place the patient in sitting position with his back to you.
Ask the patient to sit with his elbow flexed and his hand on his lap so that the muscles of shoulders are relaxed.
3. Feel the joint margin with the thumb and mark a point 1.5–2 cm inferior and medial to the acromium. Advance the needle approximately 2.5 cm in the direction of corocoid process. Inject the plunger with very little or no resistance.
4. Ask the patient to actively move his shoulder a few times after finishing the injection and this should be painless after the local anesthetic takes an effect.
Subacromial–Subdeltoid Bursal Injection
Subacromial–Subdeltoid (SA–SD) bursa separates the cora- coacromial arch and deltoid muscle from the rotator cuff.
SA–SD bursa injection is a very common procedure used for
Fig. 13.1 Glenohumeral joint injection – posterior approach.
Cp coracoid process, Ap tip of acromion process
117 13 Arthrocentesis in the Elderly
several shoulder pathologies (e.g., subacromial bursitis, impingement syndrome, rotator cuff tendonitis, adhesive capsulitis, and calcific tendonitis). Injection of local anes- thetics and impingement tests can be helpful in diagnosis.
Technique
1. Prepare 2 ml methylprednisolone 40 mg/ml (or equiva- lent), and 3 ml lidocaine (1%) in a 5 ml volume syringe using 21–23 gauge,1.5 in. needle.
2. Ask the patient to sit with his elbow flexed and his arm in internal rotation. Feel depression below acromial process postero-laterally with thumb. Insert the needle aiming to position slightly anterior and inferior to the acromial pro- cess (Fig. 13.2). Little or no resistance should be encoun- tered while injecting as SA–SD bursa has a potentially large space.
Acromioclavicular Joint Injection
Acromioclavicular joint (ACJ) OA is a very common condi- tion in the elderly [24]. However, most of them are clinically asymptomatic [25]. ACJ is a synovial plane joint with a very small joint space, therefore only small amount of fluid can be injected inside.
Technique
1. Prepare 0.25 ml of methylprednisolone 40 mg/ml (or equivalent), and 0.25 ml of lidocaine (2%) in a 2 ml volume syringe, using 25 gauge, 5/8 in. needle.
2. While the arm in external rotation, palpate and mark the ACJ.
3. Insert the needle directing inferiorly and slightly posteri- orly to the depth of 3/8–5/8 in. aiming toward the center of the joint space.
Suprascapular Nerve Block
Suprascapular nerve block could be useful to manage radiat- ing shoulder pain from the neck. It could be tried if the shoul- der pain has not responded to shoulder joint injection.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml (or equivalent), and 2 ml of bupivacaine(0.5%) in a 10 ml volume syringe, using 23 gauge, 1 in. needle.
2. Place the patient in sitting position with his back to you.
Ask the patient to sit with his elbow flexed and his hand on his lap so that the muscles of shoulders are relaxed.
Ask the patient to flex the neck forward.
3. Feel the spine of the scapula. Mark the point midway between the acromium and medial end of the spine of the scapula. Insert the needle 2 cm superior and medial to that point aiming toward the suprascapular fossa.
Biceps Tendon Injection
The long head of biceps arises from the capsule to pass inside the bicipital grove in front of the glenohumeral joint. Bicipital tendonitis present with localized pain over the tendon. The aim is to inject around the tendon and not the tendon itself due to rupture risk.
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent), and 1 ml of lidocaine (1%) in a 2 ml volume syringe, using 25 gauge, 5/8 in. needle.
Fig. 13.2 Subacromial–subdeltoid (SA–AD) bursal injection. AP acro- mion process
2. While the arm is externally rotated, palpate the tendon inside the bicipital groove. Mark the most tender point of the tendon.
3. Directing the tip of needle upward and parallel to the bicipital groove at about 30° and advance the needle until the resistance increases sharply, which means the tendon has been entered. Withdraw the needle gently until no resistance felt, then inject the syringe.
The Elbow
Olecranon Bursa Injection
Acute and chronic olecranon bursitis caused by repetitive trauma, rheumatoid, or crystalloid arthritis are the main indi- cation of olecranon bursa injection. If crystalloid arthritis is suspected, diagnostic aspiration is indicated. Special care should be taken because of the proximity of ulnar nerve.
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent), and 3 ml of lidocaine (1%) in a 5 ml volume syringe, using 19 gauge, 1 in. needle (gauge 21–23 if aim is to inject only), in addition to 20 ml syringe, and sterile spec- imen container for fluid aspiration.
