II. Indications: Articular conditions
III. Indications: Nonarticular conditions
- Fibrositis (Localized, systemic)
-
Bursitis
- Subacromial Bursitis
- Trochanteric Bursitis
- Anserine Bursitis
- Prepatellar Bursitis
- Periarthritis
-
Tenosynovitis or Tendonitis
- Dequervain's Tenosynovitis
- Trigger Finger
- Bicipital Tendonitis
- Tennis Elbow (Lateral Epicondylitis)
- Golfer's Elbow
- Plantar Fasciitis
- Neuritis
IV. Contraindications: Intra-articular Injection
- Overlying Cellulitis
- Severe Coagulopathy
- Anticoagulant therapy (relative contraindication)
- Septic effusion or Septic Joint
- More than 3 injections per year in weight bearing joint
- Lack of response after 2-4 injections
- Bacteremia
- Unstable joints
- Inaccessible joints
- Joint prosthesis
- Osteochondral Fracture
- Overlying soft tissue infection or dermatitis
V. Precautions
- Do not inject directly into tendons
- Injection into tendon sheath is appropriate
- Tendon weakens with direct injection (rupture risk)
- Do not inject high risk tendons
- Avoid Achilles tendon injection
- Avoid Patella tendon injection
- Aspirate before injection to confirm no vessel
- Avoid needle Trauma to cartilage on Joint Injection
- Limit Corticosteroid Injections to >4 week intervals
- Intra-articular Injections are typically limited to 3 month intervals
- Limit Corticosteroid to one large joint per visit
-
Exercise caution with nearby nerves
- Withdraw needle if patient reports Paresthesias
- Example: Ulnar Nerve lies close to medial epicondyle
VI. Complications
- Postinjection flare (2-5%)
- Relieved with ice to the area for 15 minutes/hour
- Resolves within 24 to 48 hours
- More common with longer acting Corticosteroids
- Steroid Arthropathy (0.8%)
- Tendon rupture (<1%)
- Facial Flushing (<1%)
- Skin atrophy or depigmentation (<1%)
- Iatrogenic Infectious Arthritis post-ArthrocentesisSeptic Joint (<0.07%)
- Within 3-4 days of aspiration
- Transient paresis of injected extremity (Rare)
- Hypersensitivity Reaction (rare)
- Asymptomatic pericapsular calcification (43%)
- Acceleration of cartilage attrition (unknown Incidence)
- Seen with frequent injections (e.g. 1970s NFL players)
- Local Anesthetic Systemic Toxicity
-
Hyperglycemia in Diabetes Mellitus patients
- Single Intra-articular Injections do not typically affect Blood Sugars
- Soft tissue and peritendinous injections increase Blood Sugars for 5-21 days
- Wang (2006) J Hand Surg 31(6):979-81 [PubMed]
- Younes (2007) Joint Bone Spine 74(5): 472-6 [PubMed]
- Reference
VII. Preparations: Based on duration and potency
- See Injectable Corticosteroid for dosing
- Short-Acting and Low Potency
- Intermediate-Acting and Intermediate Potency
- Prednisone
- Prednisolone tebutate (Hydeltra)
- Triamcinolone (Aristocort, Aristospan, Kenalog)
- Methylprednisolone acetate (Depo-Medrol)
- Long-Acting and High Potency
- DexamethasoneSodium phosphate (Decadron)
- Betamethasone (Celestone Soluspan)
VIII. Preparations
- Preferred agents for large Joint Injections (longer duration but local skin reaction risk)
- Triamcinolone hexacetonide (Aristospan)
- Triamcinolone Acetonide (Kenalog)
- Preferred agents for small joints and soft tissue
- Methylprednisolone acetate (Depo-medrol)
IX. Needles
- Joint Injection
- Needle Gauges 22-27 with length of 1.5 inches (author prefers 27 gauge)
-
Joint Aspiration
- Needle Gauges 18-20 with length of 1.5 inches
- Special Circumstances: Spinal needle
- Obesity interferes with joint or bursa access
- Trochanteric Bursitis
X. Efficacy: Corticosteroid Injection
-
Shoulder Injection
-
Adhesive Capsulitis
- Fair evidence of good short-term and good long-term relief
- Subacromial impingement
- Good evidence of poor short-term and poor long-term relief
-
Adhesive Capsulitis
-
Elbow Injection
-
Lateral Epicondylitis
- Weak evidence of good short-term but poor long-term relief
-
Medial Epicondylitis
- Weak evidence of fair short-term but poor long-term relief
-
Lateral Epicondylitis
-
Wrist Injection
-
Carpal Tunnel
- Weak evidence of good short-term but poor long-term relief
- DeQuervain Tenosynovitis
- Weak evidence of fair short-term relief
- Wrist Osteoarthritis
- No evidence available for short-term or long-term relief
-
Carpal Tunnel
-
Hand Injection
-
Hand Osteoarthritis
- No evidence available for short-term or long-term relief
-
Trigger Finger
- Weak evidence of good short-term and fair long-term relief
-
Hand Osteoarthritis
-
Hip Injection
-
Greater Trochanteric Bursitis
- Fair evidence of good short-term and fair long-term relief
-
Hip Osteoarthritis
- Fair evidence of good short-term and fair long-term relief
-
Greater Trochanteric Bursitis
-
Knee Injection
-
Knee Osteoarthritis
- Fair evidence of good short-term but poor long-term relief
-
Knee Osteoarthritis
-
Foot Injection
- Morton Neuroma
- No evidence available for short-term or long-term relief
- Morton Neuroma
- References