J S T A I (A) : Oint and Oft Issue Spiration and Njection Rthrocentesis

CHAPTER 180
Joint and Soft Tissue Aspiration

and Injection (Arthrocentesis)
Thad J. Barkdull • Francis G. O’Connor • John M. McShane
Joint and soft tissue aspiration and injection are both clinically Editor’s note: If you or your patient can localize the area of dis-
rewarding and relatively simple procedures for primary care clini- comfort near a joint with one finger, a bursitis or tendonitis is much
cians to learn and perform. They are also very much appreciated by more likely the cause and it will likely benefit from an injection,
our patients. In the United States, 8% of ambulatory visits are for especially if other therapies have failed.
musculoskeletal conditions, and 13% of these patients have osteo-
arthritis (OA) as a comorbid condition. Steroid join injection fell
into disfavor for many years because the procedure was overused and
Therapeutic
abused. When appropriate guidelines are followed, however, compli- • T o remove exudative fluid from a septic joint
cations are extremely rare, and the injections can be very beneficial • To relieve pain in a grossly swollen joint (e.g., traumatic effusion)
to the patient by reducing symptoms. The usual alternative to focal • To reduce pain and inflammation by injecting lidocaine, with or
treatment with injection is systemic nonsteroidal antiinflammatory without corticosteroids, or saline for trigger points (see Chapter
drugs (NSAIDs) which have significant toxicity and risk with pro- 181, Trigger-Point Injection), noninfectious inflammatory ar-
longed use. In the United States, almost two-thirds of family physi- thritis, tendinitis, bursitis, or neuritis
cians use corticosteroid injections as part of a treatment plan. • To stimulate the body’s inflammatory cascade in order to pro-
Primary care clinicians should master the technique of aspiration mote healing (i.e., prolotherapy, [Dagenais, 2007])
and injection for many reasons. If the clinician aspirates an inflamed
Indications for Corticosteroid Injections
joint, a diagnosis can often be made immediately. If a joint is dis-
tended, pain can be relieved rapidly by aspirating the fluid. Injecting Corticosteroids have a marked effect on inflammation. There are no
an anesthetic, steroid, hyaluronic acid, prolotherapy, or other solution good data to indicate that steroid injections decrease the long-term
(e.g., botulinum toxin, intraarticular NSAIDs are being studied) can adverse effects of chronic degenerative OA, but there is no doubt that
not only provide focal pain relief without the toxicity of the systemic they result in acute symptomatic improvement, especially over the first
medications, it can also provide valuable diagnostic information. 1 to 4 weeks. Several meta-analyses and systematic reviews support the
The clinician should not withhold the benefits of injection therapy use of the intraarticular corticosteroids in the treatment of adhesive
because of incomplete familiarity with the exact anatomy involved. capsulitis or impingement syndrome of the shoulder (Blanchard, 2010;
Basic knowledge of soft tissue and bony landmarks is enough to pro- Gaujoux-Viala, 2009; Griesser, 2011), osteoarthritis (OA) of the knee
vide a reliable method for identification of needle insertion sites. The (Arroll, 2004; Cheng, 2012; Hepper, 2009) and tendon injections for
emerging role of musculoskeletal ultrasound in office-based practice lateral and medial epicondylitis of the elbow (Krogh, 2013; Coombes,
offers additional opportunities to improve diagnostic and therapeu- 2010), carpal tunnel syndrome (Marshall, 2007), de Quervain tenosy-
tic techniques. The reader may want to refer to Chapter 171, Mus- novitis and trigger finger (Peters-Veluthamaningal, 2009). Randomized
culoskeletal Ultrasound, for related information. One joint that the trial data also support steroid injection of the hip for OA (Qvistgaard,
process of injection is completely changed with ultrasound guidance 2006). For trochanteric bursitis, now generally called greater trochan-
is the knee. Instead of going very near cartilage, possibly bumping it ter pain, there is evidence supporting steroid injections (Brinks, 2011).
when injecting blindly, without ultrasound, the suprapatellar pouch is Cochrane has recently found some systematic review evidence support-
localized with ultrasound. This is a pouch above the knee which com- ing steroid injections for plantar fasciitis (David, 2017).
municates into the capsule. With ultrasound guidance, the pouch can Box 180.1 lists the conditions that are improved with local corti-
be injected by directing the needle through the quadriceps muscle. costeroid therapy. Localized pain that persists more than a few weeks
after a trial of NSAIDs warrants an injection with steroids. Injections
should be considered primarily when the potential toxicity or intoler-
ance to NSAIDs outweighs the risk of local corticosteroids. Tramèr
Indications et al. (2001) noted in their metaanalysis that individuals chronically
(≥2 months) using NSAIDs had a 1:1220 chance of dying from a gas-
Diagnostic trointestinal complication. Morbidity risks associated with prolonged
• T o evaluate synovial fluid and determine whether an effusion is NSAID use, including gastrointestinal bleeding, are even greater. In
from an infectious, rheumatic, traumatic, or crystal-induced origin contrast, death occurring after intraarticular injections comes pre-
• To perform a therapeutic trial to differentiate between various dominantly from septic arthritis, which occurs in anywhere from 1 in
conditions (e.g., costochondritis vs. coronary artery disease, tro- 3000 to 1 in 50,000 cases—with a mortality rate of about 15%.
chanteric bursitis vs. deep hip disease, occipital trigger points vs.
Indications for Hyaluronic Acid Supplementation
vertebral disease)
• To differentiate an intraarticular from extraarticular origin of Synovial fluid functions as a lubricant and a shock absorber in the
pain symptoms joint. In OA, it retains very little of these intrinsic physical properties.

1221
Downloaded for SBC Institute (eefiap@yopmail.com) at University of Sharjah from ClinicalKey.com by Elsevier on June 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
1222 ORTHOPEDICS AND SPORTS MEDICINE
At a critical load, normal synovial fluid changes its mechanical proper- experts are already using it in other joints, although this is considered
ties from viscous lubricant to elastic shock absorber. This change occurs off-label and usually not covered by insurance. The materials injected
between walking and running and is determined by the dynamic stress (hylans and hyaluronans) are pharmacologically inert so the Food and
of both the frequency and the force of the load—a property which is Drug Administration classifies them as “devices,” not “drugs.”
diminished in OA. In addition, the concentration of hyaluronan in the
synovial fluid in patients with OA is less than normal. Injected hylans • Approved for use in knee only
and hyaluronans have properties similar to normal synovial fluid, and • May be used instead of, or after, intraarticular corticosteroid in-
although they may only remain in the knee less than 2 weeks, the ben- jections and before surgical intervention
eficial effects can persist up to a year (mean duration of 8.2 months). • Effective in all stages of OA of the knee, although it wanes in the
There is some evidence that they stimulate endogenous production most advanced stages
of the synovial fluid. There is no evidence that viscosupplementation • Is being studied for use in other joints
retards the progression of joint deterioration, but a Cochrane review
Indications for Prolotherapy
(Bellamy, 2006) concluded that viscosupplementation showed benefi-
cial effects on pain and patient function; this modality shows promise Prolotherapy is an alternative form of injection therapy, used by some
of postponing for years the need for total knee replacement. Studies are clinicians to treat chronic musculoskeletal pain syndromes. Prolo is
ongoing to assess its efficacy in other joints, because it is currently only derived from proliferation, because the treatment causes the prolifera-
Food and Drug Administration–approved for use in the knee. Certain tion (growth and formation) of new connective tissue in areas that have
become weak. The concept behind this technique is to stimulate the
body’s own inflammatory cascade to promote reabsorption of unhealthy
BOX 180.1 Conditions Improved With Local Corti- tissue, such as degenerative fibroblasts in injured tendons, and the cre-
costeroid Injection ation of new, healthy tissue. Inflammation-promoting agents (>10%
dextrose solutions, phenol- or sodium-morrhuate–containing solutions,
Articular Conditions autologous blood, platelet-rich plasma) are injected into the area of
Coccydynia injury, often with the aid of ultrasound to best localize the target.
Crystal-induced arthritis Prolotherapy is most often described in use with tendinopathy, and
• Gout there is some evidence to suggest that it is an effective therapy in treating
• Pseudogout the degenerative tissues identified. The treatment most likely achieves
Ganglions its maximal benefit when coupled with physical therapy focused on
Osteoarthritis further stimulating growth of new tendinous tissue (Dagenais, 2007).
Rheumatoid arthritis As prolotherapy is an emerging technique that can be highly operator
Seronegative spondyloarthropathies dependent, those interested in providing this service are encouraged to
• Ankylosing spondylitis consult with a prolotherapist or complete a course of instruction prior
• Arthritis associated with inflammatory bowel disease to beginning prolotherapy injections in an office practice. As of 2014,
• Psoriasis a Cochrane review found insufficient evidence for use of platelet-rich
• Reiter syndrome plasma prolotherapy for treating musculoskeletal soft tissue injuries.
Nonarticular Conditions
Bursitis Contraindications
• Anserine
• Olecranon • C ellulitis or broken skin over the intended entry site for the in-
• Prepatellar jection or aspiration
• Subacromial • Anticoagulant therapy that is not well controlled
• Trochanteric • Severe primary coagulopathy
Costochondritis • Infected effusion of a bursa or a periarticular structure (for injection)
Fibrositis • More than three previous injections in a weight-bearing joint in
• Localized (trigger points) the preceding 12-month period (relative—concern for theoretic
• Systemic joint destruction)
Morton neuroma • Suspected bacteremia (Unless the joint itself is suspected as the
Neuritis source of the bacteremia, it should not be tapped. Doing so could
• Carpal tunnel syndrome inoculate the joint space and cause infection.)
• Cubital tunnel syndrome • Unstable joints (for steroid injection)
• Tarsal tunnel syndrome • Inaccessible joints (For many primary care clinicians, this in-
Periarthritis cludes the hip joint, the sacroiliac joint, and the joints of the
• Adhesive capsulitis vertebral column.)
Tenosynovitis/tendonitis • Joint prostheses (If infection is suspected, consider a referral to
• Bicipital tendonitis the orthopedist that placed the prosthesis, if possible.)
• de Quervain disease • Pregnancy (relative)
• Golfer’s elbow (medial epicondylitis) • Lack of response to two or three prior injections (relative)
• Impingement syndrome
• Plantar fasciitis
• Rotator cuff Equipment
• Supraspinatus tendonitis
• Tennis elbow (lateral epicondylitis) In the past, joint injections were frequently performed without gloves
• Trigger finger with only an alcohol wipe. In contrast, some clinicians still use an
Tietze syndrome extensive sterile draping procedure. Although the former is most likely
inadequate, the latter is probably unnecessary unless the patient is

