Intra-articular and Soft Tissue Steroid Injections

Indications

1. Osteoarthritis and inflammatory arthritis
2. Meniscal tears
3. Tendinitis
4. Tenosynovitis


Contraindications

1. Infection
2. Allergy to steroids or lidocaine
3. Warfarin therapy
1. International normalized ratio (INR) > 4.5


Complications

1. Transient increase in pain (most common)
1. Occurs in approximately 5% of patients
2. Subsides within 24 hours
3. May be caused by the less soluble steroids
2. Skin and subcutaneous tissue atrophy
3. Depigmentation
4. Systemic effects (fairly common)
1. Usually mild and resolve quickly
2. Flushing, slight agitation
3. May worsen glucose control in patients with diabetes
5. Adrenal suppression (when given more than 1 to 2 times per month)
6. Infection occurs in 1 in 10,000 patients

Technique

1. Sterile, often helpful to anesthesize the injection area with a small needle
2. Aspirate any fluid in the joint to improve pain relief
3. Large joints: a 10-cc combination of lidocaine and steroid
4. Small joints: 1 cc to 5 cc combination of lidocaine and steroid


Efficacy

Osteoarthritis of the Knee1,2
Randomized trials have shown a significant benefit of corticosteroid injection over placebo at 1 to 3 weeks (in various studies). Using pain as an outcome measure, the benefit is not significant when studied at 6 to 12 weeks.

In one study, the presence of a joint effusion and the ability to aspirate the joint correlated with a better response to the steroid treatment.2 When comparing steroid injection to placebo, there was a significant benefit only at 1 week.

Osteoarthritis of the Hip1-2
Patients experienced a significant reduction in pain at 2 and 12 weeks; however, the effect was lost by 26 weeks.


References

1. Creamer P. Intra-articular corticosteroid treatment in osteoarthritis.Curr Opin Rheumatol.1999;11(5):417.

2. Gaffney K, Ledingham J, Perry JD. Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response.Ann Rheum Dis.1995;54:379-381.

3. Ike R. Therapeutic injection of joints and soft tissues. In:Primer on the Rheumatic Disorders.Atlanta, Ga: Arthritis Foundation; 2001.