Steroid Injections- The Ortho PA Playbook

Steroid injections are one of the most common procedures in orthopedic practice—but they're also surrounded by myths, misconceptions, and a lot of patient questions.

In this episode, we're breaking down all of it. We tackle the questions patients ask every day, from "Will this hurt?" and "How long will it last?" to "How many injections can I get?" and "Will it damage my cartilage?"

Along the way, we discuss:

• How steroid injections actually work
• When they're appropriate—and when they're not
• Common side effects and how to counsel patients
• Cortisone flares, skin changes, and effects on blood sugar
• Timing injections around surgery
• Ultrasound-guided vs. landmark-guided injections
• Tips for setting realistic patient expectations
• Common myths we hear in clinic (and whether they're fact or fiction)

Whether you're a new orthopedic PA, a seasoned clinician looking to sharpen your patient education, or simply someone curious about corticosteroid injections, this episode is packed with practical pearls you can use in clinic the very next day.

Join us as we separate fact from fiction, answer the questions patients are thinking—but don't always ask—and help you become more confident when it's time to say, "Okay, little pinch!"

Transcript

SPEAKER_01 0:00

Welcome to Joint Effort PAs, where two orthopedic surgery PAs get real about life in medicine. From tips and tricks to professional growth, work-life balance, and everything in between. We're here to share what we've learned and what we're still figuring out. Let's get into it. We are back with a clinical topic, as promised.

SPEAKER_00 0:25

That's right.

SPEAKER_01 0:26

To uh to go between our fun and our seriousness. Well, we have to go both ways.

SPEAKER_00 0:32

It is serious. This is serious business. Well, I'll tell you, I had a lot of laughs after last week. I got a lot of good feedback after last week. Yeah. Well, I texted you a little bit of that.

SPEAKER_01 0:41

Yes, yes. I died when I saw that message. Yeah.

SPEAKER_00 0:45

Yeah. That's uh I know. Anyway, so uh we will we will continue to mix it up.

SPEAKER_01 0:51

I think this topic is like when I was thinking of things to do, I was like, this is so simple. And I feel like everybody probably thinks they know everything there is to know about it because it's something you just do all the time, but like maybe you don't. I don't know.

SPEAKER_00 1:05

Well, I think uh the difference in academic world versus in practical world, there's there's a lot, there's a lot of nuances. So um we're gonna talk about steroid injections. Yes, steroid. Administering them, thinking of administering them, administering them again, yeah.

SPEAKER_01 1:22

When not to, um, all of those things. So yeah, let's get into it. Well, how first off, how was how was your week? My week was great. Yeah.

SPEAKER_00 1:31

My week was great. I I was uh I want to say off, but like I definitely was not off. I was not in the office last week, out of office, but I did a lot of good things. I hired a medical assistant, I hired a PA, I hopefully found another PA. Um, but I also did a lot of fun things.

SPEAKER_01 1:49

That's exciting. Did you take any calls while on the beach under a blanket?

SPEAKER_00 1:52

Uh I timed them so that I was not on the beach, I was more in the clubhouse. And when everybody left the beach and I was left there standing in just my bathing suit on my phone, I was irate. Like literally irate. I had to do like the walk of shame back to the house.

SPEAKER_01 2:05

Do people like give you a hard time when you're they're like, oh, it's vacation, you're not working still.

SPEAKER_00 2:09

You know what's funny? You know, it's funny. So my husband does not work in medicine. He works in construction. And um, if you've been following, he's had quite quite a busy past couple weeks. He never, never brings work on vacation and scrutinizes me when I do. Um, and he worked every single day. Did he? Yes, just because he's got a situation where they hired a new guy and they fired a guy, so he's like, you know, taking on this other guy's department. So um he was on the phone all the time. And I didn't hate it. Like I was kind of like.

SPEAKER_01 2:39

Did you feel closer to him because of that? Like, wow, look at a little bit, a little bit. I really did.

SPEAKER_00 2:45

I was kind of like, I thought to myself, I'm like, wow, you get so mad at me when I take a phone call. But he was, it was like every day until almost 10 or 11, he was like working.

SPEAKER_01 2:54

That's awesome. Why why do I think that's awesome? I'll tell you what's awesome about it.

SPEAKER_00 2:58

Well, what's awesome about it is my sister came with us on vacation. My sister is me, so we woke up every day at five and then we went to the gym or running or took the dogs out, so we could do our thing in the morning, and I wasn't like taking away from time that I could have had because my husband was working. So by the time he was checked out and I was ready to go, it was beach time. I love that. Yeah, but it was good. How was your week? Did you hold down the fort here?

SPEAKER_01 3:18

Uh yes, yeah. It was a busy week. Um, but it was good overall, like a lot of case variety. Um, some big fracture cases, another thumb replacement. So how many of you guys done now? Oh gosh, we're at like eight now. Every week we're doing more and more and more. Um we actually did the first one this week where it was like a maybe maybe not situation because it was questionable and um ended up not doing it, but yeah, it was good, just a lot of variety. This week will be even busier. I think we're already scheduled for 22 cases of my gosh. Yeah, that's a lot. That's a lot. Yeah, it is a lot. And then my doc is out the entire week, the week following. So yeah, it'll be interesting, but I'm ready for it. I'm pumped, I'm thrilled. I have bought a lot of like double shot espresso in preparation. Um, and it's gonna be a great week. Can't wait.

