Local glucocorticoid injections in soft tissues and joints
Table of contents
- 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).
- 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
- In smaller joints and soft tissues. Because of the risk of skin atrophy (picture Atrophy of the skin after corticosteroid injection1), intracutaneous or subcutaneous injection should be avoided.
- In the finger tendon sheaths
- 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.
Linked evidence summaries
- Intra-articular steroid injections in the knee appear to improve pain, movement, stiffness and swelling of the joint in adults with rheumatoid arthritis. The knee should be rested after a steroid injection.B
- Intra-articular corticosteroids may improve pain and function in the treatment of knee osteoarthritis in the short term (up to 6 weeks). Longer term benefits have not been confirmed.C
- Intra-articular injections for adhesive capsulitis of the shoulder may have some short-term beneficial effect.C
- Subacromial corticosteroid injection for rotator cuff disease appears to provide some short-term improvement in pain and range of motion compared to placebo.B
- Corticosteroid and lidocaine injections in combination may be more effective than lidocaine alone for the treatment of trigger finger.C
- Corticosteroid injection may relief pain in pregnant or lactating women with de Quervain apos;s tenosynovitis.C
- Local corticosteroids may have some effect for heel pain in the short term.C
- Local corticosteroid injection for carpal tunnel syndrome provides greater clinical improvement in symptoms one month after injection compared to placebo or systemic steroids.A
- Glucocorticosteroid and lidocaine injection may be an effective therapy for pain in trochanteric bursitis.C
- A corticosteroid injection is an effective treatment for lateral epicondylitis in the short-term pain relief, but the results are paradoxically reversed after six weeks, with high recurrence rates of epicondylitis with corticosteroid injections.A
- Intra-articular hyaluronic acid may have a small effect on pain in comparison with intra-articular placebo in knee osteoarthritis.C
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