A Practical Guide to Injection Therapy in Hand Tendinopathies: A Systematic Review of Randomized Controlled Trials
Abstract
:1. Introduction
2. Materials and Methods
2.1. Search Strategy
2.2. Selection of Articles
2.3. Data Extraction
2.4. Quality Assessment
3. Results
3.1. Trigger Finger
3.1.1. Injection Technique
3.1.2. Needle
3.1.3. Drugs
3.1.4. Outcomes
3.1.5. Clinical Results
Article | Population Sample | Injection Technique | Experimental Group | Control Group | Follow-Up | Outcomes | Conclusions |
---|---|---|---|---|---|---|---|
Sato et al., 2012 [44] | N = 137 Trigger finger grade 2–4 on the Quinnell grading system. | - Injection into the osteofibrous canal. - At the level of the A1 pulley. | CS GROUP: injection of 2 mL of methylprednisolone acetate (40 mg/mL). Possible second infiltration one month later in case of failure of the procedure. | PERCUTANEOUS RELEASE GROUP: unlocking the A1 pulley with a 40 × 12 needle, using longitudinal movements in the direction of the axis of the flexor tendon. OPEN SURGERY GROUP: surgical incision of 2 cm transverse to the axis of the finger at the palmar skin fold, followed by a subcutaneous dissection and the longitudinal opening of the A1 pulley. | 1 and 2 weeks, and 1, 2, 4, and 6 months. | Cure (remission of the trigger for 6 months); relapse within 6 months; therapeutic failure with persistence of the trigger after surgical treatment or after the second injection; local pain following the procedure; joint pain at the IP joint of the thumb and at the PIP joint of the fingers; ROM (total active motion—TAM); complications. | Open and percutaneous interventions allow for a higher healing rate than CS infiltrations (100% vs. 57% after one CS infiltration and 86% after two CS infiltrations). On the other hand, infiltration is associated with less pain in the first month after the procedure. With regard to ROM, open surgery causes worse results in the first 4 months. |
Cecen et al., 2015 [39] | N = 74 | - Infiltration into the synovial sheath. - Just distal to the A1 pulley. - 26 G needle. | ULTRASOUND GUIDED INFILTRATION (Bodor and Flossman method) 40 mg/mL methylprednisolone. In case of failure of the procedure, a second infiltration was performed after one month. | NON-ULTRASOUND-GUIDED INFILTRATION 40 mg/mL methylprednisolone. In case of failure of the procedure, a second infiltration was performed after one month. | 6 weeks and 6 months. | Pain (VAS), Quinnell grading system (to evaluate relapses). | CS injection is recommended as the primary (valid, low cost, and low risk) treatment option for the trigger finger. The use of ultrasound guidance increases cost, time, and difficulty without clinical benefits compared to the blind technique. |
Yildirim et al., 2016 [43] | N = 40 Trigger finger grade 2 on the Quinnell grading system. | - Infiltration in the palmar side. - 45° needle inclination. - Distally inside the nodule near the A1 pulley. - 26 G needle. | CS GROUP: 0.5 mL betamethasone + 0.5 mL lidocaine 2%. Possible second infiltration after 3 months in case of persistence of symptoms. | ESWT GROUP: 3 sessions per week, 1000 pulses, energy 2.1 bar, frequency 15 Hz. | Baseline and 1, 3, and 6 months. | Pain (VAS), disability (q-DASH), Quinnell grading system (patient considered cured if equal to 0). | CS and ESWT have the same therapeutic efficacy, so ESWT may be a less invasive treatment option, particularly for patients who have contraindications to CS. |
Hansen et al., 2017 [45] | N = 165 Trigger finger grade >2 on the Quinnell grading system. | - Ultrasound-guided infiltration. - An injection inside the sheath with 1 mL of corticosteroid, and an injection outside the sheath with 1 mL of corticosteroid. - Close to the pulley A1. - Palm side. - 23 G needle. | CS GROUP: 1 mL triamcinolone acetonide (40 mg/mL) + 1 mL lidocaine (10 mg/mL). | OPEN SURGERY GROUP: surgical incision of 2 cm transverse to the axis of the finger at the palmar skin fold, followed by a subcutaneous dissection and the longitudinal opening of the A1 pulley. | Baseline and 3, and 12 months. | Trigger finger score (TFS), pain upon palpation, complications. | Open surgery is superior to ultrasound-guided CS injections. On the other hand, complications after open surgery are greater; CS injections therefore remain a good first-line treatment due to the low morbidity associated with the procedure. Furthermore, the injection does not preclude or prevent the patient from undergoing surgery later. |