SPEAKER_00 4:13

Um, do you guys have like the football rush when it hits August?

unknown 4:17

Uh yeah.

SPEAKER_00 4:18

Will you have that?

SPEAKER_01 4:18

Yeah, I mean, I feel like some years it's been worse than others. Last year, I really don't think we got hit with a lot of football injuries. We'll definitely get a few here and there.

SPEAKER_00 4:27

Burning question Will you cover any football?

SPEAKER_01 4:29

I was going to, and then I looked at the list. Now in the defense of everybody else, I might have taken like a week and a half to two before I actually pulled up the list that was sent out, but they had all already been this the school I typically cover was uh covered. So yeah, that's funny you say that.

SPEAKER_00 4:46

I looked at it yesterday and I was like, oh my god.

SPEAKER_01 4:49

Yeah.

SPEAKER_00 4:49

Yeah.

SPEAKER_01 4:50

So maybe, maybe not. We'll see. I covered a high school, you know, and I I like doing it.

SPEAKER_00 4:55

I mean, yeah, I don't know from the past. I don't mind doing it. I definitely have one, two, three, four. I had like seven last year, which was like it was a lot. I have about four this year, so uh that's five. I miscount it. Anyway, I'm here for it.

SPEAKER_01 5:07

Yeah, no, they're fun. I'm sure I'll end up uh filling in for one of them. I just don't like to go to the ones that are like really far away. Yeah, no, I hear you. It's not fun for me. So all right. What is fun for me are injections though. So we're doing injections.

SPEAKER_00 5:22

I know one of the main reasons that that I like ortho, and then when I have students or like have like new grads or whatever, like it's very procedure heavy. Yeah. And you even more so. You guys are splinting, casting, setting, yeah, taking pins out. Um, we do injections all the time. Yeah. Yeah. I think more so ten a day at least. Oh, at least. I think more so than like what academic world would suggest is normal. Yeah.

SPEAKER_01 5:45

Or appropriate.

SPEAKER_00 5:46

Well, no, I mean, I think just being in the specialty we're in, anti-inflammatories and steroid injections are like go-tos.

SPEAKER_01 5:54

Yeah. Yeah. Yeah. I mean, I really I probably use steroid injections significantly more than I use like prescribing oral anti-inflammatories. Oh, yeah. I don't really like to prescribe oral insects because one, when people come to see a specialist, they've probably already tried that.

SPEAKER_00 6:08

Yes, very true.

SPEAKER_01 6:09

And that's something that like maybe their PCP would have recommended and suggested. And I need to offer them something that's different and a little bit more aggressive by the time they get to us. Yeah. Um, and and we have the more nuanced options we can offer. So injections, steroid injections. There's multiple types of steroids. I feel like, you know, it's highly practice dependent, and then based on like what the docs you work with have used in their training, um, as far as the dose you use and the type of steroid you use, because I worked with some people in the past who use dexamethasone versus uh kenalog, which is primarily what we use here.

SPEAKER_00 6:45

Triamsinolone. Yeah.

SPEAKER_01 6:47

So um the difference between the two, so dexamethesone is water soluble, triamcinolone, kenalog are fat soluble. So um they linger around a little bit more, so longer lasting effect, um, but a little sometimes more of a side effect profile with kenalog and triamcinolone than DEXA. Um so yeah, we'll get into a little bit of that, but um injection-wise, so you probably do more steroids than anything else, right? You do you do HA.

SPEAKER_00 7:18

We do HA. We use steroid injections uh intraticular. So whether that is um knee, I I do them knee, I do them ankle, I do them CMC. I know you do, um, clino humoral AC joint. Yeah. Yeah. Um, and very, very effective for localized pain, especially if they have patients already tried the oral anti-inflammatories. Um different though than hyaluronic acid injections, different than PRP. Um, I will also use steroid in some of my nerve blocks. So whether I'm doing like a radial nerve block, yeah, radial nerve block, carpal tunnel um injection, or even a geniculate nerve block. So big fan of using just like a really low dose steroid in a nerve block, too.

SPEAKER_01 8:00

Do you still use triumcinolone for those or will you use DEXA for those?

SPEAKER_00 8:03

DEXA for my radials. Um yeah, I do triumcinolone for my carpal tunnels, although I've had a couple patients that that's blant or skin. So yeah, moving on.

SPEAKER_01 8:12

Yes, yes, that is one of the side effects with it. So, first off, what are our thoughts on steroid injections? Are they good? Are they bad? What do you say to a patient when they come in and they're like, let's say you're seeing them, because this is highly dependent on what you're treating, how you're gonna answer it. Um, NeoA. We'll start very simple. So they you offer them a steroid injection, they're like, Well, isn't that Beth, isn't that just gonna like mask my pain? Isn't this just a band-aid? Like, does it fix the problem?

