Joint Injections/Aspiration

Overview and Description

Joint injections and aspirations are valuable procedures for managing musculoskeletal conditions, both for diagnostic and therapeutic purposes. As with any procedure, success depends on knowing the correct diagnosis, correct procedure, and using the best medication. Joint aspirations play a critical role in the diagnosis of inflammatory arthropathies. When the underlying diagnosis is unknown, aspiration and synovial fluid analysis should be performed for diagnostic purposes to look at crystals, Gram stain, glucose, uric acid, and/or total protein. Aspiration of synovial fluid from a swollen joint, due to synovitis or hemarthrosis, may quickly relieve severe pain by reducing intra-articular pressure. If septic arthritis is highly suspected, steroid injection should be deferred after exclusion of sepsis by joint fluid culture.

The purpose of therapeutic joint injections is to relieve pain, reduce inflammation, and improve mobility. Local anesthetics may be injected with corticosteroids to provide additional, rapid pain relief.

Relevance to Clinical Practice

As for any musculoskeletal complaint, it is imperative to obtain a careful history and thorough physical examination. Red flags such as infection or malignancy should be ruled out. A functional assessment of the patient should be obtained. Judicious use of imaging studies and laboratory tests should be ordered when appropriate. Once a diagnosis is established, an outlined treatment plan should be given. Joint injections can be done for diagnostic and therapeutic purposes to aid with the rehabilitation program.

Peripheral joint injections and aspirations can be done with or without imaging (landmark-guided). Ultrasound guidance is more commonly used when treating peripheral joints, while fluoroscopy is more commonly used to view axial joints. Current data shows that performing peripheral joint or soft tissue injections with ultrasound guidance improves accuracy; however, there are conflicting results on differences in improvements in pain, function, and quality of life.^1-3

As with any procedure, informed consent must be obtained from the patient. For documentation purposes, this should be done in a written format. Risks, benefits, alternatives, and expectations from the proposed procedure should be explained, and the patient should have adequate opportunities to ask questions.

One commonly used injectate for therapeutic treatment of a painful joint is an anti-inflammatory steroid. Selection of steroids for injections depends on the practice and level of comfort of the physician. The clinical effects of steroids result from several different mechanisms of action. Intra-articular corticosteroids work by reducing synovial blood flow, lowering the local leukocyte and inflammatory modulator response, and altering local collagen synthesis.⁴ The combination of these effects reduces pain and inflammation. Hydrocortisone esters are more effective in producing these effects than their parent compounds. Solubility is reduced when there is a branched esterification of the corticosteroid, allowing them to remain at the injection site longer.⁵ Clinically, insoluble steroids have a longer duration of action and a higher incidence of cutaneous side effects. Triamcinolone hexacetonide is the least soluble of the commonly used injectable steroids and has a longer duration of action, followed by triamcinolone acetonide. Betamethasone has a high solubility, shorter duration of action, and fewer cutaneous side effects. A table of commonly used injectable corticosteroids and their clinic characteristics is summarized below.⁴³

The injectable lidocaine maximum dose is 300mg or 4.5mg/kg.⁶ For example 2% lidocaine = 2g/100mL or 20mg/mL, therefore, to inject 100mg = 5mL of 2%. There have been no randomized controlled trials to show the best dose of steroids for peripheral joints. Recent publications show no enhanced improvement with doses higher than equivalent of 40mg methylprednisolone or 10mg dexamethasone; though, with doses higher than this, there are increased side effects including reduced immunity.

Bupivacaine and lidocaine have been shown to be chondrotoxic, though toxicity is based on amount of time the chondrocyte are exposed and the dose of local anesthetic.^7,8 This research was more aimed at studying post-op bupivacaine pain pumps which the dose and time are much greater than performing a single joint injection.

As with the choice of corticosteroids, the choice of local anesthetic for injection is based on clinical preference. When both the corticosteroids and local anesthetics are used together, many patients will experience relatively rapid relief of symptoms immediately following the injection. This is the initial action of the local anesthetic. However, patients then often experience a transient increase in pain as the local anesthetic wears off. Commonly used local anesthetics and their clinical characteristics are summarized below.

