dexamethasone for trigger point injection

No laboratory test or imaging technique has been established for diagnosing trigger points.9 However, the use of ultrasonography, electromyography, thermography, and muscle biopsy has been studied. Tender points, by comparison, are associated with pain at the site of palpation only, are not associated with referred pain, and occur in the insertion zone of muscles, not in taut bands in the muscle belly.8 Patients with fibromyalgia have tender points by definition. Figure 24-3 Palpation of trigger points prior to injections. Call your doctor for preventive treatment if you are exposed to chickenpox or measles. erythema or redness of skin or mucous membrane. High doses or long-term use of steroid medicine can lead to thinning skin, easy bruising, changes in body fat (especially in your face, neck, back, and waist), increased acne or facial hair, menstrual problems, impotence, or loss of interest in sex. History/Background and/or General Information. To minimize pain and inflammation after leaving the office, the patient should be advised to apply ice to the injection site (for no longer than 15 minutes at a time, once or twice per hour), and non-steroidal anti-inflammatory agents may be used, especially for the first 24 to 48 hours. Copyright 2002 by the American Academy of Family Physicians. Pharmacologic treatment of patients with chronic musculoskeletal pain includes analgesics and medications to induce sleep and relax muscles. Other rare, but possible, complications include pneumothorax (when injecting thoracic trigger points), perilymphatic depigmentation, steroid arthropathy, adrenal suppression, and abnormal uterine bleeding. Epidemiology of Trigger Finger: Metabolic Syndrome as a New Perspective of Associated Disease. Several other substances, including diclofenac (Voltaren), botulinum toxin type A (Botox), and corticosteroids, have been used in trigger-point injections. However, these injections seldom lead to significant, long-lasting relief. Palpate the soft tissue or bony landmarks. Most pain is the result of tissue stretching and can be mitigated by injecting slowly. Trigger Point Therapy takes just a few minutes, and is performed by our Medical Doctor. A central trigger point (TrP) located within a taut band of muscle. Call your doctor for instructions if you miss a dose. Locations of trigger points in the iliocostalis. ICD-9 code: 727.03 "trigger finger" (acquired) ICD-10 code: M65.3 "trigger finger" nodular tendinous disease; CPT code: 20550 "Injection(s); single tendon sheath, or ligament, aponeurosis" Materials Needed. The injection technique recommended by Hong and Hsueh for trigger points was modified from that proposed by Travell and Simons. Time to Improvement After Corticosteroid Injection for Trigger Finger. Dexamethasone (injection) Generic name: dexamethasone (injection) [ DEX-a-METH-a-sone ] Brand names: Decadron, De-Sone LA Dosage forms: injectable solution (10 mg/mL; 10 mg/mL preservative-free; 4 mg/mL); injectable suspension (8 mg/mL); intravenous solution (6 mg/25 mL-NaCl 0.9%) Drug class: Glucocorticoids soluble agents (dexamethasone and betamethasone) [9]. Data sources include IBM Watson Micromedex (updated 5 Feb 2023), Cerner Multum (updated 22 Feb 2023), ASHP (updated 12 Feb 2023) and others. Consider steroids such as triamcinolone or dexamethasone to possibly add to the local anesthetic mixture (optional) Several precautions should be taken when using steroid injections. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. A thoracic epidural injection may provide pain relief for several different types of back problems, like: Injuries causing irritation of the spinal nerves. Patients report few systemic symptoms, and associated signs such as joint swelling and neurologic deficits are generally absent on physical examination.14, In the head and neck region, myofascial pain syndrome with trigger points can manifest as tension headache, tinnitus, temporomandibular joint pain, eye symptoms, and torticollis.15 Upper limb pain is often referred and pain in the shoulders may resemble visceral pain or mimic tendonitis and bursitis.5,16 In the lower extremities, trigger points may involve pain in the quadriceps and calf muscles and may lead to a limited range of motion in the knee and ankle. Copyright 1996-2023 Cerner Multum, Inc. Trigger points are painful "knots" in your muscles that can be very sensitive to touch/pressure. increased appetite. ; Fibromyalgia - Fibromyalgia patients with tender and painful area more than 6 are not suitable for injections. That means you'll have little to no downtime at all. In some cases, these trigger points may originate from injury or damage to a specific joint in the neck (the facet joint). Trigger point injections provide quick, long-lasting