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“ The Art of the Injection”. By Jon C. Brillhart PA-C Daivd Lannik MD Portsmouth Orthopedics, Inc. Joint Injection Challenge. The art of good injection therapy is to place the appropriate amount of the appropriate medication into the exact site of the affected tissue.

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“ The Art of the Injection”

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The art of the injection l.jpg

“The Art of theInjection”

By Jon C. Brillhart PA-C

Daivd Lannik MD

Portsmouth Orthopedics, Inc

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Joint Injection Challenge

The art of good injection therapy is to place the appropriate amount of the appropriate medication into the exact site of the affected tissue.

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“The right medicine”,

“in the right quantity”,

“given in the right stop”,

“at the right time”.

Quoted from David Lannik MD, 2005.

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Rational for injections

  • Diagnostic

    1.) Joint Aspiration (confirm nature fluid)

    2.) Provide symptom relief of affected body part.

  • Therapeutic

    1.) Increase mobility and decrease pain.

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Indications for Diagnostic and Therapeutic Injections

Soft Tissue conditions

  • Bursitis

  • Tendonitis or tendinosis

  • Trigger points

  • Ganglion cysts

  • Neuromas

  • Entrapment syndromes

  • Fasciitis

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Indications for Diagnostic and Therapeutic Injections

Joint Conditions

  • Effusion of unknown origin or suspected infection.

  • Crystalloid arthropathies

  • Synovitis

  • Inflammatory arthritis

  • Advanced osteoarthritis

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Absolute and Relative Contraindications to Therapeutic Joint and Soft Tissue Injections

Absolute contraindications

  • Local cellulitis

  • Septic arthritis

  • Acute fracture

  • Bacteremia

  • Joint prosthesis

  • Achilles or patella teninopathies

  • History of allergy or anaphylaxis to injectable constituents

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Absolute and Relative Contraindications to Therapeutic Joint and Soft Tissue Injections

Relative contraindications

  • Minimal relief after two previous injections

  • Underlying coagulopathy

  • Anticoagulation therapy

    (avoid soft tissue injection)

  • Evidence of surrounding joint osteoporosis

  • Anatomically inaccessible joints

  • Uncontrolled diabetes mellitus

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Top Six Injections

  • Chronic subdeltoid bursitis

  • Shoulder capsulitis

  • Knee osteoarthritis

  • Tennis elbow

  • Trapezio metacarpel joint OA

  • Plantar fasciitis

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General guidelines

  • Check patient’s allergies

  • Don’t forget “the patient” (discuss the procedure in patient friendly terms, side effects, what to expect, etc).

  • Obtain informed consent! (verbal vs written)

  • Place patient in comfortable position that allows easy access to area injected.

  • Take time to identify structure being injected by locating pertinent anatomical landmarks.

  • Be empathetic, and reassure patient.

  • Document, Document, Document!!!

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  • Safety (oxygen, anaphylaxis kit,

    crash cart, msds)

  • Appropriate needles and syringes

  • Medication with “in date” expirations!

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Skin preparation

The skin should be prepared with

providone-iodine or similar antiseptic solution. (Alcohol)

The risk of infection with use of alcohol skin preparation alone is reportedly estimated at 1 in 10,000.

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Synthetic analogues of the adrenal glucocorticocoid hormone “cortisol” (hydrocortisone) with is secreted by the innermost layer (zona reticularis) of the adrenal cortex.

*Suppress inflammation (RA, PA, Gout).

*Suppress inflammatory flares (OA/DJD).

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Corticosteroid Agents by Relative Potencies, Duration, and Dose


Hydrocortisone acetateLowShort10 to 25 mg for

(Hydrocortone)soft tissue and

small joints

50 mg large joints

MethylprednisoloneIntermediateIntermediate2 to 10 mg for

(Depo Medrol)soft tissue and

Triamcinolonesmall joints

(Aristocort)10 to 80 mg for

large joints

Dexamethasone sodiumHighLong0.5 to 3 mg for

(Decadron)soft tissue and small


2 to 4 mg large joints

Betametasone sodiumHighLong1 to 3 mg for soft tissue

phosphate and acetateand small joints

(Celestone Soluspan)2 to 6 mg large joints

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Recommended maximum dosages and volumes for joint injections


Shoulder30 mg10 ml

Elbow20 mg5 ml

Wrist, Thumb10 mg2 ml

Fingers5 mg1 ml

Hip40 mg5 ml

Knee40 mg10 ml

Ankle, foot20 mg5 ml

Toes10 mg1ml

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Side-effects of steroid injection therapy