SPEAKER_00 8:40

Yeah, let's do a whole segment on like the conversation surrounding the steroid. Patient comes in, their friend told them they need a steroid injection. They're kind of like ready to go, I'm here for my steroid injection. And then like they ask for it. And I love those visits because you're like pinpoint, you know what you want. You know what you want. But when you're taking the cap off the needle, they're like, wait, but I just had a steroid injection like last week in my back. Is it okay to have one today in my knee? But my friend said also like it kind of eats away my cartilage. So, like, do you think it does? Is the one you're gonna give me, is that gonna do that? Also, I'm diabetic and I'm not supposed to get an injection. And my A1C was eight last eight today when I woke up. Um, but anyway, or aren't you gonna use ultrasound to inject my knee with that steroid injection? So the conversation, right? So many things. I so many things. So when a patient comes in wanting a steroid injection, I will go through the whole, you know, what is a steroid injection and why we do it. Like how does it work, right? So, like an anti-inflammatory, it is, you know, our advils and our motions are NSAID non-steroidal. This is a steroidal anti-inflammatory. This is meant to decrease inflammation, let's say in your knee. Okay. It will not make your knee not arthritic. It is not going to reverse the pathology of your knee. It is literally meant to treat the inflammation from what you have. If you are not hurting today, I would not do a steroid injection just because you have arthritis. So when patients come in and they're like, I'm here for my steroid shop, but actually my knee feels fine today, I will discourage them from doing that. Yeah. Um, a very good example of when it is appropriate is someone overdid it working in the yard and their knee's like killing them. Perfect. Acute on chronic flare-up, perfect situation for a steroid. Um, someone who's about to go to Disney and walk like 20,000 steps when they're just walking 2,000, perfect, perfect for a steroid. Um, but I will have the conversation with, yes, we use these, we use them as infrequently, frequently as possible, right? So I like to space them out every 12 weeks. Um, if a patient is diabetic, I will alter the dosage. I will also educate them that it will throw their um their glucose into the 300s for a couple days. They definitely need to know that. Um, and then I'll get in the conversation about ultrasound, but I have a nice spiel about what it is, what it's not.

SPEAKER_01 10:53

For ultrasound specifically. Uh no, for steroids, just for steritic. Yeah, yeah. I tell patients, like in simple terms of, you know, oh, this is just gonna mask and cover up my pain versus um cure it.

SPEAKER_00 11:08

Yeah.

SPEAKER_01 11:08

For arthritis specifically, yes, you're right. Like what you're saying is absolutely 100% right. We are gonna mask and cover up the pain, but you're you have a degenerative condition that is not going to reverse itself. Um, you're not gonna regrow cartilage magically because we'll we just haven't gotten there yet, maybe one day. Um and so you are wanting something right now to feel pain relief, right? Like you're hurting, you want to be able to do the things you want to do, pain-free. So this is an option to get you there, to allow you to do those things. And yes, there are definitive options for it, like joint replacements. We can cross that bridge when we come to it. This is for you right now to feel better. So yeah.

SPEAKER_00 11:51

Now we're like, okay, but what about the band-aid? Like, you know, you've got the the CrossFit guy that is like, but it's just a band-aid. Yeah, I don't really want to do something that's not gonna fix my problem. Well, okay, let's launch into your shoulder. So you've got rotator cuff impingement, you clearly are still working out. Yeah, it bothers you sometime at nighttime and there's no weakness whatsoever. So in this case, that's I would maybe use a steroid injection to decrease the inflammation. Then also we pair that with, you know, posture correction, physical therapy, whatever, and we go from there.

SPEAKER_01 12:21

So that's an instance where I would tell them, like, this is a we can think of it more as a curative thing because we're not using it to just purely mask something. Right. This is a part of like the treatment algorithm to get you long-term pain-free because you don't have a massive tear that we're just covering up the pain from. Um, you have this like snowball effect inflammatory process, and you need to be able to tolerate the therapy and XYZ. So um, yeah, those are those are different scenarios. And so I think there is like a nuance of injecting people with arthritis for, you know, flare-ups.

SPEAKER_00 12:57

Acute on chronic.

SPEAKER_01 12:58

Yeah. Versus bursitis, impingement, teninopathies. Um, those are it's a different story.

SPEAKER_00 13:06

It was a different story. But I think you have to be you have to educate the patient. You have to be educated on where they are in the teninopathic cascade or or around the spectrum so that you know when to use it and when to stop using it. Yeah. Um, also for patients who have massive tears who don't want surgery, hey, can't I just do a steroid? That's also a different conversation. So some people, 85, non-dominant arm, never gonna have surgery on that arm. Sure. Yeah. We can do a steroid, but every time I see them, I'm like, just so you know, this is not fixing your tear at 85, it's probably contributing to it worsening. Yeah. But if we have made that decision that that is what we are doing, then that's that's what we'll do.

SPEAKER_01 13:47

But is that person going to be a good candidate regardless for a primary cuff repair?

SPEAKER_00 13:52

Oh no. So no, we've already made that choice.

SPEAKER_01 13:54

And you know, I'll tell them that too. I'm like, look, yeah, it might be worsening, but are you gonna have a primary cuff repair? Probably not. And like the success rate wouldn't be super high either. So at that point, it is a temporizing palliative thing until you send them to us. I know for reverse. Yeah. So, you know, yeah, yeah.