relief from trigger point pain Injections reduce the amount of referred pain Injections help to minimize the effects of other symptoms, including fatigue, stiffness, and disability Injections can be done quickly and conveniently in your physician's office or at a pain clinic Bethesda, MD 20894, Web Policies Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Avoid being near people who are sick or have infections. Capillary hemorrhage augments postinjection soreness and leads to unsightly ecchymosis.10 Patients should refrain from daily aspirin dosing for at least three days before injection to avoid increased bleeding. (From Muscolino JE: The muscle and bone palpation manual with trigger points, referral patterns, and stretching. The calcitonin gene-related peptide may be associated with this condition becoming chronic, as is hypothesized to occur in some patients with CLBP. Dexamethasone injection is also used for diagnostic testing. A common practice is to use 0.5 to 2mL per trigger point, which may depend on the pharmacologic dosing limits of the injected mixture. MeSH For therapeutic injections, the procedure should be performed when acute or chronic symptoms are present, after the diagnosis and therapeutic plan have been made, and after consideration has been given to obtaining radiographs. Patients should be educated to look for signs of infection including erythema, warmth, or swelling at the site of injection, or systemic signs including fever and chills. Avoid receiving any other type of vaccine without your doctor's advice, including a yearly flu shot. Consequently, suspensions are longer acting. See permissionsforcopyrightquestions and/or permission requests. Store at room temperature away from moisture and heat. PMC 2021 May;16(3):321-325. doi: 10.1177/1558944719855686. It differentiates a trigger point from a tender point, which is associated with pain at the site of palpation only (Table 1).8, A latent trigger point does not cause spontaneous pain, but may restrict movement or cause muscle weakness.6 The patient presenting with muscle restrictions or weakness may become aware of pain originating from a latent trigger point only when pressure is applied directly over the point.9. Roberts JM, Behar BJ, Siddique LM, Brgoch MS, Taylor KF. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbances, and joint problems may all predispose to the development of micro-trauma.5 Occupational or recreational activities that produce repetitive stress on a specific muscle or muscle group commonly cause chronic stress in muscle fibers, leading to trigger points. A healthcare provider will give you this injection. The sequence of injections was randomized by Latin square design. 2008 Sep;67(9):1262-6. doi: 10.1136/ard.2007.073106. Joint and soft tissue injections. Trigger point injections are a therapeutic modality to treat myofascial trigger points, especially in symptomatic patients, and have been demonstrated effectiveness to inactivate trigger points. Clinicians should also inquire about medication history to note prior hypersensitivity/allergy or adverse events (AEs) with drugs similar to those being considered, and evaluate contraindications for these types of drugs. Figure 24-4 Trigger point injection technique. Available for Android and iOS devices. Can I use expired neomycin and polymyxin b sulfates, dexamethasone ophthalmic. The rates 3 months after injection were 27 of 41 in the triamcinolone cohort and 22 of 31 in the dexamethasone cohort. Most patients, if they are going to respond, will respond after the first injection. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial. Dexamethasone can affect growth in children. Documentation is kept as part of the patient's record. Hematoma formation; avoid by applying direct pressure for at least two minutes after injection. You may report side effects to FDA at 1-800-FDA-1088. Injection of joints, bursae, tendon sheaths, and soft tissues of the human body is a useful diagnostic and therapeutic skill for family physicians. 3. Using a needle with a smaller diameter may cause less discomfort; however, it may provide neither the required mechanical disruption of the trigger point nor adequate sensitivity to the physician when penetrating the overlying skin and subcutaneous tissue. Soft tissue (fat) atrophy and local depigmentation are possible with any steroid injection into soft tissue, particularly at superficial sites (e.g., lateral epicondyle). Patients should sign documentation that informed consent for the procedure was given and understood. Local tenderness, taut band, local twitch response, jump sign, Occur in specific locations that aresymmetrically located, May cause a specific referred pain pattern, Do not cause referred pain, but often cause a total body increase in pain