Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

Infiltrative Treatment of Morton's Neuroma: A Systematic Review

BACKGROUND

Morton's neuroma (MN) is one of the most frequent neurological pathologies in feet, affecting approximately 4% of the general population. The treatment of MN can be surgical, conservative, and infiltrative, with different substances used in the injections for MN, as steroids, sclerosing solutions, and others. This review aims to evaluate the efficacy of current infiltrative therapy for Morton's neuroma and, additionally, to define adverse effects of this therapy.

MATERIAL AND METHODS

A literature search was performed in PubMed, Embase, CINHAL, Epistemonikos, Web of Science (WOS), SPORTSDiscus and Cochrane Library. This search involved the application of all types of infiltrative treatment applicable to MN. The search was limited to original data describing clinical outcomes and pain using the Visual Analogue pain Scale (VAS) or the Johnson Satisfaction Scale, between February and June 2023.

RESULTS

Twelve manuscripts were selected (six randomized controlled trials and six longitudinal observational studies) involving 1,438 patients. Capsaicin was reported to produce a VAS score reduction of 51.8%. Corticosteroids also reported a high level of efficacy. Alcohol and Hyaluronic Acid injections are well tolerated, but the effects of their application need further research. There were no serious adverse events.

CONCLUSIONS

Corticosteroids, sclerosant injections, hyaluronic acid and capsaicin have been shown to be effective in reducing the pain related to MN.

Causal relationship between plasma metabolites and carpal tunnel syndrome risk: evidence from a mendelian randomization study

Background

Carpal tunnel syndrome (CTS) is a common symptom of nerve compression and a leading cause of pain and hand dysfunction. However, the underlying biological mechanisms are not fully understood. The aim of this study was to reveal the causal effect of circulating metabolites on susceptibility to CTS.

Methods

We employed various Mendelian randomization (MR) methods, including Inverse Variance Weighted, MR-Egger, Weighted Median, Simple Mode, and Weighted Model, to examine the association between 1,400 metabolites and the risk of developing CTS. We obtained Single-nucleotide polymorphisms (SNPs) associated with 1,400 metabolites from the Canadian Longitudinal Study on Aging (CLSA) cohort. CTS data was derived from the FinnGen consortium, which included 11,208 cases and 1,95,047 controls of European ancestry.

Results

The results of the two-sample MR study indicated an association between 77 metabolites (metabolite ratios) and CTS. After false discovery rate (FDR) correction, a strong causal association between glucuronate levels (odd ratio (OR) [95% CI]: 0.98 [0.97-0.99], p FDR = 0.002), adenosine 5'-monophosphate (AMP) to phosphate ratio (OR [95% CI]:0.58 [0.45-0.74], p FDR = 0.009), cysteinylglycine disulfide levels (OR [95% CI]: 0.85 [0.78-0.92], p FDR = 0.047) and CTS was finally identified.

Conclusion

In summary, the results of this study suggest that the identified glucuronate, the ratio of AMP to phosphate, and cysteinylglycine disulfide levels can be considered as metabolic biomarkers for CTS screening and prevention in future clinical practice, as well as candidate molecules for future mechanism exploration and drug target selection.

Surface anatomy in dermatology: Part II-Impact on perioperative management, procedural technique, and cosmesis

This CME series reviews updated Delphi consensus surface anatomy terminology through the lens of common medical and procedural dermatology scenarios, helping to underscore high-yield points that can be readily integrated into clinical practice to support patient care. Part I of the series reviewed the current state of standardized surface anatomy, provided an illustrative review of consensus terminology, highlighted prominent landmarks that can aid in critical diagnoses, and related the importance of precise terminology to principles of medical management. Part II will utilize consensus terminology to heighten recognition of key landmarks in procedural dermatology to support optimal functional and aesthetic outcomes.

Evidence for exercise therapy in patients with hand and wrist tendinopathy is limited: A systematic review

BACKGROUND

Several studies reported the efficacy of exercise therapy in hand and wrist tendinopathy. However, no systematic review synthesized the effect of exercise therapy on these patients.

PURPOSE

This study aimed to perform a systematic review to summarize evidence if exercise therapy may be considered an effective treatment in conservative management for patients with hand and wrist tendinopathy.

STUDY DESIGN

This was a systematic review.

METHODS

A literature search in MEDLINE, Cochrane Library, PEDro, and Embase was conducted from their inception until April 10, 2022. Two independent reviewers included the studies administering exercise therapy in patients with hand and/or wrist tendinopathy in the review and extrapolated the data. Methodological quality was assessed using the framework developed by Murad et al for case reports and case series and the PEDro score for clinical trials.

