Académique Documents
Professionnel Documents
Culture Documents
Injection techniques are helpful for diagnosis and therapy in a wide variety of muscu-
loskeletal conditions. Diagnostic indications include the aspiration of fluid for analysis O A patient informa-
and the assessment of pain relief and increased range of motion as a diagnostic tool. tion handout about
joint and soft tissue
Therapeutic indications include the delivery of local anesthetics for pain relief and the
injection, written by
delivery of corticosteroids for suppression of inflammation. Side effects are few, but the authors of this
may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tis- article, is provided on
sue atrophy. Injection technique requires knowledge of anatomy of the targeted area page 290.
and a thorough understanding of the agents used. In this overview, the indications,
contraindications, potential side effects, timing, proper technique, necessary materials,
pharmaceuticals used and their actions, and post-procedure care of patients are pre-
sented. (Am Fam Physician 2002;66:283-8,290. Copyright 2002 American Academy of
Family Physicians.)
I
This article is one in a njection of joints, bursae, tendon pathology. Physical examination is extremely
series of Office Proce- sheaths, and soft tissues of the human helpful in ascertaining the diagnosis. Knowl-
dures articles coordi-
body is a useful diagnostic and thera- edge of the anatomy of the area to be injected
nated by Dennis A.
Cardone, D.O., peutic skill for family physicians. is essential. Intratendinous injection should
C.A.Q.S.M., associate With training, physicians can incor- be avoided because of the likelihood of weak-
professor, and Alfred F. porate joint and soft tissue injection into ening the tendon. Corticosteroid injections
Tallia, M.D., M.P.H., daily practice, yielding many benefits. For also should be avoided in cases of Achilles or
associate professor,
example, a lidocaine (Xylocaine) injection patella tendinopathies.
Department of Family
Medicine, UMDNJ into the subacromial space can help in the Therapeutic responses to corticosteroid
Robert Wood Johnson diagnosis of shoulder impingement syn- injections are variable.4 The patients response
Medical School, New dromes, and the injection of corticosteroids to previous injection is important in deciding
Brunswick, New Jersey. into the subacromial space can be a useful whether and when to proceed with reinjec-
therapeutic technique for subacromial tion. Most patients, if they are going to
impingement syndromes and rotator cuff respond, will respond after the first injection.
tendinopathies. Evidence-based reviews of If the patient has achieved significant benefit
joint and soft tissue injection procedures after the first injection, an argument can be
have found few studies that support or refute made to give a second injection if symptoms
the efficacy of common joint interventions in recur. However, patients who have gained no
medical practice.1-3 However, substantial symptom relief or functional improvement
practice-based experience supports the effec- after two injections should probably not have
tiveness of joint and soft tissue injection for any additional injections, because a subse-
many common problems. quent positive outcome is low.
These injections are most useful in If therapeutic effect is achieved, a maximum
instances of joint or tissue injury and inflam- of four injections per year is recommended.
mation. History of pain, local and referred, There is some concern that corticosteroid
will provide important clues to the underlying preparations, with repeated use, may accelerate
normal, aging-related articular cartilage atro-
phy or may weaken tendons or ligaments.
Joint and soft tissue injection is most useful in instances of When symptoms are resistant, or when there is
a history of trauma, a radiograph or other
joint and tissue injury and in inflammatory conditions.
imaging study should be performed to help
assist in the diagnosis.
JULY 15, 2002 / VOLUME 66, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 283
the possibility of introducing infection and
Patients who have not gained any symptom relief after two precipitating further or new bleeding into the
steroid injections should probably not have any additional joint. Also, early reaccumulation of fluid can
occur in many cases.
injections.
Therapeutic injection with corticosteroids
should always be viewed as adjuvant therapy.6
The improper or indiscriminate use of corti-
Indications costeroids is likely to have a bad outcome.
The indications for joint or soft tissue aspi- These injections should never be undertaken
ration and injection fall into two categories: without diagnostic definition and a specific
diagnostic and therapeutic. A common diag- treatment plan in place. Physicians should
nostic indication for placing a needle in a joint resist external pressure for a quick return of
is the aspiration of synovial fluid for evalua- athletes to playing sports by the use of joint or
tion. Synovial fluid evaluation can differenti- soft tissue injections. Table 1 lists soft tissue
ate among various joint disease etiologies and joint condition indications for diagnostic
including infection, inflammation, and and therapeutic injections.
trauma. A second diagnostic indication
involves the injection of a local anesthetic to Contraindications
confirm the presumptive diagnosis through As with any invasive diagnostic or thera-
symptom relief of the affected body part. peutic injection procedure, there are absolute
Therapeutic indications for joint or soft tis- and relative contraindications (Table 2).7
sue aspiration and injection include decreased Drug allergies, infection, fracture, and tendi-
mobility and pain, and the injection of med- nous sites at high risk of rupture are absolute
ication as a therapeutic adjunct to other forms contraindications to joint and soft tissue
of treatment.5 Caution must be exercised injection. Relative contraindications are less
when removing fluid for pain relief because of well defined and should be considered on a
case-by-case basis. Physicians should be aware
that the contraindications listed are for thera-
TABLE 1 peutic injection and do not apply for diagnos-
Indications for Diagnostic and tic aspiration of joints or soft tissue areas. For
Therapeutic Injection instance, suspected septic arthritis is a con-
traindication for therapeutic injection, but an
Soft tissue conditions indication for joint aspiration.
