Orthopedics

Feature Article 

Steroid Injections in the Upper Extremity: Experienced Clinical Opinion Versus Evidence-based Practices

Gary Kegel, MD; Astrid Marshall, BA; O. Alton Barron, MD; Louis W. Catalano, MD; Steven Z. Glickel, MD; Margaret Kuhn, MD

Abstract

A survey regarding upper-extremity steroid injection practices was distributed to all active members of the American Society for Surgery of the Hand (ASSH) and American Shoulder and Elbow Surgeons (ASES) using SurveyMonkey. Response rates for the ASSH and ASES were 26% and 24%, respectively.

The potency-adjusted dose of steroid injected for common hand and wrist injections ranged from 0.375 to 133.33 mg and for shoulder injections ranged from 0.375 to 250 mg. These ranges span 356-fold and 667-fold differences, respectively. Potency-adjusted doses differed significantly between steroid types for all injections evaluated in this study. American Society for Surgery of the Hand members gave significantly smaller doses of steroid for the glenohumeral and acromioclavicular joints than ASES members. Only 9% of respondents based injection practice on a scientific reference. Sixteen percent of ASSH and 31% of ASES respondents reported no specific rationale for their steroid injection practice; 78% of ASSH and 52% of ASES respondents attributed their rationale to some kind of instruction from their mentors or colleagues.

Upper-extremity surgeons demonstrate substantial variability in their practice of steroid injections, with up to a 667-fold range in steroid dose. Experienced clinical opinion is the principal rationale for these injection practices; little rationale is based on formal scientific evidence.

The authors are from CV Starr Hand Surgery, New York, New York.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Gary Kegel, MD, CV Starr Hand Surgery, 1000 10th Ave, New York, NY 10019 (cvstarr2@gmail.com).

Abstract

A survey regarding upper-extremity steroid injection practices was distributed to all active members of the American Society for Surgery of the Hand (ASSH) and American Shoulder and Elbow Surgeons (ASES) using SurveyMonkey. Response rates for the ASSH and ASES were 26% and 24%, respectively.

The potency-adjusted dose of steroid injected for common hand and wrist injections ranged from 0.375 to 133.33 mg and for shoulder injections ranged from 0.375 to 250 mg. These ranges span 356-fold and 667-fold differences, respectively. Potency-adjusted doses differed significantly between steroid types for all injections evaluated in this study. American Society for Surgery of the Hand members gave significantly smaller doses of steroid for the glenohumeral and acromioclavicular joints than ASES members. Only 9% of respondents based injection practice on a scientific reference. Sixteen percent of ASSH and 31% of ASES respondents reported no specific rationale for their steroid injection practice; 78% of ASSH and 52% of ASES respondents attributed their rationale to some kind of instruction from their mentors or colleagues.

Upper-extremity surgeons demonstrate substantial variability in their practice of steroid injections, with up to a 667-fold range in steroid dose. Experienced clinical opinion is the principal rationale for these injection practices; little rationale is based on formal scientific evidence.

The authors are from CV Starr Hand Surgery, New York, New York.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Gary Kegel, MD, CV Starr Hand Surgery, 1000 10th Ave, New York, NY 10019 (cvstarr2@gmail.com).

Injectable corticosteroids have been used for musculoskeletal pathology for more than 50 years and remain an integral component of nonoperative treatment for many conditions. According to Hill et al,1 more than 90% of 233 orthopedists surveyed from the American Academy of Orthopaedic Surgeons use steroid injections in their practice.2

No specific, established guidelines exist for selecting steroid type or dose, although some studies have attempted to ascertain the current common practice among physicians. Centeno and Moore3 surveyed 506 rheumatologists regarding their injection practices for the knee and discovered that more than 80% of respondents preferred 1 of 3 steroid preparations using doses ranging from less than 10 to 240 mg. However, the study did not specify whether these amounts are adjusted for the relative potency of the different steroid preparations. This variability seemed to be influenced by the geographical location of practice.3

