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Musculoskeletal Injections and Alternative Options: A practical guide to 'what, when and how?'

Authors:
Maneesh Bhatia at University Hospitals Of Leicester NHS Trust
Maneesh Bhatia
Dev Mahadevan at Royal Berkshire NHS Foundation Trust
Dev Mahadevan
Harvinder Pal Singh at Honorary Associate professor, University of Leicester
Harvinder Pal Singh
  • Honorary Associate professor, University of Leicester
R. Aujla at University Hospitals Of Leicester NHS Trust
R. Aujla
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Abstract

Musculoskeletal injections for joint or tendon problems are performed commonly and their use is on the rise. This book helps doctors from various disciplines including orthopaedics, sports medicine, rheumatology radiology and primary care as well as allied health care professionals understand the indications and local anatomy to safely perform injections with complication avoidance. In addition this book provides useful information regarding other alternatives including physiotherapy and novel modalities. The content is supported by current evidence, guidelines, and companion videos.
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... Prolotherapy involves injecting irritants and hyperosmolar solutions that create controlled injury and inflammation in a joint [54]. The goal of prolotherapy is to improve blood flow and initi-ate the healing cascade, leading to deposition and hypertrophy of collagen resulting in joint regeneration [55]. ...
... Therefore, patients should anticipate a period of swelling and stiffness after treatment. Patients should be encouraged to ambulate as soon as possible after intervention to promote healing and joint mobility [55]. ...
CT-Guided Core Needle Biopsy of Non-Spinal Bone Lesions: Comparison of Occult and Visible Bone Lesions
Article
  • Jun 2022
  • AM J ROENTGENOL
Background: CT guidance may be used for biopsy of indeterminate bone lesions detected by MRI or PET that are not visible (i.e., occult) by CT due to equipment-, patient-, and operator-related factors. Objective: To assess diagnostic yield (DY) and diagnostic performance of CT-guided core needle biopsy (CNB) of occult non-spinal bone lesions and to identify the most common benign and malignant diagnoses for occult lesions undergoing CNB. Methods: This retrospective study included 1033 adult patients who underwent CT-guided non-spinal bone CNB between January 2004 and December 2020. Lesions were classified as occult or visible on CT; biopsies of occult lesions relied on targeting anatomic landmarks using prebiopsy MRI or PET/CT. Pathologic results of CNB were classified as diagnostic or nondiagnostic to calculate DY of CNB. For nondiagnosti CNBs, final diagnoses were established by subsequent pathologic, clinical, and imaging follow-up. Results: The sample included 70 occult lesions (mean age, 56.8 years; 38 women, 32 men) and 963 visible lesions (59.6 years; 475 women, 488 men). Malignancy rate was lower for occult than visible lesions (42.9% vs 60.8%; p=.004). DY was lower for occult than visible lesions (37.1% vs 76.9%; p<.001). Diagnostic performance for detecting malignancy based on final diagnoses was lower for occult than visible lesions in terms of sensitivity (76.7% vs 93.7%; p=.003), specificity (7.9% vs 54.5%; p<.001), and accuracy (38.2% vs 80.0%; p<.001). Final diagnoses among malignant occult and visible lesions included metastasis (frequencies of 63.3% vs 65.4%), lymphoma/leukemia (33.3% vs 11.6%), and myeloma (3.3% vs 10.4%); final diagnoses among benign occult and visible lesions included red marrow (34.2% vs 8.2%), reactive marrow (26.3% vs 11.8%), and fracture (18.4% vs 3.8%). Occult lesions detected by MRI versus by PET/CT had lower malignancy rate (39.3% vs 68.0%; p=.03) and lower DY (30.4% vs 60.0%; p=.01). Conclusion: At CT-guided CNB, malignancy rate and DY are lower for occult than visible lesions. Leukemia/lymphoma and red marrow are more common among occult than visible lesions. Clinical Impact: Understanding these characteristics can help guide radiologists', referring providers', and patients' expectations when requesting and performing CNB of occult bone lesions.
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... These observations were confirmed by another study conducted at Piramal Dadabhai (PD) Hinduja Hospital and Seth Gordhandas Sunderdas (GS) Medical College, Mumbai, in 2019 by Desai et al. on 354 patients where the incidence of IM-induced nerve injuries was observed as 82.5% [4]. More than 50% of deltoid intramuscular injections (IM) are given indiscriminately by untrained staff in unregistered settings in clinical practice, especially in Southeast Asian countries [3,5]. In East Asia and the West, extensive research is done namely by Cheung et al., Chen et al., Kim et al., and Nakajima et al. [1,[6][7][8]. ...
The Recommended Deltoid Intramuscular Injection Sites in the Adult Population: A Cadaveric Pilot Study With an Orthopedic Perspective
Article
Full-text available
  • Aug 2024
Background and aim The deltoid is a common site for intramuscular injections, but guidelines for administration lack standardization. Global researchers propose various techniques, and recent study reports indicate a 1.5-15% incidence of nerve palsies due to injections. This pilot cadaveric study aimed to standardize the deltoid intramuscular injection sites in the Southeast Asian population. Methods This cadaveric study of a two-year duration was conducted in the Department of Anatomy as an intramural research project in collaboration with the Departments of Anatomy and Orthopedics. In the first year of study, which was the pilot phase of the project, the available six cadavers, i.e., 12 upper extremity specimens were dissected. Anthropometric measurements of deltoid muscle along with the distance of underlying neurovascular structures like the axillary nerve and posterior circumflex humeral artery were measured from neighboring bony landmarks. This article presents the observations of the six cadavers studied in the pilot phase and shall be followed up by another article after the project. Results In adults, in anatomical position, the mean distances of the axillary nerve and posterior circumflex humeral artery from the mid-acromial point are 8.19±0.616 and 8.66±0.968 cm, respectively. The deltoid thickness at 3, 5, and 7 cm from mid-acromial point was observed to be 1.079±0.13 cm (0.5-1.78 cm), 1.599±0.12 cm (1-2.96 cm), and 1.815±1.0 cm (1.2-2.5 cm), respectively. The acquired qualitative and quantitative data were tabulated, graphically represented, and statistically analyzed. Conclusions The deltoid intramuscular injection (IMI) must be given at or below the level of the midpoint of the deltoid muscle, but never in the upper half. We recommend a site, 4 fingerbreadths/9 cm below the mid-acromion point as the safest site to avoid injury to any underlying neurovascular structures.
