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 arthrocentesis, 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 concerning issues such as infection and 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 injection and aspiration can be done with or without imaging. Ultrasound guidance is more commonly used when treating peripheral joints while fluoroscopy is more commonly used to view axial joints. Data seem to be clear that performing peripheral joint or soft tissue injections with ultrasound improves accuracy; though, research has conflicting results on improvements in pain, function, and quality of life.1-4
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, and expectation from the proposed procedure should be explained, and the patient should have adequate opportunity to ask questions.
One medication 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.5 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.6 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.
The injectable lidocaine maximum dose is 300mg or 4.5mg/kg.7 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. Most 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 immune system to fight against infection.
Bupivicaine and lidocaine have been shown to be chondrocytotoxic, though toxicity is based on amount of time the chrondrocytes are exposed and the dose of local anesthetic.8,9 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.
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 giving a peripheral joint injection. A review of the current literature shows that there is likely more risk in discontinuing anticoagulation than continuing anticoagulation while performing peripheral joint injection. ASRA (American Society for Regional Anesthesia) classifies peripheral joint injections as low risk for bleeding.10
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.11 Soft tissue or peritendinous injections can cause elevation of blood glucose that persist from 5 – 21 days.12 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 before proceeding with the intervention.13
The most common complications of intra-articular steroid injection are14
- Post-injection flare of pain (5%)
- This risk can be reduced by taking a one-time oral NSAID after the injection
- Less soluble formulations, 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 risk15
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 which is generally accepted 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 hopefully get pain control and functional recovery.16
Care should be taken to not overly utilize steroid injections as cartilage reduction has been shown to occur.17 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.
Another therapeutic medication to treat joint pain is hyaluronic acid, HA. This can be called viscosupplementation. It appears to have a slower onset of action than intra-articular steroids, but the effect can last longer.17,18 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.17
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.20 In axial facetogenic low back pain, medial branch radiofrequency ablation may provide benefit if high-quality selection criteria that utilizes history, exam, and medial branch nerve blocks is 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.21,22 The shoulder and hip are other potential targets for RFA therapy that require more high-quality studies to determine safety and efficacy.23,24 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.
Cutting Edge/ Unique Concepts/ Emerging Issues
Ultrasound guided percutaneous tenotomy is an emerging minimally invasive treatment modality for tendinopathy made possible by ultrasound. Traditionally, a needle is used to fenestrate an injured tendon by repeatedly passing the needle through focal areas of tendinopathy as visualized by ultrasound.25,26 This is thought to convert a degenerative process to an acute inflammatory process that can enable tendon healing. Advances in technology has enabled percutaneous ultrasonic tenotomy (PUT): phacoemulsifaction with equipment that simultaneously debrides and aspirates necrotic tissue in the injured tendon. Percutaneous tenotomy can lead to symptomatic and functional improvements in joint pain that is at least partially mediated by tendinopathy.
There is evidence demonstrating the efficacy and safety of platelet rich plasma (PRP) injections for multiple peripheral musculoskeletal conditions. The best evidence of PRP effectiveness is for knee osteoarthritis, hip osteoarthritis, and lateral epicondylitis. Though, the promising biological rationale, the positive preclinical findings, and the successful early clinical experience of PRP injections are not confirmed by the recent high-level randomized controlled trials.27-37
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, that it is 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.38 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.39,40 Cost is another issue with PRP and stem cells as commercial and government insurance does not cover it.
- Zadro J, Rischin A, Johnston RV, Buchbinder R. Image-guided glucocorticoid injection versus injection without image guidance for shoulder pain. Cochrane Database of Systematic Reviews 2021, Issue 8. Art. No.: CD0091.
- Cho C, Min B, Bae K, Lee K, Kim D. A prospective double-blind randomized trial on ultrasound-guided versus blind intra-articular corticosteroid injections for primary frozen shoulder. Bone Joint J 2021;103-B(2):353–359.
