Your opinion on trigger point injections

[winterallsummer]

Hello,

 

I was wondering if some PAs would mind chiming in on their opinion on trigger point injections.

 

1. Do you do these in your practice, or do you wish you did?  Why or why not?

 

2. What is your opinion on what to inject?  Are ADRs from steroids and long term anesthetics a deal breaker for you?

 

3. Where did you learn to do these?

 

This was not addressed at all in my school but as I am previewing jobs, several places ask for PAs with experience for "trigger point injections."  I am reading up on these and seems like some controversy on this so was hoping for some real life opinions on the subject.

[EMEDPA]

I do these as well as shoulder joint injections. learned them on the job a few years out of school. in the er setting I don't use steroids for the trigger point injections(use straight marcaine 0.5%) but do for the shoulder injections(with kenalog + anesthetic). .

there is a good discussion of how to do these in Essentials of musculoskeletal care, a must have text if you do procedural ortho stuff at all.

[rev ronin]

1. Yes, I do therm.

 

2. It really depends on what you're trying to do.  For straight muscle injections, just anesthetic.  For joints, anesthetic plus steroid.

 

3. I got taught OJT in my first job.  I now do a couple a week in family practice.

[True Anomaly]

I've done it only once- only marcaine/lidocaine into the SCM- was taught to do so by my ER director who is one of the main editors of "Roberts and Hedges".  

[mdebord]

I do them; learned from colleagues (PA and physician alike) on the job.  I use marcaine and Depo (3:1 ratio) for muscular, more steroid for joints.  In addition to my limited anecdotal evidence that they do work, there are a few other reasons to do them.  We're always being pushed to bring in more procedural dollars, for one.  Also, I've found that it's a good alternative in patients that are begging me to refill their narcotics.  

[rev ronin]

I do them; learned from colleagues (PA and physician alike) on the job.  I use marcaine and Depo (3:1 ratio) for muscular, more steroid for joints.  In addition to my limited anecdotal evidence that they do work, there are a few other reasons to do them.  We're always being pushed to bring in more procedural dollars, for one.  Also, I've found that it's a good alternative in patients that are begging me to refill their narcotics.  

You don't mix any lido in with your marcaine and depo?  I was taught to do 'em that way for patient comfort.  Or do you inject lidocaine first, and THEN add the steroid and marcaine afterwards?

[primadonna22274]

I was trained to do them with 50:50 lido-marcaine mix. Easy and reasonably effective.

Funny thing though: I was going to inject one last Christmas break in the ED--this lady had miserable trapezius spasm with a rock-hard trigger point. After just 20-30 sec of myofascial release (probably the easiest osteopathic technique I know, literally you "rub out" the tender point until the tissue softens, basically the same thing your massage therapist does with those knots in your neck and back), the trigger point was GONE. So try the myofascial release first. If they can tolerate it, easy and quick and no risk of infection, allergic reaction to injected drug, etc.

[mdebord]

You don't mix any lido in with your marcaine and depo?  I was taught to do 'em that way for patient comfort.  Or do you inject lidocaine first, and THEN add the steroid and marcaine afterwards?

 

You are correct, sorry about the lack of clarity.  Lido first, then the mix.

[Acebecker]

I do them.  Some studies show equivocal improvement with lido/marcaine vs. dry needling.  the thought is that interruption of the pain/spasm cycle by providing another stimulus is really the important part.  I had one lady who cried out of sheer joy when I did a trigger point injection in her back because it was the first time she'd been pain free in years; I used a lidocaine/marcaine mix.  often I'll buffer it, too.  completely anecdotally successful and I'm always terrified of causing a PNTX.  but I will continue to do them and may do a trial of dry needling for trigger points in the future. 

[EMEDPA]

use a needle of appropriate length and there will be no concern for ptx, even if you go deep. 27g 1.5" works for most folks.

[Acebecker]

academically I understand that there's a lot of soft tissue to the chest wall and penetrating it would be quite difficult and that even *if* I went through with a 27g needle (which is what I always use) the likelihood of a pntx would still be nil, the misgiving is still present.  maybe a million trigger point injections under my belt will help.  let me just note that when I say "terrified" I don't mean literal terror or debilitating fear; I won't hesitate to do a trigger point when indicated.  I like to think of it as a (relatively) healthy respect for everything that can go wrong during a procedure. 

[Just Steve]

I am seeing all the providers use ultrasound for trigger points on the chest wall just to ensure a pneumo doesn't happen at the clinic I am working.  Joints all get US guidance as well. There are enough studies showing that even in the hands of "experts", joint injections are only about 50% accurate placement when doing it blind.  

[EMEDPA]

I am seeing all the providers use ultrasound for trigger points on the chest wall just to ensure a pneumo doesn't happen at the clinic I am working.  Joints all get US guidance as well. There are enough studies showing that even in the hands of "experts", joint injections are only about 50% accurate placement when doing it blind.  

PROBABLY SOME OF THIS IS FOR BILLING PURPOSES. U/S GUIDANCE = $$$

[meaux]

I too was taught OJT.  I do them them the same way everyone else here has said.  I would like to learn the U/S guided ones for sure, that is serious RVU.