Joint Injection

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
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
1. Withdraw needle if patient reports Paresthesias
2. Example: Ulnar Nerve lies close to medial epicondyle
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)

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
Steroid Arthropathy (0.8%)
Tendon rupture (<1%)
Facial Flushing (<1%)
Skin atrophy or depigmentation (<1%)
Iatrogenic Infectious Arthritis post-ArthrocentesisSeptic Joint (<0.07%)
1. 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)
1. Seen with frequent injections (e.g. 1970s NFL players)
Local Anesthetic Systemic Toxicity
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
Reference
1. Gray (1983) Clin Orthop Relat Res, (177): 253-63 [PubMed]

Local Anesthetic
1. See LAST Reaction
2. Lidocaine
3. Bupivacaine
4. Ropivacaine
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)
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)

See Injectable Corticosteroid for dosing
Short-Acting and Low Potency
1. Cortisone
2. Hydrocortisone
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)
Long-Acting and High Potency
1. Dexamethasone Sodium phosphate or Decadron (6 days)
2. Betamethasone or Celestone Soluspan (14 days)

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

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
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
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
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
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
Knee Injection
1. Knee Osteoarthritis
  1. Fair evidence of good short-term but poor long-term relief
Foot Injection
1. Morton Neuroma
  1. No evidence available for short-term or long-term relief
References
1. Foster (2015) Am Fam Physician 92(8): 694-9 [PubMed]