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Joint InjectionAka: Soft Tissue Injection

See Also
Indications: Articular conditions
1. Rheumatoid Arthritis
2. Seronegative Spondyloarthropathy
  1. Ankylosing Spondylitis
  2. Inflammatory Bowel Disease arthritis
  3. Psoriasis
  4. Reiter's Syndrome
3. Crystal-induced arthritis
  1. Gout
  2. Pseudogout
4. Osteoarthritis
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
Contraindications: Intra-articular injection
1. Overlying Cellulitis
2. Severe coagulopathy
3. Anticoagulant therapy (relative contraindication)
4. Septic effusion
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
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 >4 week intervals
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
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 (<.07%)
7. Transient paresis of injected extremity (Rare)
8. Hypersensitivity Reaction (rare)
9. Asymptomatic pericapsular calcification (43%)
10. Hyperglycemia in Diabetes Mellitus patients
11. Acceleration of cartilage attrition (unknown)
12. Reference
  1. Gray (1983) Clin Orthop Relat Res 177):253
Preparations
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 (Aristocort, Aristospan, Kenalog)
  4. Methylprednisolone acetate (Depo-Medrol)
4. Long-Acting and High Potency
  1. Dexamethasone sodium phosphate (Decadron)
  2. Betamethasone (Celestone Soluspan)
Needles
1. Joint Injection
  1. Needle Gauges 22-25 with length of 1.5 inches
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
Reference

Rheumatology Book

Intra-Articular Disorders

Myofascial Pain

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Joint InjectionAka: Soft Tissue Injection

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