2. Place the patient in supine position with the elbow flexed 90° and placed over the chest. The needle is inserted directly into the area of maximal fluctuance of the bursa between the two halves of the triceps tendon, where it should be easily aspirated and injected.
Elbow Joint Injection
Elbow joint effusion is a relatively common problem.
Aspiration of synovial fluid could be necessary to exclude septic or crystal arthritis. Therapeutic injection could be similarly beneficial. Although there are several described approaches, the described approach is most commonly used by the authors.
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent), and 1 ml of lidocaine (1%) in a 2 ml volume syringe, using 21–23 gauge 1 in. needle.
2. Place the patient in supine position with the elbow flexed 90° and placed over the chest. Palpate and mark the cleft
between the lateral epicondyle and olecranon process.
Insert the needle perpendicular to the skin and parallel to the radius. Injection medial to the olecranon process should be avoided as the ulnar nerve passes in the ulnar groove between the medial epicondyle and olecranon process.
Tennis Elbow Injection
Lateral epicondylitis is caused by tendonopathy of the com- mon extensor origin of the forearm muscles. Diagnosis is made by the presence of increased pain against resisted extension of the wrist.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml (or equivalent), and 2 ml of lidocaine (2%) in a 5 ml volume syringe, using 25 gauge 5/8 in. needle.
2. Place the patient in a supine position with the elbow flexed to 90° and placed over the chest. Palpate and mark the most tender point in the common extensor tendon.
Advance the needle until reaching the bone surface, with- drawing slightly then inject.
The Wrist and Hand
Carpal Tunnel Injection
Corticosteroid injection can be very beneficial in mild to moderate sensory carpal tunnel syndrome (Fig. 13.3).
However, if there is muscle wasting or weakness, then a sur- gical opinion should be sought. The median nerve (MN) lies below the palmaris longus tendon. In the 15% of cases where the tendon is not visualized, estimation of the position of ten- don as it would lie just lateral to the extensor carpi radialis (ECR) tendon is helpful. Injection under ultrasound guid- ance is the best and safest practice.
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equivalent) and 1 ml of lidocaine (1%) in a 2 ml volume syringe, using 25 gauge 5/8 in. needles.
2. Place the patient in sitting position facing you and stabilize the palm facing upward and dorsiflexed to 30°. The pal- maris longus tendon is visualized by asking the patient to oppose the thumb and little finger. Insert the needle at an
119 13 Arthrocentesis in the Elderly
angle of approximately 45° at the distal palmar crease toward the index finger and below the palmaris longus tendon (from the ulnar side). If the patient feels any par- asthesia, withdraw the needle slightly and reposition it as it is an indication of penetrating the median nerve.
3. Continue to apply wrist splint for at least 2 weeks after the injection. Pain in the injected area may continue for 2–3 days after the injection.
Metcarpophalangeal and Proximal Interphalangeal Joints Injection
Injection of the finger joints is mainly indicated for hand OA. Only small amount of steroid can be injected due to the limited joint space. Multiple injections of different joints can be done in the same session.
Technique
1. Prepare 0.25 ml of methylprednisolone 40 mg/ml (or equivalent) and 0.25 ml of (2%) lidocaine in a 1 ml volume syringe, using 25 gauge 5/8 in. needles.
2. Palpate and mark the joint line which is located about ¼ inch distal to the MCP prominence. With the joint slightly flexed, insert the needle perpendicular to the skin from the dorsolateral side to avoid the neurovascular bundle.
Ganglion
Aspiration and local corticosteroid injection could be effec- tive for ganglions smaller than 3 cm, where no neurovascular compression is suspected. However, it is associated with a high recurrence rate and surgery is often required.
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent), and 1 ml of lidocaine (1%) in a 2 ml volume syringe, using 19 gauge, 1.5 in. needle, in addition to 20 ml syringe for aspiration.
2. Hold the joint in a position that makes the ganglion most prominent. Insert the needle in the area of maximum fluc- tuance and aspirate with back and forth movement to evac- uate a multifoci cyst. The content should be very viscous and translucent fluid. Steroid could be injected thereafter.
First Carpometacarpal Joint
OA of the first Carpometacarpal (CMC) joint is a very com- mon condition in the elderly usually present with squaring of the hand associated with tenderness at the first CMC prominence.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml (or equivalent) and 0.5 ml of (2%) lidocaine in a 2 ml volume syringe, using 25 gauge 5/8 in. needles.