SPEAKER_00 14:15

Now, uh, so the steroid itself decreases the inflammatory response, right? So it interrupts the inflammatory cascade. When we administer a steroid by itself versus with um any local anesthetic, do you see that the patients have a different response? Do you always mix yours with local anesthetics?

SPEAKER_01 14:32

I never do it in isolation unless I'm like doing some sort of procedure where I'm pre-injecting lidocaine and then just the steroid afterwards. So there's still lidocaine in it. Like, for example, I have some patients that CMC injections are super painful. Yes. So some of them I'll pre-inject lidocaine, I'll like do a wheel over the skin and then go ahead and push some into the joint because like the joint expansion itself can be painful. So I'll give it like five minutes or so, and then I will just do plain steroid, but there's still a mix of lidocaine and with it. Yeah.

SPEAKER_00 15:08

Yeah. Um, now what is your spiel with how quickly it'll work?

SPEAKER_01 15:14

Um, depending on what I'm treating, I feel like usually an intra-articular or four, yeah, treating OA a couple of days. Yeah. Um, if it is something like trigger finger, carpal tunnel, I usually tell them up to two weeks because it may help with the pain more quickly, but to decrease the inflammation enough to notice the effects of like decreased locking or their finger being able to bend completely, that can take a couple of weeks.

SPEAKER_00 15:45

So local anesthetic immediately works on the nerves. Yeah. Uh, which is why we use that, it gets into the tissue faster better. Where corticosteroids don't. It takes hours or days or whatever. So mixing that together gives them the immediate pain relief. But what I will generally tell them is, oh, and this is mostly lidocaine plus a little bit of a steroid. The lidocaine is for the now, right? You may feel good now, but that will wear off, and then there's a little bit of time before that steroid kicks in. Um, but steroid injections turn off genes that make inflammatory proteins, turn on genes that suppress inflammation. So they work kind of at a different level.

SPEAKER_01 16:21

Yeah. So what do you tell people as far as like NSAIDs or like taking oral NSAIDs versus doing a steroid injection? I think an injection is safer most of the time.

SPEAKER_00 16:31

Yeah, I think the way less systemic effects, and not to say there's no systemic effects. Um steroid injections, when you administer them, they can cause a steroid flare. And if you're doing this 10 times a day, I don't want to speak for you, but I don't think you're educating patients 10 times a day that they may have these side effects, right? Um, it's the patients you don't tell that always get them.

SPEAKER_01 16:51

Yeah, they call back and they're like, oh my god, my heart's racing. Yeah, I'm dying.

SPEAKER_00 16:55

Yeah. So facial um flushing, a little bit of tachycardia, uh, insomnia, um, increased thirst. What is that? Polydipsia, is that what that's called? I don't know. I don't know. I'm doing a little bored thing right now. They're thirsty. They're thirsty. Um, but no, it will uh it will uh have those systemic side effects, and it's always the patients you don't tell that to that it happens to. Um, and very transient, like maybe for that night of, and then that's it, it will raise um your blood glucose for up to three days, 72 hours into the 300s.

SPEAKER_01 17:30

So, Beth, will the steroid injection make me fat?

SPEAKER_00 17:33

Oh, yeah, right. I don't want to gain any weight. So, no. Uh, and again, I'm asked that at least five times a week.

SPEAKER_01 17:41

Yeah.

SPEAKER_00 17:42

Yeah. So localized injections, no. It's not enough as a systemic effect to give you Addison's disease or anything like that. Yeah. Um, it will also treat other things. Like I had a guy I used to do knee injections for, and his psoriasis on his hands would clear up every time. So added benefit, right? Yeah, yeah. But also some patients are like, well, I'm on Eloquist and I can't take anti-inflammatories. I'm like, well, then this is the ticket for you. Yeah. Yeah. This is our only option. Or cumidon or whatever. Yeah. So some patients will come in and say, Well, I need clearance for my cardiologist. I'm like, okay, you do you. Like, I'm ready to go. Right.

SPEAKER_01 18:13

And that's what in those I do the same thing in those instances because I'm not like, I will educate people, like, hey, your cardiac condition or being on blood thinners does not preclude you from getting this. Like, I don't have a reason that me doing this would be wrong. Yeah. You're not going to bleed out from my 22 gauge needle, even though you're on Eliquis.

SPEAKER_00 18:31

Um, so what areas will you inject? Almost anything. I know, me too.

SPEAKER_01 18:37

I mean, like, so easily. Like a little steroid there. Especially if nobody else will do it. Like that makes me even more want to do it. It's like, oh, nobody else here wants to do that. I'm like, yeah. Okay.

SPEAKER_00 18:49

So CMC.

SPEAKER_01 18:51

CMC, yes, I do a ton of CMC injections. Love hate with it because people do really well with them. Yeah. Um, they can be super, super painful. And they're actually, I feel like they're pretty challenging to do out of all the intra-articular injections. Um, I do them blind typically. I just think it's easier for me to like the hands. I don't have the extra like fumbling the small space of the ultrasound. Um, and most of the time I can feel myself like pop into the joint and I can tell that I'm in there. But I do have a couple of patients that um maybe didn't get great relief with blind ones. And so I do ultrasound guided for them.