Bursitis
Tendonitis or tendinosis Timing of Injections
Trigger points Appropriate timing can minimize compli-
Ganglion cysts
cations and allow a clear diagnosis or thera-
Neuromas
peutic response. For diagnostic injections, the
Entrapment syndromes
Fasciitis
procedure should be performed when acute
or chronic symptoms are present, when the
Joint conditions
diagnosis is unclear or needs to be confirmed,
Effusion of unknown origin or suspected infection
(only diagnostic) when consideration has been given to other
Crystalloid arthropathies diagnostic modalities, and when septic arthri-
Synovitis tis has been ruled out (by aspiration and fluid
Inflammatory arthritis analysis). For therapeutic injections, the pro-
Advanced osteoarthritis cedure should be performed when acute or
chronic symptoms are present, after the diag-
284 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 2 / JULY 15, 2002
Joint Injections
JULY 15, 2002 / VOLUME 66, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 285
attention to the depth of needle insertion to
Low-solubility corticosteroid agents should not be used avoid needle trauma to articular cartilage.
for soft tissue injection because of the increased risk of Finally, avoid injecting several large joints
simultaneously because of the increased risk
surrounding tissue atrophy.
of hypothalamic-pituitary-adrenal suppres-
sion and other adverse effects.9
Address correspondence to Dennis A. Cardone, D.O., Department of Family Medicine, Potential Complications
University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical
School, 1 Robert Wood Johnson Pl. MEB288, New Brunswick, NJ 08903 (e-mail: car- A number of potential complications can
donda@umdnj.edu). Reprints are not available from the authors. arise from use of joint and soft tissue proce-
286 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 2 / JULY 15, 2002
Joint Injections
dures.10 Local infection is always possible, but sign documentation that informed consent
it can be avoided by following the proper tech- for the procedure was given and understood.
nique. Joint injections should always be per- A third party should witness the patients
formed using sterile procedure to prevent signing. Documentation is kept as part of the
iatrogenic septic arthritis. Local reactions at patients record.
the injection site may include swelling, tender-
ness, and warmth, all of which may develop a Necessary Equipment
few hours after injection and can last up to All joint and soft tissue injection or aspira-
two days. A postinjection steroid flare, tion techniques should be performed wearing
thought to be a crystal-induced synovitis gloves. When injecting or aspirating a joint
caused by preservatives in the injectable sus- space, sterile technique should be used. Non-
pension, may occur within the first 24 to 36 sterile gloves can be used when injecting or
hours after injection.11 This is self-limited and aspirating soft tissue regions. Necessary
responds to application of ice packs for no equipment for joint and soft tissue injection
longer than 15-minute intervals. or aspiration is listed in Table 4.
Soft tissue (fat) atrophy and local depig-
mentation are possible with any steroid injec- Site Preparation
tion into soft tissue, particularly at superficial The entry point for injection or aspiration
sites (e.g., lateral epicondyle). Periarticular should be identified. The point of entry can be
calcifications are described in the literature, marked with an impression from a thumb-
but they are rare. Tendon rupture can be nail, a needle cap, or an indelible ink pen. The
avoided by not injecting directly into the ten- important goal is to minimize risk of infection
don itself. at the site. Prepare the area with an alcohol or
Systemic effects are possible (especially after povidone-iodine (Betadine) wipe. For all
triamcinolone acetonide [Aristocort] injec-
tion or injection into a vein or artery), and
patients should always be acutely monitored
TABLE 4
for reactions. Alterations in taste have been
Equipment Tray Contents for Joint
reported for one to two days after steroid or Soft Tissue Injection or Aspiration
injection. Hyperglycemia is possible in
patients who have diabetes.