2. Palpate and mark the joint line by localizing it in the ana- tomical snuffbox. Flex the patient thumb across his palm and hold it firmly. Insert the needle in the joint space between the extensor pollicis longus and the common sheath of the abductor pollicis longus and extensor pollicis brevis.
Trigger Finger Injection
Digital flexor tenosynovitis is a common condition associ- ated with RA and psoriatic arthritis. It could be detected by finding a palpable tender nodule over the flexor tendons proximal to the MCP joint.
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent) and 1 ml of (2%) lidocaine in a 2 ml volume syringe, using 25 gauge 5/8 in. needle.
Fig. 13.3 Carpal tunnel injection. PL palmaris longus, ECR extensor carpi radialis
2. Position the palm looking upward and the fingers extended and thumb abducted, insert the needle with 45° inclina- tion distal to the proximal crease over the MCP joint and advance it proximally aiming to the nodule. When the needle inside the tendon sheath the resistance to the plunger will disappear.
De Quervain’s Tenosynovitis Injection
Repetitive strain is the main cause of inflammation of abduc- tor pollicis longus and extensor pollicis brevis common sheath. This leads to movement associated pain, swelling, and crepitus at the radial side of the wrist beneath the base of the thumb.
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent) and 1 ml of (2%) lidocaine in a 2 ml volume syringe, using 25 gauge 5/8 in. needles.
2. Insert the needle just distal to the point of maximal ten- derness, and advance it proximally along the line of the tendon directing toward the radial styloid.
The Hip
Hip Injection
The scope of hip injection is mainly diagnostic. However, therapeutic injection could be performed. Because the hip is a deep joint, it is more successfully injected under ultrasound or radiological guidance.
Greater Trochanteric Injection
Patients with trochanteric bursitis or greater trochanteric pain syndrome usually present with hip pain over the greater trochanter when they lie on the affected side. A steroid injection can be very effective in resolving the symptoms;
however, many injections actually treat a number of poten- tial underlying pathologies, including tears of the gluteal muscles, and other nearby bursitis. Occasionally, pain at this site may be part of a wider chronic pain syndrome, such as fibromyalgia. Injection in this situation may be less successful.
Technique
1. Prepare 2 ml of methylprednisolone 40 mg/ml (or equiva- lent) and 5 ml of (1%) lidocaine in a 10 ml volume syringe, using 21–23 gauge 2 in. needles.
2. The patient is placed in lateral recumbent position lying on the unaffected side with hip flexed to about 30°. Greater trochanter can be identified as bony protrusion at the proximal lateral end of the femur. Palpate and mark the most tender point. Insert the needle perpendicular to the skin until it reaches the hard bony surface, withdraw the needle slightly, aspirate then inject.
The Knee
Knee Injection
Therapeutic knee injection (Fig. 13.4) with corticosteroids is a very common procedure in the elderly with OA. Supra- patellar pouch (SPP) is a horseshoe-like bursa that extends behind the upper half of patella and quadriceps tendon and in front of femur and connected to the knee joint space. Both the patellofemoral and femorotibial joints are incorporated within the same joint cavity. The aim during knee injection is to place the needle in the SPP, thus insuring delivering the drug to the knee. Both lateral and medial approaches can be used for knee injection.
Technique
1. Prepare 2 ml of methylprednisolone 40 mg/ml (or equiva- lent), and 8 ml of lidocaine (1%) in a 10 ml volume syringe, using 21–23 gauge 1.5 in. needle in addition to 20 ml syringe, sterile specimen container for fluid aspiration.
Fig. 13.4 Knee injection. SPP suprapattelar pouch
121 13 Arthrocentesis in the Elderly
2. The patient should be in supine position. The knee should be relaxed in a slightly flexed position. Bending the knee over a towel or paper roll is helpful. Palpate either the lateral or medial border of the patella. Identify the point where the top 1/3 meets the bottom 2/3. Insert the needle under the patella in a slightly cranial position toward the SPP just proximal to the upper pole of the patella.
3. Aspirate the synovial fluid then inject the steroids, unless the fluid was purulent which may indicate septic arthritis.
Use compression dressing and the joint should be rested for 24–48 h.
The Foot
Ankle Injection (Tibiotalar)
OA, RA, crystal, and spondyloarthropathy commonly affect the ankle joint (Fig. 13.5).
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent), and 1 ml of lidocaine (2%) in a 2 ml volume syringe, using 21–23 gauge, 1.5 in. needle.
