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
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Related Studies
Definition (HL7V3.0) | <p>Injection, intraarticular</p> |
Concepts | Therapeutic or Preventive Procedure (T061) |
MSH | D007270 |
SnomedCT | 231271000, 150858008, 27813003 |
HL7 | IARTINJ |
LNC | LA11297-1 |
English | Injection, Intra-Articular, Injection, Intraarticular, Injections, Intra Articular, Injections, Intra-Articular, Injections, Intraarticular, Intra Articular Injections, Intraarticular Injection, Intraarticular Injections, Intra-Articular Injection, INJECT INTRAARTICULAR, INTRA ARTICULAR INJECT, INJECT INTRA ARTICULAR, INTRAARTICULAR INJECT, Intra-Articular Injections, Injection;intra-articular, intraarticular injection, injections intraarticular, intra articular injection, intra-articular injection, intra-articular injections, Injection into joint (procedure), Injections, Intra-articular, Injection, intraarticular, Intra-articular injection, Injection into joint, Injection into joint cavity, Intra-articular injection (procedure) |
Swedish | Ledinjektioner |
Czech | injekce nitrokloubní, intraartikulární injekce, injekce intraartikulární |
Finnish | Nivelensisäiset injektiot |
Russian | IN"EKTSII VNUTRISUSTAVNYE, VPRYSKIVANIIA VNUTRISUSTAVNYE, ВПРЫСКИВАНИЯ ВНУТРИСУСТАВНЫЕ, ИНЪЕКЦИИ ВНУТРИСУСТАВНЫЕ |
Japanese | 関節内注射, 注射-関節内 |
French | Injections articulaires, Injections intra-articulaires |
Polish | Wstrzyknięcia dostawowe |
Croatian | UNUTARZGLOBNE INJEKCIJE, INJEKCIJE, INTRAARTIKULARNE |
Norwegian | Intraartikulære injeksjoner, Injeksjoner, intraartikulære |
Spanish | inyección intrarticular (procedimiento), inyección intrarticular, Inyecciones Intraarticulares |
German | Injektionen, intraartikuläre, Intraartikuläre Injektionen |
Italian | Iniezioni intraarticolari |
Dutch | Injectie, intra-articulaire, Injecties, intra-articulaire, Intra-articulaire injectie |
Portuguese | Injeções Intra-Articulares |
Ontology: Injection of soft tissue (C0185357)
Concepts | Therapeutic or Preventive Procedure (T061) |
SnomedCT | 24456005 |
English | Injection of soft tissue (procedure), Injection of soft tissue, Injection of soft tissue, NOS |
Spanish | inyección en partes blandas (procedimiento), inyección en partes blandas |