Modified from Pfenninger JL. Injections of joints and soft tissue. Part I. immunosuppressed, diabetic, or at high risk of infection. Most injections
General guidelines. Am Fam Physician. 1991;44:1196. are administered after an alcohol, chlorhexidine, or povidone–iodine
wipe. Gloves (sterile or nonsterile) should be used. When a culture is
180 –––– JOINT AND SOFT TISSUE ASPIRATION AND INJECTION (ARTHROCENTESIS) 1223
anticipated, sterile gloves are more customary. Masks are unnecessary.

Universal blood and body fluid precautions should be followed.
Required equipment includes the following:

• Chlorhexidine, povidone-iodine wipes, or alcohol wipes
• Sterile or nonsterile gloves
• Sterile drapes (optional)
A
• 22- to 27-gauge, 1.5-inch needle for injections
• 18- to 21-gauge, 1.5-inch needle for aspirations
• 30-gauge, 0.5-inch needle, if skin anesthesia is to be given (usu-
ally not needed)
• 1- to 10-mL syringe for injections (Luer-Lok is recommended)
• 3- to 50-mL syringe for aspirations
• Single-dose vials of 1% lidocaine
B
Note: There are two reasons to use single-dose vials. It is extremely
Fig. 180.1 (A) Example of precipitation of steroid (Celestone Soluspan)
rare to have an allergic reaction to lidocaine (an amide). Although when mixed with lidocaine solution from a multidose vial. (B) Steroid in solu-
rare, reactions do occur to the preservative (parabens) that is used in tion (Celestone Soluspan) when mixed with lidocaine from a single-dose vial.
multidose vials. Local anesthetics with an ester base (e.g., procaine It is preferable to have the steroid in solution rather than in precipitated form.
[Novocain]) can cause allergic reactions. So, using a single-dose vial (Courtesy John L. Pfenninger, MD, The Medical Procedures Center, Midland, MI.)
of lidocaine makes it highly unlikely that there will be a reaction.
Second, many steroids will precipitate when mixed with the para-
bens preservative. This leads to uneven distribution in the syringe
as well as the injection of small crystals into the site, and these crys-
tals themselves could cause an inflammatory process (Fig. 180.1). TABLE 180.1 Relative Potency of Corticosteroids
Theoretically, a homogeneous solution would be more efficacious,
although no studies have looked at the issue and many feel it is a Relative Anti- Approximate
inflammatory Equivalent
moot point and of little concern. Certain manufacturers, however,
Corticosteroid Potency Dose (mg)
do not recommend injecting precipitated steroids.
Many practitioners will use a longer-acting local anesthetic such Short-Acting Preparations
as bupivacaine (Marcaine). Although this addition in most cases Cortisone 0.8 25
will not have any untoward effects, it should be noted that there Hydrocortisone 1 20
have been instances of myotoxicity associated with bupivacaine,
Intermediate-Acting Preparations
and given that it is only intended to provide short- to medium-term
Prednisone 3.5 5
relief of symptoms, one might question its regular use.
Prednisolone tebutate (Hydeltra-TBA) 4 5
Editor’s note: Although it is only one study (Karpie and Chi, Triamcinolone (Aristocort, Aristospan, 5 4
2007) and it only involved bovine cartilage, since reading this study, Kenalog)
I have quit mixing any “caine” analgesic with injectable steroids for Methylprednisolone acetate 5 4
intraarticular injections. As it turns out, this allows me to give a (Depo-Medrol)
slightly higher dose of steroid per injection and injected pure ste-
roid preparations also seem to offer some immediate analgesic effect. Long-Acting Preparations
When injecting a tendon or a bursa, I still mix the steroid with lido- Dexamethasone (Decadron-LA) 25 0.6
Betamethasone (Celestone Soluspan) 25 0.6
caine; I want the steroid to diffuse over a large area.
Modified from Leversee JH. Aspiration of joints and soft tissue injections. Prim
• Hemostat (to be used if joint is to be aspirated then injected us- Care 1986;13:572.
ing different syringes but same needle)
• Tubes for culture or other laboratory studies (if aspiration is performed)
• Injectable corticosteroid preparation (Tables 180.1 and 180.2)
TABLE 180.2 Common Corticosteroids and Recommended Dosages for Various Joint Injections
Concentration Large Joint* Medium Joint† Small Joint†,‡ Ganglia Tendon Bursa
Corticosteroid (mg/mL) Dosage (mg) Dosage (mg) Dosage (mg) (mg) Sheath (mg) (mg)
Hydrocortisone acetate 25, 50 40–100 20–40 8–20 20–40 20–50 40–90

Prednisolone tebutate (Hydeltra-TBA) 20 20–30 10–20 8–10 10–20 4–10 20
Prednisolone sodium phosphate 20 10–20 5–10 4–5 5–10 3–8 20
Triamcinolone hexacetonide (Aristospan) 5, 20 20–30 10–20 8–10 10–20 4–10 20
Triamcinolone diacetate (Aristocrat) 25, 40 20–40 10–20 8–10 10–20 4–10 20
Triamcinolone acetonide (Kenalog) 10, 40 20–40 10–20 8–10 10–20 4–10 20
Methylprednisolone acetate (Depo- 20, 40, 80 20–40 10–40 8–10 4–20 4–10 20
Medrol)
Dexamethasone sodium phosphate 4 2–4 1–3 0.8–1 1–2 0.4–1 2–3
(Decadron)
Dexamethasone acetate (Decadron-LA) 8 2–4 1–3 0.8–1 1–2 0.4–1 2–3
Betamethasone acetate/phosphate 6 6–12 3–6 1.5–3 1–3 1.5–2 3–6
(Celestine Soluspan)
*Such as knee, shoulder, ankle.
†Such as elbow, wrist.
‡Such as metacarpophalangeal, interphalangeal, acromioclavicular, temporomandibular.
TABLE 180.3 Steroid Solubility TABLE 180.4 Adverse Effects of Local Corticosteroid

