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The use of systemic corticosteroids for the treatment of symptomatic arthritis began shortly after the discovery and synthesis of cortisone in the 1940s.1 Intra-articular steroid injections followed shortly thereafter. In 1951, Hollander published the results of a large series of patients treated with corticosteroid joint injections. Since then, corticosteroid injections have played an important role in the diagnosis and management of acute and chronic joint and periarticular pain problems.

Intra-articular and periarticular injections are indicated for diagnostic, prognostic, and therapeutic purposes (Table 67-1).

Table 67-1 Indications for Joint and Periarticular Injection

Diagnostic Injection

A careful history, physical examination, and supporting radiographic studies are important in the evaluation of a patient with a pain complaint, but often these three components of the evaluation fail to identify the source or sources of the patient’s pain. Despite some limitations, a series of accurately performed local anesthetic injections often is the best diagnostic “test” we have to identify the pain generator(s) contributing to the patients pain problem.

Prognostic Injection

Injection techniques may help to determine if a more definitive therapeutic intervention is indicated. Pain relief following a local anesthetic injection into an arthritic joint may lead to consideration of viscosupplementation or may convince a surgeon that an operation is indicated (Fig. 67-1). The decision to perform total joint replacements or bursectomies frequently is guided by the response to one or more diagnostic injections.

Figure 67-1

Diagnostic injection of an osteophyte on the femoral head. This was subsequently treated with surgery.

Prognostic injections may help to determine if a joint denervation procedure is indicated. Chronic facet pain and discogenic pain often are treated with denervation procedures (e.g., radiofrequency). A denervation procedure is performed following a series of carefully controlled prognostic local anesthetic blocks.

Therapeutic Injection

Injections are used to treat a variety of inflammatory and noninflammatory joint and periarticular soft tissue pain problems.

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic systemic inflammatory disease with polyarticular involvement. Because this is a systemic disease, the principal therapeutic agents are systemic anti-inflammatory and/or immune modulating drugs. Injection of isolated joint flare-ups with local anesthetic and corticosteroid may help to quickly restore function and allow participation in physical therapy. Studies have demonstrated short-term pain relief and improved periarticular muscle strength in patients following intra-articular corticosteroid injection of a symptomatic rheumatoid joint.3,4 For a flare-up of a single or a couple of joints, it is preferable to inject one or two joints rather than ...

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