1/21/14

Temporomandibular Joint Injection

Acute or chronic capsulitis

Causes and findings:
• Trauma - often after a car accident or meniscal tear
• Osteoarthritis, poor jaw alignment, nocturnal teeth grinding
• Pain over joint
• Pain on eating, especially hard or large foods
• Headaches
• Painful:
• opening, deviation or protrusion of jaw with asymmetry of movement
• clicking or locking

Equipment:
Syringe - 1ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 0.75 ml 2%
Total volume - 1 ml

Anatomy:
The temporomandibular joint space can be palpated just in front of the ear as the patient opens and closes the mouth. A meniscus lies within the joint and the needle must be placed below this to enter the joint space. The joint can be infiltrated most easily when the jaw is held wide open.

Technique:
• Patient lies on unaffected side with head supported and mouth held open
• Identify and mark joint space
• Insert needle vertically into inferior compartment of joint space below meniscus
• Inject solution as a bolus

Aftercare:
The patient should avoid excessive movement of the jaw such as biting on a large apple or hard food. Gentle active movements and isometric exercises are carried out. A guard to prevent grinding the teeth at night and/or the advice of an orthodontist might be helpful.

Comments:
It might be necessary to manoeuvre the needle about to avoid the meniscus. If the meniscus is displaced, reduction by manipulation should be attempted about 1 week after giving the injection when the inflammation has subsided.

Temporomandibular Joint
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Sacrococcygeal Joint Injection

Coccydynia - strain of coccygeal ligaments, subluxation

Causes and findings:
• Trauma - fall onto buttock
• Prolonged sitting on hard surfaces
• Pain localized over sacrococcygeal joint
• Coccyx might be subluxed

Equipment:
Syringe - 1ml
Needle - 23G 1 inches (25mm) blue
Kenalog 40 - 20 mg
Lidocaine - 0.5 ml 2%
Total volume - 1 ml

Anatomy:
The ligaments at the sacrococcygeal joint line are usually very tender and can be palpated both on the dorsal and ventral surfaces. The gloved finger palpates the angle of the coccyx to check for subluxation of the bone.

Technique:
• Patient lies prone over small pillow
• Identify and mark tender site on dorsum of coccyx at joint line
• Insert needle down to touch bone
• Pepper solution around into tender ligaments

Aftercare:
Advise patient to avoid sitting on hard surfaces and to use a ring cushion. At follow-up 2 weeks later, manipulation of the coccyx might be necessary to correct any subluxation; the anti-inflammatory effect of the steroid enables this to be performed with less discomfort. The gloved finger is inserted into the rectum and a firm anteroposterior movement applied. Sometimes an audible click can be heard and some days later the relief of pain is apparent.

Comments:
Pain in this area can be symptomatic of psychological or psychosexual distress, in which case the appropriate treatment/advice is required. With somatic pain the protocol above appears to work either well or not at all. Surgery is not usually indicated or particularly successful.

Sacrococcygeal Joint
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Sacroiliac Joint Injection

Acute or chronic strain or capsulitis

Causes and findings:
• Acute sacroiliitis
• Ankylosing spondylitis
• Chronic ligamentous pain after successful manipulation
• Usually female - often pre- or post-partum or traumatic incident such as fall onto buttocks
• Pain over buttock, groin or occasionally down posterior thigh to calf
• Pain after rest, or long periods of sitting or standing
• Pain on stressing: posterior ligaments in hip flexion, oblique adduction and transversely anterior ligaments in Faber or 4 test (hip flexion, abduction and external rotation)

Equipment:
Syringe - 2 ml
Needle - 22G 3-3.5 inches (75-90mm) spinal
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The sacroiliac joint surfaces are angled obliquely posteroanteriorly, with the angle being more acute in the female. The dimples at the top of the buttocks indicate the position of the posterior superior iliac spines. The easiest entry point is usually found in a dip just below and slightly medial to the spines.

Technique
• Patient lies prone over small pillow
• Identify and mark posterior superior iliac spine on affected side
• Insert needle a thumb's width medial and just below this bony landmark at level of second sacral spinous process
• Angle needle obliquely antero-laterally at an angle of about 45 °
• Pass needle between sacrum and ilium until a ligamentous resistance is felt.
• Inject solution as a bolus within joint if possible, or pepper posterior capsule

Aftercare:
Movement within the pain-free range is encouraged - a lunging motion with the foot up on a chair can help relieve pain, as can moderate walking. The patient should avoid hip abduction positions and sit correctly. A temporary belt is worn if the joint is unstable, and sclerosing injections can be given to increase stability.

Comments:
This is not a very common injection; usually manipulation, mobilization and exercise techniques clear the majority of chronic sacroiliac joint symptoms. The needle often comes up against bone when attempting this injection and then has to be manoeuvred around to allow for the variations in bony shape before entering the joint space. It is unusual to have to repeat this injection and the joint can often be successfully manipulated if necessary a week later if necessary.

Sacroiliac Joint
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Caudal Epidural Injection

Acute or chronic low back pain or sciatica

Causes and findings:
• Disc lesion, acute nerve entrapment
• Central or bilateral pain in low back with or without sciatica or root signs
• Usually painful flexion and side flexion away from painful side and nerve root tension signs

Equipment:
Syringe - 1ml
Needle - 21G 1.5 inches (40mm) green
Kenalog 40 - 40 mg
Lidocaine - Nil
Total volume - 1 ml

Anatomy:
The spinal cord ends at the level of L1 and the thecal sac ends at S2 in most individuals. The aim of this injection is to pass a disinflaming solution through the sacral hiatus and up the canal so that it bathes the posterior aspect of the intervertebral disc, anterior aspect of the dura mater and any affected nerve roots centrally. The sacral cornua are two prominences that can be palpated at the apex of an equilateral triangle drawn from the posterior superior spines on the ileum to the coccyx. There is a thick ligament at the entrance to the canal. The angle of the curve of the canal varies widely and the placement of the needle reflects this.

Technique:
• Patient lies prone over small pillow
• Identify sacral cornua at base of imaginary triangle with thumb
• Insert needle between cornua and pass horizontally through ligament
• Pass needle slightly up canal adjusting angle to curve of sacrum
• Aspirate to ensure needle has not penetrated thecal sac or blood vessel
• Slowly inject solution into epidural space
• Keep hand on sacrum to palpate for swelling caused by suprasacral injection

Aftercare:
The patient lies prone for 10 min and then supine for a further 10 min. He or she can continue to do whatever is comfortable and is reassessed about 10 days later. If the injection has helped it can be repeated at 1- or 2-week intervals as long as improvement continues. The causes of the back pain should then be addressed - weight, posture, work positions, lifting techniques, exercise, abdominal control, etc.

Comments:
Occasionally the canal is difficult to enter. This might be because of a bifid or very small canal or because the angle of the sacrum is very concave. Reangulation
of the needle might be necessary. If clear fluid or blood is aspirated at any point the procedure is abandoned and attempted a few days later. If the patient feels faint or dizzy during the injection, stop injecting and wait for the symptoms to go. If they do not, abandon the procedure. Caudal epidural is safe provided1 3 7:
• there is no allergy to local anaesthetic (not used in this method)
• there is no local sepsis
• the patient is not on anticoagulant therapy

Alternative approach:
If the affected level is higher than the common L5/S1 level, more volume may be required to reach these levels. In this case we recommend addition of up to 10 ml of normal saline, depending on the level of the lesion and the size of the patient.