Steroid Solubility (% wt/vol)
Therapy
Estimated
Triamcinolone hexacetonide 0.0002 Complication Prevalence
Triamcinolone acetate 0.004
Prednisolone tebutate 0.001 Postinjection flare 2%–5%
Methylprednisolone acetate 0.001 Steroid arthropathy 0.8%
Hydrocortisone acetate 0.002 Tendon rupture <1%
Facial flushing <1%
Skin atrophy, depigmentation <1%
Iatrogenic infectious arthritis 0.01%
A reasonable rule of thumb is that the greater the water solu- Transient paresis of injected extremity Rare
bility of the corticosteroid, the more rapid the onset of action, Hypersensitivity reaction Rare
and the shorter the duration of effect. Thus steroids with a lower Asymptomatic pericapsular calcification 43%
degree of water solubility would in general be more effective in a Acceleration of cartilage attrition Unknown
chronic disease process, such as OA, whereas an acute inflammatory From Gray RG, Gottlieb NL. Intraarticular corticosteroids: an updated assess-
process might be more responsive to a shorter-acting preparation ment. Clin Orthop Relat Res. 1983;177:253.
(Table 180.3).
Note: It is best to pick out one or two preparations and learn
them well. It is not necessary to be familiar with all the drugs listed. prior to musculoskeletal injections. If the patient has used it before,
There is no consensus in the literature as to the “best” drug or the their patient satisfaction is generally much less if not available for
optimal dosages. Table 180.2 offers our recommendations for appro- the next injection. I have also quit using a subcutaneous local anes-
priate dosing. Instead of stocking them in a primary care clinic, thetic injection or an injection along the anticipated needle track.
which would be very expensive if allowed to expire, giving the Local anesthetic injections burn; there is also no way I can also guar-
patient a prescription to obtain the supplement at a pharmacy is antee where the steroid injection needle will track. For most intraar-
usually an option. ticular injections, I now use a 23-gauge needle, the same needle used
for flu shots in our clinics. So I tell the patient we will be doing an
• Ethyl chloride spray (optional) injection very similar to a flu shot even though we are entering the
• Hyaluronic acid preparation (if used)—sodium hyaluronate (Hy- joint. Almost all patients tolerate this very well.
algan, Supartz, Euflexxa, Orthovisc, Monovisc) and hylan G-F
20 (Synvisc and Synvisc-one); dosages, and estimated cost per
treatment (note dynamic marketplace with marked variability)
Technique
are as follows: Before injection therapy, consider the differential diagnosis. If a
• Hyalgan: five injections, 1 week apart ($990.00) tumor or fracture is possible, radiographs should be obtained. Many
• Supartz: five injections, 1 week apart ($1110.00) times, especially with trigger-point injection (see Chapter 181, Trig-
• Euflexxa: three injections, 1 week apart ($1110.00) ger-Point Injection), x-rays are unnecessary. Other diagnoses may
• Orthovisc: three injections, 1 week apart ($1536.00) also be fairly straightforward and not require a prior radiographic
• Synvisc: three injections, 1 week apart ($1195.00) examination either. If the diagnosis is in question or if the patient
• Synvisc-one: one injection ($1195.00) is at risk for bone metastases (e.g., a history of breast or prostate
• Monovisc: one injection ($1170) cancer), the condition should be clarified before injection therapy.
• Adhesive bandage dressing Generally, the clinician injects a combination of lidocaine with
• Ultrasound (see later discussion for information regarding ultra- the steroid of choice. Single-dose vials of lidocaine should be used to
sound-guided injections and Chapter 171, Musculoskeletal Ul- avoid the preservative/precipitation problems (see earlier comments
trasound) and the “Complications” section). Using a rather large volume of
lidocaine may be beneficial. Not only does it disperse the steroid in a
less concentrated solution, the volume itself may have a therapeutic
Preprocedure Patient Preparation effect. In some instances, only a minimal amount of lidocaine can
Inform the patient of the risks, benefits, and possible complications be used (e.g., ganglion cysts, trigger fingers). In other sites, larger
of injection therapy. This information is especially important if ste- amounts are recommended (e.g., lidocaine 5 to 10 mL in a shoulder
roids are used. Rarely is there ever a complication from the use of or knee mixed with 0.5 to 1 mL of selected steroid). A good rule of
lidocaine alone. However, with steroids, and especially with repeated thumb is to use more, not less, when it comes to lidocaine.
injections, there are some adverse consequences (see the Compli- The recommended dosages of medications (Table 180.5) and the
cations section and Table 180.4). There can be some pain or dis- specific techniques for various injection sites (Figs. 180.2 to 180.24)
comfort, and damage to nearby structures. Alternatives to injection are included in this chapter.
should be discussed, if there are any. Warn the patient of a possible
failure to obtain relief, and that a second or even a third injection
may be needed. Whether or not steroids have significant adverse General
effects on the cartilage and bone itself when steroids are injected
The general approach is as follows:
into the joint space, and the degree of this reaction, is controversial.
However, the effects would appear to be minimal, especially when 1. Identify the site of entry and mark it with a thumbnail, ball-
used appropriately. If they are diabetic, hyperglycemia can occur, so point pen, or indelible marker. Making a circular indentation at
they may need to monitor their sugars more closely over the next few the designated site with the retracted end of a ballpoint pen is
days. If a local anesthetic is going to be used in the skin, the patient an excellent way to avoid losing your landmarks when cleaning
should be warned. They should also be informed if ethyl chloride is the area.
available and will be used to numb the skin prior to injection. 2. Prep the area with an alcohol, chlorhexidine, or povidone-
Editor’s note: Since I cannot always be sure I’ll have ethyl iodine wipe. (Note that alcohol often removes ink and skin
chloride spray available, I have somewhat quit using it as an analgesic marker solutions.)
TABLE 180.5 Needle Size and Drug Dosage for Injection Therapy

Dose of 1% Dose of Methylprednisolone
Anatomic Structure Needle Gauge (Length) Lidocaine (mL) Acetate (mg)
Abductor tendon of thumb (de Quervain disease) 25 (1.5 inch) 3–4 10–20
Acromioclavicular joint 22–25 (1–1.5 inch) 2–4 4–10
Ankle 22 (1–1.5 inch) 3–5 20–40
Anserine bursa 22–25 (1.5 inch) 3–5 20–40
Biceps tendon 22 (1.5 inch) 5–10 10–20
Calcaneal bursa 22 (1.5 inch) 5 20–40
Carpal tunnel 25 (1.5 inch) 1 20–40
Elbow 25 (1.5 inch) 3–4 10–20
Radiohumeral joint 22 (1–1.5 inch) 3–5 20–30
Lateral or medial epicondyle (“tennis elbow,” “golfer’s elbow”) 22–25 (1–1.5 inch) 3–5 10–30
Olecranon bursa 22 (1–1.5 inch) 2–3 10–20
Finger and toe joints (interphalangeal) 25 (1 inch) 0.5–1.0 4–10
Flexor tendon sheath (trigger finger) 25 (1 inch) 0.25–0.5 4–10
Ganglion of wrist, other 18–20 (1–1.5 inch) 0.25–0.5 4–10
Hip joint 20 (1.5–3 inch) 5 40–80
Knee intraarticular space 20 (1.5 inch) 5 20–80
Plantar fascia 22 (1.5 inch) 2–4 15–30
Prepatellar bursa 20–22 (1–1.5 inch) 3 20–40
Shoulder intraarticular space 20 (1.5 inch) 5–7 20–40
Shoulder rotator cuff tendon 18–20 (1.5 inch) 5 20–40
Shoulder subacromial bursa 22 (1.5–2 inch) 5–7 30–40
Tarsal tunnel 25 (1.5–1 inch) 1–2 10–20
Temporomandibular joint 25 (1.5–1 inch) 1–2 5–20
Trigger point 25 (1.5 inch) 3–5 10–30
Trochanteric bursa 22 (1.5–2 inch) 5–10 20–40
Wrist joint 22–25 (1–1.5 inch) 2–4 20–40
Modified from Pfenninger JL. Injections of joints and soft tissue. Part II. Guidelines for specific joints. Am Fam Physician. 1991;44:1690.
A B
C
Fig. 180.2 Injecting finger and toe joints. (A) Appropriate technique for injecting a finger joint. Tendons run over the dorsum of the finger, whereas nerves
and vessels run laterally. Open the joint slightly by flexing it and then inject between the ligaments and the vascular structures as noted. The needle enters
at a 45-degree angle to the joint. Any of the finger (B) and toe (C) joints may be aspirated or injected in the lateral or medial aspect. Slightly flex the joint to
open the joint space. Direct the needle to enter just medial or lateral to the extensor tendon, avoiding too lateral or medial an approach where the nerve
and vascular structures run. Use a 25-gauge, 1-inch needle with 0.5 to 1.0 mL 1% lidocaine and 4 to 10 mg of methylprednisolone acetate or equivalent
(see Tables 180.2 and 180.5).
Annular pulleys
Synovial sheath
Flexor digitorum
superficialis tendon
Annular
pulleys
B
Fig. 180.4 Wrist joint. (A) Injection of the wrist joint. The hand is held in
slight flexion, and the needle is inserted just distal to the radius in the “snuff
box.” (B) Flex the joint 20 degrees to open the joint spaces. The dorsal ap-
proach is generally used. Position the needle perpendicular to the skin sur-
face. Enter at a site distal to the radial head and lateral to the extensor pollicis
longus tendon (just ulnar to the anatomic “snuff box”). If the needle can be
B easily inserted to 1 or 2 cm, it is correctly positioned in the joint space. The
intercarpal joints have interconnecting synovial spaces, and the contents of
Fig. 180.3 Trigger finger. (A) The anatomy of a finger showing the annular
one correctly placed injection will disperse into the entire joint complex. Use
pulleys, which maintain the flexor close to the bony structures. When the
an 18- to 20-gauge, 1- to 1.5-inch needle with 0.5 to 1.0 mL 1% lidocaine
tendon becomes inflamed and enlarges, it catches on the pulleys, causing a
and 4 to 10 mg of methylprednisolone acetate or equivalent (see Tables 180.2
snapping with extension or a “trigger finger.” (B) Identify the flexor tendon
and 180.5).
involved. Insert the needle at the distal palmar crease. Attempt to position
it peritendinously. When the needle is in position, the syringe will move with
flexion of the finger. Use a 25-gauge, 1-inch needle with 0.25 to 0.5 mL 1%
lidocaine and 4 to 10 mg of methylprednisolone acetate or equivalent (see
Tables 180.2 and 180.5).
A B C
F
D E
Fig. 180.5 A ganglion is a manifestation of joint inflammation. (A) Frontal view. (B) Side view. (C) Example of an unusual ganglion cyst on the thenar emi-
nence. (D) Aspiration of the cyst. Hold the needle in position with the hemostat and remove the syringe. Attach the steroid-containing syringe and inject the
contents. (Some have used fibrin sealants, hypertonic saline, and other irritants for attempts to “scar down” the cyst.) (E) The contents are often thick, and
there may only be minimal return of a gel-like material. (F) Use an 18- to 20-gauge, 1- to 1.5-inch needle with 0.5 to 1.0 mL 1% lidocaine and 4 to 10 mg of
methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5). (A–E, Courtesy John L. Pfenninger, MD, The Medical Procedures Center, Midland, MI.)
Fig. 180.6 De Quervain disease. Maximally abduct the thumb to accentuate and
identify the tendon. Insert the needle parallel to (but not into) the tendon. Inject at
the areas of greatest tenderness. Postinjection splinting may still be necessary. Use a
25-gauge, 1.5-inch needle with 3 to 4 mL 1% lidocaine and 10 to 20 mg of methyl-
prednisolone acetate or equivalent (see Tables 180.2 and 180.5).
Median nerve
Palmaris aponeurosis
Flexor
retinaculum
Palmaris longus tendon

