Local Glucocorticoid Injections in Soft Tissues and Joints

Principles

• The skin is carefully cleaned with spirit-containing cleanser, and good aseptic principles are followed. The site of the injection is determined and marked before cleansing (video Marking the Site for Puncture).
• If an ultrasound device is available, it is used, as necessary, to check the existence and location of fluid.
  • A hip joint injection requires ultrasound guidance.
• 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. 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.
• Other joints (provided that fluid can be obtained through aspiration) and small joints can be treated with glucocorticoid only or with a combination of glucocorticoid and an anaesthetic.
• Intra-articular injections should be reserved for inflamed joints: swelling or hydrops and pain (see Clinical Diagnosis of Joint Inflammation in the Adult).
• Triamcinolone
  • 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
  • Triamcinolone, when extravasated outside the joint cavity, carries a higher risk of side effects (tendon rupture, skin atrophy, cartilage damage) than methylprednisolone.
• 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 F1), intracutaneous or subcutaneous injection should be avoided.
  • In the finger tendon sheaths
• The needle should be as thin (see table T1) 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 and soft tissues may be injected more frequently, but not into the skin!.
  • If the need for injections is consistently high, assess the potential for enhancing the effectiveness of the basic rheumatic treatment and, in the case of severely damaged joints, the need for a consultation with a specialist in rheuma-orthopedics.
• 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.
• Systemic adverse effects are possible.
  • Repeated injections can cause adrenocortical insufficiency, i.e. adrenal suppression.
  • The control of diabetes can be negatively affected for a few weeks. This effect is smaller with a long-acting preparation (less is transferred into the circulation due to its large crystal structure).
• Glucocorticoid injections, especially when used repeatedly, can impair the structure and metabolism of articular cartilage and predispose to tendon degeneration. Tendon ruptures are relatively rare.
• 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.

Injection sites

Recommended quantity of injection fluid

• A ready-made combination of a glucocorticoid and a local anaesthetic is used, or the glucocorticoid is diluted with a local anaesthetic or with saline, if needed.
• The knee joint: 1-2 ml of glucocorticoid and possibly 1-2 ml NaCl.
  • The same amount is used in Baker's cyst. The injection is given into the knee joint if there is effusion in the joint; otherwise, the injection can be given directly into the cyst.
• The glenohumeral joint: 1 ml of glucocorticoid and 1-2 ml of local anaesthetic (video Restricted Motion of the Shoulder; Intra-Articular Injection); the subacromial bursa: 1 ml of glucocorticoid and 1(-2) ml of local anaesthetic
• The ankle joint: 1 ml
• The wrist joint: 0.5 ml (video Restricted Motion of the Wrist in a Patient with Rheumatoid Arthritis)
• Soft tissues: 0.4-1 ml and the same quantity of local anaesthetic or 0.9% NaCl (video Flexor Tenosynovitis in Rheumatoid Arthritis)
• MCP and MTP joints, temporomandibular joints: 0.2 ml of glucocorticoid (0.2 ml of anaesthetic may additionally be administered)
• PIP and DIP joints: 0.1-0.3 ml of glucocorticoid (a combination preparation containing an anaesthetic is recommended)

Recommended needle size

• See table T1.
• When a large needle is used for the injection it is recommended first to apply local anaesthesia to the injection site using as small a needle as possible.

Other injection therapies

• Intra-articular hyaluronate injections may to some degree relieve the symptoms in osteoarthritis of the knee Intra-Articular Hyaluronic Acid for Knee Osteoarthritis , but the benefit-risk ratio is uncertain. Hyaluronate may be tried for the treatment of knee osteoarthritis if glucocorticoid injections are not effective.