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INJECTION TECHNIQUES
IN MUSCULOSKELETAL MEDICINE
A PRACTICAL MANUAL FOR CLINICIANS IN PRIMARY AND SECONDARY CARE
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INJECTION TECHNIQUES
IN MUSCULOSKELETAL MEDICINE
A PRACTICAL MANUAL FOR CLINICIANS IN PRIMARY AND SECONDARY CARE
FIFTH EDITION
Stephanie Saunders,
FCSP, FSOM
Founder and Director, Orthopaedic Medicine Seminars, London, England
Steve Longworth,
MB, ChB, MSc (Sport and Ex Med), FRCGP,
FRACGP, DM-SMed DPCR, FSOM
General Practitioner, CY O’Connor Village Medical Centre, Piara Waters, Perth, Western Australia
,
Foreword by Jonathan Botting FRCGP
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2019
© 2019 Elsevier Ltd. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher. Details on
how to seek permission, further information about the Publisher’s permissions policies
and our arrangements with organizations, such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright
by the Publisher (other than as may be noted herein).
First edition 1997
Second edition 2002
Third edition 2006
Reprinted 2007, 2008, 2009
Fourth edition 2012
Fifth edition 2019
ISBN 978-0-7020-6957-4
Notices
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described
herein. Because of rapid advances in the medical sciences, in particular, independent
verification of diagnoses and drug dosages should be made. To the fullest extent of the
law, no responsibility is assumed by Elsevier, authors, editors or contributors for any
injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or
ideas contained in the material herein.
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THE DRUGS vviiii
Dedication
To Alan – with my thanks for his quiet patience during the writing of this
edition (despite having no idea what it was about), and to my family for
their amused tolerance.
SS
To Stephanie, who taught me such a lot, and to my patients, who taught
me even more.
SL
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vviiiiii CONTENTS
Acknowledgements
Thanks to the supportive team at Elsevier and to Ryan Probyn for baring his
body for the photos.
THE DRUGS iixx
Foreword
Stephanie Saunders helped me transform the care i give my patients; her
teaching continues to influence my everyday practice as a GP. We met on
her Orthopaedic Medicine course; i was a GP outnumbered by
physiotherapists. Outnumbered and out of my depth. Through her expert
teaching i have progressed from pupil to practitioner to teacher.
What she and Steve Longworth (a GP and musculo-skeletal expert) bring
to this book is their clarity and depth of thought combined with a
forensically detailed approach to diagnosis and treatment. This is delivered in
very easy to follow steps, laid out with great clarity which makes the book
both an effortless and intuitive source of reference.
Stephanie’s Orthopaedic Medicine course exposed my own inadequate
level of musculoskeletal knowledge gained in training as a doctor. My
experience as a GP and GP trainer has uncovered similar gaps in knowledge
in many of the doctors i meet.
This book should be considered a core reference in every GP practice,
and every physiotherapy, rheumatology and orthopaedic department. it
should also be considered an essential read for every trainee in those
specialties.
The opening chapters succinctly and clearly provide detailed references
for evidence based joint injection practice. Next the reader is introduced to a
logical, chapter structure based on anatomical location, each encompassing
how to diagnose specific conditions and how to treat them.
For physiotherapists extending their practice to incorporate injection
therapy this book is invaluable. For rheumatology and orthopaedic
departments this book provides an excellent guide to assessing and injecting
patients without the need for imaging. For GPs and for doctors in training
the book does all of the above, and in addition it introduces them to a
range of conditions not covered in most generic medical training.
Almost 30 years in GP practice has taught me how often colleagues and
trainees fit their patients and their symptoms to conditions that they are
familiar with. This book will not only give clinicians the skill to diagnose and
treat more with confidence but also to know when not to treat.
in writing this foreword i have come to realise that in our on-line world
where every fact is available at the touch of a button i have but three
reference books that never gather dust in my clinic. One is a photographic
atlas of anatomy (now sadly out of print), the second is the British National
Formulary (on-line but better in print) and the third is my copy of Injection
Techniques in Musculoskeletal Medicine. it is the last of these that deserves
the title of vade mecum.