Mardani-Kivi et al., 2018 [51] | N = 166 | - Ultrasound-guided infiltration. - Palmar side. - 30–45° needle inclination. - At the A1 pulley. - 26 G needle. - 40 mg/mL methylprednisolone acetate (1 mL) + 0.5 mL of 2% lidocaine. | INTRA-SHEATH GROUP: infiltration administered outside the tendon sheath. | EXTRA-SHEATH GROUP: infiltration administered inside the tendon sheath, with US views that confirmed tendon sheath distention. | Baseline, 3 and 6 weeks, and 3, 6, and 12 months. | Quinnell grading system. | No difference between ES and IS injection in terms of efficacy on the finger’s functionality. This conclusion implies the lack of necessity of US-guided injections, which increases cost, time, and labor. |
Kosiyatrakul et al., 2018 [52] | N = 120 Trigger finger grade II, IIIA, or IIIB based on Green’s classification. | - Injection into the flexor tendon sheath. - Palmar side. - 45° needle inclination. - At the A1 pulley. - 25 G needle. | 5 mg GROUP (A) vs. 10 mg GROUP (B) vs. 20 mg GROUP (C): (A): 0.5 mL of 10 mg/mL triamcinolone acetonide + 0.5 mL of 1% lidocaine. (B): triamcinolone acetonide 10 mg/mL without any dilution. (C): 0.5 mL of 40 mg/mL triamcinolone acetonide + 0.5 mL of 1% lidocaine. All patients received 1 mL of injected fluid. Before the injection, the skin and subcutaneous tissue were anesthetized with 2 mL of 1% lidocaine. | Baseline, 1, 2, and 6 weeks, and 3, 6, 9, and 12 months. | Pain and triggering of the finger. | There is an association between outcome and dosage of CS in the first 6 months. Triamcinolone acetonide 5 mg had a lower success rate during that period of time. Patients with single-digit involvement had a higher success rate. Only 2 patients complained of skin dryness and discoloration in the area of injection. | |
Jegal et al., 2019 [48] | N = 120 Trigger finger > 6 months unresponsive to conservative treatments (including CS injection). | - Injection through the operative site. - Palm side. - 26 G needle. | PERCUTANEOUS PULLEY RELEASE GROUP: percutaneous release of the A1 pulley with a specially designed hook-shaped knife. | PERCUTANEOUS RELEASE GROUP + CS INFILTRATION: injection of 0.5 mL of triamcinolone (40 mg/mL) at the end of the percutaneous release procedure. | Baseline, 3 weeks, and 3 months. | Pain (VAS), modified patient global impression of improvement (PGI-I), modified Quinnel grade. | Simultaneous steroid injection at the time of surgical release provides greater subjective improvement in the early period after percutaneous trigger finger release. |
Jimenez et al., 2020 [42] | N = 160 | - Palmar access: injection with the needle inclined at 45° at the level of the metacarpal head. - Dorsal access: injection with a 25 G needle, directing the needle towards the subcutaneous tissue at the level of the head of the metacarpal, in the dorsal radial or dorsal ulnar area depending on the case. | GROUP WITH PALMAR ACCESS: 1 mL of betamethasone 6 mg/mL + 1 mL mepivacaine 2%. | GROUP WITH DORSAL ACCESS: 1 mL of betamethasone 6 mg/mL + 1 mL mepivacaine 2%. | Baseline and 1, 3, and 12 months. | Pain (VAS) | The extra-sheath corticosteroid injection through the dorsal web space is less painful and at least as effective as the palmar midline technique. So, it should be considered in the initial treatment of the trigger finger and trigger thumb. |