A B Distal palmar crease
Distal crease
Flexor retinaculum
Radial artery
Flexor
tendons
Median nerve Palmaris Ulnar artery Flexor

aponeurosis and nerve tendons
E
D
Fig. 180.7 Carpal tunnel syndrome. Four approaches to injection: (A) Traditional method. Dorsiflex the wrist 30 degrees or keep it flat and rest it on a rolled
towel. Insert the needle at the distal crease of the wrist either lateral or medial to the palmaris longus tendon. (B) Find the tendon by having the patient flex the middle
finger against resistance or abduct the thumb and little finger together. Angle the needle downward at a 45-degree angle toward the tip of the middle finger. If there
is any discomfort in the fingers, withdraw and reposition the needle. Advance 1 to 2 cm until there is no resistance, and then inject the medication. (C) Alternative
method. Insertion of the needle directly over the carpal tunnel. Use a perpendicular approach going directly through the flexor retinaculum into the median nerve
space. (D) A third method of injecting the carpal tunnel. The needle is inserted just radial to the pisiform bone and directed toward the carpal tunnel just beneath the
transverse carpal ligament. The needle goes dorsally and distally to terminate within the carpal tunnel just to the ulnar side and dorsal to the median nerve. (E) A more
recent approach is to inject on the volar aspect of the forearm 4 cm proximal to the wrist crease between the palmaris longus tendon (see previous description) and
the radial flexor tendon. The needle is inserted in a distal direction with the syringe lifted 10 to 20 degrees up from the parallel. This approach supposedly minimizes
chances of trauma to the nerve. In all cases (A–E), the injection should be given with minimal pressure, slowly. If there is resistance or if the patient feels “pins and
needles” in the fingers, stop immediately. If an intraneural injection occurs, there will be significant pain after injection and surgical decompression may be needed.
Use a 25-gauge, 1.5-inch needle with 1 mL 1% lidocaine and 20 to 40 mg of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5).
A B
Fig. 180.8 Lateral epicondylitis (tennis elbow). (A–B) Find the area of greatest tenderness over the lateral epicondyle. Insert the needle perpendicularly until
bone is felt. Withdraw the needle 1 to 2 mm and inject. It may be beneficial to fan out the injections in several directions into the extensor aponeurosis and the
radial collateral ligament. Massage the injection site. If distal tenderness is still present after several minutes, another injection in a fanlike pattern may be neces-
sary. Some experts recommend “fenestrating” the tendon by tapping it up to 20 times with the needle around the area of most discomfort. This may stimulate
healing. Medial epicondylitis (golfer’s elbow) is treated in a similar fashion. Use a 22- to 25-gauge, 1.5-inch needle with 3 to 5 mL 1% lidocaine and 10 to 30 mg
of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5).
A B
Olecranon process
Olecranon bursa
C
Fig. 180.9 Olecranon bursa, aspiration and injection. (A) An enlarged bursa secondary to bursitis. (B) Aspirating the olecranon bursa. This bursa is easily
identified and entered. (C) Insert a large-bore needle directly into the bursa and aspirate until fluid is returned. Whether cloudy or not, the fluid should be sub-
mitted for culture and concurrent infection should be ruled out. Await the culture results before injecting with a steroid. It is next to impossible to tell whether
the bursa is infected or not on a clinical basis. While waiting for the culture results, place the patient on nonsteroidal antiinflammatory drugs (NSAIDs) and
wrap the area tightly. If infection is suspected, start an antibiotic to cover gram-positive pathogens while waiting for culture results. Once infection is ruled out,
steroids can be used. In a double-blind study comparing focal steroid injection into the olecranon bursa with systemic NSAIDs, the most rapid benefit and most
lasting effect came from steroid injections. Use an 18- to 21-gauge needle for aspiration. Use a 22-gauge, 1- to 1.5-inch needle with 2 to 3 mL 1% lidocaine and
10 to 20 mg of methylprednisolone acetate or equivalent for injection (see Tables 180.2 and 180.5). (Courtesy John L. Pfenninger, MD, The Medical Procedures
Center, Midland, MI.)
A B
Radial head
Lateral
epicondyle
Synovium
of joint
C
Olecranon process
Fig. 180.10 Elbow joint. (A) Injection of the elbow joint. (B) Flex the elbow 45 degrees. Identify the lateral epicondyle. Inject into the joint space just distal
to the lateral epicondyle and superior to the olecranon process of the ulna. A slight concavity can be felt just inferior to the radial head and helps identify the
proper point of insertion. (C) Use a 22-gauge, 1- to 1.5-inch needle with 3 to 5 mL 1% lidocaine and 20 to 30 mg of methylprednisolone acetate or equivalent
(see Tables 180.2 and 180.5).
Subacromial space
Acromion
Subacromial
bursa
Coracoid Greater tubercle
process of the humerus
Fig. 180.11 Acromioclavicular joint. With the patient seated and arm at the Scapula
side, palpate the clavicle, moving laterally until a prominence is felt. This is the
acromioclavicular joint. It is about 1.5 to 2 cm inward from the lateral edge to the
acromion. Insert the needle from an anterior or superior position into the joint
and angle it medially, then inject. Use a 22-gauge, 1- to 1.5-inch needle with 5 to
7 mL 1% lidocaine and 30 to 40 mg of methylprednisolone acetate or equivalent
(see Tables 180.2 and 180.5). Since there is limited space to inject, this is often a
painful procedure and benefits from ultrasound guidance.
Supraspinatus muscle Suprascapularis muscle
Infraspinatus muscle
Teres minor muscle
Greater tubercle
Deltoid
Humerus
Scapula
A Posterior view Anterior view
Lateral approach
B
Fig. 180.12 Shoulder: Subacromial bursa. Most injection procedures involving the shoulder will include an injection into the subacromial bursa. Palpate the
superior surface of the shoulder, progressing laterally until there is a slight drop-off. This is the lateral edge of the acromion. The now palpable soft spot above the
humeral head is the location of the subacromial bursa. Direct the needle perpendicular to the surface and insert the needle through the deltoid muscle into the bursa.
The needle should be free floating, since it is within a space, not in a muscle or tendon. The tendon of the supraspinatus, the muscle most commonly involved in a
rotator cuff syndrome, is directly medial to this bursa and can be entered by directing the needle deeper. If the tendon is calcified as it is entered, a gritty sensation
may be felt. Inject within the bursa, not within the tendon. (A) The muscles of the rotator cuff are demonstrated. They include the supraspinatus, the infraspinatus,
teres minor, and the subscapularis. (B) The technique of a subacromial bursa injection, anterior view. (C) Injecting the subacromial bursa, posterior approach. Use
a 22-gauge, 1- to 1.5-inch needle with 5 to 7 mL 1% lidocaine and 30 to 40 mg of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5). It can be
reached from anterior, lateral, or posterior approach, but outcome studies suggest using lateral approach, especially in women who may have slightly smaller bursa.
Supraspinatus Acromion
tendon
Subacromial
bursa
Supraspinatus
muscle
Coracoid
Glenohumeral process
joint capsule
A B
Fig. 180.13 Shoulder: Rotator cuff (supraspinatus tendinitis). (A) Use the same approach as that used for injecting the subacromial bursa (see Fig. 180.13).
However, insert the needle deeper to reach the peritendinous area. (B) Alternatively, have the patient rotate the flexed arm behind the back. Palpate the inferior
edge of the acromion. The greater tuberosity of the humerus lies just below it. The tendon lies in the hollow between these two bones. Use an 18- to 20-gauge,
1.5-inch needle with 5 mL 1% lidocaine and 20 to 40 mg of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5).
Acromion
Subacromial space
Greater tubercle
Fig. 180.14 Shoulder: Short head of the biceps. The short head of the
biceps attaches to the coracoid process. This is the palpable bony promi- A B
nence located inferior to the clavicle and medial to the humerus over the
anterior portion of the shoulder. Rarely does this area have to be injected, Fig. 180.15 Shoulder: Bicipital tendinitis (injection of the long head of
but should a patient have pain and discomfort over the coracoid process, the biceps tendon). (A) Have the patient seated with arm flexed 90 degrees.
insert a needle directly into the point of maximal tenderness until it reaches Identify the biceps tendon by placing your hand on the patient’s shoulder
the bone. Withdraw the needle 1 or 2 mm and inject. Only a small volume of with your fingers posteriorly and the thumb anteriorly over the proximal hu-
steroid is needed along with relatively larger amounts of lidocaine. Additional merus. Internally and externally rotate the patient’s arm. The bicipital groove
steroid may be injected parallel to the tendon distally (if it is palpable). Use is palpable anteriorly and the tendon “snap” can be felt under your thumb.
a 22-gauge, 1.5-inch needle with 5 to 10 mL 1% lidocaine and 10 to 20 mg Identify the most tender area of the tendon (usually in the bicipital groove on
of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5). the humerus). Insert the needle into this groove and attempt to make a peri-
tendinous injection of steroid and lidocaine. Often, a slip of the subacromial
bursa surrounds the more proximal portion of the tendon. (B) If pain persists
on palpation after the injection, further injection in a fanlike peritendinous
pattern may be needed more distally. Use a 22-gauge, 1.5-inch needle with
5 to 10 mL 1% lidocaine and 10 to 20 mg of methylprednisolone acetate or
equivalent (see Tables 180.2 and 180.5).
A B
Fig. 180.16 Shoulder: Intraarticular shoulder joint injection. A posterior or an anterior approach can be used to inject into the space of the shoulder joint
(scapulohumeral or glenohumeral joint). (A) In the anterior approach, externally rotate the shoulder. This movement opens the joint space. Identify the coracoid
process. Insert the needle 1 cm inferior and 1 cm lateral to the coracoid process, and direct the needle perpendicularly, or slightly laterally, into the glenohumeral
joint. The properly inserted needle should not contact bone. (B) With the posterior approach, the patient is again seated with the arm internally rotated across
the waist. Palpate the inferoposterior aspect of the acromion with the thumb. Place the index finger on the coracoid process. Insert the needle just below the
acromion and aim toward the coracoid. Insert 2 to 3 cm deep. Use a 20-gauge, 1.5-inch needle with 5 to 7 mL 1% lidocaine and 20 to 40 mg of methylpredni-
solone acetate or equivalent (see Tables 180.2 and 180.5).
Femoral
Hip joint neck
Lesser
trochanter
Greater Femur
trochanter
Trochanteric Lateral fascia
bursa
A B
Fig. 180.17 Trochanteric bursa. (A) Trochanteric bursa is located at the most superior prominent portion of the femur. A bony prominence can be palpated.
Tenderness in this area generally denotes trochanteric bursitis. Direct the needle perpendicular to the femur at the point of maximal tenderness, and insert until
bone is felt. Withdraw the needle 2 to 3 mm and inject. Frequently the pain will radiate more distally (as it might with lateral epicondylitis in the arm) down the
lateral portion of the femur along the fascia. If the patient is still experiencing discomfort 5 minutes after injection of the bursa and massage of the area, a more
distal injection may be necessary at the areas of tenderness. (B) Injecting for trochanteric bursitis. Use a 22-gauge, 1.5- to 2-inch needle with 5 to 10 mL 1%
lidocaine and 20 to 40 mg of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5).
Prepatellar
bursa
A Infrapatellar Pes anserine