Caudal Epidural
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Lumbar Nerve Roots Injection

Nerve root inflammation

Causes and findings:
• Spinal stenosis
• Nerve-root entrapment
• Acute or chronic sciatica with or without root signs
• Painful: flexion and side bending usually away from painful side straight leg raise, slump test

Equipment:
Syringe - 1ml
Needle - 22G 3-3.5 inches (75-90mm) spinal
Kenalog 40 - 40 mg
Lidocaine - Nil
Total volume - 1 ml

Anatomy:
The lumbar nerve roots emerge obliquely from the vertebral canals between the transverse processes at the level of the spinous process. Draw a vertical line along the centre of the spinous processes and horizontal lines at each spinous level. Two fingers' width laterally along the horizontal line marks entry site for the needle.

Technique:
• Patient lies prone over small pillow to aid localization of spinous processes
• Identify spinous process at painful level and mark spot along horizontal line
• Insert needle and pass perpendicularly to depth of about 3 inches (7cm)
• Aspirate to ensure needle point is not intrathecal
• Inject solution as a bolus around nerve root

Aftercare:
Patient keeps mobile within pain limits and is reassessed up to 2 weeks later. Repeat as necessary.

Comments:
This injection can be especially effective when the patient is in severe pain and conservative manual therapy techniques are impossible to administer. It can also be given when caudal epidural has proved unsuccessful - the caudal is technically an easier procedure but the solution might not reach the affected part of the nerve root. The needle must be repositioned if it encounters bone at a distance of about 2 inches (5 cm) as this means it is touching the lamina or facet joint. Equally, repositioning is necessary if the patient complains of sharp 'electric shock' sensation because the needle will be in the nerve root. If clear fluid is aspirated the needle is intrathecal and the procedure must be abandoned, although it can be attempted a few days later. Two levels can be infiltrated at a time. A large patient may require a larger needle. If the first level injected does not relieve the symptoms, a level above or below can be tried. This is well worth trying before considering surgery.

Lumbar Nerve Roots
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Lumbar Facet Joints Injection

Chronic capsulitis

Causes and findings:
• Osteoarthritis or traumatic capsulitis, ankylosing spondylitis
• Spondylolysis/spondylolysthesis
• Unilateral low back pain, sometimes with dull vague aching down leg
• Painful limitation in the capsular pattern - most: loss of extension; less: loss of both side flexions; least: loss of flexion
• In younger patients with spondylolysis, often most painful movement is combined extension with side flexion to the painful side

Equipment:
Syringe - 1ml
Needle - 22G 3-3.5 inches (75-90mm) spinal
Kenalog 40 - 40 mg
Lidocaine - Nil
Total volume - 1 ml

Anatomy:
The lower lumbar facet or zygaphophyseal joints lie lateral to the spinous processes - approximately one finger width at L3, one and a half at L4 and two fingers' width at L5. They cannot be palpated but are located by marking a vertical line along the centre of the spinous processes and horizontal lines across between each process. The posterior capsule of the joint is found by inserting the needle the correct distance for that level laterally on the horizontal line.

Technique:
• Patient lies prone on small pillow to aid localization of the spinous interspace
• Identify and mark one or more tender levels
• Insert needle at first selected level vertically down to capsule
• Aspirate to ensure needle point is not intrathecal
• Deposit solution into and around capsule
• Withdraw needle and repeat at different levels if necessary

Aftercare:
Patient avoids excessive movement while maintaining activity. Abdominal strengthening and mobilizing exercises should be performed regularly. Occasional mobilization and hamstring stretching will help to maintain flexibility.

Comments:
If the capsule is not found immediately, gently 'walk' needle around bone until a hard end-feel is reached.

Alternative approach:
Some practitioners perform injection of the lumbar facets under fluoroscopy, but they can be safely reached in the above manner provided the end-point of the needle on bone is reached. This approach is more cost effective.
Lumbar Facet Joints
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Cervical Facet Joints Injection

Acute or chronic capsulitis

Causes and findings:
• Osteoarthritis, rheumatoid arthritis or traumatic capsulitis
• Pain in posterior neck, up to head, into scapula or to point of shoulder
• Increased by sleeping in awkward positions and end-of-range movement
• Painful limitation in the capsular pattern: both rotations, side flexions and extension
• Tender over one or more facet joints

Equipment:
Syringe - 1ml
Needle - 25G 1.5-2 inches (40-50mm) green
Kenalog 40 - 20 mg
Lidocaine - Nil
Total volume - 0.5 ml

Anatomy:
The facet or zygaphophyseal joints in the cervical spine are plane joints lying at angles of approximately 30-45 ° to the vertical. They can be palpated by identifying the spinous process and moving a finger's width laterally, and are felt as a flat pillar. The affected levels are sensitive to pressure.

Technique:
• Patient lies on unaffected side with roll under neck
• Neck is held in flexion and slight side flexion away from the painful side
• Identify and mark the tender joint
• Insert needle just distal to joint parallel to the spinous processes and angle upwards at an angle of 4 5 ° cephalad
• Pass through the thick extensors aiming towards patient's upper ear until point touches bone
• Aspirate to ensure needle point is not intrathecal
• Gently 'walk' along bone until needle touches joint capsule - a hard endfeel
• Inject solution in bolus intracapsular or pepper into capsule

Aftercare:
Patient maintains gentle movement, continues correct posture and is careful to sleep with a suitable number of pillows to maintain the head in a neutral position. Prone lying should be abandoned. Manual traction, mobilizing and sustained stretching techniques together with friction massage to the joint capsule helps maintain comfortable movement.

Comments:
Although this appears to be an alarming injection, it is perfectly safe provided great care is taken that the needle always lies parallel to the spinous process and never angles medially, and that the point touches bone before depositing the solution. The results in the osteoarthritic neck can be good for several months, provided the patient does not strain the neck and maintains mobility and good posture as above.

Alternative approach:
This injection can be done under imaging which ensures correct placement but is less cost effective.

Cervical Facet Joints
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Plantar Fascia Injection

Acute fasciitis

Causes and findings:
• Idiopathic, overuse, poor footwear
• Pain on medial aspect of heel pad on putting foot to ground in the morning
• Tender area over medial edge of origin of fascia from calcaneus

Equipment:
Syringe - 1ml
Needle - 21G 1.5-2 inches (40-50mm) green
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The plantar fascia, or long plantar ligament, arises from the medial and lateral tubercles on the inferior surface of the calcaneus. The lesion is always found
at the medial head and the area of irritation can be palpated by deep pressure with the thumb.

Technique:
• Patient lies prone with foot supported in dorsiflexion
• Identify tender area on heel
• Insert needle perpendicularly into medial side of soft part of sole just distal to heel pad. Advance at 45 ° towards calcaneus until it touches bone
• Pepper solution in two rows into fascia at its medial bony origin

Aftercare:
A heel support is used for at least 1 week after the injection, followed by intrinsic muscle exercise and stretching of the fascia. Standing on a golf ball to apply
deep friction can be helpful and orthotics can be applied. Taping can also be used.