Although the study by Centeno and Moore3 focused on the knee, injectable corticosteroids have also found widespread use in the upper extremity.1 Skedros et al4 compared parameters of shoulder girdle injections among orthopedic surgeons (n=105), rheumatologists (n=20), and primary care sports medicine/physical medicine and rehabilitation physicians (n=44). Although their study was underpowered for certain analyses, they found no significant differences in the dose of steroid (P>.3) but found significant differences in the volume of local anesthetic used (P<.01). The local anesthetic concentration was not assessed. They also found that 41% of orthopedic surgeons, 44% of rheumatologists, and 29% of primary care sports medicine/physical medicine and rehabilitation physicians exceeded the recommended dose of steroid injected into the acromioclavicular joint (10–40 mg methlyprednisolone acetate, 5–40 mg triamcinolone acetonide, 5–40 mg triamcinolone hexacetonide, or 1.5–6 mg betamethasone sodium phosphate and betamethasone acetate).4 Despite being underpowered for some analyses, these data are indicative of the variability among practitioners.

Despite the widespread use of steroid injections in clinical practice, little research has focused on determining dosages to maximize efficacy and minimize toxicity. In preparation for a prospective study to address this issue, the authors investigated the injection practices of hand and upper-extremity surgeons. The hypothesis was that the variability suggested for other specialties would pertain to their cohort. Furthermore, the authors hypothesized that the rationale for these injection practices is not evidence based.

Materials and Methods

A survey (created and administered using SurveyMonkey) of upper-extremity steroid injection practices was distributed via e-mail to all active members of the American Society for Surgery of the Hand (ASSH) and American Shoulder and Elbow Surgeons (ASES). The survey was sent twice to maximize the response rate. The ASSH survey queried both the steroid and local anesthetic type, dose, and volume practitioners use for trigger finger, carpal tunnel syndrome, De Quervain’s tenosynovitis, finger joint, lateral epicondylitis, subacromial space, glenohumeral joint, and acromioclavicular joint injections. The ASES survey was identical but limited to lateral epicondylitis, subacromial space, glenohumeral joint, and acromioclavicular joint injections. Both surveys asked the amount of time respondents were in practice, their geographical location, and their rationale for their injection practices. Statistical analysis was conducted with Stata version 11 statistical software (StataCorp, College Station, Texas).

A linear regression model was created to examine the relationship between potency-adjusted steroid dosage and years of surgical practice, geographic location of surgeons, and the type of steroid used. For each steroid type, all analyses were repeated for each injection site.

Additional analyses used bivariate statistics, with chi-square testing, to determine whether steroid or local anesthetic type used by hand and shoulder surgeons varied by years in practice or geographic location. All bivariate analyses were repeated for each steroid type at each injection site. For all associations found to be significant in bivariate analysis, simple logistic regression was conducted to produce odds ratios and 95% confidence intervals.

Results

Of 2845 e-mails sent to ASSH members, 56 did not deliver, leaving 2789 successfully transmitted surveys; 724 (26%) responses were received. Two members were excluded: 1 who sees only pediatric patients and another whose e-mail address was a duplicate from 2 identical IP addresses.

Ninety-one (24%) of 378 members of the ASES responded. One was excluded because radiologists perform all injections at his institution. Respondent demographics are shown in Table 1.

ASSH Respondent Demographics

Table 1: ASSH Respondent Demographics

Table 2 lists the most common volumes used for these injection sites. The range of volumes spanned up to a 32-fold difference. The preferred choice of steroid and local anesthetics for both societies can be seen in Figures 1 and 2, respectively. Triamcinolone acetonide is the most commonly used steroid, and lidocaine is, by far, the preferred local anesthetic.

ASES Respondent Demographics

Table 2: ASES Respondent Demographics

Choice of steroid medication. Abbreviations: B, betamethasone sodium phosphate and beta-methasone acetate; B (Dipro), betamethasone dipropionate and betamethasone sodium phosphate; B+D, betamethasone sodium phosphate and betamethasone acetate+dexamethasone; B+MA, betamethasone sodium phosphate and betamethasone acetate+methylprednisolone acetate; D, dexamethasone; HA, hydrocortisone acetate; MA, methylprednisolone acetate; TA, triamcinolone acetonide; TA+MSS, triamcinolone acetonide+methylprednisolone sodium succinate; TH, triamcinolone hexacetonide.

