Image Guided Steroid Injections

Overview

Many musculoskeletal conditions resolve with time and conservative management.

Steroid injections are a useful tool in the management of several Musculoskeletal conditions. The role of steroid injection can be used as a diagnostic tool to confirm or refute the apparent source of the pain generator or therapeutically. Where conservative measures have failed, steroids injections can be used as an adjunct to directly reduce inflammation thereby reducing pain and allowing time and physiotherapy regimes to improve outcomes. Other roles for steroid use, include reducing size of scar tissue such as Morton neuroma, modulating the healing process and breaking a pain cycle.

The majority of steroid injections can be administered using bony land markers and can be performed in GP surgeries or by the MSK interface service. These options should be explored before referring. Please see Steroid injection in the community section below.

GPs are asked not to request +/- steroid injection when requesting a diagnostic ultrasound

Referral pathway

Referrals for ultrasound guided steroid injections can be made via ICE following a confirmed diagnosis on imaging and patient has failed simple conservative measures. 

‘Do not request a diagnostic ultrasound and indicate +/- steroid injection’

ICE ultrasound requests that include +/- steroid injection will be booked only for ultrasound, and the clinical radiologist will discuss and decide with the patient if a steroid injection is appropriate management and discuss the risks vs benefits of such an injection with the patient, and re-book for that procedure if appropriate.

When referring please include the following information:

Document in the clinical dialogue box that imaging has confirmed a diagnosis. 

• Detail where and when the imaging has been performed for the study and report to be available for the chosen provider.
• State duration of conservative measures, if there was any improvement and if the patient was referred to the MSK interface service. 
• Document how many steroid injection have been performed for the current MSK condition and if the most recent injection was performed under image guidance.

Referral for ultrasound steroid injections are limited to the below diagnosis following failed conservative measures: 

Please note that referral for and removal of Ganglion is not routinely commissioned by the ICB. Please see the Ganglion Removal Prior Approval Policy for further information

Wrist

• Osteoarthritis of the wrist or small joints of the hand and fingers
• Synovitis of the wrist or small joints of the hand and fingers
• Tendon sheath injections for tenosynovitis
• Trigger finger

Elbow 

• Osteoarthritis of the elbow joint
• Synovitis of the elbow joint
• Bursitis

Shoulder

• SASD bursa injections - Bursitis/breaking pain cycle
• Bicep tendinosis
• ACJ OA/synovitis
• Sternoclavicular OA/Synovitis

Hip 

• Trochanteric bursitis (only refer if clinically guided injection is not possible due to body habitus)
• Iliopsoas bursitis

Knee 

• Osteoarthritis of the knee (only refer if clinically guided injection is not possible due to body habitus)
• Inflammatory arthritis of the knee
• Bursitis
• Popliteal cyst

Ankle 

• Osteoarthritis of the ankle
• Inflammatory arthritis of the ankle
• Retrocalcaneal bursitis

Foot (please also see Foot & Ankle problems FAQ page in Remedy)

• Osteoarthritis of the small joints of the foot
• Inflammatory arthritis of the small joints of the foot
• Morton neuroma/ intermetatarsal bursitis (only refer for one injection. Refer to MSK Interface service if patient represents.)
• Plantar fasciitis 

Considerations

• Failed clinically guided steroid injection can be requested and performed 6 weeks following the initial injection.
• Repeated steroid injections should be limited due to concerns of joint damage. Therefore should not be performed more often than every six weeks and limited to 3 times a year and five in a lifetime, unless the patient is under secondary care.
• Exceptions will be made to repeat referrals for those patients that require injections for chronic conditions such as osteoarthritis, bouts of inflammatory arthritis or can not proceed to a surgery if indicated due to specific circumstances. 
• Steroid injections which require Fluoroscopic guidance are limited to MSK interface services and secondary care, these include: -
  • Shoulder injection for Osteoarthritis
  • Shoulder hydro dilation for frozen shoulder (Adhesive capsulitis)
  • Hip injection for OA
  • Nerve root blocks 

• Steroid injection for lateral or medial epicondylitis is via the interface services. 
• Direct referral for image guided steroid injection for carpal tunnel is not available across BNSSG.
• Patients should not be referred for a steroid injection if the patient is to have a joint replacement within 6 months.

Steroid injections in the community

Guidelines on use of steroid injections in the community were released by NHS England on 31.7.20:

Clarification regarding corticosteroid injections for GPs, First Contact and Community Physiotherapists 

Corticosteroid injections (intraarticular and intramuscular) may be used where clinically indicated and the benefits outweigh the risks. An individual risk analysis must take place on a case by case basis and the lowest possible dose of corticosteroid must be used.

A corticosteroid injection must not be performed if the patient has an infection or suspected infection, including possible COVID-19 infection, being mindful that the incubation period for COVID-19 can be up to 14 days.

Patients must be aware of the potential increased risk and lack of clear evidence related to the risk of corticosteroid injections during the COVID-19 pandemic. Informed consent must be obtained and documented prior to proceeding with the injection.

Please see the full guidance which contains more details including caveats.

Waiting List & Pathway Management

For full details please see the attached Steroid Injection waiting list management

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.