Comments:
Although this would appear to be an extremely painful injection, this approach is much kinder than inserting the needle straight through the heel pad, and patients tolerate it well.

Plantar Fascia
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Peroneal Tendons Injection

Acute or chronic tendinopathy

Causes and findings:
• Overuse
• Pain at lateral side of ankle or foot
• Painful: resisted eversion of the foot
• Tender area above, behind or below the lateral malleolus

Equipment:
Syringe - 1ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 0.75 ml 2%
Total volume - 1 ml

Anatomy:
The peroneus longus and brevis run together in a synovial sheath behind the lateral malleolus. The longus then divides to pass under the arch of the foot to insert at the base of the big toe, and brevis inserts into the base of the fifth metatarsal. The division of the two tendons is the entry point for the needle and can be found by having the patient hold the foot in strong eversion and palpating for the V-shaped fork of the tendons.

Technique:
• Patient lies supine with foot supported in some medial rotation
• Identify and mark division of the two tendons
• Insert needle perpendicularly at this point, turn and slide horizontally under skin towards malleolus
• Deposit solution into combined tendon sheath. There should be minimal resistance and often a sausage-shaped bulge is observed

Aftercare:
Avoid any overuse for about 1 week. Resolution of symptoms should then lead to consideration of change in footwear, orthotics and strengthening of the evertors.

Comments:
Occasionally the tendinopathy occurs at the insertion of the peroneus brevis. The same amount of solution is then peppered into the teno-osseous junction by inserting the needle parallel to the skin to touch the base of the fifth metatarsal.

Peroneal Tendons
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Toe Joints Injection

Acute or chronic capsulitis

Causes and findings:
• Overuse or trauma
• Hallux valgus
• Pain in toe joint
• Painful and limited: extension of the big toe, flexion of other toes

Equipment:
Syringe - 2 ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 20 mg
Lidocaine - 1 ml 2%
Total volume - 1.5 ml

Anatomy:
The first metatarsophalangeal joint line is found by palpating the space produced at the base of the metacarpal on the dorsal aspect, while passively flexing and extending the toe. Palpation of the collateral ligaments at the joint line of the other toes will identify the affected joint or joints.

Technique:
• Patient lies with foot supported
• Identify and mark joint line and distract affected toe with one hand
• Insert needle perpendicularly into joint space avoiding extensor tendons
• Deposit solution as bolus

Aftercare:
Avoidance of excessive weight-bearing activities for at least 1 week, together with taping of the joint and a toe pad between the toes. Care in choice of footwear and orthotics might be necessary.

Comments:
As with the thumb joint injection, this treatment can be very long-lasting. The other toe joints are injected from the medial or lateral aspect while under traction.

Toe Joints
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Midtarsal Joint Injection

Acute or chronic capsulitis

Causes and findings:
• Overuse or trauma - female ballet dancers who over-point or football players
• Pain on dorsum of foot - usually at third metatarsocuneiform joint line
• Painful and limited: adduction and inversion of midtarsal joints

Equipment:
Syringe - 2 ml
Needle - 23G 1 inches (25mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
There are several joints in the mid-tarsus, each with its own capsule. Gross passive testing followed by local joint gliding and palpation should identify the joint involved.

Technique:
• Patient lies with foot supported in neutral
• Identify and mark tender joint line
• Insert needle down into joint space
• Pepper some solution into capsule and remainder as bolus into joint cavity

Aftercare:
Avoidance of excessive weight-bearing activities for at least 1 week is advised. Mobilizing and strengthening exercises and retraining of causal activities follow. Orthotics and weight control, if necessary, are useful additions.

Comments:
This is a successful treatment provided sensible attention is paid to aftercare.

Midtarsal Joint
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Achilles Bursa Injection

Chronic bursitis

Causes and findings:
• Overuse - runners and dancers
• Pain posterior to tibia and anterior to body of Achilles tendon
• Painful: resisted plantarflexion, especially at end range full passive plantarflexion

Equipment:
Syringe - 1ml
Needle - 25G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The Achilles bursa lies in the triangular space anterior to the tendon and posterior to the base of the tibia and the upper part of the calcaneus. It is important to differentiate between tendinitis and bursitis here because both are caused by overuse. In bursitis there is usually more pain on full passive plantarflexion when the heel is pressed up against the back of the tibia, thereby squeezing the bursa. Also, palpation of the bursa is very sensitive and the pain is usually felt more at the end of rising on tip-toe rather than during the movement. The best approach is from the lateral side to avoid the posterior tibial artery and nerve.

Technique:
• Patient lies prone with foot held in some dorsiflexion
• Identify and mark tender area on lateral side of bursa
• Insert needle into bursa avoiding piercing the tendon
• Deposit solution as bolus

Aftercare:
Avoid overuse activities for at least 10 days, then start a stretching and eccentric exercise programme. Female ballet dancers need to avoid overplantarflexing the ankle when on point.

Comments:
It is important to avoid penetrating the Achilles tendon and depositing the solution there. Any resistance to the needle requires immediate withdrawal and repositioning well anterior to the tendon.

Achilles Bursa
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Achilles Tendon Injection

Chronic tendinitis

Causes and findings:
• Overuse
• Pain at posterior aspect of ankle
• Painful: resisted plantarflexion on one foot or from full dorsiflexion

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The achilles tendon lies at the end of the gastrocnemius as it inserts into the posterior surface of the calcaneus. It is absolutely contraindicated to infiltrate the body of the tendon because this is a large, weight-bearing, relatively avascular tendon with a known propensity to rupture.

Technique:
• Patient lies prone with foot held in dorsiflexion over end of bed. This keeps the tendon under tension and facilitates the procedure
• Identify and mark tender area of tendon - usually along the sides
• Insert needle on medial side and angle parallel to tendon. Slide needle along side of tendon, taking care not to enter into tendon itself
• Deposit half solution while slowly withdrawing needle
• Insert needle on lateral side and repeat procedure with remaining half of solution

Aftercare:
Absolute avoidance of any overuse is essential for about 10 days. Deep friction to the site should then be given a few times, even if the patient is asymptomatic, to prevent recurrence. When pain free, graded stretching and strengthening exercises are begun and should be continued indefinitely. Orthotics and retraining in the causal activity are often necessary.

Comments:
Although there are reports of tendon rupture after injection here, this has usually occurred as a result of repeated injections of large dose and volume into the body of a degenerate tendon and with excessive exercise postinjection. Because of this recognized risk therefore, we recommend scanning the tendon prior to injecting to ascertain the extent of the degeneration (Chapter 2). Clear degenerative changes within the substance, rather than just around the periphery, would indicate an absolute contraindication to injection. Depositing the solution along the sides is safe and effective but should not be repeated more than once in one attack. The committed athlete should preferably be offered deep friction and a graduated stretching/strengthening programme.

Alternative approaches:
No one method has been entirely successful in treating this condition. Recent novel approaches include the continuous application of topical glyceryl trinitrate and injection of a sclerosing local anaesthetic (Polidocanol; see Chapter 1).

