Joint Injection

Aka: Joint Injection, Intra-articular Injection, Soft Tissue Injection

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II. Indications: Articular Conditions

  1. Diagnostic Testing
    1. Monoarthritis
    2. Septic Arthritis
  2. Rheumatoid Arthritis
  3. Osteoarthritis
  4. Seronegative Spondyloarthropathy
    1. Ankylosing Spondylitis
    2. Inflammatory Bowel DiseaseArthritis
    3. Psoriasis
    4. Reiter's Syndrome
  5. Crystal-induced Arthritis
    1. Gout
    2. Pseudogout

III. Indications: Nonarticular Conditions

  1. Fibrositis (Localized, systemic)
  2. Bursitis
    1. Subacromial Bursitis
    2. Trochanteric Bursitis
    3. Anserine Bursitis
    4. Prepatellar Bursitis
  3. Periarthritis
    1. Adhesive Capsulitis
  4. Tenosynovitis or Tendonitis
    1. Dequervain's tenosynovitis
    2. Trigger Finger
    3. Bicipital Tendonitis
    4. Tennis Elbow (Lateral Epicondylitis)
    5. Golfer's Elbow
    6. Plantar Fasciitis
  5. Neuritis
    1. Carpal Tunnel Syndrome
    2. Tarsal Tunnel Syndrome
    3. Costochondritis
    4. Tietze's Syndrome

IV. Contraindications: Intra-articular Injection

  1. Overlying Cellulitis
  2. Severe Coagulopathy
  3. Anticoagulant therapy (relative contraindication)
  4. Septic effusion or Septic Joint
  5. More than 3 injections per year in weight bearing joint
  6. Lack of response after 2-4 injections
  7. Bacteremia
  8. Unstable joints
  9. Inaccessible joints
  10. Joint prosthesis
  11. Osteochondral Fracture
  12. Overlying soft tissue infection or dermatitis

V. Precautions

  1. Do not inject directly into tendons
    1. Injection into tendon sheath is appropriate
    2. Tendon weakens with direct injection (rupture risk)
    3. Do not inject high risk tendons
      1. Avoid Achilles tendon injection
      2. Avoid Patella tendon injection
  2. Aspirate before injection to confirm no vessel
  3. Avoid needle Trauma to cartilage on Joint Injection
  4. Limit Corticosteroid Injections to >3 month intervals or more (esp. joint, tendon injections)
  5. Limit Corticosteroid to one large joint per visit
  6. Exercise caution with nearby nerves
    1. Withdraw needle if patient reports Paresthesias
    2. Example: Ulnar Nerve lies close to medial epicondyle
  7. Ultrasound guided needle insertion improves the accuracy and safety of injection and aspiration
    1. Ultrasound may assist in avoiding neurovascular structures
    2. Ultrasound may help guide needle placement to largest pocket for aspiration (e.g. Knee Aspiration)

VI. Complications

  1. Postinjection flare (2-5%)
    1. Relieved with ice to the area for 15 minutes/hour
    2. Resolves within 24 to 48 hours
    3. More common with longer acting Corticosteroids
  2. Steroid Arthropathy (0.8%)
  3. Tendon rupture (<1%)
  4. Facial Flushing (<1%)
  5. Skin atrophy or depigmentation (<1%)
  6. Iatrogenic Infectious Arthritis post-ArthrocentesisSeptic Joint (<0.07%)
    1. Within 3-4 days of aspiration
  7. Transient paresis of injected extremity (Rare)
  8. Hypersensitivity Reaction (rare)
  9. Asymptomatic pericapsular calcification (43%)
  10. Acceleration of cartilage attrition (unknown Incidence)
    1. Seen with frequent injections (e.g. 1970s NFL players)
  11. Local Anesthetic Systemic Toxicity
  12. Hyperglycemia in Diabetes Mellitus patients
    1. Soft tissue and peritendinous injections increase Blood Sugars for 5-21 days
    2. Intraarticular injections may increase Blood Glucose variably from 1 to 21 days (onset within 84 hours)
      1. Previously intraarticular injection was not thought to significantly affect Serum Glucose
      2. However, later reviews show risk of significantly increased Blood Sugars (up to 500 mg/dl)
        1. Extended release Triamcinolone Acetonide does not demonstrate significant Glucose increase
        2. Crystalline suspension Triamcinolone Acetonide is associated with significant Serum Glucose increase
        3. Russell (2018) Rheumatology 57(12): 2235-41 [PubMed]
    3. References
      1. Choudhry (2016) JBJS Rev 4(3): e5 [PubMed]
      2. Wang (2006) J Hand Surg 31(6):979-81 [PubMed]
      3. Younes (2007) Joint Bone Spine 74(5): 472-6 [PubMed]
  13. Reference
    1. Gray (1983) Clin Orthop Relat Res, (177): 253-63 [PubMed]