SPEAKER_00 19:30

But Hannah, mine didn't work. You didn't hit the right spot.

SPEAKER_01 19:34

Well, then I will do an ultrasound guide to be sure.

SPEAKER_00 19:37

But what if, okay, well, okay, we'll go with back to that. All right, so CMC yes, trigger finger, yes, and how many times?

SPEAKER_01 19:43

Yes, our typical algorithm is two, but that's not like a hard and fast no. I mean, it it it depends. All these things are so dependent. And that's why like it can be really hard to just give somebody an algorithmic approach of like this is what we do and and why. Um, so you've gotten two trigger finger injections in the past, but they've been spread out three years apart from each other. Like, like I'm gonna do a third one. Um, but like, is this clearly a recurrent issue that like you wouldn't even have to be dealing with getting these repeat injections if we just released it? Yes. Um, and then I will educate them as with like any tendon issue that there is some risk of tendon attritional wear with the steroid injections. Um, there's some studies out there that have shown like X number of trigger finger injections, like you hit beyond a certain threshold and increase risk of the tendon rupturing, which is bad.

SPEAKER_00 20:39

So that, yeah, so that trigger finger also biceps tendon, proximal biceps, tendon sheath. Love doing those injections, especially when you look do them under ultrasound and you see the tendon is just like swimming. But I will always tell the patient there's a risk of rupture here.

SPEAKER_01 20:52

So again, this is a hard sense because it does it, it doesn't matter.

SPEAKER_00 20:56

It doesn't matter. But if they if it happens, then they're like, oh my god, it ruptured, you need to fix it. If you don't have that conversation before, then you're screwed. Um, but having that conversation, and again, if it ruptures, problem solved, right?

SPEAKER_01 21:08

Exactly. Yeah, then now I've permanently fixed this. You're welcome.

SPEAKER_00 21:12

Yeah. Uh but those ones I will be a little bit careful with. I will do them, but I will definitely tell the patient, like, hey, listen, we can't just continue to repeat, repeat. Um, but very different conversation with subacromial injections like rotator cuff, those ones, very low risk of rupture. But if you are continuing to inject the subacromial space, there is an increased risk of infection or delayed healing postoperatively.

SPEAKER_01 21:34

Have you noticed when you're scoping somebody, like if somebody's gotten a shit ton of steroid injections, do you feel like the tendon looks shittier because of it? Or if you ever like see steroid material in your own. You will, yeah.

SPEAKER_00 21:46

Yeah, you will see a little bit of calcification from repeat steroid injections. But it's like it's more so that than the evidence of the tissue just being garbage. Okay. I think the tissue's garbage because it's garbage. And if we've injected it, I don't think that's the reason why it's garbage. Um I would think you'd see it more with your trigger fingers. Yeah. Um Glenny Hermal OA. I love injecting that one. Yeah. Just because very satisfying. Yeah, it's very satisfying. And same with same with AC joint. Yeah. Um, but on a pain scale, AC joint, oof.

SPEAKER_01 22:12

Yeah.

SPEAKER_00 22:12

It's always those guys that legit pass out. Yeah. They do. They just pass out. And like you're right there. Like you're right in their face. Yeah. Um least favorite one to inject? S C joint. S C joint. I do that though. Again, that's the one no one will do.

SPEAKER_01 22:28

It is the one no one will do. And I think I asked you the first time I ever did it, I asked you about it. I was like, ugh. Yeah. Yeah, I do it under ultrasound.

SPEAKER_00 22:36

Yeah. And you could see it very it's like A C joint. You can see it very well, but you're you're in the territory that you don't want to like twitch or you don't want to twitch.

SPEAKER_01 22:43

I don't know. Or subclevian. Yeah.

SPEAKER_00 22:46

Um the tennis elbow I've done way less of just because I I favor interarticular injections. Um again, with that one associated risk if you continue to inject that it's just going to essentially buy them a ticket to surgery.

SPEAKER_01 22:58

But yeah, my doc's uh SC joint has been very inflamed.

SPEAKER_00 23:03

He's like, well, say goodbye.

SPEAKER_01 23:05

Say goodbye to his V-Nex.

SPEAKER_00 23:07

Oh my god.

SPEAKER_01 23:08

It was like what was prominent. Um and I ultrasounded it, and I'm like, yeah, like it's clearly inflamed. Like, should we inject it? Like he was he like, absolutely not.

SPEAKER_00 23:19

Oh my god. But for some reason, SC joint, when they're inflamed, women cannot handle it. Cannot handle it. I think it's here's a sight of it. It's a sight of it, or they think it's a tumor. Now, will you titrate up or down based on effectiveness?

SPEAKER_01 23:34

Like for the steroid, like so yeah, let's get into like timeline.