- Sheth, T., Miranda, O.M. & Johnson, B. Assessment of patient satisfaction, functionality, and quality of life after ultrasound-guided knee intervention: a prospective study. Clin Rheumatol 40, 735–740 (2021).
- Daniels EW, Cole D, Jacobs B, Phillips SF. Existing Evidence on Ultrasound-Guided Injections in Sports Medicine. Orthopaedic Journal of Sports Medicine. February 2018.
- Wei AS, Callaci JJ, Juknelis D, et al. The effect of corticosteroid on collagen expression in injured rotator cuff tendon. J Bone Joint Surg Am. 2006;88(6):1331â€“1338.
- Naredo E, Rull M. Aspiration and injection of joints and periarticular tissue and intralesional therapy. In: Rheumatology, Sixth, Hochberg MC, Silman AJ, Smolen JS, et al (Eds), Elsevier Mosby, Philadelphia 2015. Vol 1, p.544.
- Rosenberg PH, et al. Maximum recommended doses of local anethetics; a multifactorial concept. Reg Anes Pain Med. 2004; 29:564-575.
- Gulihar A, et al. Articular cartilage and local anesthetic: A systematic review of the current literature. J Ortho. 2015 Oct 31:12(Suppl 2):S200-10
- Chu CR, et al. In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. Mar 2010; 92: 599-608.
- Narouze S, Benzon H, Provenzano D, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (Second Edition): guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018. 43(3):225-62
- Waterbrook AL, Balcik BJ, Goshinska AJ. Blood Glucose Levels After Local Musculoskeletal Steroid Injections in Patients With Diabetes Mellitus: A Clinical Review. Sports Health. 2017 Jul/Aug;9(4):372-374.
- 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
- Patel J, Schneider BJ, Smith CC; Spine Intervention Society’s Patient Safety Committee. Fact Finders for Patient Safety: Intra-Articular Corticosteroid Injections and Hyperglycemia. Pain Med. 2018 May 1;19(5):1091-1092.
- Roberts N., Hauptman H. Joint aspiration or injection in adults: Complications. www.UptoDate.com 2021.
- Patel J, Smith C; Spine Intervention Society’s Patient Safety Committee. Swabbing Vial Tops. Pain Med. 2019 Aug 1;20(8):1633-1634.
- Cohen SP, Bhaskar A, Bhatia A, Buvanendran A, Deer T, Garg S, Hooten WM, Hurley RW, Kennedy DJ, McLean BC, Moon JY, Narouze S, Pangarkar S, Provenzano DA, Rauck R, Sitzman BT, Smuck M, van Zundert J, Vorenkamp K, Wallace MS, Zhao Z. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. 2020 Jun;45(6):424-467.
- 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.
- Wang CT, Lin J, Chang CJ, et al. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. A meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2004;86-A:538-545.
- Tammachote, N,; Kanitnate, S; Yakumpor, T; Panichkul, P. Intra-Articular, Single-Shot Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis, A Double-Blind, Randomized Controlled Trial. The Journal of Bone and Joint Surgery: June 1, 2016 – Volume 98 – Issue 11 – p 885-892.
- Leggett LE, Soril LJ, Lorenzetti DL, Noseworthy T, Steadman R, Tiwana S, Clement F. Radiofrequency ablation for chronic low back pain: a systematic review of randomized controlled trials. Pain Res Manag. 2014 Sep-Oct;19(5):e146-53.
- Huang Y, Deng Q, Yang L, et al. Efficacy and Safety of Ultrasound-Guided Radiofrequency Treatment for Chronic Pain in Patients with Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Pain Res Manag. 2020;2020:2537075. Published 2020 Sep 19.
- Chen AF, Mullen K, Casambre F, Visvabharathy V, Brown GA. Thermal Nerve Radiofrequency Ablation for the Nonsurgical Treatment of Knee Osteoarthritis: A Systematic Literature Review. J Am Acad Orthop Surg. 2021 May 1;29(9):387-396.