bursa bursa
Sartorius
Semitendinosus
Prepatellar bursa Gracilis
Deep infrapatellar
bursa Pes anserinus
B
Fig. 180.18 Hip joint proper. (A) Experience is necessary to inject the hip
joint itself. Even experienced practitioners often use fluoroscopy. An anterior
or posterior approach can be taken. However, the anterior approach is most B
common. Great care must be taken to avoid entering any of the blood vessels
or nerves coursing through the inguinal canal area. Position the hip so that the Fig. 180.19 Prepatellar bursa, one of nine bursa around the knee, but
leg is maximally extended and internally rotated. Use a long needle to enter 2 the one most frequently inflamed. (A) Identify the bursa, which is located
to 3 cm below the anterior superior spine of the ilium and 2 to 3 cm lateral between the skin and the patella. (B) Insert the needle just above the patella
to the femoral pulse. The needle should point posteromedially at a 60-degree and at the lateral portion of the bursa, and direct it to the center of swelling.
angle to the skin and then should course through the capsule ligaments until it Aspirate fluid (for culture), switch syringes, and then inject. (Although the
reaches bone. Withdraw the needle slightly and aspirate for fluid. Injection may data are not as documented as for olecranon bursitis, the protocol for inject-
then be carried out, and there should be little resistance. (B) Injecting the hip. ing this bursa can be the same.) Use a 20- to 22-gauge, 1- to 1.5-inch needle
Use a 20-gauge, 1.5- to 3-inch needle with 5 mL 1% lidocaine and 40 to 80 with 3 mL 1% lidocaine and 20 to 40 mg of methylprednisolone acetate or
mg of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5). equivalent (see Tables 180.2 and 180.5).
Patella
Bursa
Tibia
Fibula
A B
Quadriceps
muscle
Suprapatellar
bursa
Joint space Popliteal

Patella bursa
C Lateral
femoral
Patellar tendon condyle
Infrapatellar
fat pad Tibia
D
Fig. 180.20 Knee joint. The knee is one of the easiest joints to enter and one of the most common joints to aspirate and inject. Slightly flex the knee using
a towel in the popliteal space with the patient lying on an examination table. Either a lateral (A) or medial (B) approach may be used. For the lateral approach,
palpate the superior lateral aspect of the patella and insert the needle 1 cm superior and 1 cm lateral to this point. Apply gentle pressure on the contralateral side
of the knee to encourage the fluid to pool in the area of aspiration. Direct the needle under the patella at a 45-degree angle to the midjoint area. Aspirate all fluid
before injection. There should be no resistance. (C) Other approaches include entering medially or laterally directly above the joint line with the patient seated,
or going directly through the patellar tendon just below the patella. Another option is to enter the joint capsule from either side of the patellar tendon just below
the patella. This is an excellent location when there is little cartilage left; the knee is basically bone on bone so there is little room to maneuver the patella. (D)
The knee joint space is large and is readily entered from multiple approaches. Use a 20-gauge, 1- to 1.5-inch needle with 5 mL 1% lidocaine and 20 to 80 mg of
methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5). A Baker cyst is a sac of synovial fluid that has leaked out of a hole in the posterior capsule
of the knee. It generally indicates significant internal knee problems, and steroid injections are only a temporary relief frowned on by many clinicians. Insert the
needle 3 cm medial to the midline and 3 cm below the popliteal crease. Take care to avoid the popliteal artery, vein, and nerve. Use a 20-gauge, 1- to 1.5-inch
needle with 5 mL 1% lidocaine and 20 to 80 mg of methylprednisolone acetate or equivalent (see Table 180.2).
3. Draw up the proper amounts of steroid and anesthetic into a single 7. If lidocaine or steroid is to be injected, it is often necessary
syringe and mix well by tipping the syringe backward and forward. to inject in two or three slightly different areas at the site of
4. Note that although using smaller caliber needles may provide the tenderness. This is not necessary when the joint space itself has
patient with less pain, it is more difficult to determine whether been entered, although some practitioners advocate reposition-
the appropriate space for injection has been entered. In contrast, ing within bursal spaces because of the potential presence of
larger bore needles will be more painful. Based on the site of in- septations that may interfere with full dissolution within the
jection, and the constitution of the patient, you may decide to desired area.
inject a superficial anesthetic (e.g., lidocaine) or use ethyl chlo- 8. Although much has been written regarding laboratory evalua-
ride spray on the skin prior to the intraarticular injection to allow tion of joint fluid aspirates, Schmerling (1990) reported that the
for the use of a larger needle. white blood cell (WBC) count and polymorphonucleocyte per-
5. Using appropriate syringes and needles, either aspirate or inject centage were the only helpful tests to determine the etiology of
the site as indicated. After insertion but before injection, pull an exudate. Use lavender-topped Vacutainers for these studies. It
back the plunger to be sure the needle is not in a blood vessel. is recommended that synovial fluid be examined within 1 hour
Universal blood and body fluid precautions should be followed. after arthrocentesis. WBC counts of mildly inflammatory fluids
6. If aspiration of an effusion is to be followed by injection, there can decrease to “noninflammatory range” within 5 to 6 hours.
are two choices: (1) have two needle/syringe setups and enter the Glucose, protein, lactate dehydrogenase, complement fixation,
area twice; or (2) enter once, aspirate, grasp the needle with a electrolyte, uric acid levels, rheumatoid factor, and antinuclear
hemostat (being careful not to change the position of the needle antibodies are of little benefit. Fluids for chemistry testing if de-
tip), remove the syringe with the aspirate, then replace it with sired should be transported in green- or red-topped tubes and be
the lidocaine/steroid syringe, and finally inject the contents. analyzed within 4 hours.