Kosiyatrakul et al., 2021 [47] | N = 90 Trigger finger grades 1–3 of Green’s classification. | Digital block with anesthetic: - identification of the flexor tendon at the level of the metacarpal head. - injection into the subcutaneous space above the A1 pulley. - 30 G needle. CS infiltration: - injection into the flexor tendon sheath at the head of the metacarpal. - 25 G needle. | Subcutaneous single-injection digital block (SSIDB) with 2 mL of 1% lidocaine, before injecting 1 mL of 10 mg triamcinolone acetonide. | SSIDB with 1 mL of 1% lidocaine, before injecting 1 mL of 10 mg triamcinolone acetonide. CONTROL GROUP: application of an ethyl chloride spray on the skin at the level of the metacarpal head, before injecting 0.5 mL of 1% lidocaine and 0.5 mL of triamcinolone acetonide. | Post-procedure. | Pain during the procedure (VAS). | Single-injection subcutaneous digital block with 2 mL of 1% lidocaine was highly effective in reducing pain associated with CS injection for the trigger finger. |
Patrinely et al., 2021 [46] | N = 73 | - Injection at the A1 pulley level. - 27 G needle. | CS + ANESTHETIC GROUP: triamcinolone (1 mL, 40 mg) + 1% lidocaine with epinephrine (1 mL). | CS GROUP: triamcinolone (1 mL, 40 mg) + normal saline (1 mL, placebo). | Post-procedure. | Post-procedure pain (VAS with an image of the Wong–Baker Pain FACES Pain Rating Scale). | In treating trigger fingers, corticosteroid injections are effective and have relatively little associated pain. This study demonstrates that injection-associated pain is greater when lidocaine with epinephrine is combined with CS. Using CS is not only less painful but also more simple, effective, and safe. |
Tajik et al., 2022 [50] | N = 60 | - Injection at the A1 pulley level. - 29 G needle. | CS GROUP: a single injection of 40 mg/mL methylprednisolone + 0.5 mL of lidocaine. | CS GROUP + SPLINT: a single injection of 40 mg/mL methylprednisolone + 0.5 mL of lidocaine. Then, immobilization of the MCP joint with a static thermoplastic splint that blocks the MCP joint in a neutral position (24 h a day). | Baseline and 1 and 3 months. | Pain (NPRS) and functionality with grip strength (dynamometer), stages of stenosing tenosynovitis (SST), Boston questionnaire that includes symptom severity scale (SSS) and functional status scale (FSS). | The full-time wearing of a static MCP splint for 3 months immediately following a single CS + lidocaine injection increases and stabilizes the clinical benefits of CS treatment. |
Atthakomol et. al., 2023 [49] | N = 120 | - Injection into the flexor tendon sheath. | CS GROUP: 1 mL of 1% lidocaine without epinephrine and 1 mL of triamcinolone acetonide (10 mg/mL). SPLINT + CS GROUP | SPLINT GROUP: involved the patient wearing a fixed metacarpophalangeal joint orthosis in the neutral position at least 8 h per day for 6 consecutive weeks. | 6, 12, and 52 weeks after the intervention. | Pain (VAS) and Michigan Hand Outcomes Questionnaire (MHQ). | Splinting alone is recommended as the initial treatment for trigger finger because there were no clinically important differences between splinting and CS injection alone in terms of pain reduction and functional improvement of up to 1 year. The combination of CS injection and splinting is disadvantageous because the benefits in terms of pain reduction and functional improvement are not different from those achieved with CS injection or splinting alone. |
Article | Population Sample | Injection Technique | Experimental Group | Control Group | Follow-Up | Outcomes | Conclusions |
---|---|---|---|---|---|---|---|
Liu et al., 2015 [40] | N = 36 Trigger finger grade ≥ 1 on the Quinnell grading system. | - Ultrasound-guided infiltration. - Palmar access. - At the level of the A1 pulley. - Inside the sheath of the flexor tendons. - 25 G needle. - Needle inclination at 45°. | HA GROUP: 1 mL of HA. | CS GROUP: 1 mL of triamcinolone 10 mg/mL. | Baseline, 3 weeks, and 3 months. | Quinnell trigger finger scale, Michigan Hand Outcome Questionnaire (MHQ) scale, pain (VAS), total active movement (TAM) scale, grip strength (dynamometer). | HA had good therapeutic effects with effects similar to those of CS. MHQ scores continued to increase in the HA group and not in the CS group at the 3-month follow-up. HA therefore presents several advantages compared to CS: it induces a continuous specific functional improvement in the hand and reduces the risk of adverse events. |