Figure 1: Choice of steroid medication. Abbreviations: B, betamethasone sodium phosphate and beta-methasone acetate; B (Dipro), betamethasone dipropionate and betamethasone sodium phosphate; B+D, betamethasone sodium phosphate and betamethasone acetate+dexamethasone; B+MA, betamethasone sodium phosphate and betamethasone acetate+methylprednisolone acetate; D, dexamethasone; HA, hydrocortisone acetate; MA, methylprednisolone acetate; TA, triamcinolone acetonide; TA+MSS, triamcinolone acetonide+methylprednisolone sodium succinate; TH, triamcinolone hexacetonide.

Choice of local anesthetic. Abbreviations: Bu, bupivacaine; EC, ethyl chloride; L, lidocaine; L/Bu, lidocaine and bupivacaine; L/R, lidocaine and ropivacain; L epi, lidocaine with epinephrine; L topical, topical lidocaine; M, mepivacaine; M/Bu, mepivacaine and bupivacaine; R, ropivacaine.

Figure 2: Choice of local anesthetic. Abbreviations: Bu, bupivacaine; EC, ethyl chloride; L, lidocaine; L/Bu, lidocaine and bupivacaine; L/R, lidocaine and ropivacain; L epi, lidocaine with epinephrine; L topical, topical lidocaine; M, mepivacaine; M/Bu, mepivacaine and bupivacaine; R, ropivacaine.

Table 3 lists steroid dose equivalencies and relative anti-inflammatory potencies based on oral administration because equivalencies for injectable steroids were not found. Figure 3 shows the potency-adjusted steroid dose administered, allowing comparison between the different steroids. The range in potency-adjusted steroid dose for trigger finger, carpal tunnel, De Quervain’s tenosynovitis, finger joint, and lateral epicondylitis was 0.375 to 133.33 mg, and the range in the sub-acromial space and glenohumeral and acromioclavicular joints was 0.375 to 250 mg. These ranges span 356-fold and 667-fold differences, respectively. Median potency-adjusted steroid dose and interquartile range (IQR) for each injection site are as follows: trigger finger, 5 mg (IQR, 5–10 mg); carpal tunnel, 10 mg (IQR, 5–10 mg); De Quervain’s tenosynovitis, 10 mg (IQR, 5–10 mg); finger joint, 5 mg (IQR, 2.5–10 mg); lateral epicondylitis, 10 mg (IQR, 5–10 mg); subacromial space, 10 mg (IQR, 10–20 mg); glenohumeral joint, 10 mg (IQR, 10–20 mg); and acromioclavicular joint, 10 mg (IQR, 5–10 mg).

Total Volumes Injecteda

Table 3: Total Volumes Injected

Line graph showing number of respondents using specific adjusted dose. Each color line represents a different anatomic location for injection. All corticosteroid doses used by at least 1 survey respondent. Most commonly used doses for all anatomic locations marked with arrows. Dose adjusted for medication potency based on guidelines in Drug Facts & Comparisons.6 (Equivalent potency doses: triamcinolone, 4 mg; betamethasone, 0.6 mg; methylprednisolone, 4 mg; dexamethasone, 0.75 mg). Aristospan; Sandoz, Princeton, New Jersey. Celestone Soluspan; Merck Canada Inc, Kirkland, Quebec, Canada. Decadron and Depo-Medrol; Pfizer Inc, New York, New York. Kenalog; Bristol-Meyers Squibb, Princeton, New Jersey.

Figure 3: Line graph showing number of respondents using specific adjusted dose. Each color line represents a different anatomic location for injection. All corticosteroid doses used by at least 1 survey respondent. Most commonly used doses for all anatomic locations marked with arrows. Dose adjusted for medication potency based on guidelines in Drug Facts & Comparisons.6 (Equivalent potency doses: triamcinolone, 4 mg; betamethasone, 0.6 mg; methylprednisolone, 4 mg; dexamethasone, 0.75 mg). Aristospan; Sandoz, Princeton, New Jersey. Celestone Soluspan; Merck Canada Inc, Kirkland, Quebec, Canada. Decadron and Depo-Medrol; Pfizer Inc, New York, New York. Kenalog; Bristol-Meyers Squibb, Princeton, New Jersey.