Medial malleolus
Sartorius
Semitendinosus
Gracilis
Pes anserinus
Anserine bursa
(below the tendons)
Fig. 180.21 Anserine bursa. The anserine bursa is located on the upper
medial portion of the tibia under the insertion of the sartorius, semitendino- Fig. 180.22 Ankle joint. Anteromedial approach is the easiest. Have the
sus, and gracilis tendons. This bursa frequently becomes inflamed in elderly, patient maximally dorsiflex the toe, accentuating the extensor tendon. Iden-
somewhat obese women; the symptoms are aggravated by going up and tify the hollow between the anterior medial malleolus and the long exten-
down stairs. Palpate and find the point of maximal tenderness, and insert the sor tendon. This is the spot for injection. The needle must be inserted ap-
needle perpendicular to the tibia. When bony resistance is encountered, with- proximately 3 cm and directed slightly lateral. Use a 22-gauge, 1- to 1.5-inch
draw the needle 2 or 3 mm and inject several areas in a fanlike fashion. Use needle with 3 to 5 mL 1% lidocaine and 20 to 40 mg of methylprednisolone
a 22- to 25-gauge, 1.5-inch needle with 3 to 5 mL 1% lidocaine and 20 to 40 acetate or equivalent (see Tables 180.2 and 180.5).
mg of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5).
90
A B
C
Fig. 180.23 Calcaneal spur/plantar fasciitis. Two approaches can be used. Many clinicians prefer to direct the needle from the lateral side of the foot (A)
rather than from the inferior (plantar) side (B). The adipose tissue of the heel is uniquely segmented to provide cushion for the foot. If the plantar approach is
used and steroid leaks out through the tract, atrophy could result, and thus the patient would have heel pain while walking. Nevertheless, many clinicians ap-
proach directly from the plantar position to inject steroid right over a calcaneal spur. Using the lateral approach, the clinician would direct the needle to enter
just below the bony prominence of the calcaneus, and just anterior to the heel pad, and go to the midline until the point of maximal tenderness is reached (C).
Use a 22-gauge, 1.5-inch needle with 2 to 4 mL 1% lidocaine and 15 to 30 mg of methylprednisolone acetate or equivalent (see Tables 180.2 and 180.5).
• T ypically used in areas of degenerative tissue (i.e., tendinosis).

• Because of common usage with tendinous tissues, care must be
taken to inject into the peritendinous areas rather than into the
body of the tendon itself.
• Ultrasound can be considered to confirm placement of agent into
the desired area.
• Because an inflammatory response is the desired outcome, edu-
cating the patient regarding anticipated pain over the next 24 to
48 hours is strongly encouraged. Some practitioners even advo-
cate the use of opioid analgesics for pain control in the immedi-
ate postinjection period.
• There are no current recommendations for the ideal proinflam-
matory agent; availability (i.e., dextrose solutions) or desire to
utilize the patient’s own fluids (i.e., autologous blood, platelet-
rich plasma) are two of the considerations made in determining
Fig. 180.24 Morton neuroma. Approach the foot from dorsal aspect.
Insert needle 1 to 2 cm proximal to affected web space. Insert needle per- the appropriate agent.
pendicularly all the way to the plantar surface. Do not penetrate skin, but • Lidocaine should be injected to provide local anesthesia prior to
estimate depth by observing tenting of skin. Withdraw 1 cm and inject. Use using the other agents.
a 25-gauge, 1.5-inch needle with 3 to 5 mL 1% lidocaine and 10 to 30 mg of • Volume of agent should be based on the size of the area involved;
methylprednisolone acetate or equivalent (see Table 180.2). most tendinous injections usually require no more than 5 mL of
solution. Some areas will allow for a greater volume to be placed,
but may cause more postinjection pain.
If the exudate is cloudy, the WBC count is elevated, or a septic • Although there is no consensus as yet for the appropriate interval
joint is strongly suspected, do not inject the area, and a culture is also or total number of injections that should be administered, it is
indicated. For cultures, submit as much fluid as possible. “Swabbed reasonable to wait at least 4 to 6 weeks between treatments. If
samples” may not be adequate. Large-volume specimens (over 2 mL) more than five injections are necessary, consideration should be
support viability of most microorganisms for up to 24 hours at room made for other therapies.
temperature. Nevertheless, transport to the laboratory ASAP. Do not
refrigerate! Large samples may be sent in the syringe used to aspirate
them or in a sterile 5- or 10-mL container that has no additives (i.e.,
a red-topped glass tube). For volumes less than 2 mL, consider using
Ultrasound Guidance for Injections
bottles with culture media (e.g., Port-A-Cul) inside. Test tube con- Also see Chapter 171, Musculoskeletal Ultrasound.
tainers with anticoagulant additives (i.e., lavender- or green-topped Ultrasound is an extremely valuable modality that can allow the
containers) should not be used. clinician to identify the structure to be injected and guide the needle
to its precise location. This can be particularly beneficial in reducing
If there is any suspicion of gouty arthritis, examine the fluid for crys- the pain associated with “blind” localization of small joint spaces,
tals under polarized light. making the patient more comfortable, and thus more compliant,
A peripheral smear may be helpful when a bloody tap is obtained during the procedure.
after trauma. The presence of fat cells indicates a fracture. Ultrasound-guided injections also allow the clinician greater
The Pfenninger articles listed in the bibliography contain many confidence in interpreting the results of an injection. For exam-
tables of other characteristics of synovial fluid for differential ple, a missed injection into the acromioclavicular joint may
diagnosis, although the benefit of additional studies is un- suggest another etiology of a patient’s shoulder pain, resulting
proved. in further erroneous testing and treatment regimens unless the
error is identified on ultrasound. When the injection is per-
formed with ultrasound, the clinician has objective evidence
Technique of Injection for Hyaluronic Acid of appropriate placement of the medication and can therefore
“Devices” derive more accurate conclusions regarding the efficacy of the
• M ust be intraarticular. medication.
• More demanding than steroid intraarticular injections because In order to perform ultrasound-guided injections, the cli-
it must be placed within the synovial space, not the surrounding nician must have some training in the use of diagnostic ultra-
soft tissue. sound. The machine used should ideally have at least one
• Some experts use fluoroscopy or ultrasound to be certain of in- multifrequency transducer in order to allow for visualization of
traarticular injection. both superficial and deeper structures. Power Doppler capability
• Do not mix with lidocaine or steroids. is also valuable because it allows the clinician to avoid vascu-
• Drain all effusions before injection. lature and to better observe the flow of the medication in the
• Forced injections push material into the elasticity zone and then actual space intended.
are very difficult to administer; slow injections must be given When performing ultrasound-guided injections, the following
with a 22-gauge or larger needle (which again may necessitate supplies are needed:
the use of superficial anesthesia with lidocaine or ethyl chloride
spray to allow for better tolerance by the patient). • Ultrasound gel
• Patient should avoid strenuous activity for 48 hours. • Antiseptic, such as alcohol, chlorhexidine, or povidone-iodine
• Derived from chicken or rooster combs, so an allergy to eggs or • Gauze pads and adhesive bandages
feathers would dictate caution. • Ethyl chloride spray (optional)
• Syringes (It is important to ensure that all air has been cleared
out of both the needle and the syringes to be used, because air
Technique of Injection for Prolotherapy bubbles obscure ultrasound images.)
A complete course of instruction prior to beginning prolotherapy • Needles of appropriate length to reach the target
injections in an office practice is recommended. • A pair of forceps or a needle holder

BOX 180.2 Possible Complications of Intraarticular or

Soft Tissue Injections
Local Complications
• Bleeding
• Charcot-like arthropathy
• Fat necrosis
• Hemarthrosis
• Iatrogenic infection; septic arthritis
• Intraarticular calcification
• Nerve damage from inadvertent injection
• Osteonecrosis
• Pain
• Periarticular calcification
• Pneumothorax (thoracic trigger points)
• Postinjection flare
• Skin depigmentation
• Subcutaneous atrophy
Fig. 180.25 Ultrasound-guided injection. Clinician demonstrates ultrasound • Tendon rupture
guidance for injection of proximal hamstring tendinopathy. Note the needle is • Tenosynovitis
parallel to the longitudinal axis of the probe to facilitate visualization on the ac-
companying computer screen for identification. (Courtesy John M. McShane, MD.) Systemic Complications
•A cne
•A drenal suppression
The standard technique for performing therapeutic injections •A llergic reactions or anaphylaxis from local or preserva-
under ultrasound guidance is as follows: tives in multidose vials
• Avascular necrosis
1. With the patient in a comfortable position, place some ultra- • Flushing of the face
sound gel over the area to be visualized and then use the ultra- • Impaired glucose tolerance
sound transducer to identify the structure to be injected. • Menstrual irregularity; uterine bleeding
2. Once the structure has been identified, place the transducer so • Muscle wasting and myopathy
that its long axis will be parallel to best line for the needle to take • Osteoporosis
in order to reach its target (Fig. 180.25). • Pancreatitis
3. Use appropriate antiseptic solution to cleanse the skin at the • Posterior subcapsular cataracts
end of the transducer where the needle will enter. Be sure not to • Psychological upset
move the transducer once the skin has been prepared. • Steroid arthropathy
4. If desired, use the ethyl chloride spray to superficially anesthetize • Syncope
the skin that will be punctured by the needle.