- Eckmann MS, McCormick ZL, Beal C, Julia J, Cheney CW, Nagpal AS. Putting Our Shoulder to the Wheel: Current Understanding and Gaps in Nerve Ablation for Chronic Shoulder Pain. Pain Med. 2021 Jul 25;22(Suppl 1):S2-S8.
- Feigin G, Peng PWH. Hip Ablation Techniques. Phys Med Rehabil Clin N Am. 2021 Nov;32(4):757-766.
- Jacobson JA, Kim SM, Brigido MK. Ultrasound-Guided Percutaneous Tenotomy. Semin Musculoskelet Radiol. 2016 Nov;20(5):414-421.
- Vajapey S, Ghenbot S, Baria MR, Magnussen RA, Vasileff WK. Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review. Sports Health. 2021 May-Jun;13(3):258-264.
- Chen P, Huang L, Ma Y, Zhang D, Zhang X, Zhou J, Ruan A, Wang Q. Intra-articular platelet-rich plasma injection for knee osteoarthritis: a summary of meta-analyses. J Orthop Surg Res. 2019 Nov 27;14(1):385.
- Zhao J, Huang H, Liang G, Zeng LF, Yang W, Liu J. Effects and safety of the combination of platelet-rich plasma (PRP) and hyaluronic acid (HA) in the treatment of knee osteoarthritis: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2020 Apr 11;21(1):224.
- Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2016 Jun;17(2):101-12.
- Lin MT, Wei KC, Wu CH. Effectiveness of Platelet-Rich Plasma Injection in Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Diagnostics (Basel). 2020 Mar 28;10(4):189.
- Giovannetti de Sanctis E, Franceschetti E, De Dona F, Palumbo A, Paciotti M, Franceschi F. The Efficacy of Injections for Partial Rotator Cuff Tears: A Systematic Review. J Clin Med. 2020 Dec 25;10(1):51.
- Lin MT, Chiang CF, Wu CH, Huang YT, Tu YK, Wang TG. Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials. Arch Phys Med Rehabil. 2019 Feb;100(2):336-349.e15.
- Dallari D, Stagni C, Rani N, Sabbioni G, Pelotti P, Torricelli P, Tschon M, Giavaresi G. Ultrasound-Guided Injection of Platelet-Rich Plasma and Hyaluronic Acid, Separately and in Combination, for Hip Osteoarthritis: A Randomized Controlled Study. Am J Sports Med. 2016 Mar;44(3):664-71.
- Grassi A, Napoli F, Romandini I, Samuelsson K, Zaffagnini S, Candrian C, Filardo G. Is Platelet-Rich Plasma (PRP) Effective in the Treatment of Acute Muscle Injuries? A Systematic Review and Meta-Analysis. Sports Med. 2018 Apr;48(4):971-989.
- Zhang YJ, Xu SZ, Gu PC, Du JY, Cai YZ, Zhang C, Lin XJ. Is Platelet-rich Plasma Injection Effective for Chronic Achilles Tendinopathy? A Meta-analysis. Clin Orthop Relat Res. 2018 Aug;476(8):1633-1641.
- Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L. Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline. Am J Sports Med. 2019 Jun;47(7):1654-1661.
- Le ADK, Enweze L, DeBaun MR, Dragoo JL. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Curr Rev Musculoskelet Med. 2018 Dec;11(4):624-634.
- Zhao L, Kaye AD, Abd-Elsayed A. Stem Cells for the Treatment of Knee Osteoarthritis: A Comprehensive Review. Pain Physician. 2018 May;21(3):229-242.
- Pas HI, Winters M, Haisma HJ, Koenis MJ, Tol JL, Moen MH. Stem cell injections in knee osteoarthritis: a systematic review of the literature. Br J Sports Med. 2017 Aug;51(15):1125-1133.
- van den Boom NAC, Winters M, Haisma HJ, Moen MH. Efficacy of Stem Cell Therapy for Tendon Disorders: A Systematic Review. Orthop J Sports Med. 2020 Apr 30;8(4):2325967120915857.
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 A. Murphy, MD
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Alpha Anders, MD
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