Depending on the steroid, statistically significant differences existed in the mean potency-adjusted doses (Table 4).4–10 In general, respondents who used methylprednisolone acetate, triamcinolone acetonide, or triamcinolone hexacetonide tended to give a significantly lower potency-adjusted dose of steroid than those using betamethasone sodium phosphate and betamethasone acetate or dexamethasone sodium phosphate. Local anesthetic dose is represented in Figure 4, with toxic doses reached by some respondents. Figure 5 shows the variability in the components used for trigger finger injections. Trigger finger injections were selected for detailed analysis because this site was injected most commonly.

Steroid Medication Potency Equivalence4–10

Table 4: Steroid Medication Potency Equivalence4–10

Local anesthetic doses used by American Society for Surgery of the Hand and American Shoulder and Elbow Surgeons members. Doses are shown in milligrams, calculated by multiplying the concentration (commonly labeled as %, for which 1%=10 mg/mL for all local anesthetics in this study) by the volume administered.

Figure 4: Local anesthetic doses used by American Society for Surgery of the Hand and American Shoulder and Elbow Surgeons members. Doses are shown in milligrams, calculated by multiplying the concentration (commonly labeled as %, for which 1%=10 mg/mL for all local anesthetics in this study) by the volume administered.

Percent of respondents using each specific combination of steroid medication and local anesthetic for trigger finger. Respondents reported 31 different combinations for trigger finger injections. Abbreviations: B, betamethasone sodium phosphate and betamethasone acetate; B (Diprospan) (Schering-Plough Labo N.V., Heist-op-den-Berg, Belgium), betamethasone dipropionate and betamethasone sodium phosphate; Bu, bupivacaine; D, dexamethasone; EC, ethyl chloride; L, lidocaine; M, mepivacaine; MA, methylprednisolone acetate; R, ropivacaine; TA, triamcinolone acetonide; TH, triamcinolone hexacetonide.

Figure 5: Percent of respondents using each specific combination of steroid medication and local anesthetic for trigger finger. Respondents reported 31 different combinations for trigger finger injections. Abbreviations: B, betamethasone sodium phosphate and betamethasone acetate; B (Diprospan) (Schering-Plough Labo N.V., Heist-op-den-Berg, Belgium), betamethasone dipropionate and betamethasone sodium phosphate; Bu, bupivacaine; D, dexamethasone; EC, ethyl chloride; L, lidocaine; M, mepivacaine; MA, methylprednisolone acetate; R, ropivacaine; TA, triamcinolone acetonide; TH, triamcinolone hexacetonide.

The respondents were divided into groups by years in practice and geographic distribution. Although scattered statistically significant differences exist, they do not follow any overarching trends other than that practitioners with more than 15 years in practice were less likely to use lidocaine than those with fewer than 7 years of experience (P<.05).

American Society for Surgery of the Hand members gave significantly smaller adjusted doses than ASES members in the glenohumeral joint (ASSH mean, 13.31 mg; ASES mean, 21.86 mg; P=.04) and acromioclavicular joint (ASSH mean, 10.85 mg; ASES mean, 15.99 mg; P=.02). For lateral epicondylitis (ASSH mean, 11.60 mg; ASES mean, 12.64 mg; P=.57) and subacromial space (ASSH mean, 16.58 mg; ASES mean, 20.53 mg; P=.09) injections, no significant difference was noted (Table 5).

Mean Potency-adjusted Dose

Table 5: Mean Potency-adjusted Dose

Table 6 lists the respondents’ rationale for their injection practices. Educated and experienced “word of mouth” (combining “learned in fellowship,” “what colleagues use/advise,” and “learned in residency”) accounted for the rationale in 78% of ASSH respondents and 52% of ASES respondents.

