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An injection of PRP in the elbow may be less painful for the patient if the provider first applies a topical anesthetic.
Courtesy of Allan Mishra, MD

AAOS Now

Published 9/1/2015
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Robert J. Dimeff, MD

Instant Topical Anesthetics Gaining Fans Among Both Physicians and Patients

The fear of needles is a real condition and one that doesn’t discriminate by size or age. In my many years working in sports medicine, I’ve seen. professional athletes exhibit the same anxiety over a needle stick as my smallest pediatric patients.

Because injections are a common form of pain relief for musculoskeletal conditions and ailments, needle phobia can be an especially challenging problem in orthopaedics. Fortunately, orthopaedic surgeons can take steps to calm their patients’ fears and ease the pain of an injection—whether it’s a cortisone shot, autologous blood injection, platelet-rich plasma (PRP) injection, stem cell therapy, intravenous (IV) stick, or any other in-office treatment involving a needle.

Talk about it
Acknowledging the patient’s fear is very important. Start by explaining the procedure and how the use of an instant topical anesthetic will reduce the pain of an injection. This gives the patient power over the unknown, which helps alleviate the anxiety. Keep it simple. For example, I tell my patients, “I’m going to use an anesthetic to numb the skin so you shouldn’t feel the needle stick.”

Prior to administering an injection, I ask my patients to lie down. This not only tends to relax them, it also reduces their view of the needle. When patients must remain seated for a posterior shoulder injection, I try to hide the needle, and when feasible, I draw up the medications at the nursing station.

When a topical anesthetic is applied prior to the injection and the patient doesn’t see the needle coming, the typical response is, “That’s it?”

Unfortunately, many musculoskeletal disorders are not resolved with one injection. Frequently, therapy requires patients to return to the office for a series of injections, and getting patients who exhibit needle phobia to adhere to an injection schedule can be difficult. However, when I explain the benefits of topical anesthetics and use them prior to the first injection, reluctant patients are often willing to come back for subsequent injections and nearly always request that I continue to use a topical anesthetic.

Compassionate care
Surprisingly, the use of topical anesthetics prior to injections is not standard procedure for some physicians. I work with orthopaedic surgery, family medicine, and many other primary care residents and supervise numerous injection therapies. The use of topical anesthetics is quick and easy to teach, and after the first use, both the providers and the patients are sold.

Either the physician or an assistant or nurse practitioner can apply the topical anesthetic. The physician should mark the area of the injection with a fingerprint or marker.

For example, when using a skin refrigerant, simply spray an area about 2 cm2 square in the region of the injection or IV stick. Hold the can 10" to 12" away from the skin and spray until the skin turns white, but for no more than 10 seconds. Wait a second or two and administer the injection.

Our residents routinely reach for the topical anesthetic when preparing a patient for an injection. They are comfortable knowing their patients are at ease.

Needles and injections are unavoidable in an orthopaedic practice; therefore, the potential for patient anxiety and discomfort will always exist. Topical anesthetics, when used initially and consistently, can calm patients, diminish their pain, and make them more receptive to returning for subsequent injections, increasing the likelihood of successful outcomes.

Robert J. Dimeff, MD, is the medical director of sports medicine at UT Southwestern Medical Center, Dallas, and is a professor of orthopaedic surgery and family and community medicine. He is currently the director of medical services and team physician for the NHL Dallas Stars hockey team and University of Texas Dallas athletic department.

Dr. Dimeff reports potential conflicts of interest. For more information, visit www.aaos.org/disclosure