Achilles Tendon
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Lateral Ligament Injection

Acute ligamentous sprain

Causes and findings:
• Inversion injury
• Pain at lateral side of ankle
• Painful: passive inversion of ankle

Equipment:
Syringe - 1ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 0.75 ml 2%
Total volume - 1 ml

Anatomy:
The anterior talofibular ligament runs medially from the anterior inferior edge of the lateral malleolus to attach to the talus. It is a thin structure, approximately
the width of the little finger. The bifurcate calcaneocuboid ligament runs from the calcaneus to the cuboid and is often also involved in ankle sprains. Both ligaments run parallel to the sole of the foot.

Technique:
• Patient lies supported on table
• Identify and mark anterior inferior edge of lateral malleolus
• Insert needle to touch bone
• Pepper half solution around origin of ligament
• Turn needle and pepper remainder into insertion on talus

Aftercare:
Patient keeps ankle moving within pain-free range. For the first few days, ice, elevation and taping in eversion are helpful, together with a pressure pad behind the malelleous to control swelling. Exercises to strengthen the peronei and proprioception usually need to be given.

Comments:
This injection is an option when the pain is very acute or where conservative treatment has failed in the chronic stage.

Alternative approaches:
This lesion responds very well in the acute stage to a regime of ice, elevation, gentle massage, active and passive mobilization and taping.

Lateral Ligament
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Deltoid Ligament Injection

Acute or chronic sprain

Causes and findings:
• Trauma
• Obesity
• Overpronation of the foot
• Pain over medial side of heel below medial malleolus
• Painful: passive eversion of ankle in plantarflexion

Equipment:
Syringe - 1ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 0.75 ml 2%
Total volume - 1 ml

Anatomy:
The deltoid ligament is a strong cuboid structure with two layers. It runs from the medial malleolus to the sustentaculum tali on the calcaneum and to the tubercle on the navicular. Sprains here are not as common as at the lateral ligament, but because they do not seem to respond well to friction and mobilization, injection is worth trying. The inflamed part is usually at the origin on the malleolus.

Technique:
• Patient sits with medial side of foot accessible
• Identify lower border of medial malleolus and mark mid-point of ligament
• Insert needle and angle upwards to touch bone at mid-point of ligament
• Pepper solution along attachment to bone

Aftercare:
Activity should be limited for at least 1 week. To prevent recurrence, the biomechanics of the foot must be carefully checked. Orthotics are almost always necessary and, in the overweight patient, advice on diet must be given.

Comments:
This is an uncommon but usually successful injection.

Deltoid Ligament
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Subtalar Joint Injection

Chronic capsulitis

Causes and findings:
• Trauma - usually after fracture or severe impaction injury, often many years later
• Overuse in the older obese
• Pain deep in medial and lateral sides of heel
• Painful and limited: passive adduction of the calcaneus

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 30 mg
Lidocaine - 1.25 ml 2%
Total volume - 2 ml

Anatomy:
The subtalar joint is divided by an oblique septum into anterior and posterior
portions. It is slightly easier to enter the joint just above the sustentaculum
tali, which projects a thumb's width directly below the medial malleolus.

Technique
• Patient lies on side with foot supported so that medial aspect of heel faces upwards
• Identify bump of sustentaculum tali
• Insert needle perpendicularly immediately above and slightly posterior to sustentaculum tali
• Deposit half solution here
• Withdraw needle slightly and angle obliquely anteriorly through septum into anterior compartment of joint space and deposit remaining solution here

Aftercare:
The patient should avoid excessive weight-bearing activities for at least 1 week. Orthotics and weight control are helpful in preventing recurrence.

Comments:
This is a difficult injection to perform due to the anatomical shape of the joint. It can be repeated at infrequent intervals if necessary.

Subtalar Joint
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Ankle Joint Injection

Chronic capsulitis

Causes and findings:
• Post-trauma
• Pain at front of, or within, ankle
• Painful and limited: more passive plantarflexion less passive dorsiflexion

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 30 mg
Lidocaine - 1.25 ml 2%
Total volume - 2 ml

Anatomy:
The easiest and safest entry point to the ankle joint is at the junction of the
tibia and fibula just above the talus. A small triangular space can be palpated
there.

Technique:
• Patient lies with knee bent to 90° and foot slightly plantarflexed
• Identify and mark small triangular space by passively flexing and extending the ankle while palpating
• Insert needle into joint angling slightly medially and proximally to pass into joint space
• Deposit solution as bolus

Aftercare:
Excessive weight-bearing activities are avoided for at least 1 week. The patient should be warned that heavy overuse of the foot will cause a recurrence of symptoms and therefore long-distance running should be avoided. Weight control is also advised and footwear should be checked to ensure correct support.

Comments:
The ankle joint rarely causes problems except after severe trauma or fracture, and then often many years later. The infiltration is usually very successful in giving long-lasting pain relief and can be repeated if necessary at intervals of at least 3 months with an annual X-ray to monitor degenerative changes.

Ankle Joint
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Baker's Cyst Injection

Causes and findings:
• Spontaneous insidious onset, usually in osteoarthritic joint
• Obvious swelling in the popliteal fossa - often quite large

Equipment:
Syringe - 10 ml
Needle - 19G 1.5 inches (40mm) green
Kenalog 40 -
Lidocaine -
Total volume -

Anatomy:
Baker's cyst is a sac of synovial fluid caused by seepage through a defect in the posterior wall of the capsule of the knee joint, or by effusion within the semimembranosus bursa. The popliteal artery and vein and posterior tibial nerve pass centrally in the popliteal fossa and must be avoided.

Technique:
• Patient lies prone
• Mark spot two fingers medial to mid-line of fossa and two fingers below the popliteal crease
• Insert needle at marked spot and angle laterally at 45 ° angle
• Aspirate fluid found

Aftercare:
A firm compression bandage can be applied for a day or two.

Comments:
If anything other than clear synovial fluid is removed, a specimen should be sent for culture and the appropriate treatment instigated. Invariably the swelling returns at some point but can be re-aspirated if the patient wishes.

Baker's Cyst
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Infrapatellar Tendon Injection

Chronic tendinitis

Causes and findings:
• Overuse - jumpers and runners
• Pain at inferior pole of patella
• Painful: resisted extension of knee

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The infrapatellar tendon arises from the inferior pole of the patella and it is here that it is commonly inflamed. The tendon is at least two fingers wide at
its origin. It is an absolute contraindication to inject corticosteroid into the body of the tendon as it is a large, weight-bearing and relatively avascular structure. Tenderness at mid-point of the tendon is usually caused by infrapatellar bursitis.

Technique:
• Patient sits with knee supported and extended
• Place web of cephalic hand on superior pole of patella and tilt inferior pole up. Identify and mark tender area at origin of tendon on distal end of patella
• Insert needle at mid-point of tendon origin at an angle of 45°
• Pepper solution along tendon in two rows. There should always be some resistance to the needle to ensure that the solution is not being introduced intra-articularly

Aftercare:
Absolute rest is recommended for at least 10 days before a stretching and strengthening programme is initiated.

Comments:
Injecting the origin of the infrapatellar tendon at the inferior pole is very safe, provided adequate rest is maintained afterwards and that no more than two injections are given in one attack. In an ageing patient with a chronic tendinopathy, scanning is recommended first to ensure that there are no degenerative changes in the substance of the tendon.

Alternative approach:
In the case of the committed athlete or if scanning shows changes as above, deep friction, electrotherapy and taping should be given as potential danger of rupture is more real.