Rationale for Steroid Injection Practice

Table 6: Rationale for Steroid Injection Practice

Discussion

This study shows great variability among members of ASSH and ASES in their injection practices for the upper extremity. For trigger finger injections alone, steroid doses span a 356-fold difference. Excluding outliers, even the range of most common doses spans an 8-fold difference. One explanation may be the type of steroid used; the results show significant differences between steroid types in the amount used. Each steroid formulation has a different relative potency; some physicians may be unaware of this and incorrectly assume that the same volume of different steroids provides equivalent doses.

The tremendous variability in dosing reveals the dearth of established standards for the various upper-extremity injections. Efforts have been made to determine optimal dosing for trigger finger injections. Two prospective studies, 1 of which was randomized, double-blind, and controlled,11 showed that 20 mg of methylprednisolone acetate was effective.12 Using the current study’s conversion factor to account for its relative potency (Table 3), the amount of steroid delivered in both studies would have been 5 adjusted milligrams. Comparing this with the doses used in the current study study, 204 (32% of the 633 who specified a dose) respondents used this dose, 178 (28%) used double the effective dose, and 60 (9%) used 3 or more times the effective dose.

With the knowledge that an average hand surgeon injects 50 trigger fingers per year and that 1036 members of the ASSH (37% of approximately 2800 current members) use more than twice this effective dose, by calculating the average cost of 1 adjusted milligram of steroid ($1.11 based on packaging from Henry Schein Inc (Indianapolis, Indiana), McGuff Company Inc (Santa Ana, California), and Moore Medical (Farmington, Connecticut), and assuming 5 adjusted milligrams ($5.54) is an effective dose for a trigger finger injection, it can be determined that $356,776 is spent unnecessarily each year. With increasing focus on health care expenditures, this may be one area where we can save.

That ASSH respondents with hand surgery training administer a lower potency-adjusted steroid dose for glenohumeral and acromioclavicular joint injections than ASES respondents with shoulder surgery training highlights the potential influence of clinical opinion over scientific reason. If their injection practices were based on scientific evidence, both groups would use comparable techniques. One limitation of the current study is that the distribution lists for each society were not cross-referenced to account for physicians with dual membership; however, if many physicians responded from both societies, one would expect the results between societies to be more similar rather than showing significant differences.

Twelve percent of ASSH respondents and 11% of ASES respondents listed avoiding specific risks as their rationale for their injection practices. As we continue to establish standard recommendations for steroid injections, we may consider the following risk factors.

Neurotoxicity

Mackinnon et al13 revealed that in rats, intra-fascicular injections of hydrocortisone and triamcinolone hexacetonide produced severe damage, methylprednisolone acetate and triamcinolone acetonide produced moderate damage, and dexamethasone sodium phosphate produced minimal damage. Despite these findings, the current study found that, for carpal tunnel injections where intrafascicular nerve injection is possible, of 665 respondents 13 (2%) use steroids (triamcinolone hexacetonide) that may cause severe damage to nerves, 347 (52%) use steroids (methylprednisolone acetate+triamcinolone acetonide) that may cause moderate damage, 73 (11%) use steroids (dexamethasone sodium phosphate) that may cause minimal damage, and 13 (2%) use no steroid in the carpal tunnel.

Chondrotoxicity of Local Anesthetics

Multiple studies have shown dose- and time-dependent chondrotoxicity of both 0.25% and 0.5% bupivacaine.13–16 In the current study, of the 624 respondents who perform finger joint (intra-articular) injections, 44 (7%) use 0.5% and 21 (3%) use 0.25% bupivacaine. Of 425 respondents who perform glenohumeral joint injections, 41 (9.6%) use 0.5% and 21 (4.9%) use 0.25% bupivacaine.

Concern has also been raised about the dose- and time-dependent chondrotoxic effects of intra-articular lidocaine.17 Of 624 respondents in the current study who administer finger joint injections, 63 (10%) use 2%, 396 (63%) use 1%, and 11 (1.8%) use 0.5% lidocaine. Of 425 respondents who perform glenohumeral joint injections, 37 (8.7%), 229 (54%), and 2 (0.5%) use 2%, 1%, and 0.5% lidocaine, respectively.