RESULTS

Seven case reports, 3 case series, and 2 randomized controlled studies were included and methodologically evaluated, obtaining a low score for all the analyzed studies. The total number of included patients in the analyzed studies was 106, of which 54 were female, 13 were male, and 39 were not specified. The type of exercise was widespread and often not really well described: it varies from eccentric forearm training to mobilization with movement, passing through strengthening exercises, grip proprioception training, and self-management exercises according to the McKenzie method. The dosage was often not precise, making it difficult to reproduce the therapeutic proposals. Exercise therapy was always administered together with different treatments; therefore, its efficacy alone is difficult to distinguish, although in some cases, the patients improved pain and functionality.

CONCLUSIONS

Evidence on the efficacy of exercise therapy in patients with hand and wrist tendinopathies is limited. Future research is strongly recommended to determine the appropriate dosage of the exercise therapy to determine clinical changes in these patients.

Association between hyperlipidemia and trigger finger: A nationwide population-based cohort study

The cause of trigger fingers remains uncertain. High lipid levels in the blood may reduce blood supply to the distal fingers and promote inflammation. We aimed to explore the association between hyperlipidemia and trigger finger. A nationwide population-based cohort study using longitudinal data from 2000 to 2013, 41,421 patients were included in the hyperlipidemia cohort and 82,842 age- and sex-matched patients were included in the control cohort. The mean age was 49.90 ± 14.73 years in the hyperlipidemia cohort and 49.79 ± 14.71 years in the control cohort. After adjusting for possible comorbidities, the hazard ratio of trigger finger in the hyperlipidemia cohort was 4.03 (95% confidence interval [CI], 3.57-4.55), with values of 4.59 (95% CI, 3.67-5.73) and 3.77 (95% CI, 3.26-4.36) among male and female patients, respectively. This large-scale population-based study demonstrated that hyperlipidemia is correlated to trigger finger.

Is This Going to Hurt, Doc? Predicting Pain with Corticosteroid Injections for Upper Extremity Conditions

Corticosteroid injections (CSIs) are used in a wide variety of upper extremity pathologies for both diagnostic and treatment purposes. Many patients ask about pain associated with the procedure before agreeing to proceed. The purpose of this study was to correlate perceived pain tolerance and resilience with patient-reported injection pain during and immediately after injection.

Methods

One-hundred patients indicated for a CSI for an upper extremity condition were recruited for the study. Patients completed a Brief Resilience Scale, Patient-Reported Outcomes Measurement Information System pain interference form, and assessment of pain tolerance before injection. Physicians predicted pain tolerance and resilience for each patient. Immediately after the procedure, patients completed a second survey, assessing pain during and 1 minute after injection.

Results

Physician-predicted patient resilience and pain tolerance was lower than that self-reported by patients. Pain with injection was inversely correlated with physician-predicted pain tolerance and resilience but not with patient-reported pain tolerance. Injection pain ratings did not correspond with patients' willingness to undergo subsequent injections.

Conclusions

Procedural pain is an important consideration for many patients, especially in awake procedures. Appropriate counseling is crucial to support informed consent and enhance patient outcomes. This study demonstrated that a physician's clinical experience can be used to predict a patient's pain with CSI and should be considered when counseling patients.

Comparison of Distal and Proximal Local Steroid Injection for Carpal Tunnel Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Local steroid injection (LSI) in the carpal tunnel is a mainstay of conservative treatment in patients with carpal tunnel syndrome (CTS). Currently, clinicians generally perform a conventional proximal approach (PA) or novel distal approach (DA) for LSI. Recent systematic reviews comparing the two injection methods are lacking. This systematic review and meta-analysis aimed to assess whether LSI using the DA was superior to PA in treating patients with CTS.

METHODS

Databases including Pubmed, Embase, and the Cochrane library were searched up to 30 May 2022 to identify relevant randomized controlled trials (RCTs) comparing the DA with the PA steroid injection in patients with CTS. The outcomes mainly included Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQs) and Functional Status Scale (BCTQf), visual analog scores (VAS), electrophysiological outcomes, pain of injection, duration of injection, or adverse events.

RESULTS

Five RCTs involving 339 patients were identified. Pooled analysis showed that the DA group took less time [mean difference (MD) -19.91; 95% CI -34.48 to -5.35; P = 0.007] and acquired better sensory nerve action potential amplitude [standardized mean difference (SMD) -0.37; 95% CI -0.62 to -0.11; P = 0.005]. The two groups were not significantly different in terms of BCTQs and BCTQf, VAS, other electrophysiological outcomes, pain of injection, or adverse events (P > 0.05).