sensitivity, Lidocaine (Xylocaine, 1 percent, without epinephrine) or procaine (Novocain, 1 percent), 22-, 25-, or 27-gauge needles of varying lengths, depending on the site to be injected, Aspirin ingestion within three days of injection, The presence of local or systemic infection. Once a trigger point has been located and the overlying skin has been cleansed with alcohol, the clinician isolates that point with a pinch between the thumb and index finger or between the index and middle finger, whichever is most comfortable (Figures 3a and 3b). Tell any doctor who treats you that you are using dexamethasone. Although there were no differences 3 months after injection, our data suggest that triamcinolone may have a more rapid but ultimately less durable effect on idiopathic trigger finger than does dexamethasone. When clinicians were asked to examine patients with either myofascial pain, fibromyalgia, or healthy controls, the number of tender points identified was generally consistent.43 Even among experts in myofascial pain and fibromyalgia there was inconsistency in the number of taut bands, presence of referred pain, and local twitch responses reported. 2021 Aug 3;13(8):e16856. The indication for TPIs is CLBP with active trigger points in patients who also have myofascial pain syndrome that has failed to respond to analgesics and therapeutic exercise, or when a joint is deemed to be mechanically blocked due to trigger points and is unresponsive to other interventions. When symptoms are resistant, or when there is a history of trauma, a radiograph or other imaging study should be performed to help assist in the diagnosis. 12 None of these models have been accepted as the gold standard but they can be used to assess severity and assist in selecting the appropriate referral and treatment options. The patient should keep the injection site clean and may bathe. Before Taking. We can do trigger point injections, usually using a cocktail of lidocain and dexamethasone, we have used Serapin and like it for occipital trigger areas, but prefer the dexamethasone for trapezius and rhomboid areas. Specific medications such as Botox are only approved for other indications and are thus used off-label for TPIs with CLBP. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. As with any invasive diagnostic or therapeutic injection procedure, there are absolute and relative contraindications (Table 2).7 Drug allergies, infection, fracture, and tendinous sites at high risk of rupture are absolute contraindications to joint and soft tissue injection. Arch. Active trigger points can cause spontaneous pain or pain with movement, whereas latent trigger points cause pain only in response to direct compression. A set of trigger point injections means injections in several trigger points in one sitting. They produce pain locally and in a referred pattern and often accompany chronic. Side effects are few, but may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tissue atrophy. In comparative studies,17 dry needling was found to be as effective as injecting an anesthetic solution such as procaine (Novocain) or lidocaine (Xylocaine).10 However, post-injection soreness resulting from dry needling was found to be more intense and of longer duration than the soreness experienced by patients injected with lidocaine.10, One noncontrolled study17 comparing the use of dry needling versus injection of lidocaine to treat trigger points showed that 58 percent of patients reported complete relief of pain immediately after trigger-point injection and the remaining 42 percent of patients claimed that their pain was minimal (12/10) on the pain scale. Cardone DA et al. Decadron, Dexamethasone Intensol, Baycadron, Dexpak Taperpak, +4 more. Mixing the corticosteroid preparation with a local anesthetic is a common practice for avoiding the injection of a highly concentrated suspension into a single area. The needle should be long enough so that it never has to be inserted all the way to its hub, because the hub is the weakest part of the needle and breakage beneath the skin could occur.6, An injectable solution of 1 percent lidocaine or 1 percent procaine is usually used. Trigger points help define myofascial pain syndromes. Both dry needling and injection with 0.5 percent lidocaine were equally successful in reducing myofascial pain. A trigger point injection (TPI) is an outpatient procedure used to treat painful areas of muscle that contain trigger points, or "knots" of muscle that form when muscles do not relax. DENNIS A. CARDONE, D.O., C.A.Q.S.M., AND ALFRED F. TALLIA, M.D., M.P.H. Increased bleeding tendencies should be explored before injection. Find patient medical information for dexamethasone sodium phosphate injection on WebMD including its uses, side effects and safety, interactions, pictures, warnings