Prescribing in practice

Practical guide to joint and soft

tissue injection techniques
James Galloway MRCP and Marwan Bukhari PhD, FRCP
Steroid injections are a key
tool in the management of
musculoskeletal conditions
and are now the most fre-
quently performed proce-
dure in rheumatological
practice. Here, the authors
illustrate the correct tech-
nique for administering
these injections and high-
light some of the points to
consider.
Figure 1. The authors encourage a medial approach to injection of the knee joint; a
combination of 40mg triamcinolone acetonide and 4ml lidocaine is recommended

usculoskeletal conditions ment – up to six months – from a for the treatment of localised
M account for a vast number of
attendances in primar y care.
single joint injection. The longer-
term benefits of intra-articular
inflammation. These include
trochanteric bursitis, flexor teno-
Treatment of these problems steroids have been less well synovitis, medial or lateral epi-
involves a number of therapeutic defined. There is limited evidence condylitis, and carpal tunnel
options, including intra-articular that supports their role in reducing syndrome.
aspiration and injection. synovial inflammation and destruc-
Joint injections were first tion, and no evidence suggesting Joint aspiration
attempted in the 1920s, using sub- that they cause adverse effects on The usual indication for joint aspi-
stances such as lactic acid or petro- the joint when given in appropri- ration is to evaluate an acutely
leum jelly. It was not until the early ate doses at not more than three or swollen and inflamed (‘hot’) joint.
1950s that intra-articular injections four times per year.1,2 Synovial fluid analysis allows differ-
of steroids was introduced and Osteoarthritis (OA) is a weaker entiation between crystal arthropa-
shown to be helpful. 1,2 They are indication for steroid injection – a thy and sepsis. There is also some
now the most frequently per- single trial has shown no benefit of evidence to support the routine
formed procedure in rheumato- intra-articular steroids over saline, aspiration of joints prior to steroid
logical practice.3 although other studies have been injection to improve efficacy.6
more optimistic.5 However, in prac-
Indications tice, many rheumatologists use Type of agent to use (see
Joint injection intra-articular steroids for OA with Table 1)
The primary indication for joint apparent success. Should lidocaine be mixed with the
injection is inflammatory arthritis4 steroid?
(eg rheumatoid arthritis, spondyl- Soft tissue injection Many rheumatologists will mix
arthropathies). Many patients will There are many soft tissue injec- some local anaesthetic with their
experience prolonged improve- tions that are regularly performed steroid preparation for injection.