Taken together, 83% and 77% of respondents who perform finger and glenohumeral joint injections, respectively, use a local anesthetic concentration that has potential chondrotoxic effects (either 0.5% or 0.25% bupivacaine or 2% or 1% lidocaine). Of note, Dragoo et al18 counter with the claim that 0.25% bupivacaine and 1% lidocaine do not cause significant chondrocyte death. Therefore, the safety of lower doses remains unclear, but evidence exists to suggest using them cautiously.

Chondrotoxicity of Steroids

Several studies have demonstrated chondrotoxicity of betamethasone sodium phosphate, betamethasone acetate, and triamcinolone acetonide.19–21 In the current study, of 624 respondents from the ASSH who perform finger joint (intra-articular) injections, 434 (69.6%) use an agent that may be chondrotoxic (194 [31.1%] beta-methasone acetate+240 [38.5%] triamcinolone acetonide). Fifty-three (8%) use dexamethasone sodium phosphate, which may be safe for intra-articular use.20 Of the 425 respondents from the ASSH and ASES who inject the glenohumeral joint, 247 (58%) use potentially chondrotoxic steroids (96 [23%] betamethasone acetate+151 [36%] triamcinolone acetonide). Thirty-three (8%) use dexamethasone sodium phosphate.

Soft Tissue Depigmentation or Fat Atrophy

The pathogenesis of depigmentation and fat atrophy at the site of steroid injection is unknown; however, more water-soluble steroid formulations are thought to be less likely to cause such adverse effects.22–24 For a soft tissue injection (eg, De Quervain’s tenosynovitis), 75 (11%) of those surveyed used dexamethasone sodium phosphate, a soluble steroid. Triamcinolone acetonide, a relatively insoluble steroid that would theoretically have a greater chance of causing soft tissue depigmentation or fat atrophy, was used by 237 (35%) respondents.24

Conclusion

This study shows significant variability in the steroid injection practices of upper-extremity surgeons that is based more on clinical opinion than scientific evidence. This suggests the need for clinical studies to determine the optimal effective type and dose of steroid for various injections. This analysis could have significant cost-saving and risk-reducing implications while maximizing the effectiveness of these treatments.

