What is the proper technique for administering cortisone (corticosteroid) injections for the treatment of tendonosis?

Proper Technique for Administering Corticosteroid Injections for Tendonosis

Corticosteroid injections for tendonosis should be used with caution as they may inhibit healing and reduce the tensile strength of the tendon tissue, potentially predisposing to spontaneous rupture. 1, 2

Indications and Contraindications

• Corticosteroid injections may provide more effective short-term relief than NSAIDs in the acute phase of tendon pain but do not alter long-term outcomes 1, 2
• Injections should be avoided in the Achilles, patellar, and quadriceps tendons due to high risk of tendon rupture 1, 3, 4
• Consider alternative treatments before injecting as recent evidence suggests corticosteroid injections may produce worse long-term outcomes compared to other treatments 5

Proper Injection Technique

• Use strict aseptic technique to prevent infection 6
• Shake the vial before use to ensure uniform suspension and inspect for clumping or granular appearance 6
• For tendon sheath injections:
  • Ensure injection is made into the tendon sheath rather than the tendon substance to avoid tissue damage 6
  • For epicondylitis (tennis elbow), infiltrate the preparation into the area of greatest tenderness 6

Dosage Guidelines

• Initial dose: 2.5 mg to 5 mg for smaller joints/tendons and 5 mg to 15 mg for larger joints/tendons 6
• For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas are usually sufficient 6
• Dosage requirements are variable and must be individualized based on the condition being treated and patient response 6

Administration Procedure

1. Position the patient appropriately to access the affected tendon
2. Clean the injection site with antiseptic solution
3. Consider using a local anesthetic prior to injection 6
4. Use the appropriate needle size (typically 25-gauge for smaller tendons, 22-gauge for larger tendons)
5. Insert the needle into the peritendinous area, avoiding direct injection into the tendon substance 1
6. Aspirate before injecting to ensure the needle is not in a blood vessel 6
7. Inject the medication slowly into the area of greatest tenderness 6
8. Apply pressure after withdrawing the needle to prevent bleeding

Post-Injection Care

• Rest the affected area for 24-48 hours after injection
• Apply ice for 10-minute periods through a wet towel to reduce post-injection pain 1
• Avoid activities that require repetitive tendon use for at least 2 weeks after injection 2
• Monitor for potential complications such as:
  • Local skin atrophy or depigmentation 7
  • Tendon weakening or rupture 3, 8
  • Post-injection flare (temporary increase in pain) 7

Important Cautions

• Limit the number of injections to minimize risk of tendon rupture - multiple injections increase this risk significantly 2, 8
• The average rupture time after the last injection has been reported to be approximately 11 weeks (range 3-32 weeks) 8
• Consider MRI to assess tendon integrity before injection in cases of chronic tendinopathy 8
• For epicondylitis (tennis elbow), corticosteroid injections may be worse than no intervention in the intermediate and long term 7

Alternative Approaches to Consider

• Physical therapy with eccentric exercises has proven beneficial for Achilles and patellar tendinosis 1
• NSAIDs (oral or topical) may provide adequate pain relief with fewer risks 1
• Orthotic devices can help unload the affected tendon during healing 1
• For persistent cases, newer options like sodium hyaluronate injections may offer better long-term outcomes than corticosteroids 7