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Prescribing in practice

Methylpred- Triamcinolone Hydrocortisone

large glycosaminoglycan that occurs
nisolone acetonide
naturally within the synovial fluid.
Their use in veterinary practice to
Available Depo-Medrone Kenalog 40mg/ml 25mg/ml (1ml improve performance in arthritic
doses 40mg/ml Adcortyl 10mg/ml vials) joints dates back many years.
(1, 2 or 3ml vials) (both available in In the USA they were first
available premixed 1ml vials) licensed for human use in 1997,
with lidocaine using a regimen of three to five
injections at weekly inter vals.
Advantages possibly causes possibly causes less associated soft Following the publication of sev-
less postinjection less postinjection tissue atrophy eral randomised trials in the USA
flare flare there was considerable hope for
the use of these products. However,
Disadvantages crystal precipitates shown to be less a more recent meta-analysis sug-
can form if mixed efficacious in gested only a small benefit over
with lidocaine joint injection placebo – perhaps more compara-
ble to the use of NSAIDs. It also
Typical site/ raised concerns over the likelihood
dose of publication bias.
knee 80mg 40mg In summar y, because of its
shoulder 80mg 40mg increased cost along with the
subacromial 40mg 20mg inconvenience of requiring a series
bursa of three to five injections, it should
ankle 40mg 20mg be reser ved for people in whom
soft tissue 25mg other treatment options have
failed.
Table 1. Commonly used preparations for joint injections
Side-effects
There have been several studies • there may be a volume effect of Side-effects of injecting steroids
over the years that have not con- the local anaesthetic on expanding include skin atrophy at the site of
clusively shown benefit of this prac- the joint capsule in shoulder cap- injection, depigmentation and dis-
tice. However, there are some sulitis and other large joints7 coloration at the site.
theoretical reasons why it may be • anaesthetics may reduce post- Postinjection flare is a well-
of benefit: injection flare reported phenomenon, which is
• anaesthetics may also prolong the due to steroid cr ystals forming
Absolute
duration of time the steroid within the joint.
• sepsis within the joint or soft
remains within the joint by pro- Infection is not common8 and
tissue
moting vasoconstriction and is estimated at between 1:2000 and
• prosthetic joints
thereby delaying clearance. 1:20 000 procedures. It can some-
• injection into a tendon
times be difficult to differentiate
What size needle should be used? infection and postinjection flare.
Relative
Generally, the smallest needle pos- Typically, postinjection flare starts
• flare in the joint postinjection
sible should be used, which is nor- and resolves within 48 hours,
when performed previously
mally a 25-gauge (blue) for most whereas infection develops after 48
• active psoriatic lesions (or other
sites. A 22-gauge (green) is prefer- hours and is associated with sys-
skin disease) at the site of
able for knee joints, or for when temic features, eg fever, malaise.
injection
aspiration is expected to reveal vis- There is no real evidence to sug-
• oral anticoagulation (although
cous fluid. gest joint injections predispose to
experienced injectors may
Charcot’s joints, although there are
proceed with caution)
Hyaluronic acid some anecdotal reports associated
Intra-articular hyaluronans are with more frequent injections.
Table 2. Contraindications to joint becoming an increasingly used treat- Systemic glucocorticoid effects
injection ment for OA. Hyaluronic acid is a have been seen only in patients

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Prescribing in practice

Injection technique

Joint and soft tissue injections should be used in conditions that are clearly
demarcated and well diagnosed and in which the injector is comfortable with
the procedure. Some general guidance follows:
• exact location of the needle is not always necessary as even the more
experienced injectors can obtain good response rates with periarticular
injections13
• it is a clean, not sterile procedure; evidence suggests that, despite wide
variation in precaution against sepsis, this is rare8
• anatomical landmarks are important and using them reduces the discomfort
of scraping bone
• a drawing-up needle should be used that is separate from the injecting
needle (no touch technique)14
• 24-48 hours rest is beneficial, especially in weight-bearing joints 15
• they should be administered at a maximum of 3 a year as they tend to lose
their efficacy over time in noninflammatory conditions

receiving injections on a regular (Kenalog) combined with 4ml

basis, ie every month.9,10 lidocaine.
Hypersensitivity to injected There are multiple approaches
steroids can occur and is probably that are described for knee joint
due to the diluent rather than the injection. We recommend a medial
steroid itself. approach. Locating the insertion of
the tendon of quadriceps femoris
Common injection areas – into the proximal patella, follow one-
anatomical approach to third of the way around the medial
specific injection sites border of the patella and insert the
Knee joint needle 2cm below this parallel to
Painful knee effusions in patients the horizontal axis (see Figure 1).
with rheumatic disease are both
common and disabling. Aspiration Shoulder
can relieve significant pressure and Glenohumeral joint This is one of the
increase range of movement, while commonest places for injection.
steroid instillation will often produce Pathology in the glenohumeral
many months of symptom relief. joint tends to present as a global
We recommend using restriction in internal and external
40mg triamcinolone acetonide rotation. The classical example is
adhesive capsulitis (frozen shoul-
der). The other main indication is
rheumatoid or other inflammatory
arthritides.
Injecting the glenohumeral
joint is easiest using the posterior
approach. Tracing the spine of the
scapula laterally to the acromial
angle, the needle should be
inserted approximately 2cm below
this mark, pointing towards the
coracoid process (see Figure 2).
Figure 2. The glenohumeral joint is one Use 4ml of 2 per cent lidocaine and
of the most common sites for injection 40mg triamcinolone acetonide.

