Procedure
Joint Injection
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Joint Injection
, Intra-articular Injection, Soft Tissue Injection
See Also
Arthrocentesis
Intra-articular Corticosteroid
Elbow Injection
Ankle Injection
Hand Injection
Hip Injection
Knee Injection
Shoulder Injection
Spray and Stretch
Trigger Point Injection
Tendon Sheath Injection
Regional Anesthesia
Indications
Articular Conditions
Diagnostic Testing
Monoarthritis
Septic Arthritis
Rheumatoid Arthritis
Osteoarthritis
Seronegative
Spondyloarthropathy
Ankylosing Spondylitis
Inflammatory Bowel Disease
Arthritis
Psoriasis
Reiter's Syndrome
Crystal-induced
Arthritis
Gout
Pseudogout
Indications
Nonarticular Conditions
Fibrositis
(Localized, systemic)
Bursitis
Subacromial Bursitis
Trochanteric Bursitis
Anserine
Bursitis
Prepatellar Bursitis
Periarthritis
Adhesive Capsulitis
Tenosynovitis
or
Tendonitis
Dequervain's
Tenosynovitis
Trigger Finger
Bicipital
Tendonitis
Tennis Elbow
(
Lateral Epicondylitis
)
Golfer's Elbow
Plantar Fasciitis
Neuritis
Carpal Tunnel Syndrome
Tarsal Tunnel Syndrome
Costochondritis
Tietze's Syndrome
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
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 Injection
s 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
Paresthesia
s
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
)
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
Corticosteroid
s
Steroid
Arthropathy
(0.8%)
Tendon rupture (<1%)
Facial
Flushing
(<1%)
Skin atrophy or depigmentation (<1%)
Iatrogenic
Infectious Arthritis
post-
Arthrocentesis
Septic 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 Sugar
s 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 Sugar
s (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
Choudhry (2016) JBJS Rev 4(3): e5 [PubMed]
Wang (2006) J Hand Surg 31(6):979-81 [PubMed]
Younes (2007) Joint Bone Spine 74(5): 472-6 [PubMed]
Reference
Gray (1983) Clin Orthop Relat Res, (177): 253-63 [PubMed]
Medications
Gene
ral
Local Anesthetic
See
LAST Reaction
Lidocaine
Bupivacaine
Ropivacaine
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)
Degenerative Joint Disease
Sit (2020) Ann Fam Med 18(3): 235-42 [PubMed]
Tendinopathy
or ligamentous disorders
Scarpone (2008) Clin J Sport Med 18(3): 248-54 [PubMed]
Hyaluronic Acid (limited evidence of marginal benefit)
Knee Osteoarthritis
Platelet
rich plasma (low efficacy and expensive)
Knee Osteoarthritis
Lateral epicondylopathy (
Tennis Elbow
)
Medications
Corticosteroid
s Based on Duration and Potency
See
Injectable Corticosteroid
for dosing
Short-Acting and Low Potency
Cortisone
Hydrocortisone
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)
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
Technique
Specific Injections
Gene
ral
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
See
Tendon Sheath Injection
See
Trigger Point Injection
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
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
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
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
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
Knee Injection
Knee Osteoarthritis
Fair evidence of good short-term but poor long-term relief
Foot
Injection
Morton Neuroma
No evidence available for short-term or long-term relief
References
Foster (2015) Am Fam Physician 92(8): 694-9 [PubMed]
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]
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