and user ratings. If additional tender points are palpable, they should be isolated, needled and injected. Corticosteroid injections for trigger finger. Before To prevent complications, adhere to sterile technique for all joint injections; know the location of the needle and underlying anatomy; avoid neuromuscular bundles; avoid injecting corticosteroids into the skin and subcutaneous fat; and always aspirate before injecting to prevent intravascular injection. Written by Cerner Multum. The patient should be placed in a comfortable or recumbent position to produce muscle relaxation. Seigerman D, McEntee RM, Matzon J, Lutsky K, Fletcher D, Rivlin M, Vialonga M, Beredjiklian P. Cureus. itching of the genital area. Therapeutic indications for joint or soft tissue aspiration and injection include decreased mobility and pain, and the injection of medication as a therapeutic adjunct to other forms of treatment.5 Caution must be exercised when removing fluid for pain relief because of the possibility of introducing infection and precipitating further or new bleeding into the joint. There are several proposed histopathologic mechanisms to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking. Appropriate timing can minimize complications and allow a clear diagnosis or therapeutic response. About 23 million persons, or 10 percent of the U.S. population, have one or more chronic disorders of the musculoskeletal system.1 Musculoskeletal disorders are the main cause of disability in the working-age population and are among the leading causes of disability in other age groups.2 Myofascial pain syndrome is a common painful muscle disorder caused by myofascial trigger points.3 This must be differentiated from fibromyalgia syndrome, which involves multiple tender spots or tender points.3 These pain syndromes are often concomitant and may interact with one another. Antidepressants, neuroleptics, or nonsteroidal anti-inflammatory drugs are often prescribed for these patients.1. There is some concern that corticosteroid preparations, with repeated use, may accelerate normal, aging-related articular cartilage atrophy or may weaken tendons or ligaments. We report on 68 women who underwent injections by a single physician and show an improvement in VAS pain scores in 65% of patients. Dosage. Therapeutic injection should be performed only with or after the initiation of other therapeutic modalities (e.g., physical therapy). trigger finger, several similar models have been proposed. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. The injection is usually given in a center for pain relief by a healthcare professional, with the patient either sitting or lying down. The intensity of pain was rated on a 0 to 10 cm visual analogue scale (VAS) score. Fine and colleagues reported that the analgesic effects of TPIs could be reversed with intravenous naloxone. Participants were randomly . They involve injecting a small amount of an anesthetic to relieve pain. Abdul et al. If the patient has achieved significant benefit after the first injection, an argument can be made to give a second injection if symptoms recur. Pressure is then applied to the injected area for two minutes to promote hemostasis.10 A simple adhesive bandage is usually adequate for skin coverage. Long term side effects (depending on frequency and dose) include thinning of skin, easy bruising, weight gain, puffiness in the face, higher blood pressure, cataract formation, and osteoporosis (reduced bone density). The injection should flow easily and should not be uncomfortable to the patient. Knowledge of the anatomy of the area to be injected is essential. Thus, these two pain syndromes may overlap in symptoms and be difficult to differentiate without a thorough examination by a skilled physician. underlying neurovascular structures), However, may result in more post-injection soreness, Some studies demonstrate no additional benefit with, Mechanism of Trigger Point Injection effect is likely more than antiinflammatory activity, Prevents burying needle to hub (risk or breakage), Allows for necessary mechanical disruption, Optimal: 25-27 gauge 1.25 to 1.5 inch needle, Alternative: Tuberculin syringe (5/8 inch), Anticipate initial increased pain on injection, Local twitch and referred pain confirms placement, Fix tender spot between fingers (1-2 cm in size), Warn patient of possible pain on injection (associated with pH of medication, tissue expansion), Direct needle at 30 degree angle off skin, Use a fanning technique of injection (0.3 to 0.5 ml at a time), Repeat until local twitch or tautness resolves, Cycles of redirecting needle and reinjecting, Redirect needle into adjacent tender areas, Hold direct pressure at injection site for 1-2 minutes, Full active range of motion in all