So we use corticosteroids

14 April of 2008

So we use corticosteroids. We generally give them intraarticularly. And the patients very often do feel better, sometimes for quite a while. But, are there other ways to do it? Well, yes. This is from an article from down under by Sanbrook that looked at whether it matters that you inject into the joint. In fact others have found that we don’t always hit the joint when we try to aspirate and inject the knee. Even experienced rheumatologists, and yet you actually do have a better result if you get the cortisone in the joint. Sanbrook here says that the pain arises from structures besides those inside the knee, and half of his treated patients received a periarticular injection, like this around the patella, and the other half had intraarticular corticosteroid injections. After 12 weeks there was really quite a difference favoring this treatment. So now and then in a patient with knee pain, you might want to inject in a somewhat different route. Now, there are other reasons to aspirate and inject. In this particular gentleman who we wanted to send to physical therapy, removing the effusion can also improve his quadriceps strength, his quadriceps function temporarily which is inhibited by an effusion, and temporarily the corticosteroid may help him participate better in physical therapy.

There are other local therapies for local disease and had he been resistant about having an injection, we could go back to some that have been on the drug store counter for years, and some more that may be coming out, although all those rubs on the drug store counter are usually combinations of counter-irritants that produce local warmth and dilatation merely with … sometimes with some coolness as well. The salicylates that are there mainly to induce local warmth also can achieve therapeutic tissue levels, so Aspercreme produces aspirin levels in the joint, basically. Capsaicin – that’s been around for a long time before we started a test and marketed it. We found that in addition to warming the joint it also may deplete some of those type C fibers of neurotransmitters and thus reduce pain that way. We’ve seen some posters at this meeting about some of the prescription non-steroidal rubs that may soon be coming our way. Now if you want them you have to ask a compounding pharmacist to make them up for you. But they are a rather useful way of getting local therapy, local antiinflammatory effects without the systemic effect of these medications.

This particular fellow took his corticosteroid injection and then had an assessment by a therapist. Our biomechanical findings in this case are: fairly generalized weakness in the lower extremities. We looked at his quadriceps in this case, particularly palpated the VMO to look at its activity and timing. Looked at his hip extensors, because we are also thinking about his hip and abductors. He also showed tight hamstrings and extremely tight posterior calf musculature bilaterally. We also had some excessive lateral glide on his right patella during the extension. Our evaluation was: generalized lower extremity weakness and stiffness, knee flexion contracture and instability. He didn’t feel sure it would hold him up. VMO atrophy and pain with a little bit of swelling that we could determine, although he stated that it was much better and feeling stronger after his aspiration and injection. We consider that we must also be aware of his hip osteoarthritis and manage that simultaneously here. So our goal is to reduce knee and hip pain and improve function in his quality of life working on the farm as an independent farmer, and to reduce the risk of secondary illness and disability which often accrues when people have arthritis. In fact, arthritis in people over 50 is the major reason most people limit physical activity. About 12% of people over 60 say they are limited in their physical activity because of their arthritis. So we need to consider that in the gentleman as well.

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