Infrapatellar Tendon
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Quadriceps Expansion Injection

Muscle sprain

Causes and findings:
• Overuse
• Pain usually on superior medial side of patella
• Painful: on going down hill or down stairs bresisted extension of the knee

Equipment:
Syringe - 2ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 1.75 ml 2%
Total volume - 2 ml

Anatomy:
The quadriceps muscle inserts as an expansion around the borders of the patella. The usual site of the lesion is at the superior medial pole of the patella. This is found by pushing the patella medially with the thumb and palpating up and under the medial edge with a finger to find the tender area.

Technique:
• Patient half lies on table with knee relaxed
• Identify and mark tender area usually on medial edge of superior pole of patella
• Insert needle and angle horizontally to touch bone of patella
• Pepper solution along line of insertion

Aftercare:
Patient avoids overusing the knee for at least 1 week and, when pain free, begins progressive strengthening and stretching programme.

Comments:
This lesion, like the coronary ligament, responds very well to two or three sessions of strong deep friction. The injection is used therefore when the friction is not available, the area is too tender, or to disinflame the expansion prior to friction a week later, in a combination approach. The same technique may be used to inject inflamed plicae around the patella rim.

Quadriceps Expansion
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Iliotibial Band Bursa Injection

Chronic bursitis

Causes and findings:
• Overuse - especially long-distance runners
• Pain on the outer side of the knee above the lateral femoral condyle
• Painful: resisted abduction of leg passive adduction of leg

Equipment:
Syringe - 2ml
Needle - 23G 1 inches (25mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The bursa lies deep to the iliotibial band just above the lateral condyle of the femur.

Technique:
• Patient sits with knee supported
• Identify and mark tender area on lateral side of femur
• Insert needle into bursa passing through tendon to touch bone
• Deposit solution in bolus

Aftercare:
Absolute rest must be maintained for about 10 days and then a stretching and strengthening programme initiated. Footwear and running technique should be checked and corrected if necessary.

Comments:
The lower end of the iliotibial tract itself can be irritated, but invariably the bursa is also at fault. If both lesions are suspected, infiltration of both at the same time can be performed.

Iliotibial Band Bursa
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Pes Anseurine Bursa Injection

Chronic bursitis

Causes and findings:
• Overuse - especially dancers or runners
• Pain just proximal to insertion of medial flexors of knee
• Painful: resisted flexion of knee

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The pes anseurine is the combined tendon of insertion of the sartorius, gracilis
and semi-tendinosus. It attaches on the medial side of the tibia just below
the knee joint line. The bursa lies immediately under the tendon just posterior
to its insertion and is extremely tender to palpation in the normal knee.

Technique:
• Patient sits with knee supported
• Identify the pes anseurine tendon by making patient strongly flex knee against resistance. Follow the combined tendons distally to where they disappear at insertion into tibia. The bursa is found as an area of extreme tenderness slightly proximal to the insertion
• Insert needle into centre of tender area through tendon until it touches bone
• Deposit solution in bolus

Aftercare:
The patient should avoid overuse activities for at least 1 week, when graded stretching and strengthening exercises are started.

Comments:
It is important to remember that the bursa is extremely tender to palpation on everybody, so comparison testing must be done on both knees.

Pes Anseurine Bursa
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InfraPatellar Bursa Injection

Acute or chronic bursitis

Causes and findings:
• Overuse -long distance running or prolonged kneeling
• Trauma - direct blow or fall
• Pain anterior knee below patella
• Painful: resisted extension of knee passive flexion of knee
• Tenderness at mid-point of patella tendon

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
There are two infrapatellar bursae - one lies superficial and one deep to the tendon. In a small study it was found that the infrapatellar bursa consistently lay posterior to the distal third of the tendon and was slightly wider; a fat pad apron extends from the retropatellar fat pad to partially compartmentalize the bursa. The technique described is for the deep bursa, which is more commonly affected.

Technique:
• Patient sits with leg extended and knee supported
• Identify and mark tender area at mid-point of tendon
• Insert needle horizontally at the lateral edge of the patellar tendon just proximal to the tibial tubercle. Ensure that the needle does not enter the tendon
• Deposit solution as bolus

Aftercare:
The patient must avoid all overuse of the knee for at least 1 week. When the cause is occupational, such as in carpet layers, a pad with a hole in it to relieve pressure on the bursa should be used. Graded stretching and strengthening exercises are then begun.

Comments:
It would be tempting to believe that pain found at mid-point of the patella tendon is caused by tendinitis, but in the experience of the authors this is virtually unknown. Infrapatellar tendinitis is found consistently at the proximal teno-osseous junction on the patella, or rarely at insertion into the tibial tubercle. Pain here in an adolescent boy should be considered to be Osgood Schlatter's disease and should not be injected. A similar approach can be used for the superficial bursa and for the prepatellar bursa.

InfraPatellar Bursa
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Medical Collateral Ligament Injection

Acute or chronic sprain

Causes and findings:
• Trauma - typically flexion, valgus and lateral rotation of the knee as in a fall while skiing
• Pain at medial joint line of knee
• Painful: passive valgus passive lateral rotation of the knee

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1 ml 2%
Total volume - 1.5 ml

Anatomy:
The medial collateral ligament of the knee passes distally from the medial condyle of the femur to the medial aspect of the shaft of the tibia and is approximately a hand's width long and a good two fingers wide at the joint line. It is difficult to palpate the ligament as it is so thin and is part of the joint capsule. It is usually sprained at the joint line.

Technique:
• Patient lies with knee supported and slightly flexed
• Identify and mark medial joint line and tender area of ligament
• Insert needle at mid-point of tender area. Do not penetrate right through joint capsule
• Pepper solution along width of ligament in two rows

Aftercare:
Gentle passive and active movement within the pain-free range is started immediately.

Comments:
Occasionally the distal or proximal end of the ligament is affected, so the solution should be deposited there.

Alternative approaches:
Sprain of this ligament rarely needs to be injected, as early physiotherapeutic treatment with ice, massage and mobilization is very effective. The injection approach can be used when this treatment is not available or the patient is in a great deal of pain.

Medical Collateral Ligament
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Coronary Ligaments Injection

Ligamentous sprain

Causes and findings:
• Trauma - a strong forced rotation of the knee with or without meniscal tear
• Pain usually at medial joint line
• Painful: passive lateral rotation possibly meniscal tests

Equipment:
Syringe - 1ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 0.75 ml 2%
Total volume - 1 ml

Anatomy:
The coronary ligaments are small thin fibrous bands attaching the menisci to the tibial plateaux. The medial ligament is more usually affected. It can be found by placing the foot on the table with the knee at right angles and turning the foot into lateral rotation. This brings the tibial plateau into prominence and the tender
area is sought by pressing in and down onto the plateau.

Technique:
• Patient sits with knee at right angle and planted foot laterally rotated
• Identify and mark tender area on tibial plateau
• Insert needle vertically down onto plateau
• Pepper all along tender area

Aftercare:
Early mobilizing exercise to full range of motion without pain is started immediately.

Comments:
This lesion is commonly misdiagnosed; apparent meniscal tears, anterior cruciate sprain and patellofemoral joint lesions might be simple coronary ligament sprains.