Kanchanathepsak et al., 2020 [41] | N = 51 Trigger finger grade 1,2, or 3 on the Quinnell grading system with symptoms < 6 months. | - US-guided infiltration. - At the level of the A1 pulley. - From the palmar side. - 25 G needle. | HA GROUP: 1 mL LMW-HA (500–730 kD, 20 mg/2 mL). | CS GROUP: 1 mL di 10 mg/mL triamcinolone. | Baseline and 1, 3, and 6 months. | Pain (VAS) and disability (DASH). | HA and CS have a comparable therapeutic effect in the treatment of trigger fingers. However, CS injection has a faster effect in reducing pain and inflammation. |
3.2. De Quervain’s Tenosynovitis
3.2.1. Injection Technique
3.2.2. Needle
3.2.3. Drugs
3.2.4. Outcomes
3.2.5. Clinical Results
3.3. Potential Biases in the Review Process
Article | Sample | Injection Technique | Experimental Group | Control Group | Follow-Up | Outcomes | Conclusions |
---|---|---|---|---|---|---|---|
Hadianfard et al., 2013 [53] | N = 30 | - Infiltration 1 cm proximal to the radial styloid process. - Needle angled 30–45° from the skin. - The direction of the needle parallel to the direction of the tendons of the first extensor compartment. - 25 G needle. | CS GROUP: 1 infiltration with 1 mL methylprednisolone acetate + 1 mL lidocaine 2%. | ACUPUNCTURE GROUP: 5 sessions of 30 min. | Baseline and 2 and 6 weeks. | Disability (Q-DASH), pain (VAS). | Both treatments are effective, but CS has greater efficacy. |
Mardani-Kivi et al., 2014 [58] | N = 67 | - Infiltration in the first dorsal compartment in the area of maximum tenderness upon palpation. | CS + BRACE GROUP: 1 infiltration of 40 mg methylprednisolone acetate + 1 cc of lidocaine 2% + fiberglass brace for 3 weeks. | CS GROUP: 1 infiltration 40 mg of methylprednisolone acetate + 1 cc of lidocaine 2%. | Baseline, 3 weeks, and 6 months. | Disability (Q-DASH), pain (VAS). | The CS + brace association is more effective than CS alone. |
Akhtar et al., 2020 [57] | N = 134 | - Infiltration into the first extensor compartment. - 24 or 26 G needle. | CS + BRACE GROUP: 1 infiltration of 1 mL (10 mg) of triamcinolone acetonide and 1 mL of 1% lidocaine hydrochloride + thumb splint. | BRACE GROUP | Baseline and 2 and 6 weeks. | Disability (Q-DASH), pain (VAS). | The CS + brace association is more effective than the thumb brace alone. |
Shin et al., 2020 [55] | N = 48 | - Infiltration into the first extensor compartment. - 0.5 mL triamcinolone acetate 40 mg/mL -25 G needle. - The blind injection was performed with a volar approach perpendicular to the axis of the tendons of the first compartment. | US-GUIDED INJECTION GROUP | BLIND INJECTION GROUP | Baseline, 4 weeks, and 3 months. | Pain and disability (VAS, patient-rated wrist evaluation—PRWE). | CS gives good clinical results with no statistically significant difference between US-guided and blinded procedures. |
Ippolito et al., 2020 [59] | N = 26 | - Infiltration in the first dorsal compartment in the area of maximum tenderness upon palpation. - 25 G needle. | CS GROUP: 1 infiltration of 1 mL 40 mg of methylprednisolone acetate + 2 mL 2% lidocaine. | CS GROUP + BRACE for 3 weeks (can only be removed for bathing) | Baseline, 3 weeks, and 6 months | Disability (DASH), pain (VAS), Finkelstein test. | Both treatments are effective without statistically significant differences, but at 6 months, the brace could compromise the resolution of the radial side wrist pain. |
Jung et al., 2021 [56] | N = 48 | - US-guided infiltration (in-plane short axis) in the first compartment of the extensor tendons. - 25 G needle. - 0.5 mL of 2% lidocaine + 0.5 mL triamcinolone acetonide (40 mg/mL). TOTAL 1 mL | INFILTRATION GROUP OF THE 2 SUBCOMPARTMENTS: infiltration into subcompartments of the APL and EPB tendons. 0.5 mL in APL 0.5 mL in EPB | INFILTRATION GROUP OF 1 SUBCOMPARTMENT: infiltration of the EPB only. 0.5 mL in EPB | Baseline, 6 weeks, and 3 months. | Pain (VAS), complications. | Infiltration of only one subcompartment (EPB) in patients with de Quervain syndrome with a complete septum is as effective as infiltration of both subcompartments. Furthermore, a targeted injection into the EPB subcompartment alone may reduce the steroid dose used, potentially decreasing complications. |