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 Prescribing in practice

Subacromial bursa (rotator cuff)

Pain is often described over the lat-
eral aspect of the upper arm (over
the deltoid). Examination reveals
a painful arc, with pain on resisted
abduction. This can be due to the
impingement syndrome, with
inflammation in the subacromial
bursa causing restriction of the
supraspinatus tendon.
It is important to remember
Figure 3. Injection technique for lateral epicondylitis (tennis elbow)
that space is limited in the sub-
acromial bursa, and not more than on the racket and have poor tech- cia lata (running from the anterior
a total of 3ml can be injected. We nique at backhand. superior iliac crest into the iliotib-
recommend 1ml of lidocaine and Medial epicondylitis is often ial tract, which in turn attaches to
1ml of triamcinolone. referred to as ‘golfer’s elbow’, the lateral tibial condyle). The
The safest technique uses a lat- again due to presentation in peo- patient will often complain of dif-
eral approach. The patient should ple learning to play golf. There ficulty walking and of being unable
relax their neck and shoulder mus- have been some case reports of this to sleep on the affected side.
cles, sitting up with hands resting condition occurring with the use of Examination is usually diagnostic
in their lap. The injection is placed fluoroquinolones, possibly through and it is important to exclude
approximately 2cm below the mid- the same mechanism through underlying hip joint pathology.
point of the lateral edge of the which Achilles tendonitis occurs. Initial therapy with analgesics and
acromion – the gap between the Treatment should initially be with passive stretching exercises should
inferior border of the acromion rest and analgesics but, if these fail to be tried in the first instance. If these
and the humeral head is usually control symptoms, a corticosteroid fail, then lidocaine and steroid injec-
palpable – and is angled towards injection is an efficacious option.11 tion are an effective option.12
the opposite humeral head. We recommend using 1ml of Placing the patient in the lateral
local anaesthetic and 25mg hydro- decubitus position, with the hip
Wrist cortisone (Hydrocortistab). flexed to 90° to allow identification
We recommend the use of 2ml of Lateral epicondyle The patient of the superior aspect of the
lidocaine combined with 40mg of should sit with the elbow flexed to greater trochanter, the point of
triamcinolone. 90° and, with the forearm supin- maximal tenderness should be
Position the hand prone and ated (palm upwards), the needle identified and marked as the site
locate the base of the second should then be inserted into the for injection (see Figure 4). There
metacarpal bone. The joint space area over the epicondyle where is more than one bursa over the
is palpable between the extensor of there is maximal tenderness (see greater trochanter so the exact
the index finger and the thumb Figure 3). location of the pain may vary.
abductor. Medial epicondyle Laying the
patient supine, the shoulder should
Elbow (epicondylitis) be rotated externally to around 90°
Many patients presenting with and the elbow flexed to 90°. The
elbow pain have inflammation not injection is made slightly distal to
of the joint but of the periarticular the centre of the epicondyle.
structures. The most common site
is the lateral epicondyle (known as Trochanteric bursa
‘tennis elbow’). The aetiology is Bursitis is one of the commonest
repetitive wrist movements, result- causes of hip pain. Friction occurs
ing in rubbing of the extensor between the bursae around the
carpi radialis tendons over the lat- greater trochanter and both the Figure 4. Injection technique for
eral epicondyle. Classically (and tendon of gluteus medius (which trochanteric bursa; analgesics and
anecdotally), it occurs in novice inserts distally into the greater stretching exercises should be tried in
tennis players who use a tight grip trochanter) and also the tensor fas- the first instance in cases of bursitis

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Prescribing in practice

Other injections injected into arthritic joints: compara- administration of corticosteroid on