Alternative approaches:
These ligaments usually respond extremely well to deep friction massage - it is not uncommon to cure the symptoms in one session. The injection should be kept for where the friction treatment is not available or where the pain is too intense to allow the pressure of the finger. Tear or subluxation of the meniscus should be treated first by manipulation.

Coronary Ligaments
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Superior Tibiofibular Joint Injection

Acute or chronic capsulitis

Causes and findings:
• Usually trauma such as a fall with forced medial rotation and varus on a flexed knee
• Pain over lateral side of knee
• Painful: resisted flexion of knee full passive medial rotation of knee

Equipment:
Syringe - 2ml
Needle - 23G 1 inches (25mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1 ml 2%
Total volume - 1.5 ml

Anatomy:
The superior tibiofibular joint line runs medially from superior to inferior. The anterior approach is safer as the peroneal nerve lies posterior to the joint.

Technique:
• Patient sits with knee at right angle
• Identify head of fibula and mark joint line medial to it
• Insert needle at mid-point of joint line and aim obliquely laterally to penetrate capsule
• Deposit solution in bolus

Aftercare:
Advise relative rest for at least 1 week and then resumption of normal activities. Strengthening of the biceps femoris might be necessary.

Comments:
Occasionally the joint is subluxed and has to be manipulated before infiltration. The condition also occasionally occurs after severe ankle sprain.

Alternative approach:
The unstable joint can be treated with sclerotherapy.

Superior Tibiofibular Joint
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Knee Joint Injection

Acute or chronic capsulitis

Causes and findings:
• Osteoarthritis, rheumatoid arthritis or gout
• Trauma
• Pain in knee joint
• Painful and limited: more passive flexion than extension with hard end-feel
• Possible effusion

Equipment:
Syringe - 5-10 ml
Needle - 21G 1.5 inches (40mm) green
Kenalog 40 - 40 mg
Lidocaine - 4 ml 1%-9 ml 0.5%
Total volume - 5-10 ml

Anatomy:
The knee joint has a potential capacity of approximately 120 ml in the average-sized adult. The capsule is lined with synovium, which is convoluted and so has a large surface area; in the large knee, therefore, more volume will be required to bathe all the surface. Plicae, which are bands of synovium, might exist within the joint and can also become inflamed. The suprapatellar pouch is a continuum of the synovial capsule and there are many bursae around the joint.

Technique:
• Patient sits with knee supported in extension
• Identify and mark medial edge of patella
• Insert needle and angle laterally and slightly upwards under patella
• Inject solution as bolus or aspirate if required

Aftercare:
The patient avoids undue weight-bearing activity for at least 1 week and is then given strengthening and mobilizing exercises to continue at home. One study indicated that total bed rest for 24 hours after injection in rheumatoid knees showed better results; however, the rest involved a hospital stay, which would not be cost effective.

Comments:
The injection will give temporary relief from pain and, provided the knee is not overused, this can last for some time. Repeat injections can be given at intervals of not less than 3 months with an annual X-ray to monitor joint degeneration. As with the hip joint, the patient might be awaiting surgery; the injection should not be given for at least 6 weeks prior to this.

Alternative approaches:
There are several ways to infiltrate or aspirate the knee joint - through the 'eyes of the knee', the supralateral approach into the suprapatella pouch just above the lateral pole of the patella, laterally at mid-point of patella or the medial approach as shown here. One study showed that there was more successful intra-articular placement using the lateral patella approach than through the 'eyes of the knee', but did not compare the lateral with this medial approach. The advantage of this approach is that there is normally plenty of space to insert the needle between the medial condyle and the patella, where even small amounts of effusion can be aspirated. The same approach can be used whether infiltrating or aspirating serous fluid or blood. For larger volumes, 40 mg Adcortyl, giving 4 ml of volume, might be the preferred steroid with less local anaesthetic. Hyalgen or similar substances can also be injected here but are more expensive than corticosteroids and do not appear to have longer-lasting benefits.

Knee Joint
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Lateral Cutaneous Nerve Injection

Meralgia paraesthetica

Causes and findings:
• Entrapment neuropathy due to compression of the lateral cutaneous nerve of the thigh
• Obesity, pregnancy or prolonged static flexed positions
• Sharply defined oval area of numbness over anterolateral thigh
• Occasionally painful paraesthesia
• Tenderness over nerve at inguinal ligament or where the nerve emerges through the fascia

Equipment:
Syringe - 1ml
Needle - 21G 2 inches (50mm) green
Kenalog 40 - 20 mg
Lidocaine - Nil
Total volume - 0.5 ml

Anatomy:
The lateral cutaneous nerve of the thigh arises from the outer border of the psoas and crosses over the iliacus. It passes under or through the inguinal ligament, through the femoral fascia and emerges superficially about 10 cm distal and in line with the anterior superior iliac spine.

Technique:
• Patient lies supine
• Identify tender area at inguinal ligament or at distal point in thigh
• Inject as bolus around compressed nerve, avoiding nerve itself

Aftercare:
Removing the cause is of prime importance, i.e. losing weight, avoiding tight clothing, correcting sitting posture. If the patient is pregnant the compression might be from the growing fetus, and symptoms will normally abate after delivery.

Comments:
Differential diagnoses include referred symptoms from lumbar spine or sacroiliac joint lesions, or local lesions such as hip joint pathology, arterial claudication, herpes zoster. As with other nerve compression injections, the nerve itself must not be injected. If the patient reports increased tingling or burning pain, the needle
point should be moved before the steroid is injected.

Alternative approach:
This lesion often spontaneously resolves. Advice on avoidance of compression and reassurance as to the nature and normal outcome of the condition might be all that is required.

Lateral Cutaneous Nerve
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Hamstrings Origin Injection

Chronic tendinitis or acute or chronic ischial bursitis

Causes and findings:
• Overuse - such as prolonged riding on horse or bicycle, or running
• Trauma - fall onto buttock, or sudden acceleration, kicking
• Pain in buttock
• Painful: resisted extension passive straight leg raise
• Very tender over ischial tuberosity

Equipment:
Syringe - 2ml
Needle - 21G 2 inches (50mm) green
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The hamstrings have a common origin arising from the ischial tuberosity. The tendon is approximately three fingers wide here. The ischial bursa lies between the gluteus maximus and the bone of the ischial tuberosity.

Technique:
• Patient lies on unaffected side with lower leg straight and upper leg flexed
• Identify ischial tuberosity and mark tendon lying immediately distal
• Insert needle into mid-point of tendon and angle up toward tuberosity to touch bone
• Pepper solution into teno-osseous junction of tendon or inject as bolus into bursa

Aftercare:
Avoidance of precipitating activities such as sitting on hard surfaces or prolonged running is maintained for at least a week and then graduated stretching and strengthening programme is started.

Comments:
Tendinitis and bursitis can occur together at this site, in which case a larger volume is drawn up and both lesions infiltrated. As usual, it is difficult to differentiate between the two lesions, but if there is a history of a fall or friction overuse and extreme tenderness at the tuberosity, bursitis is suspected. Occasionally, haemorrhagic bursitis can occur as a result of a hard fall. Aspiration of the blood is then performed prior to infiltration.
Hamstrings Origin
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Adductor Tendons Injection

Chronic tendinitis

Causes and findings:
• Overuse or trauma
• Pain in groin
• Painful: resisted adduction passive abduction

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The adductor tendons arise from the pubis and are approximately two fingers wide at their origin. The lesion can lie at the teno-osseous junction or in the body of the tendon. The technique described is for the more common site at the teno-osseous junction.