Alcohol wipes
To avoid direct needle injury to articular Povidone-iodine (Betadine) wipes
cartilage or local nerves, attention should be Sterile and nonsterile gloves
paid to anatomic landmarks and depth of Sterile drapes
injection. Other rare, but possible, complica- 25- to 30-gauge 0.5- to 1.0-inch needle for local
tions include pneumothorax (when injecting skin anesthesia
thoracic trigger points), perilymphatic depig- 18- to 20-gauge 1.5-inch needle for aspirations
mentation, steroid arthropathy, adrenal sup- 22- to 25-gauge 1.0- to 1.5-inch needle for injections
pression, and abnormal uterine bleeding. 1 mL- to 10 mL-syringe for injections
3 mL- to 60 mL-syringe for aspirations
Informed Consent Local anesthetic
Corticosteroid preparation
Informed consent should always be Laboratory tubes for culture or other studies
obtained for any invasive procedure. Discus- (aspiration)
sion with the patient should include indica- Hemostat (if joint is to be aspirated and then
tions, potential risks, complications and side injected using the same needle)
effects, alternatives, and potential outcomes Adhesive bandage or other adhesive dressing
from the injection procedure. Patients should
JULY 15, 2002 / VOLUME 66, NUMBER 2 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 287
Joint Injections
intra-articular injections, sterile technique tion because of the small possibility of local
should be used. tissue tears secondary to temporarily high
concentrations of steroid. This risk lessens as
Steps for Injection and Joint Aspiration the steroid dissipates. Patients should be edu-
When possible, the patient should be placed cated to look for signs of infection including
in the supine position. This will help prevent erythema, warmth, or swelling at the site of
or mitigate the effects of a vasovagal or synco- injection, or systemic signs including fever
pal episode. Palpate the soft tissue or bony and chills. The patient should keep the injec-
landmarks. Follow the steps for site prepara- tion site clean and may bathe.
tion. For soft tissue injections, the following
modalities may be used for short-term partial The authors indicate that they do not have any con-
flicts of interest. Sources of funding: none reported.
anesthesia: applying ice to the skin for five to
10 minutes; applying topical vapo-coolant REFERENCES
spray; or firmly pinching the skin for three to
1. Nelemans PJ, de Bie RA, de Vet HC, Sturmans F.
four seconds at the injecting site.12 Once the Injection therapy for subacute and chronic benign
skin is anesthetized, the needle should be low back pain. Cochrane Database Syst Rev
inserted through the skin to the site of injec- 2000;2:CD001824.
2. Assendelft WJ, Hay EM, Adshead R, Bouter LM. Cor-
tion. To prevent complications, adhere to ster- ticosteroid injections for lateral epicondylitis: a sys-
ile technique for all joint injections; know the tematic overview. Br J Gen Pract 1996;46:209-16.
location of the needle and underlying 3. van der Heijden GJ, van der Windt DA, Kleijnen J,
Koes BW, Bouter LM. Steroid injections for shoul-
anatomy; avoid neuromuscular bundles; avoid der disorders: a systematic review of randomized
injecting corticosteroids into the skin and sub- clinical trials. Br J Gen Pract 1996;46:309-16.
cutaneous fat; and always aspirate before 4. Owen DS. Aspiration and injection of joints and
soft tissues. In: Kelley WN. Textbook of rheumatol-
injecting to prevent intravascular injection. ogy. 5th ed. Philadelphia: Saunders, 1997:591-
The injection should flow easily and should 608.
not be uncomfortable to the patient. Most pain 5. Nelson KH, Briner W Jr, Cummins J. Corticosteroid
injection therapy for overuse injuries. Am Fam
is the result of tissue stretching and can be mit- Physician 1995;52:1811-6.
igated by injecting slowly. If there is strong 6. Zuckerman JD, Meislin RJ, Rothberg M. Injections
resistance while injecting, the needle may be for joint and soft tissue disorders: when and how
to use them. Geriatrics 1990;45:45-52,55.
intramuscular, intratendinous, or up against 7. Genovese MC. Joint and soft-tissue injection. A
bone or cartilage, and it should be repositioned. useful adjuvant to systemic and local treatment.
Postgrad Med 1998;103:125-34.
8. Kerlan RK, Glousman RE. Injections and techniques
Postinjection Instructions and Care
in athletic medicine. Clin Sports Med 1989;8:541-
An adhesive dressing should be applied to 60.
the injection site. To minimize pain and 9. Gray RG, Gottlieb NL. Intra-articular corticosteroids.
An updated assessment. Clin Orthop 1983;177:
inflammation after leaving the office, the 235-63.
patient should be advised to apply ice to the 10. Stefanich RJ. Intra-articular corticosteroids in the
injection site (for no longer than 15 minutes at treatment of osteoarthritis. Orthop Rev 1986;
15:65-71.
a time, once or twice per hour), and non- 11. Pfenninger JL. Joint and soft tissue aspiration and
steroidal anti-inflammatory agents may be injection. In: Pfenninger JL, Fowler GC, eds. Proce-
used, especially for the first 24 to 48 hours. dures for primary care physicians. St. Louis: Mosby,
1994:1036-54.
The affected area should be rested from stren- 12. Scott W. Injection techniques and use in the treat-
uous activity for several days after the injec- ment of sports injuries. Sports Med 1996;22:406-16.
288 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 2 / JULY 15, 2002