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... These observations were confirmed by another study conducted at Piramal Dadabhai (PD) Hinduja Hospital and Seth Gordhandas Sunderdas (GS) Medical College, Mumbai, in 2019 by Desai et al. on 354 patients where the incidence of IM-induced nerve injuries was observed as 82.5% [4]. More than 50% of deltoid intramuscular injections (IM) are given indiscriminately by untrained staff in unregistered settings in clinical practice, especially in Southeast Asian countries [3,5]. In East Asia and the West, extensive research is done namely by Cheung et al., Chen et al., Kim et al., and Nakajima et al. [1,[6][7][8]. ...
‘The Recommended Deltoid Intramuscular Injection Sites in the Adult Population: A Cadaveric study with an Orthopedic Perspective’
Preprint
  • Jun 2024
Background The deltoid is a common site for intramuscular injections, but guidelines for administration lack standardization. Global researchers propose various techniques, and recent study reports indicate a 1.5-15% incidence of nerve palsies due to injections. Our cadaveric study is aimed to standardize the deltoid intramuscular injection sites in the Southeast-Asian population. Methods A cadaveric study of a 2-year duration was conducted in the Department of Anatomy in which twelve upper extremity specimens were dissected by the end of the pilot phase. Anthropometric measurements of deltoid muscle along with the distance of underlying neuro-vascular structures like the Axillary nerve and Posterior Circumflex Humeral Artery were measured from neighboring bony landmarks. Results In adults, in anatomical position, the mean distances of the Axillary nerve, and Posterior Circumflex Humeral Artery from the mid-acromial point are 8.19 ± 0.616 cm; and 8.66 ± 0.968 cm respectively. The deltoid thickness at 3, 5, and 7 cm from mid-acromial point was observed to be 1.079 ± 0.13 cm (0.5 cm to 1.78 cm), 1.599 ± 0.12 cm (1 cm to 2.96 cm), 1.815 ± 1.0 cm (1.2 cm to 2.5 cm) respectively. The acquired qualitative and quantitative data were tabulated, graphically represented, and statistically analyzed. Conclusions The deltoid IMI must be given at or below the level of the midpoint of the deltoid muscle, but never in the upper half. We recommend a site, 4 fingerbreadths / 9cm below the mid-acromion point as the safest site to avoid injury to any underlying neurovascular structures.
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... Greater trochanteric pain syndrome (GTPS) is an 'umbrella' term, used to describe a group of painful, functionally restrictive pathological soft tissue conditions around the lateral hip. These conditions include glutaeal tendinopathy (GT), glutaeal tendon tears, trochanteric bursitis (TB) and external snapping hip syndrome (Bhatia, 2019;Kumar et al., 2021;Lall et al., 2019). Between 10% and 25% of the population in the United Kingdom will suffer with GTPS symptoms (Gazendam et al., 2022;Williams & Cohen, 2009) with a yearly incidence ranging from 1.8 (Disantis & Martin, 2022;Mulligan et al., 2015) to 5.6 per 1000 patients/year (Barratt et al., 2017). ...
Is shockwave therapy effective in the management of greater trochanteric pain syndrome? A systematic review and meta-analysis
Article
Full-text available
  • Jun 2024
  • Muscoskel Care
Background Evidence is lacking for the efficacy of shockwave therapy (SWT) in the treatment of greater trochanteric pain syndrome (GTPS). Aim To investigate the efficacy of SWT on pain and function in the management of GTPS. Methods A systematic search of electronic databases and grey literature was conducted up to May 2023. Studies utilising SWT on adults for GTPS, providing measures of pain and/or function at baseline and at follow‐up were considered for inclusion. Meta‐analysis was undertaken using converted pain and functional outcomes. Studies were assessed for quality and risk of bias, and assigned a level of evidence as per the Grading of Recommendations, Assessment, Development and Evaluations criteria. Results Twelve articles ( n = 1121 subjects) were included, including five randomised controlled trials (RCTs) and seven non‐RCTs. No statistical differences were observed for pain over time f (1,5) = 1.349 ( p = 0.298) or between SWT and control f (1,5) = 1.782 ( p = 0.238). No significant differences in functional outcomes in short‐ ( H = 2.591, p = 0.181) and medium‐term follow‐up ( H = 0.189, p = 0.664) were identified between SWT and control. Moderate magnitude treatment effects for pain (Hedges‐G [HG] 0.71) favouring SWT groups over control was identified, decreasing to low for function (HG 0.20). Further pain and functional treatment effects were identified at higher magnitudes across follow‐up time‐points in SWT groups compared to control. Conclusion Moderate‐quality evidence demonstrated no statistically significant improvements in pain and function post‐SWT compared to control. Low‐quality evidence established clinical improvements throughout all included studies favouring SWT over control. Consequently, owing to relatively low incidence of side effects, SWT should be considered a viable option for the management of GTPS. Issues with both clinical and statistical heterogeneity of studies and during meta‐analysis require consideration, and more robust RCTs are recommended if the efficacy of SWT for the management of GTPS is to be comprehensively determined.
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