Contraindications to intra-articular injection include:

• Broken skin at injection site
• Known hypersensitivity to intra-articular agent
• Osteochondral or intra-articular fracture
• Prosthetic joint (relative contraindication)
• Skin infection overlying injection site
• Avascular necrosis

There has been debate on whether to discontinue anticoagulation prior to performing a peripheral joint injection. However, the majority of research states that there is likely a greater risk in discontinuing anticoagulation and thus it is not recommended to hold anticoagulation. ASRA (American Society for Regional Anesthesia) classifies peripheral joint injections as low risk for bleeding.^9-12

Single intra-articular steroid injections can have a transient yet significant effect on blood glucose levels, especially in patients with diabetes mellitus, but have little long-term effect on glycemic control.¹³ Soft tissue or peritendinous injections can cause elevation of blood glucose that persist from 5 to 21 days.¹⁴ Although significant complications are exceedingly rare, patients should be warned of hyperglycemia and those with diabetes mellitus should be advised to monitor their blood glucose for at least one week following a corticosteroid injection or until their blood glucose levels return to baseline. Prior to the procedure, patients with diabetes mellitus should check their blood glucose for at least two days. There is no safe cut-off established; however, some providers would suggest waiting until blood glucose is less than 200 mg/dl or A1c less than 10% before proceeding with the intervention.¹⁵

The most common complications of intra-articular steroid injection are¹⁶

• Post-injection flare of pain (5%)
  • This risk can be reduced by taking a one-time oral NSAID after the injection.
  • Less soluble formulations, such as triamcinolone, have higher risk than soluble forms.
  • Infection, rather than the more common post-injection flare, should be suspected if the flare lasts longer than or begins later than 48 hours after injection. The usual post-injection flare lasts hours rather than days.
• Skin atrophy (1%)
• Fat atrophy (1%)
• Facial flushing (up to 10%)
• Iatrogenic infection (<0.1%)
  • The CDC and WHO recommend single use alcohol swabbing vial tops to reduce this risk.¹⁷

The timing of when to perform therapeutic joint injection is debatable. There is no research to show the best time to perform an injection. A common practice pattern is waiting 3 months prior to performing therapeutic joint injection; during the 3-month period, activity modification, physical therapy, and medications can be used to facilitate pain control and functional recovery.¹⁸

Care should be taken to not overly utilize steroid injections as cartilage reduction has been shown to occur.¹⁹ If patients get pain relief and improved function but pain returns, then it seems reasonable to repeat every few months to maintain function and avoid surgery.

While corticosteroid injections are most frequently utilized, an alternative injectate includes nonsteroidal anti-inflammatory drugs (NSAIDs), most commonly ketorolac. Studies have shown that pain relief is similar between steroid and NSAID peripheral joint injections, and there is also less chondrotoxicity based on animal studies. This alternative is especially helpful in patients where steroid injections may be contraindicated, such as due to uncontrolled diabetes.^20,21

Another therapeutic medication to treat joint pain is hyaluronic acid (HA), or viscosupplementation. It appears to have a slower onset of action than intra-articular steroids, but the effect can last longer.^22,23 Viscosupplementation has been shown to be an effective treatment for OA of the knee with beneficial effects on pain, function, and patient global assessment at different post-injection periods, but especially at the 5- to 13-week post-injection period, with an effect on the reduction of NSAIDs monthly consumption.²² Various FDA approved formulations of hyaluronic acid exist and are summarized below.

Radiofrequency ablation (RFA) is a form of neurolysis and is a growing treatment modality that can treat both axial and peripheral joint pain. A high radiofrequency electrical current in an insulated needle tip generates thermal energy in an RFA. When properly placed, the thermal energy can create a small lesion in a nerve and disrupt the pain signal. Axial RFAs are performed under fluoroscopy, while peripheral knee RFAs can be performed under fluoroscopic and ultrasound guidance.²⁴ In axial facetogenic low back pain, medial branch radiofrequency ablation may provide benefit if high-quality selection criteria that utilize history, exam, and medial branch nerve blocks are employed. The geniculate nerve of the knee is the best studied peripheral joint target for RFA. For chronic knee pain, there is high quality evidence demonstrating geniculate nerve RFA to be superior in efficacy with fewer serious adverse events when compared to non-surgical treatment with NSAIDs and intraarticular corticosteroid injections.^25,26 Recent studies have demonstrated that RFA therapy to the articular sensory branches of the shoulder and hip can provide relatively long-lasting pain relief with minimal significant complications.^27-29 It is common practice to perform a low-dose steroid injection at the site of the RFA to theoretically decrease the chance of neuroma formation and decrease peri-procedural pain.