In patients in whom recurrent joint tive effect of and use of hydrocortisone markers of bone formation and bone
injections into typically large joints as a local antiarthritic agent. J Am Med resorption in patients with rheumatoid
are needed more than three times a Assoc 1951;147:1629-35. arthritis. Arthritis Rheum 1996;39:277-82.
2. Ziff M, Scull E, Ford D, et al. Effects in 11. Smidt N, van der Windt DA,
year, a yttrium 90 isotope injection
rheumatoid arthritis of hydrocortisone Assendelft WJ, et al. Corticosteroid
can be used in specialist centres;
and cortisone injected intra-articularly. injections, physiotherapy, or a wait-and-
alternatively osmium could be used. AMA Arch Intern Med 1952;90:774-84. see policy for lateral epicondylitis: a
This is usually reserved for patients 3. Bamji AN, Dieppe PA, Haslock DI, et randomised controlled trial. Lancet
with mono- or oligoarthritis. al. What do rheumatologists do? A pilot 2002;359:657-62.
audit study. Br J Rheumatol 1990;29:295-8. 12. Shbeeb MI, O’Duffy JD, Michet CJ
Conclusion 4. Gumpel JM. Intra-articular therapy. In: Jr, et al. Evaluation of glucocortico-
In the past many doctors have been Scott JT, ed. Copeman’s textbook of the steroid injection for the treatment of
reluctant to administer joint injec- rheumatic diseases. 6th ed. Churchill trochanteric bursitis. J Rheumatol
tions. This has been due to fears Livingstone, 1986. 1996;23:2104-6.
regarding adverse events based on 5. Jones A, Doherty M. Intra-articular cor- 13. Jones A, Regan M, Ledingham J, et
ticosteroids are effective in osteoarthritis al. Importance of placement of intra-
old studies using much larger doses
but there are no clinical predictors of articular steroid injections. BMJ
of steroids. More recent data now
response. Ann Rheum Dis 1996;55:829-32. 1993;307:1329-30.
support the use of joint injections 6. Weitoft T, Uddenfeldt P. Importance 14. Charalambous CP, Tryfonidis M,
for many conditions, and the tech- of synovial fluid aspiration when inject- Sadiq S, et al. Septic arthritis following
niques involved are both safe and ing intra-articular corticosteroids. Ann intra-articular steroid injection of the
simple. Rheum Dis 2000;59:233-5. knee – a survey of current practice
This article aims to increase the 7. Mulcahy KA, Baxter AD, Oni OO, et al. regarding antiseptic technique used dur-
knowledge and skills available to The value of shoulder distension arthrog- ing intra-articular steroid injection of the
the general practitioner, therefore raphy with intraarticular injection of knee. Clin Rheumatol 2003;22:386-90.
allowing more comprehensive steroid and local anaesthetic: a follow-up 15. Chakravarty K, Pharaoh PD, Scott
management of rheumatic disease study. Br J Radiol 1994;67:263-6. DG. A randomised controlled study of
8. Pal B, Morris J. Perceived risks of joint post injection rest following intra-artic-
in primary care.
infection following intra-articular corti- ular steroid therapy for knee synovitis.
costeroid injections: a survey of rheuma- Br J Rheumatol 1994;33:464-8.
Further reading
tologists. Clin Rheumatol 1999;18:264-5.
Doherty M. Rheumatology examina- 9. Mader R, Lavi I, Luboshitzky R.
tion and injection techniques. 2nd ed. Evaluation of the pituitary-adrenal axis Dr Galloway is specialist registrar in
London: WB Saunders, 1999. function following single intraarticular rheumatology and Dr Bukhari is con-
injection of methylprednisolone. sultant rheumatologist in the
References Arthritis Rheum 2005;52:924-8. Department of Rheumatology,
1. Hollander JL, Brown EM Jr, Jessar 10. Emkey RD, Lindsay R, Lyssy J, et al. University Hospitals of Morecambe
RA, et al. Hydrocortisone and cortisone The systemic effect of intraarticular Bay, Royal Lancaster Infirmary

56 Prescriber 19 October 2006 www.escriber.com