References

  1. Hill JJ, Trapp RG, Colliver JA. Survey on the use of corticosteroid injections by orthopedists. Contemp Ortho. 1989; 18:39–45.
  2. Cole BJ, Schumacher HR. Injectable corticosteroids in modern practice. J Am Acad Orthop Surg. 2005; 13:37–46.
  3. Centeno LM, Moore ME. Preferred intraarticular corticosteroids and associated practice: a survey of members of the American College of Rheumatology. Arthritis Care Res. 1994; 7:151–155. doi:10.1002/art.1790070309 [CrossRef]
  4. Skedros JG, Hunt KJ, Pitts TC. Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians. BMC Musculoskelet Disord. 2007; 8:63–76. doi:10.1186/1471-2474-8-63 [CrossRef]
  5. Noerdlinger MA, Fadale PD. The role of injectable corticosteroids in orthopedics. Orthhopedics. 2001; 24(4):400–405.
  6. Drug Facts and Comparisons. St Louis, MO: Wolters Kluwer Health; 2007:434.
  7. Tassiulas I, Wilder RL, Boumpas DT. Corticosteroids. In: Koopman WJ, Moreland LW, eds. Arthritis and Allied Conditions: A Textbook of Rheumatology. 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:755–774.
  8. Chrousos GP. Adrenocorticosteroids and adrenocortical agonists. In: Katzung BG, Masters SB, Trevor AJ, eds. Basic and Clinical Pharmacology. 12th ed. New York, NY: McGraw Hill; 2012:697–714.
  9. Gray RG, Gottlieb NL. Intra-articular corticosteroids. An updated assessment. Clin Orthop Relat Res. 1983; 177:235–263.
  10. Axelrod L. Glucocorticoid therapy. Medicine (Baltimore). 1976; 55:39–65. doi:10.1097/00005792-197601000-00003 [CrossRef]
  11. Lambert MA, Morton RJ, Sloan JP. Controlled study of the use of local steroid injection in the treatment of trigger finger and thumb. J Hand Surg. 1992; 17:69–70.
  12. Anderson B, Kaye S. Treatment of flexor tenosynovitis of the hand (‘trigger finger’) with corticosteroids: a prospective study of the response to local injection. Arch Intern Med. 1991; 151:153–156. doi:10.1001/archinte.1991.00400010155024 [CrossRef]
  13. Mackinnon SE, Hudson AR, Gentili F, Kline DG, Hunter D. Peripheral nerve injection injury with steroid agents. Plast Reconstr Surg. 1982; 69:482–489. doi:10.1097/00006534-198203000-00014 [CrossRef]
  14. Chu CR, Izzo NJ, Coyle CH, Papas NE, Logar A. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg Br. 2008; 90:814–820.
  15. Chu CR, Izzo NJ, Papas NE, Fu FH. In vitro exposure to 0.5% bupivacaine is cytotoxic to bovine articular chondrocytes. Arthroscopy. 2006; 22:693–699. doi:10.1016/j.arthro.2006.05.006 [CrossRef]
  16. Chu CR, Coyle CH, Chu CT, et al. In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. 2010; 92:599–608. doi:10.2106/JBJS.I.00425 [CrossRef]
  17. Karpie JC, Chu CR. Lidocaine exhibits dose- and time-dependent cytotoxic effects on bovine articular chondrocytes in vitro. Am J Sports Med. 2007; 35:1621–1627. doi:10.1177/0363546507304719 [CrossRef]
  18. Dragoo JL, Korotkova T, Kim HJ, Jagadish A. Chondrotoxicity of low pH, epinephrine and preservatives found in local anesthetics containing epinephrine. Am J Sports Med. 2010; 38:1154–1159. doi:10.1177/0363546509359680 [CrossRef]
  19. Braun HJ, Wilcox-Fogel N, Kim HJ, Pouliot MA, Harris AHS, Dragoo JL. The effect of local anesthetic and corticosteroid combinations on chondrocyte viability. Knee Surg Sports Traumatol Arthrosc. 2012; 20:1689–1695. doi:10.1007/s00167-011-1728-1 [CrossRef]
  20. Dragoo JL, Danial CM, Braun HJ, Pouliot MA, Kim HJ. The chondrotoxicity of single-dose corticosteroids. Knee Surg Sports Traumatol Arthrosc. 2012; 20:1809–1814. doi:10.1007/s00167-011-1820-6 [CrossRef]
  21. Syed HM, Green L, Bianski B, Jobe CM, Wongworawat MD. Bupivacaine and triamcinolone may be toxic to human chondrocytes. Clin Orthop Relat Res. 2011; (469):2941–2947. doi:10.1007/s11999-011-1834-x [CrossRef]
  22. DiStefano V, Nixon JE. Steroid-induced skin changes following local injection. Clin Orthop Relat Res. 1972; (87):254–256.
  23. Louis DS, Hankin FM, Eckenrode JF. Cutaneous atrophy after corticosteroid injection. Am Fam Physician. 1986; 33:183–186.
  24. Fadale PD, Wiggins ME. Corticosteroid injections: their use and abuse. J Am Acad Orthop Surg. 1994; 2:133–140.

ASSH Respondent Demographics

DemographicNo. (%)
Experience in practice, ya
  Fellow17 (2.8)
  1–5131 (21.5)
  6–1070 (11.5)
  11–20178 (29.2)
  21–30133 (21.8)
  >3080 (13.1)
Indication
  Trigger finger703 (97)
  Carpal tunnel syndrome655 (91)
  De Quervain’s tenosynovitis683 (95)
  Finger joint624 (86)
  Lateral epicondylitis611 (85)
  Subacromial space407 (56.4)
  Glenohumeral joint350 (49)
  Acromioclavicular joint360 (50)
Region of practicea
  South United Statesb165 (27.5)
  Northeast United Statesc151 (25.2)
  West United Statesd131 (21.9)
  Midwest United Statese103 (17.2)
  Canada16 (2.7)
  Europe14 (2.3)
  Asia10 (1.7)
  South America4 (0.7)
  Puerto Rico5 (0.5)
  Mexico2 (0.3)

