10. Joint Injection with Steroids

Indications

Usually palliative, local, and temporary. Generally used as an escalation beyond primary medical management of an inflamed joint (i.e. rest, NSAIDs, compression, icing, elevation). Expected improvement in 24 hours, with effect potentially lasting 2 months or longer.

  • Systemic inflammatory arthritis: not primary therapy, but may be used as adjunct to systemic therapy.
  • Crystalline arthritis: especially useful when NSAIDs are contraindicated.
  • Osteoarthritis: consider for patients with only 1-2 affected joints.

Contraindications

  • Infection in or near joint, including septic arthritis or cellulitis.
  • Concurrent bacteremia.
  • Existing severe joint destruction, local osteoporosis, or unstable joint.
  • Unstable coagulopathy.
  • Psoriatic scale over joint injection/aspiration location (relative contraindication).
  • Consult orthopedic surgeon before injecting into a prosthetic joint (relative contraindication).
  • Patients without symptom relief after two steroid injections are not recommended to undergo additional attempts because of the low likelihood of a subsequent positive response. More than four steroid injections into a joint space in a given year is not recommended out of concern that steroids may accelerate cartilage aging and atrophy of connective tissue (relative contraindication).

Adverse effects

  • Iatrogenic infection (rare).
  • Steroid arthropathy/progressive joint deterioration.
  • Tendon rupture/soft tissue atrophy/nerve damage.
  • Systemic absorption with hyperglycemia or adrenal suppression.
  • Skin hypopigmentation, especially with shallow injections.

Dose

There is no consensus on dose but the following table provides general guidance. The patient should avoid vigorous activities involving the injected joint for 24 hours after the procedure.

Size of joint

Example

Amount of Kenalog or equivalent steroid dose.

Large

Knee, ankle, shoulder

40-80 mg

Medium

Elbow, wrist

20-40 mg

Small

MCP, IP, MTP

< 10 mg

For non-joint injections:

  • Trochanteric bursa - 40-80 mg Kenalog
  • Subacromial bursa - 20-40 mg Kenalog
  • Epicondylitis - 20 mg Kenalog

Courtney P, Doherty M.  Joint aspiration and injection and synovial fluid analysis. Best Practice Clin Rheum. 2009; 23; 161-192.

Cardone DA, Tallia AF. Joint and soft tissue injection. American Family Physician 2002; 66:2:283–288.