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Frequently Asked Questions

Maintaining CPD

I have been off work for two years on maternity leave, how do I gain re validation as an injector?

There is no requirement to revalidate but a recommendation to show competence after a break. ACOPMIT is looking to provide refresher courses for injection therapists in the near future in response to this need. With most injection courses this is a total of ten injections supervised by an injecting colleague or mentor. It would be good practice to repeat this procedure. Refer back to the marking scheme you used previously or use the SOM sheet attached. Remember to update resuscitation with anaphylaxis training.( See attachments- Injection forms A&B and patient satisfaction form)


Who can legally sign my injection CPD Form?

An injecting colleague or mentor would be preferable.


What CPD stats will I have to keep and in what format?

These are for your own CPD and can be in any form. However ACPOMIT have now a data storage facility for injection data which can help with data storage as an individual or team if all are members of ACPOMIT. There is an ability to use information then for self audit and reflection. See My Details > My CPD, once this is filled in then on the Home page the Injection log will be the alternative access point.


How many injections do I have to administer a year to remain a member of ACPOMIT?

There is no requirement for membership but need you to keep a record for own CPD log. We were formed to be a support network for injection therapists.


How many injections should I be doing to remain competent in injection therapy?

There are no requirements by ACPOMIT or the HPC but we recommend 10 as per training requirements.



Do I require written consent prior to injection?

Yes, as per own PGD (Patient Group directive) requirements or as part of PSD ( patient specific directive). Written consent is required to demonstrate that patient is aware of all the implications and contraindications of injection therapy. Local steroid injection should be perceived as an invasive procedure that has the potential to cause serious complications.


Patients on anticoagulants

When should I not inject a warfarinised patient?

These patients should have a record of their current INR values (International Normalized Ratio) a blood clotting test. Different Trusts will have their own rules about injecting these patients as part of their PGD and the ranges that are safe and these should be adhered to. In practice the best policy is to have INR checked or time the injection appointment in such a way that we know the result within a week or so of the planned injection date. INR levels between 2-3 are associated with a low risk of bleeding. (Horlocker T et al 2003). Remember longer compression time post injection and inform patient they are likely to bruise over site. Warn patients if area becomes very swollen post injection that they must seek medical help.

Can patients receive injection therapy when they are on anticoagulants?

Yes if they have a stable INR and PGD allows.

Is there a safe INR range I can inject patients within?

Between 2-3 INR but check with local policy and GP if unsure.


We use epipens in our clinics in case of anaphylaxis, what are the new regulations on doses for administration of adrenaline?

Guidelines have changed and should be followed as per local policy – some trusts do not allow their physiotherapists to administer adrenaline. The Resuscitation council have an algorithm http://www.resus.org.uk/pages/anaalgo.pdf. If adrenaline administration is allowed then this should be on the injection trolley ready to be drawn up if required. Yearly resuscitation courses with anaphylaxis should be attended.


Can you confirm that the limit for interarticular repeat injections is 4 months and no more than 3 per year.?

Each patient must be assessed for individual need. Acute shoulder capsulitis injections can be more frequent in early stages. If the length of response to injection is short and repetition does not increase response then a failed injection approach needs to be taken and alternatives methods of treatment discussed. Evidence of cartilage changes not demonstrated in human, only animal studies there is a possible chondroprotective effect- very short term (Gray RG et al 1983.Weitoft T et al 2005)


In the future will I have to do ultrasound training and offer guided injections instead of blinded injections?

There is very little evidence suggests ultrasound guided injections specifically in shoulders, are more effective than blinded injections. ( See Femke Naushutz presentation here). Ultrasound machines are also very expensive and cost prohibitive in most departments. We will have to wait and see.


Are there specific training requirements before I do ultrasound guide injections?

A good ultrasound course, a great machine, a helpful mentor and lots of practice.


How long post infection is the recommended period before injection therapy can be administered?

No evidence for this - taken as a contraindication in all literature. You may need to be guided by GP especially if patient has been on antibiotics. Seek medical advice.


How long should you rest a patient post injection?

24–48 hours recommended rest to keep injection effect local, with longer term benefits demonstrated if there has been a rest period initially. (Weitoft T et all 2005, Chakravarty K et al 1994,Chatham W, Williams G, Moreland L et al 1989). There is evidence that there is a decrease in tensile strength of fascicules in tendoachilles making it more prone to rupture, and effect can last up to 3 weeks in undamaged rotator cuff after subacromial injection – no change in damaged rotator cuff ( Haraldsson et al 2006,Wei AS et al 2006. Upper limb joints with synovitis particularly elbows benefit from early mobilisation (Weitoft T et al 2010) not the same in lower limb. (Weitoft T et al 2005.)



Chakravarty K, Pharoah PD, Scott DG. A randomized controlled study of post-injection rest following intra-articular steroid therapy for knee synovitis. Br J Rheumatol 1994;33:464-8. 24 hours bed rest rheumatoid patients.

Chatham W, Williams G, Moreland L,et al: Intraarticular corticosteroid injections: Should we rest the joints? Arthritis Care Res 1989;2:70-74

Gray RG, Gottlieb NL Intra-articular corticosteroids. An updated assessment Clin Orthop Relat Res. 1983 Jul-Aug ( 177):235-63.

Haraldsson BT, Langberg H, Aagaard P, Zuurmond AM, van El B, Degroot J, Kjaer M, Magnusson SP.Corticosteroids reduce the tensile strength of isolated collagen fascicles. Am J Sports Med. 2006 Dec;34(12):1992-7. Epub 2006 Aug 10.

Horlocker TT ,D J. Wedel, H Benzon,.,D L. Brown,F. K Enneking, J A. Heit,M F. Mulroy,R W. Rosenquist, JRowlingson, M Tryba,., and C Yuan, Regional Anesthesia in the Anticoagulated Patient: Defining the Risks .The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation Regional Anesthesia and Pain Medicine, Vol 28, No 3 (May–June), 2003: pp 172–197.

Wei , A S., J J. Callaci, ; D Juknelis, ; G Marra, ; P Tonino, K B. Freedman, F H. Wezeman, The Effect of Corticosteroid on Collagen Expression in Injured Rotator Cuff Tendon J Bone Joint Surg Am. 2006;88(6):1331-1338

Weitoft T, Forsberg C.Importance of immobilization after intraarticular glucocorticoid treatment for elbow synovitis: a randomized controlled study. Arthritis Care Res (Hoboken). 2010 May;62(5):735-7

Weitoft T, Larsson A, Saxne T, Rönnblom LChanges of cartilage and bone markers after intra-articular glucocorticoid treatment with and without postinjection rest in patients with rheumatoid arthritis. Ann Rheum Dis. 2005 Dec;64(12):1750-3. Epub 2005 Apr 20.