II. Indications: Articular Conditions
- Diagnostic Testing
- Rheumatoid Arthritis
- Osteoarthritis
- Seronegative Spondyloarthropathy
- Crystal-induced Arthritis
III. Indications: Nonarticular Conditions
- Fibrositis (Localized, systemic)
- 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 >3 month intervals or more (esp. joint, tendon injections)
- 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
-
Ultrasound guided needle insertion improves the accuracy and safety of injection and aspiration
- Ultrasound may assist in avoiding neurovascular structures
- Ultrasound may help guide needle placement to largest pocket for aspiration (e.g. Knee Aspiration)
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
- Soft tissue and peritendinous injections increase Blood Sugars for 5-21 days
- Intraarticular injections may increase Blood Glucose variably from 1 to 21 days (onset within 84 hours)
- Previously intraarticular injection was not thought to significantly affect Serum Glucose
- However, later reviews show risk of significantly increased Blood Sugars (up to 500 mg/dl)
- Extended release Triamcinolone Acetonide does not demonstrate significant Glucose increase
- Crystalline suspension Triamcinolone Acetonide is associated with significant Serum Glucose increase
- Russell (2018) Rheumatology 57(12): 2235-41 [PubMed]
- References
- Reference
VII. Medications: General
- Local Anesthetic
-
Corticosteroid
- See Intra-articular Corticosteroid
- See duration and potency list below
- Indications
- Degenerative Joint Disease or inflammatory Arthropathy
- Nerve entrapment or neuritis (e.g. Carpal Tunnel)
- Bursitis or impingement syndrome
- Tendinopathy or Tenosynovitis
- Adhesive Capsulitis
- 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)
- Other solutions for injection (typically by sports medicine and other specialty care)
- Dextrose Prolotherapy (5 to 25% dextrose in Local Anesthetic, every 4 to 8 weeks for >=3 injections)
- Hyaluronic Acid (limited evidence of marginal benefit)
- Platelet rich plasma (low efficacy and expensive)
- Knee Osteoarthritis
- Lateral epicondylopathy (Tennis Elbow)
VIII. Medications: Corticosteroids 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 acetate or Aristocort, Aristospan, Kenalog (14 days)
- Methylprednisolone acetate or Depo-Medrol (8 days)
- Long-Acting and High Potency
- Dexamethasone Sodium phosphate or Decadron (6 days)
- Betamethasone or Celestone Soluspan (14 days)
IX. Technique: 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. Technique: Specific Injections
-
General
- See Arthrocentesis
- Upper Extremity Joints
- See Shoulder Injection
- See Elbow Injection
- See Hand Injection
- Lower Extremity Joints
- See Hip Injection
- See Knee Injection
- See Ankle Injection
- Soft Tissue Injections
XI. 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
XII. References
- Cardone (2002) Am Fam Physician 66(2):283-90 [PubMed]
- Creech-Organ (2023) Am Fam Physician 108(2): 151-8 [PubMed]
- Genovese (1998) Postgrad Med 103:125-34 [PubMed]
- Pfenninger (1991) Am Fam Physician 44(4): 1196-202 [PubMed]
- Scott (1996) Sports Med 22:406-16 [PubMed]
- Stephens (2008) Am Fam Physician 78(8): 971-6 [PubMed]