ASES Respondent Demographics

DemographicNo. (%)
Experience in practice, ya
  Fellow0 (0)
  1–52 (2)
  6–1012 (14)
  11–2021 (25)
  21–3028 (33)
  >3021 (25)
Indication
  Lateral epicondylitis70 (78)
  Subacromial space88 (98)
  Glenohumeral joint75 (83)
  Acromioclavicular joint87 (90)
Region of practicea
  South United Statesb16 (20)
  Northeast United Statesc16 (20)
  West United Statesd16 (20)
  Midwest United Statese14 (18)
  Canada2 (3)
  Europe8 (10)
  Asia6 (8)
  South America1 (1)
  Puerto Rico0 (0)
  Mexico1 (1)

Total Volumes Injecteda

IndicationASSHASES


Most Common Vol (Range), ccNo. Injecting Most Common Vol, n/Nb (%)Most Common Vol (Range), ccNo. Injecting Most Common Vol, n/Nb (%)
Trigger finger1 (0.5–6)228/655 (35)NANA
Carpal tunnel syndrome2 (0.5–10)212/588 (36)NANA
De Quervain’s tenosynovitis2 (0.5–7)215/639 (34)NANA
Finger joint1 (0.5–5.5)202/570 (35)NANA
Lateral epicondylitis2 (0.5–10)195/574 (34)2 (1–12)19/60 (32)
Subacromial space10 (0.5–15)67/383 (17)10 (2–15)16/78 (21)
Glenohumeral joint10 (0.5–16)51/332 (15)10 (2–15)12/64 (19)
Acromioclavicular joint2 (0.5–12)129/339 (38)2 (0.75–8)21/70 (30)

Steroid Medication Potency Equivalence4–10

MedicationEquivalent Dose, mgaAnti-inflammatory Potencyb
Triamcinolone acetonide (Kenalog)c45
Triamcinolone hexacetonide (Aristospan)d45
Betamethasone sodium phosphate & betamethasone acetate (Celestone Soluspan)e,f0.6 (alternatively reported 0.75)g20–40 (variably reported)
Methylprednisolone acetate (Depo-Medrol)h45
Dexamethasone sodium phosphate (Decadron)f,h0.7520–30 (variably reported)

Mean Potency-adjusted Dose

Medicationmg
TFCTSDQTFJLESAGHAC
Betamethasone (B)12.83±0.74a16.76±0.95a14.33±0.83a11.60±0.76a16.09±0.92a25.29±1.77a,*26.56±2.17a17.24±1.66a,*
Dexamethasone (D)15.42±1.36a20.37±1.65a19.72±1.43b9.67±1.48a20.17±1.70b21.94±3.33a,b,*19.58±3.66a,b,c,*17.44±2.92a,*
Methylprednisolone acetate (MA)7.32±0.92b9.52±1.21b8.75±1.06c5.94±0.92b10.97±1.05c16.12±1.57b,c17.22±1.79b,*10.60±1.51b,*
Triamcinolone acetonide (TA)4.89±0.66c,*6.42±0.88c,*5.19±0.76d,*4.25±0.66b,*7.18±0.82d12.33±1.47c,*12.03±1.71c,*8.24±1.40b,*
Triamcinolone hexacetonide (TH)4.54±3.21b,c,*6.36±4.05b,c,*5.29±3.57c,d,*2.91±3.06b,*4.16±3.84c,d11.63±5.40b,c,*8.67±5.84b,c,*4.69±4.31b

Rationale for Steroid Injection Practice

Rationale for Steroid Injection PracticeNo. (%) of Respondents
ASSHASES
Learned in fellowship397 (55)23 (26)
What colleagues use/advise141 (20)21 (24)
No specific rationale117 (16)27 (31)
Habit/experience with successful results101 (14)12 (14)
Avoid specific complications85 (12)10 (11)
Journal article62 (9)8 (9)
Medication has specific duration/onset of relief37 (5)3 (3)
Price/availability of medication28 (4)3 (3)
Learned in residency18 (3)2 (2)
Volume of medication to fill space injected/minimum effective volume15 (2)2 (2)
Recommendations of medication package insert3 (0.4)1 (1.1)

10.3928/01477447-20130821-15

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