directions, Repeat range of motion three times after injection, Patient avoids over-using injected area for 3-4 days, Maintain active range of motion of injected, Patient applies ice to injected areas for a few hours, Anticipate post-injection soreness for 3-4 days, Expect 2-4 months of benefit after injection, Avoid repeat injection if unsuccessful on 2-3 attempts, Re-evaluate for possible repeat injection after 4 days, Ruoff in Pfenninger (1994) Procedures, Mosby, p. 164-7, Sola in Roberts (1998) Procedures, Saunders, p. 890-901, Strayer in Herbert (2016) EM:Rap 16(11): 1-2, Warrington (2020) Crit Dec Emerg Med 34(9): 14. TPI is a procedure used to treat painful areas of muscle that contain trigger points (knots of muscle that form when muscles do not relax). Systemic effects are possible (especially after triamcinolone acetonide [Aristocort] injection or injection into a vein or artery), and patients should always be acutely monitored for reactions. Examples of predisposing activities include holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all; and moving boxes using improper body mechanics.11, Acute sports injuries caused by acute sprain or repetitive stress (e.g., pitcher's or tennis elbow, golf shoulder), surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement may also predispose a patient to the development of trigger points.12, Patients who have trigger points often report regional, persistent pain that usually results in a decreased range of motion of the muscle in question. Pain can be relieved by alternately applying moist heat and ice for a day or two. So, you can use your once-painful muscles soon after you receive the injections. The needle size used for TPIs is typically quite small, frequently 25 or 27 gauge (G), but needles as large as 21G have been reported.10-12,14,18-20,24,26,32,50 The length of needle used is dependent on the depth of the trigger point through subcutaneous tissue, but is commonly from 0.75 inches to 2.5 inches.10,12,14,18,20,46,5052 Acupuncture needles may be used for dry needling of trigger points, using 0.16 13mm for facial muscles to 0.30 75mm for larger or deeper muscles. Get emergency medical help if you have signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. The two main types of trigger points are active and latent. Needle insertion was into the subcutaneous tissue adjacent to the trigger point at an angle of 50 to 70 degrees to the skin, aiming at the taut band. Steroid injections in the upper extremity: experienced clinical opinion versus evidence-based practices. Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. Version: 5.01. The analysis was according to intention to treat principles. Medically reviewed by Drugs.com on Aug 24, 2021. Thoracic disc herniation with pain radiating into your back or arm. It was found that dexamethasone significantly in- creased the FIB already after 2 days of administration, while it significantly decreased APTT starting after 1 week of dexamethasone injections. Ball EM et al. Clipboard, Search History, and several other advanced features are temporarily unavailable. Am Fam Physicians 2002; 66(2):283-289 4. Description Your health care provider inserts a small needle and injects medicine into the painful and inflamed area. hirsutism, a condition of hair growth on parts of the body normally . These effects are believed to result from several mechanisms, including alterations in neutrophil chemotaxis and function, increases in viscosity of synovial fluid, stabilization of cellular lysosomal membranes, alterations in hyaluronic acid synthesis, transient decreases in synovial fluid complements, alterations in synovial permeability, and changes in synovial fluid leukocyte count and activity.8 Whether this is exactly the same mechanism of action that occurs with orally or parenterally administered corticosteroids is uncertain.4. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. sharing sensitive information, make sure youre on a federal Dosing is site dependent. Many researchers agree that acute trauma or repetitive microtrauma may lead to the development of a trigger point. Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy and injection, are used to inactivate trigger points. TPIs may be classified according to the substances injected, which may include local anesthetic, saline, sterile water, steroids, nonsteroidal anti-inflammatory drugs, botulinum toxin, 5-HT3 receptor antagonists, or even dry needling.1038 Although this chapter focuses on TPIs for chronic low back pain (CLBP), trigger points may occur elsewhere in the body. Thermographic imaging evaluation has previously demonstrated elevated temperatures in the referral pain pattern of trigger points, suggesting increased local heat production from increased metabolism or neural activity.65 Gerwin and colleagues recently expanded on Simons integrated hypothesis for trigger point formation and proposed a complex molecular pathway whereby unconditioned muscle undergoes eccentric exercise or trauma, which results in muscle fiber injury and hypoperfusion from capillary constriction.66 Sympathetic nervous system activation further enhances this constriction and creates a hypoxic and acidic environment, facilitating the release of calcitonin gene-related peptide and acetylcholine. nausea, vomiting. A needle with a smaller gauge may also be deflected away from a very taut muscular band, thus preventing penetration of the trigger point. Steroid injection for inferior heel pain: a randomized controlled trial. This content is owned by the AAFP. Non-sterile gloves can be used when injecting or aspirating soft tissue regions. headache. It is available in forms that can be taken by mouth, through a patch placed on the skin, as a cream, in eye drops, and as an injectable. bruising under the skin. The anesthetic provides early relief of symptoms and helps confirm the diagnosis. This is not a complete list of side effects and others may occur. Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed. Bookshelf Manufacturers advise against mixing corticosteroid preparations with lidocaine because of the risk of clumping and precipitation of steroid crystals. HHS Vulnerability Disclosure, Help It is tender to palpation with a referred pain pattern that is similar to the patient's pain complaint.3,5,6 This referred pain is felt not at the site of the trigger-point origin, but remote from it. A more recent article on trigger point management is available. The stabilizing fingers apply pressure on either side of the injection site, ensuring adequate tension of the muscle fibers to allow penetration of the trigger point but preventing it from rolling away from the advancing needle.10 The application of pressure also helps to prevent bleeding within the subcutaneous tissues and the subsequent irritation to the muscle that the bleeding may produce. Intrathecal solution and injection solution with or without methylparaben and or preservatives: 0.25%, 0.5%, 0.75% in 2, 10, 30, 50 mL. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial. The long-term clinical efficacy of various therapies is not clear, because data that incorporate pre- and post-treatment assessments with control groups are not available. To preserve autonomy, patients were permitted additional injections and operative treatment at any time. Dosage forms: injectable solution (10 mg/mL; 10 mg/mL preservative-free; 4 mg/mL), injectable suspension (8 mg/mL), intravenous solution (6 mg/25 mL-NaCl 0.9%) After the close of the study, there were 8 recurrences among patients with documented absence of triggering in the triamcinolone cohort and 1 in the dexamethasone cohort. I would recommend confirming with the provider that this is the correct medication since there is a very similar medication J1094 - Injection, dexamethasone acetate, 1 mg. Diagnostic imaging or other forms of advanced testing is generally not required before administering this intervention for CLBP. It can take as long as 20 to 30 minutes following the injection for these symptoms to present. For all intra-articular injections, sterile technique should be used. Prepare the area with an alcohol or povidone-iodine (Betadine) wipe. dexamethasone can affect the results of certain medical tests. A small amount (0.2 mL) of anesthetic should be injected once the needle is inside the trigger point. Any physician familiar with the localization of trigger points and the use of therapeutic musculoskeletal injections may perform TPIs. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. For diagnostic injections, the procedure should be performed when acute or chronic symptoms are present, when the diagnosis is unclear or needs to be confirmed, when consideration has been given to other diagnostic modalities, and when septic arthritis has been ruled out (by aspiration and fluid analysis). Click on the image (or right click) to open the source website in a new browser window. 2. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. It is reproducible and does not follow a dermatomal or nerve root distribution. To avoid direct needle injury to articular cartilage or local nerves, attention should be paid to anatomic landmarks and depth of injection. Various substances have been used for trigger point injections, including local anesthetics, botulinum toxin, sterile water, and sterile saline. Please enable it to take advantage of the complete set of features! Tell your doctor if your child is not growing at a normal rate while using this medicine.

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dexamethasone for trigger point injection