Technique:
• The patient lies supine with leg slightly abducted and laterally rotated
• Identify and mark the origin of the tendon
• Insert needle into tendon, angle towards pubis and touch bone
• Pepper solution into teno-osseous junction

Aftercare:
Rest for at least 1 week then start a graduated stretching and strengthening programme. Deep friction massage may be used as well to mobilize the scar.

Comments:
Sprain of these tendons is commonly thought to cause 'groin strain'. However, there are many alternative causes of pain in the groin (see psoas bursa technique) and these should be eliminated carefully.

Alternative approaches:
For the less common site at the body of the tendon, the solution is peppered into the tender area in the body, but deep friction massage and stretching may be more effective here.

Adductor Tendons
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Trochanteric Bursa Injection

Acute or chronic bursitis

Causes and findings:
• Usually a direct blow or fall onto hip
• Occasionally overuse or, in the thin elderly patient, lying on the same side every night, usually on a hard mattress
• Pain and tenderness over greater trochanter
• Painful: passive abduction, adduction and possibly flexion and extension of the hip resisted abduction

Equipment:
Syringe - 2ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - 1.5 ml 2%
Total volume - 2 ml

Anatomy:
The trochanteric bursa lies over the greater trochanter of the femur. It is approximately the size of a golf ball and is usually tender to palpation.

Technique:
• Patient lies on unaffected side with lower leg flexed and upper leg extended
• Identify and mark tender area over greater trochanter
• Insert needle perpendicularly at centre of tender area and touch bone of greater trochanter
• Inject by feeling for area of lack of resistance and introduce fluid there as a bolus

Aftercare:
Patient should avoid overuse for 1 week and then gradually return to normal activity. If the cause is lying on a hard mattress, the trochanter can be padded with a large circle of sticky felt. A change of lying position is encouraged and the mattress might need to be changed. Stretching of the iliotibial band can also help.

 Comments:
A fall or direct blow onto the trochanter will often cause a haemorrhagic
bursitis. This calls for immediate aspiration of blood prior to the infiltration.

Trochanteric Bursa
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Psoas Bursa Injection

Chronic bursitis

Equipment:
Syringe - 5ml
Needle - 22G 3.5 inches (90mm) spinal
Kenalog 40 - 20 mg
Lidocaine - 4 ml 1%
Total volume - 4.5 ml

Causes and findings:
• Overuse - especially sports or activities involving repeated hip flexion movements, e.g. hurdling, ballet, javelin throwing, football
• Pain in groin
• Painful: passive flexion, adduction, abduction and possibly extension resisted flexion and adduction scoop test - passive semicircular compression of femur from full flexion to adduction
• End-feel normal

Anatomy:
The psoas bursa lies between the iliopsoas tendon and the anterior aspect of the capsule over the neck of the femur. It is situated deep to three major structures
in the groin - the femoral vein, artery and nerve, lying at the level of the inguinal ligament. For this reason, careful placement of the needle is essential. Following the instructions below ensures that the needle will pass obliquely beneath the neurovascular bundle.

Technique:
• Patient lies supine
• Identify femoral pulse at mid-point of inguinal ligament. Mark a point three fingers distally and three fingers laterally. The entry point lies in direct line with the anterior superior iliac spine and passes through the medial edge of the sartorius muscle
• Insert needle at this point and aim 45° cephalad and 45° medially. Visualize the needle sliding under the three major vessels through the psoas tendon until point touches bone on anterior aspect of neck of femur
• Withdraw slightly and inject as bolus deep to tendon

Aftercare:
Absolute avoidance of the activities that irritated the bursa must be maintained for at least 1 week, then stretching of hip extension and musclebalancing programme is initiated.

Comments:
Although this injection might appear intimidating to the clinician at the first attempt, the approach outlined above is safe and effective. Very occasionally it is possible to catch a lateral branch of the femoral nerve and temporarily lose power in the quadriceps. If the patient complains of a tingling or burning pain during the process, reposition the needle before depositing solution. Differential diagnoses include local lesions such as hip joint pathology, adductor strain, hernia, abdominal muscle sprain, cutaneous nerve entrapment, pubic symphysitis, testicular disease, fracture and referred symptoms from lumbar spine, sacroiliac joint and genitourinary organs. Suspicion of any of these should be maintained until the clinician is satisfied of the cause of the symptoms. If in doubt, a diagnostic injection of local anaesthetic alone is advisable.

Alternative approaches:
For large individuals, a longer spinal needle might be required.

Psoas Bursa
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Gluteal Bursa Injection

Chronic bursitis

Causes and findings:
• Overuse
• Pain and tenderness over the upper lateral quadrant of the buttock
• Painful: passive flexion, abduction and adduction resisted abduction and extension
• End-feel normal

Equipment:
Syringe - 5ml
Needle - 22G 3.35 inches (90mm) spinal
Kenalog 40 - 40 mg
Lidocaine - 4 ml 1%
Total volume - 5 ml

Anatomy:
The gluteal bursae are variable in number, size and shape. They can lie deep to the gluteal muscles on the blade of the ilium and also between the layers of the three muscles. The painful site guides the placement of the needle but comparison between the two sides is essential as this area is always tender.

Technique:
• Patient lies on unaffected side with lower leg extended and upper leg flexed
• Identify and mark centre of tender area in upper outer quadrant of buttock
• Insert needle perpendicular to skin until it touches bone of ilium
• Inject solution in areas of no resistance while moving needle in a circular manner out towards surface - imagine the needle walking up a spiral staircase

Aftercare:
The patient must avoid overusing the leg for a week and can then gradually resume normal activities. Addressing any muscle tightness or imbalance and retraining in the causative sporting activity is necessary.

Comments:
There are no major blood vessels or nerves in the area of the bursae so the injection is safe. Feeling for a loss of resistance beneath and within the glutei guides the clinician in depositing the fluid. Pain referring from the lumbar spine or sacroiliac joint can often be mistaken for gluteal bursitis. The mere presence of tenderness mid-buttock, normal in most individuals, should not be considered diagnostic of an inflamed bursa.

Alternative approaches:
For large individuals, a longer spinal needle might be required.

Gluteal Bursa
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Hip Joint Injection

Acute capsulitis

Causes and findings:
• Osteoarthritis, rheumatoid arthritis or traumatic capsulitis with night pain and severe radiating pain no longer responding to physiotherapy
• May be on waiting list for surgery
• Buttock, groin and/or anterior thigh pain
• Painful limitation in capsular pattern - most: loss of medial rotation; less: loss of flexion and abduction; least: loss of extension
• Hard end-feel on passive testing

Equipment:
Syringe - 5ml
Needle - 22G 3.5 inches (90mm) spinal
Kenalog 40 - 40 mg
Lidocaine - 4 ml 1%
Total volume - 5 ml

Anatomy:
The hip joint capsule attaches to the base of the surgical neck of the femur. Therefore, if the needle is inserted into the neck, the solution will be deposited
within the capsule. The safest and easiest approach is from the lateral aspect. The greater trochanter is triangular in shape with a sharp angulation
inwards or the apex overhanging the neck. This part is difficult to palpate, especially on patients with excessive adipose tissue, so insert needle at least a thumb's width proximal to the most prominent part of the trochanter.