Jonathan Botting, FRCGP
London
2018
xx CONTENTS
Preface
I have always found the process of diagnosis fascinating. It is somewhat like
doing a complicated crossword puzzle, where one is given faint clues and
hints. These may or may not assist in helping one to process waves of
superfluous information in order to arrive, hopefully, at a final answer – the
all-important diagnosis.
For me, this is always the most challenging and rewarding part of clinical
practice. Choice of treatment tends to be dictated by the diagnosis and the
clinician’s skills, so is slightly less challenging but, for successful injections,
correct diagnosis is the key, together with an intimate knowledge of
anatomy. The actual process of giving the injection is simple.
For this reason, we have added a section on diagnosis in this edition,
which is based on many years of experience in treating musculoskeletal
conditions. This experience not only taught us much about human
behaviour, but also enabled us to teach a method of diagnostic reasoning to
clinicians attending our injection therapy courses. We hope it will also aid
you.
For new readers, the purpose of this text is to provide a clear practical
manual on the basic principles of injection therapy, which can be easily used
in primary care and outpatient settings. It is not intended to be an academic
text with detailed discussion of alternatives to injection therapy, of which
there are many, so further reading is recommended.
In this edition, we have added more diagnostic guides, simplified some of
the instructions, re-shot the examination process, included boxed Practical
Points and updated references, which were current when we went to print
in 2018.
This is the fifth edition of our textbook, and we are grateful for the
success of previous editions. My final thank you is, as before, to the many
wonderful patients I was fortunate enough to encounter, to the questioning
students who kept me on my toes and, of course, to my co-author Steve
Longworth, whose enthusiasm for the subject has never waned – despite his
emigration to Australia!
Stephanie Saunders, FCSP, FSOM
Richmond, England
2018
THE DRUGS xxii
About the Authors
Stephanie Saunders, FCSP, FSOM, trained at St Thomas’ Hospital, London,
and joined the Orthopaedic Medicine team there, headed by Dr James
Cyriax. He became her mentor and, in 1977, invited her to lead a teaching
group on a lecture tour in Atlanta, Georgia. This led to many years of
teaching courses in orthopaedic medicine in the United Kingdom, United
States, Canada, Australia, South Africa and several European countries, in
between running a busy private practice in London.
She was the founding Vice-Chairman of the Society of Orthopaedic
Medicine (SOM) and, as Director of Teacher Training, instructed many
clinicians in how to teach these courses. She was also founding chair and
journal editor for the Association of Chartered Physiotherapists in
Orthopaedic Medicine. in 1995, she designed and led the first injection
therapy course for chartered physiotherapists in the United Kingdom and
has continued to promote this skill in connection with the Chartered Society
of Physiotherapy (CSP) and the Department of Health. Fellowship of the
CSP was awarded for her work in achieving injection rights for allied health
professionals in the UK.
As well as being the keynote speaker at several international meetings
worldwide, she has published many papers and clinical guidelines. Her
textbook, originally entitled Injection Techniques in Orthopaedic Medicine,
now entitled Injection Techniques in Musculoskeletal Medicine, was first
published in 1997 and is now in its fifth edition. On her recent retirement,
she is even busier with family, friends and travelling with her new husband.
Dr. Stephen Longworth, MSc (Sport and Exercise Medicine), FRCGP,
FRACGP, DM-SMed, DPCR, FSOM – graduated from the University of
Manchester in the United Kingdom in 1981 and was a full-time general
practitioner (GP) in Leicester for 30 years before moving to Western
Australia, where he has worked as a GP since 2015.
For 15 years, he also worked as a Specialist Doctor in the Orthopaedic
Spine Clinic at Leicester General Hospital for one session per week, having
previously worked there in the Shoulder Clinic. He was the first General
Practitioner with Special interest in Musculoskeletal Medicine in Leicester
and, for several years, was a musculoskeletal mentor to a number of other
GP practices in Leicester.
He has a Master’s degree in Sport and Exercise Medicine and diplomas in
Musculoskeletal Medicine and Primary Care Rheumatology. He is a past
president of the Primary Care Rheumatology Society and was a tutor and
examiner for the Diploma in Primary Care Rheumatology at the University
of Bath. He was a GP Trainer, appraiser and undergraduate tutor and has
served on more committees and boards than he cares to remember. He was
a Visiting Professor in the Department of Clinical Skills at St. George’s
University Medical School, Grenada, West indies, in the Caribbean.