5. Take the needle and syringe containing the local anesthetic and From McKeag D. Complication of joint aspiration/injection. Clin
hold it parallel to the ultrasound transducer with the tip of the Atlas Office Proc. 2002;5:4.
needle aimed at the skin that has been cleansed. Keeping the
needle constantly parallel to the transducer, enter the skin, and
inject a small amount of anesthetic. and steroids are both given intravenously for other condi-
6. Using the ultrasound transducer, constantly keep the needle and tions.)
the target to be injected in view. As the needle is advanced, re- • Introduction of infection (usually Staphylococcus) into joint
peatedly inject a small amount of anesthetic ahead of the tip. space (18 infections per 250,000 injections [0.072%])
The fluid injected will be seen distending the tissue, and will help • Trauma to articular cartilage
establish the location of the needle. If the needle is moved off • Injury to nearby nerves (e.g., median nerve in carpal tunnel in-
target, slightly withdraw and redirect toward the target. jection) or other nearby structures
7. Once the structure to be injected is reached, if available, turn on • Pneumothorax (when injecting thoracic trigger points)
the power Doppler and center it over the tip of the needle. Inject • Subcutaneous fatty or skin atrophy or hyperpigmentation/hypo-
some anesthetic into the targeted area and watch for flow on the pigmentation (see Fig. 180.26)
Doppler. If the needle is placed accurately, it will be confirmed by • Adverse drug reaction (see Table 180.4)
seeing flow on the Doppler in the desired location. • Allergic drug reaction (very rare)
8. Once the location of the needle is confirmed, the needle is held • Injection of steroid into a septic joint (If there is any suspicion
in place by the forceps/needle holder and the syringe is removed. of infection, do not instill steroids until laboratory studies have
The syringe containing the fluid to be injected is then attached ruled it out.)
to the needle and the fluid is then injected. • Osteoporosis and cartilage damage (This is rare; reported cases
9. The needle is withdrawn, pressure is placed over the puncture have usually occurred after 20 to 30 injections. For joints, espe-
site, and an adhesive bandage is placed. cially weight-bearing joints, a limit of three steroid injections per
year provides a wide margin of safety.)
• Inappropriate/missed diagnosis
• Tendon rupture (To reduce the possibility of tendon rupture,
Complications inject peritendinously instead of intratendinously. Ruptures
Box 180.2 lists the possible complications of intraarticular or soft tis- usually occur after multiple injections and when the patient
sue injections. Also see Table 180.4. Possible complications include will not rest the area. Finger tendon ruptures have been re-
the following: ported after steroid injection. Gray and Gottlieb recommend
setting a limit of five total injections per finger joint. Some
• Injection into a vein or artery (This rarely causes a problem experts recommend never injecting near the Achilles ten-
except that the therapeutic effect may not occur. Lidocaine don.)
CPT/Billing Codes
Healthcare Common Procedure Coding System
(HCPCS) Codes*
20526 Injection: therapeutic (e.g., local anesthetic,

corticosteroid), carpal tunnel
20550† Injection: tendon sheath, ligament, ganglion cyst
20551 Injection: therapeutic of tendon at its origin or
insertion
20552 Injection: single or multiple trigger point(s), one
or two muscle group(s)
20553 Injection: single or multiple trigger point(s),
three or more muscle groups
20600 Arthrocentesis, aspiration and/or injection,
small joint or bursa (e.g., fingers; toes); without
Fig. 180.26 Fatty atrophy. This patient received a steroid injection for ultrasound guidance, with permanent recording
lateral epicondylosis approximately 11 months before this photo was taken, and reporting
showing an example of steroid fatty atrophy and hypopigmentation. Such 20605 Arthrocentesis, aspiration and/or injection,
changes may take up to a year to resolve, and some can be permanent chang-
es.
intermediate joint or bursa (e.g., temporoman-
dibular, acromioclavicular, wrist, elbow or ankle,
olecranon bursa); without ultrasound guidance,
• R eactions to anesthetic agent (True allergic reactions to li- with permanent recording and reporting
docaine [an amide] itself is extremely rare. Allergic reactions 20610 Arthrocentesis, aspiration and/or injection,
have been reported to the esters more frequently [e.g., pro- major joint or bursa (e.g., shoulder, hip, knee,
caine/Novocain]; when reactions to lidocaine are suspected, subacromial bursa); without ultrasound guidance,
the lidocaine has usually been drawn up from a multidose vial. with permanent recording and reporting
These vials contain paraben preservatives, which can cause 20604 Arthrocentesis, aspiration and/or injection, small
a reaction. So, if suspicions of a “caine” allergy arise, single- joint or bursa (e.g., fingers; toes); with ultrasound
dose vials of lidocaine should be used. Another reason to use guidance, with permanent recording and report-
single-dose vials is to avoid precipitation of the steroid; see ing
earlier discussion.) 20606 Arthrocentesis, aspiration and/or injection,
• Steroid flare (Steroid flares occur rarely but are very painful. intermediate joint or bursa (e.g., temporoman-
The patient actually experiences more discomfort after the in- dibular, acromioclavicular, wrist, elbow or ankle,
jection. The flare is not associated with fever, occurs within olecranon bursa); with ultrasound guidance, with
12 to 24 hours of the injection, and resolves spontaneously permanent recording and reporting
within 72 hours. It may be controlled with ice and nonsteroi- 20611 Arthrocentesis, aspiration and/or injection,
dal drugs.) major joint or bursa (e.g., shoulder, hip, knee,
• Interference with glucose metabolism. Therefore glucose levels subacromial bursa); with ultrasound guidance,
need to be followed more closely in diabetics in the first 24 hours. with permanent recording and reporting
• Problems with viscosupplementation injections M0076 Prolotherapy
• Injection site pain is more frequent. *Can also charge for any injected medications using appropriate J code.
• Rash and itching, cramps, ankle edema, muscle pain, and †Office visit can also be charged.
tachyarrhythmia have been reported.
• A local reaction can produce a massive effusion that resem-
bles a septic joint; 69% with pain experience relief after effu-
Steroids
sion resolves.
J0702 Betamethasone acetate (Celestone Soluspan)
J0810 Cortisone
J1021 Methylprednisolone acetate
Postprocedure Patient Care and Education J1040 Depo-Medrol
• A n adhesive bandage dressing or other dressing should be left on J1095 Dexamethasone acetate
for 8 to 12 hours. J1100 Dexamethasone sodium phosphate (Decadron)
• It is essential that the affected area be rested. Injection therapy J1690 Prednisolone tebutate (Hydeltra-TBA)
is not a cure itself. It is used in conjunction with other modali- J1700 Hydrocortisone acetate
ties. Physical therapy, NSAIDs, and hot or cold compresses may J2640 Prednisolone sodium phosphate
all be indicated, depending on the specific problem. If a weight- J3301 Triamcinolone acetonide (Kenalog)
bearing joint (such as the knee) is injected, rest is indicated for J3302 Triamcinolone diacetate (Aristocort)
a longer period than that for a wrist ganglion cyst injection. J3303 Triamcinolone hexacetonide (Aristospan)
• The patient should report immediately if he or she develops fe- J7506 Prednisone
ver, chills, or any sign of infection. If the discomfort from the J7321 Hyalgan or Supartz
injection does not resolve within 72 hours, the patient should be J7323 Euflexxa
examined to rule out a septic joint. J7324 Orthovisc
• The patient may bathe normally. J7235 Synvisc
• A short course of an NSAID is often beneficial at the time of J7327 Monovisc
injection; the two modalities combined may have a markedly
beneficial effect.
ICD-10-CM Diagnostic Codes Online Resources