SPEAKER_00 23:38

So you said with your trigger fingers you'll do them like twice and they have to be fairly far apart with NeoA injections. And this is your patient that has, you know, KL grade three plus. This is your 75-year-old, knows they need an ear placement, but I mean, honestly, he's doing okay and honestly doesn't want anything. Yeah. So every three-ish months. So I will tell them soonest I want you to come back, it's 12 weeks. I have some patients that count it out to the day, make their appointment. I have some patients that um they come in 12 weeks that they really needed it at eight weeks. So I will titrate up. We do a 40 milligram, at least our team does for standard. I will titrate up to 60 and the highest cell goes 80. We have some physicians that start at 80. Yeah. That's just what they give. Yeah.

SPEAKER_01 24:17

I have some patients that start at 20. Does that help them get longer?

SPEAKER_00 24:22

Yeah. I think it buys them a little bit more time. Um, but you know, it's always a conversation of what the last one didn't work. You didn't do it in the right place. Well, these also have a shelf life.

SPEAKER_01 24:33

Yeah.

SPEAKER_00 24:33

You know, um, I can't I can't make a chronic problem not chronic.

SPEAKER_01 24:39

Sometimes it's just going to be more effective than others. Like I've seen some patients that like for CMC arthritis, for example, I've injected them, you know, maybe six times at this point. And it goes the same way every time. I'm not doing anything different. I'm not like noticeably feeling like one of those was not correct. Um, and some just don't last as long as others. Yeah. So, you know, it happens. There are some times where like you know, you're like, not 100% sure if that was in the joint or not. Oh yeah. Yeah.

SPEAKER_00 25:11

And I'm like, I had one of I had one of those like two weeks ago. Um, and it happens the shoulder ones. I feel like because I do my my Glena humans under ultrasound, those ones I feel pretty good about. Like I can see it get in the capsule. I'm like, okay. Yeah. The knee injections, like I have one lady that is so valgus. We're talking like 45 to 60 degrees. I put her in a hinged knee brace because she's 85 and it straightens her out the most, but she replaces it every six months because she wears it out. And you still inject lateral for absolutely not. I injected medial, but I got to the point where I was like, oh dude, I don't even know if this is like Yeah, yeah. Um, yeah, there's there's a there's like a handful of those that I have.

SPEAKER_01 25:48

Yeah, those are those are a little bit disappointing for me because I know when they left, they're like, oh, thanks so much. I'm like fingers crossed. But will you use ultrasound anatomy-wise if you're questioning it?

SPEAKER_00 25:58

If I'm questioning it during like in your yeah, yeah.

SPEAKER_01 26:02

I mean, yeah, like I very rarely use it for CMC injections. I just feel like it's too bulky and it gets in the way. But it like rolls off also the probe is so I know you guys have a smaller probe, but the probe like rolls off of the yeah. I use it like in plane.

SPEAKER_00 26:16

I do too.

SPEAKER_01 26:17

And I would just want to like see the tip of the needle dipping down under the first metacarpal head. Yeah. And then I will chuck the ultrasound, not literally, I don't throw it across the room against the wall, but like I set it aside. I said that would be fun and dramatic. Um, I set it to the side gently as to not damage it. And uh then pull traction, pop through the joint, and do the injection. And hopefully remember to save the ultrasound images for billing. That's right. That's stuffy. You don't have 20 hands. Do you ever CMS is gonna audit me for this? Do you ever like take the picture after you've done the injection? Like you're like, oh, I forgot to save it.

SPEAKER_00 26:53

Like, absolutely.

SPEAKER_01 26:54

Just absolutely.

SPEAKER_00 26:55

Yeah. Just to say I was there. Yeah. Now, um, we talked a little bit about side effects, but the biggest one, at least for us, we do geniculate nerve blocks. And on most patients, their um medial inferior geniculate nerve, it's very superficial. Like you barely need a like a short 25 gauge needle to get down to the bone. I mean, there's on a lot of people, some people there's a big amount of fat, some people there's not. The fat atrophy that occurs in that area sometimes is like appalling. Dramatic. It's dramatic. Yeah. And it's always the females that just care.

SPEAKER_01 27:29

So those are like two of or one of the big two things that I will tell people is like side effects physically that they'll notice from a steroid injection um in certain areas. So, yeah, that area in the knee. Um, for me, it's the queer veins injections, very superficial. Yes, right there. And I use ultrasound for them so they can be in the tendon sheath to maybe decrease that a little bit, but people will still get it, especially um if they have a darker skin tone, it's gonna be more noticeable. And um, I was looking at it before this, like the incidence, and typically it does it takes a couple of weeks to months sometimes to notice the skin blanching, and it does typically resolve over the course of like six to nine months, sometimes a year, and then sometimes in rare cases, not at all.

SPEAKER_00 28:13

I know, and I've I've read like 18 months in some people, um, if if at all, right? Yeah, and that's just unfortunate. But I I've spent um, because I I manage, you know, other departments, I've spent time on the phone with this one patient, she's like 26 or something, and she got an intramuscular dexamethasone. Now, let's just talk about that for a second. It's an intramuscular injection.

SPEAKER_01 28:36

Or someone's intramuscular triumphin or no DEX.

SPEAKER_00 28:39

Okay, intramuscular dex for yeah, for like yeah, for acute like back pain or something. So she got an injection and upper outer glute, and she called back, she's like, There's a divot. I was like, that's like impossible. I mean, I didn't give the injection, so I'm like, okay, maybe it was possible. She's like, I can't live like this. Like, I need I need to know how to fix that. So we had her come actually, she didn't come to us, but she went to her dermatologist to do an HA injection in the fat.