VII. Medications: General

  1. Local Anesthetic
    1. See LAST Reaction
    2. Lidocaine
    3. Bupivacaine
    4. Ropivacaine
  2. Corticosteroid
    1. See Intra-articular Corticosteroid
    2. See duration and potency list below
    3. Indications
      1. Degenerative Joint Disease or inflammatory Arthropathy
      2. Nerve entrapment or neuritis (e.g. Carpal Tunnel)
      3. Bursitis or impingement syndrome
      4. Tendinopathy or Tenosynovitis
      5. Adhesive Capsulitis
    4. Preferred agents for large Joint Injections (longer duration but local skin reaction risk)
      1. Triamcinolone hexacetonide (Aristospan)
      2. Triamcinolone Acetonide (Kenalog)
    5. Preferred agents for small joints and soft tissue
      1. Methylprednisolone acetate (Depo-Medrol)
  3. Other solutions for injection (typically by sports medicine and other specialty care)
    1. Dextrose Prolotherapy (5 to 25% dextrose in Local Anesthetic, every 4 to 8 weeks for >=3 injections)
      1. Degenerative Joint Disease
        1. Sit (2020) Ann Fam Med 18(3): 235-42 [PubMed]
      2. Tendinopathy or ligamentous disorders
        1. Scarpone (2008) Clin J Sport Med 18(3): 248-54 [PubMed]
    2. Hyaluronic Acid (limited evidence of marginal benefit)
      1. Knee Osteoarthritis
    3. Platelet rich plasma (low efficacy and expensive)
      1. Knee Osteoarthritis
      2. Lateral epicondylopathy (Tennis Elbow)

VIII. Medications: Corticosteroids Based on Duration and Potency

  1. See Injectable Corticosteroid for dosing
  2. Short-Acting and Low Potency
    1. Cortisone
    2. Hydrocortisone
  3. Intermediate-Acting and Intermediate Potency
    1. Prednisone
    2. Prednisolone tebutate (Hydeltra)
    3. Triamcinolone acetate or Aristocort, Aristospan, Kenalog (14 days)
    4. Methylprednisolone acetate or Depo-Medrol (8 days)
  4. Long-Acting and High Potency
    1. Dexamethasone Sodium phosphate or Decadron (6 days)
    2. Betamethasone or Celestone Soluspan (14 days)

IX. Technique: Needles

  1. Joint Injection
    1. Needle Gauges 22-27 with length of 1.5 inches (author prefers 27 gauge)
  2. Joint Aspiration
    1. Needle Gauges 18-20 with length of 1.5 inches
  3. Special Circumstances: Spinal needle
    1. Obesity interferes with joint or bursa access
    2. Trochanteric Bursitis

X. Technique: Specific Injections

  1. General
    1. See Arthrocentesis
  2. Upper Extremity Joints
    1. See Shoulder Injection
    2. See Elbow Injection
    3. See Hand Injection
  3. Lower Extremity Joints
    1. See Hip Injection
    2. See Knee Injection
    3. See Ankle Injection
  4. Soft Tissue Injections
    1. See Tendon Sheath Injection
    2. See Trigger Point Injection

XI. Efficacy: Corticosteroid Injection

  1. Shoulder Injection
    1. Adhesive Capsulitis
      1. Fair evidence of good short-term and good long-term relief
    2. Subacromial impingement
      1. Good evidence of poor short-term and poor long-term relief
  2. Elbow Injection
    1. Lateral Epicondylitis
      1. Weak evidence of good short-term but poor long-term relief
    2. Medial Epicondylitis
      1. Weak evidence of fair short-term but poor long-term relief
  3. Wrist Injection
    1. Carpal Tunnel
      1. Weak evidence of good short-term but poor long-term relief
    2. DeQuervain Tenosynovitis
      1. Weak evidence of fair short-term relief
    3. Wrist Osteoarthritis
      1. No evidence available for short-term or long-term relief
  4. Hand Injection
    1. Hand Osteoarthritis
      1. No evidence available for short-term or long-term relief
    2. Trigger Finger
      1. Weak evidence of good short-term and fair long-term relief
  5. Hip Injection
    1. Greater Trochanteric Bursitis
      1. Fair evidence of good short-term and fair long-term relief
    2. Hip Osteoarthritis
      1. Fair evidence of good short-term and fair long-term relief
  6. Knee Injection
    1. Knee Osteoarthritis
      1. Fair evidence of good short-term but poor long-term relief
  7. Foot Injection
    1. Morton Neuroma
      1. No evidence available for short-term or long-term relief
  8. References
    1. Foster (2015) Am Fam Physician 92(8): 694-9 [PubMed]

XII. References

  1. Cardone (2002) Am Fam Physician 66(2):283-90 [PubMed]
  2. Creech-Organ (2023) Am Fam Physician 108(2): 151-8 [PubMed]
  3. Genovese (1998) Postgrad Med 103:125-34 [PubMed]
  4. Pfenninger (1991) Am Fam Physician 44(4): 1196-202 [PubMed]
  5. Scott (1996) Sports Med 22:406-16 [PubMed]
  6. Stephens (2008) Am Fam Physician 78(8): 971-6 [PubMed]

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