Local glucocorticoid injections in soft tissues and joints

EBM Guidelines
Aug 16, 2018 • Latest change Oct 4, 2018
Ilkka Kunnamo

Table of contents

Extract

  • The skin is carefully cleaned with spirit-containing cleanser, and good aseptic principles are followed in performing the puncture. The site of the injection is determined and marked before cleansing (video Marking the site for puncture1).
  • If an ultrasound device is available, it is used, as necessary, to check the existence and location of fluid.
  • Soft tissues, the glenohumeral joint, the subacromial bursa and the trochanteric bursa are treated with an injection containing a glucocorticoid and a local anaesthetic in the proportion of 1:1 to 1:2, or a glucocorticoid and 0.9% NaCl in the proportion of 1:1. Small joints, other joints (provided that fluid can be obtained through aspiration) and bursae are treated with glucocorticoid only without an anaesthetic. An observed local effect of the anaesthetic soon after the injection also serves as a diagnostic test in the treatment of disorders in the glenohumeral region and in bursitides.
  • Intra-articular injections should be reserved for inflamed joints: swelling or hydrops and pain (see Clinical diagnosis of joint inflammation in the adult1).
  • Triamcinolone
    • In the knee joint 20–40 mg
    • In other large joints (elbow, wrist) 20 mg if there is obvious inflammation or if fluid can be aspirated
  • Methylprednisolone 12–80 mg depending on the size of joint/injection area
  • The needle should be as thin (see table Recommended needle size for injections into soft tissues and joins1) and the pressure applied as light as possible (do not inject against a counter pressure) so as not to damage the joint cartilage or tendons.
  • Aspiration of the joint before a glucocorticoid is injected enhances the therapeutic effect at least in rheumatoid arthritis.
  • In acute arthritis, injection to the same large joint more frequently than once a month during the first 3 months or more than 4 injections per year is not recommended. Smaller joints (other than weight-bearing joints) may be injected more frequently. In osteoarthritis, the same joint should not be injected more frequently than at 3-month intervals, and injections should only be given if other treatments are insufficient. There is no unambiguous evidence on the possible harm to the joint cartilage caused by repeated injections. Systemic adverse effects are possible if injections are given more frequently than at 4–6-week intervals.
  • Partial immobilization of the joint for 24 hours and avoiding vigorous exercise for a week after the injection improves the result of the treatment, at least as far as the large joints are concerned.
    • In weight-bearing joints, the immobilization should be as complete as possible for 24 hours. Without immobilization, the drug is absorbed too quickly from the joint to the blood circulation and its effect is decreased.

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Arthritis, Bursitis, Elbow Joint, Finger Joint, Glucocorticoids, Injections, Injections, Intra-Articular, Internal medicine, Knee Joint, Metacarpophalangeal Joint, Metatarsophalangeal Joint, Methylprednisolone, Physical medicine, Popliteal Cyst, Rheumatology, Shoulder Joint, Steroids, Tarsal Joints, Temporomandibular Joint, Toe Joint, Triamcinolone, Wrist Joint, corticosteroid injections, injection needle, proximal interphalangeal joint, soft tissue injection, steroid-anethetic injection, steroid-injections, subacromial bursitis, tendon sheath, trochanteric bursitis