Summary

Injections to Joints, Tendons and Bursae can be performed by single needle prick without an additional needle prick to infiltrate Local anaesthetic to the skin.

Abstract

Title: Is Local anaesthetic necessary to skin during steroid and PRP injections to Joints, Tendons and Bursae? (Prospective Cohort Study)

Abilash Thimmegowda1, Donald Buchanan2, Shishir Naghware2, Rudraprasad Baidyaray2, Paresh Sonsale2
1. Brighton and Sussex University Hospital, Brighton, United Kingdom
2. University Hospital Birmingham, Birmingham, United Kingdom

Keywords: Joint Injections, Local Anaesthetic, Single Needle, VAS Score,

Background

Injections to joints and bursae are performed frequently by Orthopaedic Surgeons, Sports Physicians, Family Physicians and Physiotherapists with good effect. These injections may be painful but there is no consensus on use of local anaesthesia to the skin before the injection of steroid or PRP into the joint or bursa. NICE guidance (UK) indicates that “if local anaesthetic is required, inject the local anaesthetic first, wait for 3 to 5 minutes then use a larger-bore needle to inject the drug”. A single injection technique without local anaesthetic to skin is less invasive, has lower risk of infection, saves time and allows more efficient use of theatre resources.

Objectives
We evaluated the pain patients experienced with steroid injections to various joints without prior use of local anaesthetic. Using a visual analogue scale (1 to 10) we evaluated the pain experienced with insertion of the needle to skin and with pain experienced with injection of the steroids or PRP in to the joint, tendon or bursa.

Methods

Over a three-month period, three Orthopaedic surgeons at two hospital sites evaluated patients who had injections of the hips, knees and shoulder joints, as well as patellar tendon, trochanteric and subacromial bursae. After aseptic preparation of the skin the needle was inserted. The pain with insertion of the needle was recorded and, the pain with injection of the steroid or PRP was similarly recorded on the VAS. A similar technique without local anaesthetic to skin was used throughout.

Results

Injections were given to 67 hip joints, 18 trochanteric bursae, 38 knee joints, 14 glenohumeral joints, 9 acromioclavicular joints and 35 subacromial bursae. 12 patients had PRP injections to the patella tendon. For the hip joint the mean pain score on needle insertion was 2 (0 – 4) and for steroid injection 5 (3 – 9). Trochanteric bursa 2 (1- 3) and 5 (3 -8). Knee joint 2 (1-3) and 2.5 (1-4). Glenohumeral joint 2 (1-3) and 2 (1-4). Acromioclavicular joint 1.5 (1-3) and 4 (3-8). Subacromial bursa 2 (1-3) and 3.5 (2-6). For PRP injections the scores were 2 (1-3) and 5.5 (3-9).
Overall, in 193 patients, the mean score for needle insertion to skin was 2 and injection of steroid/PRP into the joint or bursa was 4.5. Subjectively, patients felt that initial needle stick was less painful and the most painful aspect was instillation of steroid or PRP.

Conclusions

The pain with needle insertion was well tolerated uniformly in all injections. Joint injections may be done with only one needle prick effectively and safely. Local anaesthetic to skin with an additional needle is not absolutely essential. This would reduce the length of the procedure and allow more efficient use of theatre resources. It is also less invasive, less chance of infection and cost effective.
Injections to Joints, Tendons and Bursae can be performed by single needle prick without an additional needle prick to infiltrate Local anaesthetic to the skin.