Should the Epley's (canalith repositioning procedure) maneuver be performed before or after the left knee steroid (corticosteroid) injection?

Epley Maneuver Should Be Performed Before Knee Steroid Injection

The Epley maneuver should be performed before the left knee steroid injection to minimize the risk of falls and optimize patient safety.

Rationale for Sequence

Safety Considerations

• Performing the Epley maneuver first addresses the patient's vertigo before administering a procedure that may affect mobility
• Knee steroid injections with local anesthetic can temporarily affect proprioception and stability
• BPPV symptoms can cause sudden vertigo with position changes, which would be dangerous if occurring while walking with a freshly injected knee

Evidence-Based Support

• The clinical practice guideline for BPPV notes that canalith repositioning procedures (CRP) like the Epley maneuver have a success rate of up to 80% after a single treatment 1
• A Cochrane review confirms the Epley maneuver is a safe, effective treatment for posterior canal BPPV with no serious adverse effects 2
• Temporary sciatic nerve block has been reported as a potential side effect of intra-articular injections, which could further compromise balance and increase fall risk if vertigo is still present 1

Procedure Details

Epley Maneuver Protocol

1. Position patient sitting upright on examination table
2. Turn patient's head 45° toward the affected side
3. Quickly move patient from sitting to supine position with head hanging off edge of table, maintaining the 45° rotation
4. Hold this position for 30-60 seconds until vertigo and nystagmus subside
5. Turn head 90° to the opposite side (now 45° to the unaffected side)
6. Roll patient onto their side in the direction they are facing, maintaining head position
7. Return patient to sitting position 1

Post-Epley Considerations

• No postprocedural restrictions are necessary after CRP for posterior canal BPPV (strong recommendation against restrictions) 1
• The patient can immediately proceed to the knee injection without waiting period

Knee Injection Procedure

Preparation

• After completing the Epley maneuver, prepare for the knee injection using strict aseptic technique
• Use surgical gloves, skin preparation with alcohol, iodine disinfectant or chlorhexidine 3
• Consider offering local anesthetic, explaining pros and cons to the patient 1

Injection Technique

• Intra-articular glucocorticoid injections are strongly recommended for knee OA 1
• Use appropriate anatomical approach with aspiration of synovial fluid (if present) before injection 3
• Consider ultrasound guidance if available to improve accuracy 3

Post-Injection Care

• Advise patient to avoid overuse of the injected knee for 24 hours, but complete immobilization is discouraged 3
• Normal activity is recommended, but patients should be cautious about balance for the first few hours

Important Considerations

Potential Complications

• Monitor for transient hyperglycemia in diabetic patients for 1-3 days after steroid injection 1
• Local pain at the injection site is common and typically resolves within 24-48 hours 3
• Instruct patient to seek medical attention if experiencing severe pain that worsens after 48 hours, increasing redness, warmth, or swelling 3

Follow-up Recommendations

• Consider a 30-day follow-up to evaluate treatment response for both procedures
• If BPPV symptoms persist, a repeat Epley maneuver may be performed with success rates up to 84.5% after a second maneuver 4
• For knee OA, repeat injections may be considered based on response, but generally should be limited to 3-4 per year 3

By performing the Epley maneuver first, you address the patient's vertigo before introducing any potential balance or proprioception issues from the knee injection, creating the safest sequence for this patient requiring both procedures.