Systemic side-effects

  • Facial flushing

  • Menstrual irregularity

  • Impaired diabetic control

  • Emotional upset

  • Hypothalmic – pituitary axis suppression

  • Fall in ESR/CRP

  • Anaphylaxis

Local side-effects

  • Post injection flare of pain

  • Skin depigmentation

  • Subcutaneous atrophy

  • Bleeding / bruising

  • Steroid “chalk”

  • Soft-tissue calcification

  • Steroid arthropathy

  • Tendon rupture or atrophy

  • Joint / soft-tissue infection

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Local Anesthetics

  • Provide pain relief

  • May help to differentiate between local and referred pain.

  • Provide fluid volume to the injection

  • Help distribute corticosteroid in large joints

  • May be short or long acting

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Rule of….

Use more concentrated solutions (ie 2%) of lidocaine hydrochloride for small joints that require small injection volumes. (MCPJ)

Conversely, use a less concentrated (ie 1%) lidocaine hydrochloride for large joints that need increased volume. (Knee)

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Never use epinephrine / lidocaine solution on ears, nose, fingers and toes!!!

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Onset, Duration, and toxicity of local anesthetics

DrugOnsetDurationMax Vol


1%1-2 Min~ 1 Hour20 ml

2%1-2 Min~ 1 Hour10 ml


0.25%30 Min8 hours60 ml

0.50%30 Min8 Hours30ml

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“A Failure of the Supporting Structure of the Total Organ (Joint)”


  • Joint injury or deformity1

  • Imbalance of biosynthesis and degradation in cartilage, synovial fluid, bone, muscle, ligaments1

  • Inflammation1

  • Chronic wear and age1

  • Softening and loss of articular cartilage1

  • Decrease in concentrationand average molecular weight of hyaluronic acid in synovial fluid2

1. Brandt KD. In: Harrison’s Principles of Internal Medicine. 13th ed. New York, NY: McGraw-Hill; 1994:1692-1698.

2. Balazs EA, Denlinger JL. J Rheumatol. 1993;20(suppl 39):3-9.

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Hyaluronic Acid

  • Used to treat OA of the knee

  • Act as viscoelastic supplements that replace the diseased synovial fluid of the osteoarthritic joint

  • Act as a shock absorber and lubricates the joint! (How to explain this to pt?).

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Synovial Fluid

  • Highly influences intercellular matrices of joint soft tissues

  • Unique combination of elasticity and viscosity

  • Hyaluronan responsible for elastoviscous properties

  • Elastoviscosity critical for joint function

  • Elastoviscosity reduced in osteoarthritis

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ViscosupplementationBasic Principle







hylan G-F 20MW 6 million






% Elasticity

% Viscosity
























Frequency (Hz)

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  • Synvisc

  • Hylagan

  • Orthovisc

  • Suparz

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Side Effects

  • Mild pain caused by injection, usually resolve in three days following injection. (Avoid heat for 24 hours and strenous / weight bearing activity after).

  • Serious allergic reaction. (Egg based).

  • How to define (Synvisc) pseudo-sepsis vs injection flare

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Overall Response to Hylan G-F 20 Viscosupplementation

Much Better






Worse or

Much Worse


Reference: Lussier A, Cividino AA, McFarlane CA, et al. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol. 1996;23(9):1579-1585.

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  • Always be aware of participating insurance programs.

  • Seek pre-authorization per insurance

  • Per Incident “2” guidelines, (would second visit per mid level be covered?)

  • Purchasing “off shore”.

  • FDA vs Morality vs Reality.

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  • Who is the best candidate for injection?

  • When to choose preventive vs operative medicine

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OsteoarthritisCLINICAL MANAGEMENTOA Treatment Modalities

ACR 2000 GUIDELINES – Pharmacologic/Surgical Therapy

  • Mild to Moderate Pain

  • Simple analgesics (eg, acetaminophen)


  • Topical creams

  • Moderate to Severe Pain

  • COX-2–selective inhibitors (CELEBREX)

  • Rx NSAIDs plus gastro-protective agent

Additional Therapies

  • IA hyaluronans

  • IA steroids

  • Tramadol

  • Opioids

Surgical Intervention

  • Arthoplasty; osteotomy

  • Total knee replacement

Adapted from American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:1905-1915.

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Thank you,

Have a Blessed Day!


God Bless America!

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