CONCLUSION

Although providing similar improvement in pain relief or function improvement, the distal approach is superior to the proximal approach in terms of timing, without increasing other side effects. Further high-quality randomized studies are required to confirm these results.

Intraarticular injection of the interphalangeal joint for therapy of digital mucoid cysts

Mucoid cysts are associated with osteoarthritis (OA) of the digital joints and frequently recur after needle drainage, injection, or surgical ablation. This study determined whether intraarticular injection of the adjacent interphalangeal joint rather than the cyst itself might be effective in resolving digital mucoid cysts. Using paired case series design and sterile technique, 25 consecutive OA digital joints with an adjacent mucoid cyst underwent dorsal non-transtendinous intraarticular injection with a 25-gauge needle and 20-mg triamcinolone acetonide, followed by puncture and manual expression of cyst fluid. Patient pain was measured with the 10-cm Visual Analogue Pain Scale prior to the procedure and at 6 months. Cyst resolution was determined at 6 months and 3 years. The subjects were 61.0 ± 7.7 years old and 60% (15/25) female. Mucoid cysts were adjacent to 19 distal interphalangeal, 3 metacarpophalangeal, and 3 interphalangeal joints. Pre-procedural pain was 4.7 ± 1.0; procedural pain was 6.2 ± 0.6 cm, and post-procedural pain at 6 months was 1.2 ± 0.8 cm (74.5% reduction, 95% CI of difference: 3.0 < 3.5 < 4.0 (p < 0.0001)). 84% (21/25) of the cysts resolved at 6 months; however, 60% (15/25) of the mucoid cysts recurred within 3 years and required retreatment (14 adjacent joints re-injected and 1 ablative cyst surgery). No complications were noted. Intraarticular corticosteroid injection using a dorsal non-transtendinous approach of the joint adjacent to a mucoid cyst is effective resolving cysts and reducing pain at 6 months; however, 60% of mucoid cysts reoccur within 3 years and may require reinjection or surgery.Trial registration: This was not a clinical trial.

Corticosteroid injection treatment for dactylitis in psoriatic arthritis

Dactylitis – a hallmark clinical feature of psoriatic arthritis (PsA) – that occurs in 30–50% of PsA patients, is a marker of disease severity for PsA progression, an independent predictor of cardiovascular morbidity and impairs the motor functions of PsA patients. There is a paucity of evidence for the treatment due to the absence of randomized controlled trials assessing dactylitis as a primary endpoint and current practice arises from the analysis of dactylitis as a secondary outcome. Corticosteroid (CS) injections for dactylitis in PsA patients are a therapeutic treatment option for patients with isolated dactylitis or for patients with flares in tendon sheaths, despite stable and effective systemic treatment. The aim of this narrative review is to briefly illustrate the clinical aspects of dactylitis in PsA, the imaging and clinimetric tools used to diagnose and monitor dactylitis, the current treatment strategies and principally to provide a comprehensive picture of the clinical efficacy and safety with ultrasound-guide and blind techniques of CS injections for dactylitis in PsA patients.

Spezielle Schmerztherapie bei rheumatischen Erkrankungen

Schmerz als Hauptsymptom vieler chronisch-entzündlicher Erkrankungen stellt für den Patienten, aber auch für den behandelnden Arzt besonders in seiner chronifizierten Form eine große Herausforderung dar. Es gibt leider keine „Wunderpille“ mit der man Schmerzen für jeden gleich zuverlässig beseitigen kann. Es gibt aber viele Ansätze pharmakologischer als auch nicht-pharmakologischer Art und deren Kombination, um für den einzelnen Patienten wirksame Behandlungsstrategien zu finden. Um diese Strategien für jeden Patienten individuell optimal festzulegen, bedarf es zum einen eines fundamentierten Wissens über das Spektrum zur Verfügung stehender Mittel, zum anderen aber auch Erkenntnis darüber, wie diese sinnvoll nach Art der vorliegenden Schmerzformen einzusetzen sind. In dieser Übersicht wird beides behandelt, mit einem Fokus auf die medikamentöse Therapie von Schmerzen bei entzündlich-rheumatischen Erkrankungen. Dabei wird herausgearbeitet, dass es für die in diesem Zusammenhang relevantesten Formen des Schmerzes, akut-entzündlich nozizeptiv, neuropathisch und durch periphere und zentrale Sensibilisierung chronifizierte Schmerzen, jeweils andere wirksame Konzepte gibt.