Technique
• Patient lies on pain-free side with lower leg flexed and upper leg straight and resting on pillow so that it lies horizontal
• Identify apex of greater trochanter with finger while passively abducting patient's upper leg
• Insert needle perpendicularly about a thumb's width proximal to palpable apex of trochanter until it touches the neck of femur
• Inject solution as a bolus

Aftercare:
Patient gradually increases pain-free activity maintaining range with a home stretching routine but limits weight-bearing exercise.

Comments:
The lateral approach to the hip joint is both simple and safe. It is not necessary to do the technique under fluoroscopy and the procedure is not painful. There is usually no sensation of penetrating the capsule. This injection is usually given to patients who are on a waiting list for surgery, but the joint should not be
injected within at least 6 weeks of surgery because reduced immunity could result in greater possible risk of infection. It is usually successful in giving temporary
pain relief and can, if necessary, be repeated at intervals of no less than 3 months. An annual X-ray monitors degenerative changes.

 Alternative approaches:
For large patients the total volume can be increased to 8-10 ml. Forty mg Adcortyl, giving 4 ml of volume, might be the preferred steroid here. For large individuals, a longer spinal needle might be required. During the early stages of the degenerative process, when the pain is local, there is minimal night pain and end feels are still elastic with reasonably good function, physiotherapy can be effective.

Hip Joint
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Carpal Tunnel Injection

Median nerve compression under flexor retinaculum

Causes and findings:
• Overuse or trauma, post-Colles' fracture
• Pregnancy, hypothyroidism, acromegaly
• Rheumatoid arthritis, psoriatic arthropathy
• Idiopathic
• Pins and needles in the distribution of the median nerve, especially at night
• Paraesthesia can be reproduced by tapping the median nerve at the wrist (Tinnel's sign) or by holding the wrist in full flexion for 30 seconds and then releasing (Phalen's sign). Longstanding median nerve compression may cause flattening of the thenar eminence

 Equipment:
Syringe - 1ml
Needle - 23G 1.25 inches (30mm) blue
Kenalog 40 - 20 mg
Lidocaine - Nil
Total volume - 0.5 ml

Anatomy:
The flexor retinaculum of the wrist attaches to four sites: the pisiform and the scaphoid, the hook of hamate and the trapezium. It is approximately as wide as the thumb from proximal to distal and the proximal edge lies at the distal wrist crease. The median nerve lies immediately under the palmaris longus tendon at the mid-point of the wrist, and medial to the flexor carpi radialis tendon. Not every patient will have a palmaris longus so ask the patient to press tip of thumb onto tip of little finger; the crease seen at mid-point of the palm points to where the median nerve should run.

Technique:
• Patient places hand palm up
• Identify point midway along proximal wrist crease, between flexor carpi radialis and median nerve
• Insert needle at this point then angle it 45°. Slide distally until needle end lies under mid-point of retinaculum
• Inject solution in bolus

Aftercare:
The patient rests for 1 week and then resumes normal activities. A night splint helps in the early stages after the infiltration and the patient is advised to avoid
sleeping with the wrists held in full flexion - the 'dormouse' position.

 Comments:
No local anaesthetic is used here because the main symptom is paraesthesia, not pain, and it is not advisable to increase the pressure within the tunnel. Care should be taken to avoid inserting the needle too vertically, when it will go into bone, or too horizontally, when it will enter the retinaculum. If the patient experiences pins and needles, the needle is in the median nerve and must be withdrawn slightly and repositioned. Although one injection is often successful, recurrences do occur. Further injections can be given if some relief was obtained, but if the symptoms still recur surgery may be required.

Alternative approach:
The injection can be equally well performed by inserting the needle between the median nerve and the flexor tendons, using the same dose and volume.

Carpal Tunnel
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Flexor Tendon Nodule Injection

Trigger finger or trigger thumb

 Causes and findings:
• Spontaneous onset: might have osteoarthritis or palpable ganglia in the fingers or hand
• Pvheumatoid arthritis
• Painful clicking and sometimes locking of finger with inability to extend
• A tender nodule can be palpated usually at the base of the finger

Equipment:
Syringe - 1ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 0.25 ml 2%
Total volume - 0.5 ml

Anatomy:
Trigger finger is caused by enlargement of a nodule within the flexor tendon sheath, which then becomes inflamed and painful. It usually occurs at the joint lines where the tendon is tethered down by the ligaments.

 Technique:
• Patient places hand palm up
• Identify and mark nodule
• Insert needle perpendicularly into nodule
• Deposit half solution in a bolus into nodule
• Angle needle distally into sheath
• Deposit remaining solution into sheath

Aftercare:
No particular restriction is placed on the patient's activities.

Comments:
This injection is invariably effective. Although the nodule usually remains, it can continue to be asymptomatic indefinitely, but recurrence can be treated with a further injection. Occasionally a slight pop is felt as the needle penetrates the nodule. When the needle is in a tendon, a rubbery resistance is felt.

Alternative approaches:
Some clinicians insert the needle alone first and then ask the patient to flex the finger. If the needle moves, this proves that the correct site has been reached and the syringe may then be attached. As this involves delay and discomfort to the patient, we recommend the method above.

Flexor Tendon Nodule
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Thumb Tendons Injection

de Quervain's tenovaginitis

Causes and findings:
• Overuse of abductor pollicis longus and extensor pollicis brevis
• Pain over base of thumb and over styloid process of radius
• Occasional crepitus
• Painful: resisted abduction and extension of thumb passive flexion of thumb across palm especially with wrist in ulnar deviation (Finklestein's test)

Equipment:
Syringe - 1ml
Needle - 25G 0.5 inches (16mm) orange
Kenalog 40 - 10 mg
Lidocaine - 0.75 ml 2%
Total volume - 1 ml

Anatomy:
The abductor pollicis longus and extensor pollicis brevis usually run together
in a single sheath on the radial side of the wrist. The styloid process is always
tender so comparison should be made with the pain-free side. The two
tendons can often be seen when the thumb is held in extension, or can be
palpated at the base of the metacarpal. The aim is to slide the needle between
the two tendons and deposit the solution within the sheath.

Technique:
• Patient places hand vertically with thumb held in slight flexion
• Identify gap between the two tendons at base of first metacarpal
• Insert needle perpendicularly into gap then slide proximally between the tendons
• Inject solution as a bolus within tendon sheath

 Aftercare:
The patient should rest the hand for a week with taping of the tendons. This is followed by avoidance of the provoking activity and a graded strengthening regime if necessary.

Comments:
Provided the wrist is not too swollen, a small sausage-shaped swelling can often be seen where the solution distends the tendon sheath.

Alternative approaches:
This is an area where depigmentation or subcutaneous fat atrophy can occur, especially noticeable in dark-skinned thin females. Although recovery can take place, the results might be permanent. Patient should be warned of this possibility before giving their consent. The potential risk can be minimized by injecting with hydrocortisone.

Thumb Tendons
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