JOINT INJECTIONS - INDICATIONS & TECHNIQUES

I. Aspiration (Arthrocentesis) 
• May confirm diagnosis and dictate 
treatment for suspected causes of joint, tendon sheath, or bursal lesions or poorly 
defined forms of arthritis 
• Removal of fluid from a tense joint provides fast, effective pain relief and improved 
joint function 
• Blood and pus within the synovial compartment are damaging to the synovial 
membrane and joint cartilage. Permanent sequellae can result if left untreated 
Aspiration and joint injection can be performed for diagnostic and therapeutic reasons. 
Diagnostically, they are mandatory if septic arthritis is suspected, strongly advised if crystal 
arthritis or hemarthrosis suspected. They help in the differentiation of inflammatory from noninflammatory arthritis. They are also useful as imaging studies through arthroscopy and 
arthrography. 
The therapeutic value of injections include removal of tense effusions (relieve pain and 
improve function), to remove blood or pus from a joint, for tidal lavage of joints and for 
injection of steroids and other intra-articular therapies. 
Other Tests (when appropriate): 
Gram stain and culture 
Cell count (especially, WBC) 
AFB stain and Culture 
Viral Culture 
Fungal Culture 
Complement (C3, C4 ) 
Relative contraindications to intra-articular injections include severe immunodeficiency, 
anticoagulant therapy, poor response to prior injection, multiple prior injections (? more than 
three) and uncontrolled diabetes. 
Absolute contraindications for aspiration and joint injection include skin infection 
overlying site to aspirate, septicemia/bacteremia (steroid injection), coagulopathy, unstable joint, 
septic effusion (steroid injection), presence of fracture or tumor, prosthetic joint and an 
inaccessible joint. 
NOTE: Intra-articular steroids have been used for may years in the treatment of inflammation, 
tendinitis and bursitis. Despite its ubiquitous use in medicine, there remains controversy 
regarding mechanism of action, efficacy, etc

II. Steroid Injections
Utilized to provide relief of persistent localized inflammation. Exact mechanism of action 
of corticosteroids still uncertain. Corticosteroids block the arachidonic pathway, thereby 
decreasing prostaglandins and leukotrienes. 

• Primarily used after other modalities (NSAIDS, Rehab) have failed or as alternative therapy for patients who cannot tolerate 
other forms of treatment (NSAID’s) 
• Most authors agree to limit injections to no more than 3 injections per joint per year 
(especially in weight bearing joints). Exact evidence for this recommendation is 
unclear. 
• After injection, it is generally helpful to massage the area and move the joint through 
its full range of motion to distribute the medication 
• Allow 3 - 6 weeks to determine whether an injection is effective. 
• Activity of the injected joint should be modified/limited for several days - weeks after 
injection depending on the site. If patient cannot rest the affected joint following, 
reconsider giving the injection. Range of motion exercises are OK, avoid resistance 
exercises during one to two weeks after injection. 
• Pain at the site of injection is not uncommon, and can sometimes last for several days. 
If pain does not resolve (usually within 72 hrs), concern is raised for infection. 
• NEVER inject against resistance; this may indicate incorrect position of the needle. 
• Misplaced joint injections can be avoided if synovial fluid is aspirated prior to 
delivery of steroid. 
• If a joint effusion is present, it is advisable to remove as much of this fluid as possible 
prior to administration of steroid. 
• When injecting a tendinitis, the steroid should be placed adjacent to the tendon. 
Avoid injecting directly into a tendon since an injured tendon is more prone to 
rupture. 
• STERILE technique for steroid administration is recommended. Follow universal 
precautions with all injections. 

GENERAL GUIDELINES
Palpate bony landmarks of the joint/site to be injected 
Determine site for injection and mark the skin by applying pressure with needle 
cap or stick end of the Betadine swabs 
Prep the skin appropriately 
Mix steroid and anesthetic solutions 
Spray the skin with ethyl chloride (skin refrigerant) immediately before 
performing the injection 
Insert needle slowly and steadily 

When assured of the correct placement, inject solution 




III. Risks/Complications 
A. Skin atrophy 
B. Altered skin pigmentation 
C. Fat atrophy 
D. Infection- septic arthritis (1 per15,000 - 50,000 procedures) 
E. Bleeding 
F. Nerve damage 
G. Systemic Reaction 
H. Steroid Flare- transient increased inflammation at the site of injection prior to 

therapeutic response (onset usually 6 - 12 hours after injection with resolution by 72 hours). Treatment includes ice packs and NSAIDS 
I. Leakage of injected substance into surrounding soft tissue 
J. Misplaced Injection 
K. Asymptomatic pericapsular calcification 
L. Steroid Arthropathy- Theoretical increased risk of accelerated cartilage attrition 
(softening of cartilage especially in weight bearing joints). Limited studies in primate 
have shown no serious long term deleterious effects on cartilage