SPEAKER_01 29:04

That's amazing. I would love to do that.

SPEAKER_00 29:06

I know. So I've had conversations with patients who all see it on their knees, and I'm like, okay, if and when we do your visco, let's save a little bit and throw it in the skin area. I've yet to do that and been like, wow, that works. Um, but something you can try that would be super low risk.

SPEAKER_01 29:19

Yeah, I wanted to at one point for um because sometimes for CMC injections, if like if you're not in the joint completely or if like some leaks out of the joint, especially if they've had like a bajillion of these, um, you can get a lot of uh fat atrophy and skin thinning around that area. I'm like, what if I just like inject some filler into it?

SPEAKER_00 29:41

Yeah, you could.

SPEAKER_01 29:41

You know? Yeah, you definitely could. Um, that'd be cool. So actually, I was at a point last year, was it last year? I was on this kick about hand filler. So you can inject filler into like your dorsum of the hand for when your hands look creepy and do people want that? Um, well, yeah, like the internet said that they did, and Chat GBD thought it would be a really good revenue stream for us, and I got super excited about it, and I was like gonna do a training on it, and it was super expensive. And then I talked to like first of all, it was awkward patient finding, because I would look at their old people hands and I was like, you know what? You know, yeah.

SPEAKER_00 30:21

Wait, do you think my hands look old?

SPEAKER_01 30:22

No, no, I mean 90% of people were like, Oh, yeah, that's really interesting. And then when I told them the cost, they were like, it's not that interesting. Because it it's like close to four grand to have both hands done. It's a lot. I mean, at that point, I'd rather get everything else done up here. So yeah, true, true, true.

SPEAKER_00 30:39

I was pointing at my face just now in case anybody was that's unfortunate. Um, and then diabetics, like diabetics I will use sparingly. Those that are really brittle, uncontrolled diabetics, I don't like giving them full dose steroid injections. Yeah. Or I will have them like have a backup plan or something or get clearance from their doctor or whatever. Yeah. Um, but I will have patients that'll say, no, it's fine. Like my knee's hurting so bad. I just want the regular dose because I know the half dose doesn't work as well. Okay. But the risks here, like I know you're on insulin, you have to adjust. And I had one guy who came back, he was like, Hey, so I almost went into DK. And I was like, wait, what? Like, but you but you you wanted it, you said it was okay. He goes, I know, but this this has happened a couple times before.

SPEAKER_01 31:19

I'm like, buddy, like yeah, like let's fast the next time before we do gonna kill you because I but I will have some patients that they will say that they're endocrinologists like we'll not let them have that. I mean, I guess I get it. I get I get it, yeah, you know, but they're they're they're in our back pocket, like they are very, very practical for us. And we talked last week about tennis elbow and using it for that and how we feel about that. So I don't belabor that. Um the hard nose, Achilles, yeah, patellar tendon, distal biceps, tendon, distal biceps, patellar tendon, yeah. Um planar fascia, did you ever do those energy care? Yes, I liken that to like a tennis elbow injection. High, no, I won't say high, but like there is more of a risk of rupture. Um, and you probably don't want to do a bajillion of those.

SPEAKER_00 32:09

I feel like though it but rupture your planar fascia, that's like literally the release. Yeah, yeah.

SPEAKER_01 32:13

So I feel like more like the biceps, I guess. It's into that. Yeah.

SPEAKER_00 32:17

I would think more with the plantar fascia, it's more like a needling procedure anyway. You know what I mean? Like, let me just micro needle this and see if I can fix it for you.

SPEAKER_01 32:24

And that's sometimes what we'll do for um for tennis elbow uh specifically is just like needle the out of it. Yeah, it's almost like an in-office 10x procedure, PRP without the PRP. Yeah. Um, from a billing standpoint, like tricky to figure out.

SPEAKER_00 32:40

Yeah, very tricky. Um, now perisurgical, perioperative use of steroid injections. So for knees or for joints, well, actually for rotator cuffs, we will make a patient wait six weeks from subacromial to rotator cuff repair because there is research that will show that they will not heal as well.

SPEAKER_01 32:57

You said six weeks?

SPEAKER_00 32:58

Six weeks, yeah. Sometimes eight, depending. Um interarticular knee injections, if they want to have a total knee replacement. I think across the board at our practice, the surgeons wait three months. Like there must be a three-month washout. Which kind of sucks because you know, if you're hurting and you want to have your knee done, you just have to sit there and hurt. We do use interarticular tordol injections. So there is some good research that shows that that is effective. Um, I don't think obviously they work as well, but I will have like a handful of patients every yeah that's like, oh my god, that works so much better for me. Yeah. Really?

SPEAKER_01 33:29

So yeah, I don't know. I mean, we actually won't even, for any intra-articular injection, even if it's tortol, do the total within three months of like any needle entering the joint. It's safe. I'll offer like uh nerve ablation procedures or i vera for those patients. So that's another option. Um, but yeah, three-month hard window for totals, everything else, um, as far as like surgical, yeah, like tenant issues, six to eight weeks typically.