2. Place the patient in supine position. The joint line is first identified by flexing and extending the joint. A point is taken just medial to the tibialis anterior tendon or between the tibialis anterior tendon and extensor hallucis tendon.
The dorsalis pedis artery (DPA) lies lateral to the extensor hallucis tendon. The needle should be directed tangent to the curve of talus.
Plantar Fasciitis Injection
Plantar fasciitis injection could be very effective in patients presented with tenderness in the medial aspect of the heel especially with putting the heel on the ground first thing in the morning; calcaneal spur is a common concurrent finding. The plantar fascia arises from the medial and lateral tubercle of the calcaneus, and the inflammation is usually found at the medial head of the calcaneus. Plantar fasciitis injection can be very effective in temporarily resolving the symptoms or even curing the condition. The injection is often painful and may lead to fat pad atrophy which reduces shock absorption. For this reason, injecting the fat pad directly at the foot base or very frequent injections should be avoided. Rupture of plantar fascia is also a reported complication [26]. Ultrasound-guided injection has been used with better results and associated with lower recur- rence of heel pain [27, 28].
Technique
1. Prepare 1 ml of methylprednisolone 40 mg/ml (or equiva- lent), and 1 ml of lidocaine (2%) in a 2 ml volume syringe, using 21–23 gauge, 1.5 in. needle.
2. Place the patient in lateral decubitus position on the affected limb side with lower leg extended, and the upper leg flexed at the hip and knee. Palpate the medial calca- neal tuberosity and mark the maximum tender point.
Insert the needle medially perpendicular to the skin and slightly distal to the medial calcaneal tuberosity. Advance the needle aiming toward the medial calcaneal tuberosity, until it touches the bony surface.
3. Apply wrap bandage firmly for 48–72 h. Precaution should be taken to avoid injecting in the superficial layer, or injecting very distally risking the plantar nerves.
Posterior Tibialis Tendon Sheath Injection
Tarsal tunnel syndrome and posterior tibilais tenosynovitis are the main indication of this injection. Posterior tibialis tendon lies in a tenosynovial sheath and curves around the medial malleolus. Posterior tibialis tenosynovitis causes pain aggravated by resisted inversion and plantar flexion.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml(or equiv- alent), and 0.5 ml of lidocaine (2%) in a 2 ml volume syringe, using 25 gauge, 5/8 in. needle.
Fig. 13.5 Tibiotalar injection. TA tibialis anterior, EHL extensor halu- cis longus, ED extensor digitorum, DPA dorsalis pedis artery
2. Place the patient in supine position with affected leg straight and externally rotated and foot inverted. Palpate and mark the tendon just under the posterior edge of the medial malleolus.
3. Insert the needle tangent to the skin in the direction of the tendon, aspirate before injection to avoid intra-arterial injection, and injection should be against no or little resistance. Parasthesia could be a sign of neurovascular bundle engagement. One possible complication is the rup- ture of posterior tibialis tendon if the needle is misplaced or injection is done under resistance.
Morton’s Neuroma
Many patients are present with symptoms suggesting Morton’s neuroma. However, it is uncommonly diagnosed with certainty.
Clinical diagnoses should be supported with radiological findings to confirm diagnosis. The nerve located between the third and fourth toes is the most commonly affected.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml (or equivalent), and 0.5 ml of lidocaine (2%) in a 2 ml volume syringe, using 25 gauge, 5/8 in. needle.
2. Palpate and mark the place of entry which should be half way between the MTP heads and ½ in. proximal from the Web space from the dorsal side. Insert the needle perpen- dicular to the skin and advance it through the resistance of transverse tarsal ligament. A giving away sensation is felt when the needle passes through the ligament.
Metatarsophalangeal Joint Injection
Aspiration and injection could be very beneficial for the diagnosis and management of gout flare affecting usually the first MTP joint. It can also be indicated for inflammatory MTP joints arthritis.
Technique
1. Prepare 0.5 ml of methylprednisolone 40 mg/ml (or equivalent), and 0.5 ml of lidocaine (2%) in a 2 ml volume syringe, using 25 gauge, 5/8 in. needle.
2. Palpate and mark the MTP joint space medial or lateral to the extensor tendon from the dorsal side. Medial approach is preferred for the first MTP. Insert the needle perpendicular to skin with mild plantar flexion of the MTP joints.
Aspiration of the first MTP joint content before injection is important diagnostically if crystal arthropathy is suspected.