Elsevier

Mayo Clinic Proceedings

Volume 84, Issue 9, September 2009, Pages 831-837
Mayo Clinic Proceedings

CONCISE REVIEW FOR CLINICIANS
Musculoskeletal Injection

https://doi.org/10.4065/84.9.831Get rights and content

Patients commonly present to primary care physicians with musculoskeletal symptoms. Clinicians certified in internal medicine must be knowledgeable about the diagnosis and management of musculoskeletal diseases, yet they often receive inadequate postgraduate training on this topic. The musculoskeletal problems most frequently encountered in our busy injection practice involve, in decreasing order, the knees, trochanteric bursae, and glenohumeral joints. This article reviews the clinical presentations of these problems. It also discusses musculoskeletal injections for these problems in terms of medications, indications, injection technique, and supporting evidence from the literature. Experience with joint injection and the pharmacological principles described in this article should allow primary care physicians to become comfortable and proficient with musculoskeletal injections.

Section snippets

PHARMACOTHERAPY

Musculoskeletal injections typically involve a combination of local anesthetics, which provide immediate analgesia and confirmation of accurate injection placement, and corticosteroids, which provide prolonged analgesia. The main corticosteroids used in the United States for joint and soft tissue injection are betamethasone sodium phosphate/acetate (Celestone Soluspan, Schering-Plough, Kenilworth, NJ), methylprednisolone (Depo-Medrol, Upjohn, Kalamazoo, MI), triamcinolone acetonide (Kenalog,

GENERAL METHOD FOR MUSCULOSKELETAL INJECTION

Musculoskeletal injections are safe and comfortable with the use of proper technique. Adverse affects from the medications used in joint injection are rare. Intra-articular corticosteroid injections do not lead to the progression of osteoarthritis.20 Postinjection inflammation is caused by intra-articular injection of corticosteroid crystals and can mimic septic arthritis21; however, septic arthritis usually occurs later than postinjection inflammation and the findings are more persistent.

Knee Joint

Knee pain is a common presenting symptom in primary care practice. Main indications for intra-articular knee injection are osteoarthritis, Baker cyst, and pes anserine bursitis.

Osteoarthritis is a slow and progressive disease that is linked to obesity and most commonly affects the medial compartment and patellofemoral joint; however, patients often describe diffuse knee pain. Although patients may report morning stiffness, it lasts only minutes. Furthermore, the pain typically worsens with

CONCLUSION

Musculoskeletal problems are common in primary care and often respond to injections containing both corticosteroids and short-acting anesthetics. Patients frequently present with symptoms involving the shoulder, trochanteric bursa, and knee. Evidence generally supports corticosteroid injection for these anatomic locations. The risks associated with joint injection are very low with proper injection technique and in appropriately selected patients. Experience with joint injection and the

CME Questions About Musculoskeletal Injection

  • 1.

    Which one of the following injectable corticosteroid preparations has the longest duration of action?

    • a.

      Methylprednisolone

    • b.

      Triamcinolone hexacetonide

    • c.

      Betamethasone sodium phosphate/acetate

    • d.

      Triamcinolone acetonide

    • e.

      Bupivacaine

  • 2.

    Toward which one of the following anatomic landmarks should the needle be directed when performing a glenohumeral joint injection?

    • a.

      Coracoid process

    • b.

      Acromion process

    • c.

      Spine of the scapula

    • d.

      Acromioclavicular joint

    • e.

      Sternoclavicular joint

  • 3.

    To prevent which one of the following

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