More recently, cooled RFA (CRFA) and cryoablation have been proposed as effective treatments for peripheral joint pain. CRFA differs from traditional RFA in that it uses an internal water-cooling system that enables the probe to deliver larger and more spherical nerve lesions. Cryoneurolysis (CRYO) is a novel technique that involves targeted application of severe cold temperatures to peripheral nerves. CRYO differs from CRFA, in that disrupts nerve function without ablating the nerve or damaging the structural contents of the nerve bundle.^30,31

Cutting Edge/Unique Concepts/Emerging Issues

There’s growing interest in the use of platelet-rich plasma (PRP) injections for treating musculoskeletal conditions, especially knee osteoarthritis. A number of recent reviews and meta-analyses have shown PRP to be helpful in reducing pain, stiffness & function in knee osteoarthritis while compared to placebo and other intra-articular injections such as corticosteroids and hyaluronic acid.^32,33 While the strongest evidence supports its use in knee OA, there are emerging results on the benefits for other joint conditions like adhesive capsulitis and hip osteoarthritis.^34,35 Controversy in PRP comes from mixed efficacy in research and clinical practice. A suggested reason for this is that outcomes for intra articular PRP injections will vary depending on how the PRP is prepared (number of platelets, concentration, leukocyte poor vs rich etc.). Other considerations include the number of injections needed and the interval time between them. Regardless of these limitations, the overall takeaway is PRP injections appear to be a safe and good non-invasive option, particularly for patients with mild to moderate disease. Future research is needed for the development of PRP injection guidelines. Another limitation for PRP use is its high cost, as it is not yet accepted by most insurances.³⁶

There is also some evidence on the utility of proliferative injection therapy, or prolotherapy, for the treatment of peripheral joint disorders including osteoarthritis. While there is some strong evidence suggesting its efficacy for knee osteoarthritis and sacroiliac joint pain, data continues to remain limited and more high-quality studies are needed to demonstrate the efficacy of these injections.^37,38

Another controversial injectate being used is Ozone, with most of its research being focused on knee osteoarthritis. Several systematic reviews show ozone injections to be more effective than placebo, and some randomized trials found ozone to be superior to corticosteroid with longer-lasting effects, and better safety profile. However, there is no evidence to prove its superiority to other intra-articular treatments like hyaluronic acid. The research on its efficacy is limited by poor study quality and inconsistent protocols, but this treatment appears to be safe with a low cost.^39,40

Gaps in Knowledge/Evidence Base

Stem cell injections have gained popularity, with promising results. Cell therapy by implanting autologous chondrocytes has been used to regenerate local defects in the cartilage for years. Mesenchymal stromal cells (MSC) have chondrogenic potential or are enhanced by co-culture of chondrocytes. They possess two potentials: the ability to differentiate into skeletal cell lineage and the capacity to self-renew for a relatively long period of time. MSC can be accessed from several sources, including bone marrow aspirates.⁴¹ In general, evidence about the efficacy of stem cell injections is limited due to bias, size of studies, and variability in stem-cell source (bone marrow aspirate, adipose, or peripheral blood). The evidence available suggests that stem cells could be beneficial in treating knee OA and tendonous disorders. However higher quality studies are needed to make a recommendation for stem cell therapy.^42,43 Cost is another issue with PRP and stem cells as commercial and government insurances do not cover it.

References

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14. Choudhry, M.N.; Malik, R.A.; Panayioto, C. Blood Glucose Levels Following Intra-Articular Steroid Injections in Patients with Diabetes, JBJS Reviews: March 22, 2016 – Volume 4 – Issue 3 – e5
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19. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA. 2017;317(19):1967.
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43. Joshi, A. M., & Gharib, M. (2024, August 29). Steroids and corticosteroids. PM&R KnowledgeNow. https://now.aapmr.org/steroids-and-corticosteroids/

Original Version of the Topic

Jose Mena, MD, German Ojeda Correal, MD, Eddymé Danger, MD. Joint injections /aspiration. 9/20/2013

Previous Revision(s) of the Topic

Casey Murphy, MD; Stephen Kishner, MD. Joint injections /aspiration. 3/23/2017

Casey Murphy, MD, Alpha Anders, MD. Joint Injections/Aspiration. 2/9/2022

Author Disclosure

Yolanda Pham, MD, MPH
Nothing to Disclose

Anthony Iuso, DO
Nothing to Disclose

Petra Aboulhosn, MD
Nothing to Disclose

Derek Ho, DO
Nothing to Disclose