CHAPTER 71 • COMMON INJECTIONS IN SPORTS MEDICINE: GENERAL PRINCIPLES AND SPECIFIC TECHNIQUES 429- Identify structure: Put the skin under traction and
identify anatomic landmarks. If needed the skin
can be marked with a fingernail, a retracted end of
a ballpoint pen, or ink. - Aseptic technique: Using nonsterile gloves the
area may be cleansed with alcohol, povidone, or
betadine. When entering a joint, a sterile prep is
recommended. - Local anesthesia: The practice of using a preinjec-
tion anesthetic varies among practitioners. Some
authors will only use local anesthesia when using
needles larger than 25 gauge. Prior to a joint prep
and injection, I will cleanse only with alcohol
swabs and use lidocaine to raise a wheal and numb
the tract I am planning to inject. In those cases
where I’m not going in a joint, I like to use an
assistant to give a quick spray of surface coolant
prior to my introduction of the injection needle.- Needle insertion: The needle should be an exten-
sion of the finger and inserted quickly and prefer-
ably perpendicular to the skin. When introducing
the agent, aspirate first to insure you are not in the
artery or vein. Aspirated contents should be sent
for appropriate analysis. The patient should also
not be complaining of paresthesias, which would
prompt needle repositioning.
TABLE 71-3 Relative Potencies and Solubilities of Corticosteroids
RELATIVE ANTI-
INFLAMMATORY EQUIVALENT CONCENTRATION
CORTICOSTEROID POTENCY DOSE (mg) SOLUBILITY (mg/mL)
Short-acting
Cortisone 0.8 25 NA 25, 50
Hydrocortisone 1 20 0.002 25
Intermediate-acting
Triamcinolone 5 4 0.0002 20
Hexacetonide
Methylprednisilone 5 4 0.001 20, 40, 80
Long-acting
Dexamethasone 25 0.6 0.01 4, 8
Sodium Phosphate
Betamethasone 25 0.6 NA 6
SOURCE: Genovese MC: Joint and soft tissue injection: A useful adjuvant to systemic and local treatment.
Postgrad Med103(2):125–134, 1998.
TABLE 71-4 Recommended Corticosteroid and Lidocaine Dosages for Injections
SITE OF DOSE OF 1% DOSE OF DOSE OF
INJECTION LIDOCAINE (mL) TRIAMCINOLONE (mg) BETAMETHASONE (mg)
DeQuervain’s 1–2 40 6
Carpal tunnel 0.5–1 40 6
Trigger finger 1 20 3
Tennis elbow 0.5–1 40 6
Subacromial space 6–8 40 6
Glenohumeral 6–8 40–60 6–9
Acromioclavicular 1–2 40 6
Plantar fascia 1–2 40 6
Anserine bursa 2–3 40 6
Trochanteric bursa 4–5 40–60 6–9
Intraarticular knee 4–6 40–60 6–9
Morton’s neuroma 1–2 20–40 3–6
Myofascial 1–2 NA NA
Iliotibial band 1–2 20–40 3–6
Ankle 2–3 40 6
SOURCE: Stankus SJ: Inflammation and the role of anti-inflammatory medications, in Lillegard WA, Butcher
JD, Rucker KS (eds.): Handbook of Sports Medicine, 2nd ed. Boston, MA, Butterwoth-Heineman, 1999.