Das et al., 2021 [61] | N = 60 | - Infiltration 1 cm proximal from the tip of the styloid process of the radius, into the first extensor compartment. - Needle angled 45° from the skin, parallel to the direction of the tendons. | BRACE GROUP: thermoplastic thumb abduction orthosis that keeps the wrist in a neutral position, and the thumb at 90° abduction and 15–20° extension. 20 h a day for one month. | CS GROUP: 1 infiltration of 1 mL (40 mg) of methylprednisolone acetate. | Baseline and 1, 3, and 6 months. | Disability (Q-DASH), pain (VAS). | CS has a higher improvement rate in patient symptoms, but the difference between CS and brace is small in long-term follow-ups. The brace is useful in patients at risk for side effects of CS use. |
Article | Sample | Injection Technique | Experimental Group | Control Group | Follow-Up | Outcomes | Conclusions |
---|---|---|---|---|---|---|---|
Suwannaphisit et al., 2022 [54] | N = 64 | 1 infiltration along the longitudinal axis of the tendons of the first extensor compartment, either just proximal or distal to the radial styloid, at the point of maximum pain. | CS GROUP: 1 mL triamcinolone acetonide 10 mg/mL + 0.5 mL 1% xylocaine with adrenaline. | NSAID GROUP: 1 mL ketorolac 30 mg/mL + 0.5 mL 1% lidocaine with adrenaline. | Baseline and 6 weeks. | Disability (Thai-DASH), pain (verbal-NRS), grip strength (dynamometer). | Triamcinolone performs better in all outcomes: - Complete resolution of symptoms at 6 months: triamcinolone in 90% of cases, ketorolac in 40% of cases. - DASH scores: on average, lower values (indicating better functionality) with triamcinolone. -Improved grip strength recovery with triamcinolone. |
Article | Sample | Injection Technique | Experimental Group | Control Group | Follow-Up | Outcomes | Conclusions |
---|---|---|---|---|---|---|---|
Orlandi et al., 2014 [60] | N = 75 | Ultrasound-guided infiltration of the 1st extensor compartment of the wrist. - A volar in-plane approach with the probe positioned transversally to the tendons of the first extensor compartment. - 22 G needle. | CS + HA GROUP: 1 infiltration of 1 mL methylprednisolone acetate + 1 infiltration after 15 days with LMW-HA (0.8%, 16 mg/2 mL). | CS GROUP: 1 infiltration with 1 mL methylprednisolone acetate 40 mg/mL. CS + SF GROUP: 1 infiltration of 1 mL methylprednisolone acetate + 1 infiltration after 15 days of 2 mL of 0.9% saline solution. | Baseline (US, VAS, q DASH), after 1 month (VAS, qDASH), and after 3 and 6 months (US, VAS, qDASH). | Pain (VAS), disability (qDASH), US evaluation, patient’s subjective outcome. | LMW-HA infiltration after CS infiltration improves all the outcomes (US, clinical, and subjective). |
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Conflicts of Interest
References
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Frizziero, A.; Maffulli, N.; Saglietti, C.; Sarti, E.; Bigliardi, D.; Costantino, C.; Demeco, A. A Practical Guide to Injection Therapy in Hand Tendinopathies: A Systematic Review of Randomized Controlled Trials. J. Funct. Morphol. Kinesiol. 2024, 9, 146. https://doi.org/10.3390/jfmk9030146
Frizziero A, Maffulli N, Saglietti C, Sarti E, Bigliardi D, Costantino C, Demeco A. A Practical Guide to Injection Therapy in Hand Tendinopathies: A Systematic Review of Randomized Controlled Trials. Journal of Functional Morphology and Kinesiology. 2024; 9(3):146. https://doi.org/10.3390/jfmk9030146
Chicago/Turabian StyleFrizziero, Antonio, Nicola Maffulli, Chiara Saglietti, Eugenio Sarti, Davide Bigliardi, Cosimo Costantino, and Andrea Demeco. 2024. "A Practical Guide to Injection Therapy in Hand Tendinopathies: A Systematic Review of Randomized Controlled Trials" Journal of Functional Morphology and Kinesiology 9, no. 3: 146. https://doi.org/10.3390/jfmk9030146