SPEAKER_00 33:58

So do we love steroids?

SPEAKER_01 34:01

I I do because I feel like that is a large part of your practice as a PO. Like that is procedurally what you are doing. That's like your main revenue generator. Um that's your main like independent procedures that you can do. And it's fun. Maybe not for the patient always. That is true. Mostly for me, sometimes not for me.

SPEAKER_00 34:21

I think educating the patient though, as to what to expect, um, educating the patient why you're using ultrasound and why you're not, like for knees, sometimes like, why aren't you using ultrasound? Like, you know, fighting everything in my being to be like, I don't have to. Yeah. But um, like AC joint, I like to use it. Yeah. Um, interarticular elbow, I don't, intarticular knee, I don't. Um, CMC, I do, unless like I don't. Trigger fingers, I never do.

SPEAKER_01 34:46

Yeah, I was on a kick for a while where I was trying to use it because I was just, I don't know. I, you know, this was one project of me in my mind at the time, and I was like, I'm gonna use ultrasound for literally everything. Yeah. Um, and I don't know, it's just like it wasn't as easy. It's too cumbersome. There's enough room on the hand. And that lasted literally probably three clinics before I was like, F this. Like, I'm just gonna go back to doing it the way I was before. Carpal tunnel injections. Now I did, um, I had one patient not too long ago who got a carpal tunnel injection and outside practice. And from the way she describes her experience, it sounds like they probably hit her nerve. Yeah. Um, and said it was super painful and didn't work at all, and things felt like they got worse temporarily afterwards. So I did use ultrasound for her. More than anything, like I was fairly confident that I could do it blind without hitting her nerve, but because she had that experience, oh, I totally would have done ultrasound sound and then that way I can literally look at your nerve while I'm doing it and we will know that it's not in your nerve.

SPEAKER_00 35:47

Yeah. Also, you will not feel electricity.

SPEAKER_01 35:49

So yeah, it'll be amazing for you. Yeah. It was, she was like, wow, that didn't feel anything like the last one.

SPEAKER_00 35:55

I had a patient one time who said that the first several times she had a steroid injection in her knee, it hurt so bad. And when I did it, it didn't hurt. So she called back wanting another one because I couldn't possibly have done it right. Also, her knee didn't hurt anymore.

SPEAKER_01 36:10

Yeah.

SPEAKER_00 36:10

So she wanted me to comp her a steroid shop because it didn't hurt her enough. She still got the outcome she wanted, but the expectation was not there.

SPEAKER_01 36:17

So she wanted a free injection because it was better. Yeah. Because it worked and it didn't hurt.

SPEAKER_00 36:22

Yeah, it worked, it didn't hurt, but it could not have been done right, is what she said.

SPEAKER_01 36:25

Interesting. Yeah. Yeah. Those are the ones that I'm like, I want to understand.

SPEAKER_00 36:30

I want to understand, but what am I now? I'm trapped. If I refuse to, then I'm not satisfying the patient. If I do it again, now I'm putting way too much steroid in their knee. If I do it again, kind of, I put mostly lidocaine and a little bit of a steroid, it's a win-win, but I do it for free. Like what? But anyway, so steroids calm the fire. They don't rebuild the house.

SPEAKER_01 36:49

I like that. Right? What is the other one? There's another one. A good description of it.

SPEAKER_00 36:52

It's turning down the volume on inflammation, not fixing the broken speaker.

SPEAKER_01 36:57

Oh, okay. Interesting. Um, so yes, hopefully this is helpful as far as when to use them, when to not use them, and just you know, learn a little bit more about them.

SPEAKER_00 37:08

Yeah, don't be afraid of them. I think it was very scary. Like the steroid injection in a joint was like scary. You're taking a sterile environment, you're taking a steroid in there. I feel like when I got into practice, I'm like, huh, it's not that scary.

SPEAKER_01 37:19

It's not that scary. I mean, it know your anatomy and know your landmarks. And I mean, that's that's the gist of it. That's right. Um, yeah, I mean, obviously, it is a sterile procedure, so don't like you know, rub your arm against it before you do it and not clean it off or something. I don't know. That would be bad. That would be bad.

SPEAKER_00 37:44

That would be bad. Um, yeah. But very interesting. We should we should do one of these weeks talking about PRP. Just as a different. I mean, this this is not a comparative discussion today. We could have made it one, but I think PRP deserves its own time in the spotlight.

SPEAKER_01 37:59

It does. We do a lot of PRP and a lot more as of recent. So we should have some somebody uh who's has in-depth knowledge on biologics. We should. I wish we knew that person. Come join us for that. Um, so maybe, maybe not. We'll see if they're too busy for us. All right.

SPEAKER_00 38:17

Well, here's to here's to a good week this week.

SPEAKER_01 38:19

Yes, it's gonna be great.

SPEAKER_00 38:29

Thanks for tuning in to Joint Effort PAs. If you enjoyed this episode, be sure to subscribe, leave a review, and share it with a fellow PA or med minded friend. You can also follow us on Instagram at joint effortpas for updates and extra content. See you next time.