American Association of Orthopedic Medicine: http://aaomed.org/
M10.00 Gouty arthropathy site unspecified Prolotherapy
G56.00 Carpal tunnel syndrome unspecified limb
G56.20 Lesion ulnar nerve unspecified limb
G57.50 Tarsal tunnel syndrome unspecified limb RECOMMENDED READING
G57.60 Morton’s neuroma unspecified limb Altman RD, Moskowitz R. Intraarticular sodium hyaluronate (Hyalgan) in
L40.59 Psoriatic arthropathy other the treatment of patients with osteoarthritis of the knee: a randomized
M06.9 Rheumatoid arthritis unspecified clinical trial. J Rheumatol. 1998;25:2203.
M19.019 Primary osteoarthritis unspecified shoulder Anderson B, Kaye S. Treatment of flexor tenosynovitis of the hand (“trigger
M19.029 Primary osteoarthritis unspecified elbow finger”) with corticosteroids: a prospective study of the response to local
M19.049 Primary osteoarthritis unspecified hand injection. Arch Intern Med. 1991;151:153.
Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, et al. Viscosupplemen-
M17.10 Unilateral primary osteoarthritis unspecified knee tation for the treatment of osteoarthritis of the knee. Cochrane Database
M17.0 Bilateral primary osteoarthritis knee Syst Rev. 2006;2:CD005321.
M19.079 Primary osteoarthritis unspecified ankle and foot Blair B, Rokito AS, Cuomo F, et al. Efficacy of corticosteroids for subacro-
M25.519 Pain unspecified shoulder mial impingement syndrome. J Bone Joint Surg. 1996;78-A:1685.
M25.529 Pain unspecified elbow Blanchard V, Barr S, Cerisola FL. The effectiveness of corticosteroid injec-
M25.539 Pain unspecified wrist tions compared with physiotherapeutic interventions for adhesive capsu-
M25.549 Pain in joints of unspecified hand litis: a systematic review. Physiotherapy. 2010;96(2):95–107.
M25.569 Pain unspecified knee Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for
M25.579 Pain unspecified foot and ankle greater trochanteric pain syndrome: a randomized controlled trial in pri-
mary care. Ann Fam Med. 2011;9(3):226–234.
M25.619 Stiffness unspecified shoulder
Carrabba M, Paresce E, Angelini M, et al. The safety and efficacy of different
M25.669 Stiffness unspecified knee dose schedules of hyaluronic acid in the treatment of painful osteoarthri-
M54.2 Neck pain tis of the knee with joint effusion. Eur J Rheumatol Inflamm. 1995;15:25.
M54.5 Low back pain Charalambous CP, Tryfonidis M, Sadiq S, et al. Septic arthritis following
M54.30 Sciatica unspecified site intraarticular steroid injection of the knee—A survey of current practice
M53.3 Coccydynia regarding antiseptic technique used during intraarticular steroid injec-
M75.40 Impingement syndrome unspecified shoulder tion of the knee. Clin Rheumatol. 2003;22:386.
M70.60 Trochanteric bursitis unspecified hip Cheng OT, Souzdalnitski D, Vrooman B, et al. Evidence-based knee injec-
M75.50 Bursitis unspecified shoulder tions for the management of arthritis. Pain Med. 2012;13(6):740–753.
M75.100 Rotator cuff syndrome unspecified shoulder Chumacher HR, Chen LX. Injectable corticosteroids in treatment of arthri-
tis of the knee. Am J Med. 2005;118:1208.
M75.20 Tendinitis unspecified shoulder Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injec-
M75.20 Bicipital tendinitis unspecified shoulder tions and other injections for management of tendinopathy: a systematic
M77.00 Medial epicondylitis (golfer’s elbow) unspecified elbow review of randomised controlled trials. Lancet. 2010;376(9754):1751–1767.
M77.10 Lateral epicondylitis (tennis elbow) unspecified elbow Dagenais S, Yelland MJ, Del Mar C, Schoene ML. Prolotherapy injections for
M70.20 Olecranon bursitis unspecified elbow chronic low-back pain. Cochrane Database Syst Rev. 2007;(3):CD004059.
M70.50 Pes anserine bursitis unspecified knee David JA, Sankarapandian V, Christopher PRH, Chatterjee A, Macaden AS.
M76.50 Patellar tendinitis unspecified knee Injected corticosteroids for treating plantar heel pain in adults. Cochrane
M70.40 Prepatellar tendinitis unspecified knee Database Syst Rev. 2107;(2):CD009348.
M76.60 Achilles bursitis unspecified leg Dammers JW, Veering MM, Vermeulen M. Injection with methylpredniso-
lone proximal to the carpal tunnel: randomised double blind trial. BMJ.
M77.30 Heel spur unspecified foot
2000;321:884.
M65.30 Trigger finger unspecified finger Divine JG, Zazulak BT, Hewett TE. Viscosupplementation for knee osteoar-
M65.4 de Quervain disease thritis: a systematic review. Clin Orthop Relat Res. 2007;455:113.
M65.849 Tendinitis, unspecified hand/wrist Fadale PD, Wiggins ME. Corticosteroid injections: their use and abuse. J Am
M65.879 Tendinitis, unspecified foot/ankle Acad Orthop Surg. 1994;2:133.
M71.50 Bursitis unspecified site Fitzgerald RH. Intrasynovial injection of steroids: uses and abuses. Mayo Clin
M67.40 Ganglion, unspecified joint Proc. 1976;51:655.
M71.20 Baker cyst unspecified knee Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid injections for com-
M65.20 Calcific tendinitis unspecified site mon musculoskeletal conditions. Am Fam Physician. 2015;92(8):694–699.
M72.2 Plantar fasciitis Foster AH, Carlson BM. Myotoxicity of local anesthetics and regeneration of
the damaged muscle fibers. Anesth Analg. 1980;59:727.
M79.7 Fibrositis Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injec-
M72.9 Fasciitis tions for shoulder and elbow tendonitis: a metaanalysis of randomised
M79.629 Pain upper arm unspecified arm controlled trials. Ann Rheum Dis. 2009;68(12):1843–1849.
M79.639 Pain forearm unspecified arm Gedda PO. Septic arthritis from cortisone. JAMA. 1954;155:597.
M79.669 Pain lower leg unspecified leg George E. Intraarticular hyaluronan treatment for osteoarthritis. Ann Rheum
M79.659 Pain thigh unspecified leg Dis. 1998;57:637.
M79.676 Pain toe unspecified toe Gowans JDC, Granieri PA. Septic arthritis: its relation to intraarticular in-
jections of hydrocortisone acetate. N Engl J Med. 1959;261:502.
Griesser MJ, Harris JD, Campbell JE, et al. Adhesive capsulitis of the shoul-
der: a systematic review of the effectiveness of intraarticular corticoster-
Acknowledgment oid injections. J Bone Joint Surg Am. 2011;93(18):1727–1733.
The editors recognize the many contributions by John L. Pfenninger, Gray RG, Gottlieb NL. Intraarticular corticosteroids: an updated assessment.
Clin Orthop Relat Res. 1983;177:253.
MD, to this chapter in a previous edition of this text. Gray RG, Tenenbaum J, Gottlieb NL. Local corticosteroid injection therapy
in rheumatic disorders. Semin Arthritis Rheum. 1981;10:231.
Learning Resource Hay EM, Paterson SM, Lewis M, et al. Pragmatic randomized controlled trial
of local corticosteroid injection and naproxen for treatment of lateral
National Procedures Institute: www.npinstitute.com (courses and DVDs on epicondylitis of elbow in primary care. BMJ. 1999;319:964.
joint injection)
Hepper CT, Halvorson JJ, Duncan ST, et al. The efficacy and duration of Pfenninger JL. Injections of joints and soft tissue. Part II. Guidelines for spe-
intraarticular corticosteroid injection for knee osteoarthritis: a systematic cific joints. Am Fam Physician. 1991;44:1690.
review of level I studies. J Am Acad Orthop Surg. 2009;17(10):638–646. Pfenninger JL, ed. Joint injection techniques. Clin Atlas Office Proc.2002;5:4.
Hernandez-Diaz S, Garcia-Rodriguez LA. Epidemiologic assessment of the Qvistgaard E, Christensen R, Torp-Pedersen S, et al. Intraarticular treatment
safety of conventional nonsteroidal anti-inflammatory drugs. Am J Med. of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid,
2001;110(suppl 3A):20S. and isotonic saline. Osteoarthritis Cartilage. 2006;14(2):163–170.
Hollander JL. Intrasynovial corticosteroid therapy in arthritis. Maryland State Ryan M, Wong A, Taunton J, Wong J. A pilot investigation on a new treat-
Med J. 1970;19:62. ment for chronic plantar fasciitis: ultrasound guided hyperosmolar dex-
Jones A, Doherty M. Intraarticular corticosteroids are effective in osteoar- trose injections. Clin J Sport Med. 2007;17:166.
thritis but there are no clinical predictors of response. Ann Rheum Dis. Saunders S, Longsworth S. Injection Techniques in Musculoskeletal Medicine:
1996;55:829. a Practical Manual for Clinicians in Primary and Secondary Care. 4th ed.
Jones A, Regan M, Ledingham J, et al. Importance of placement of intraar- Philadelphia: Churchill Livingstone Elsevier; 2013.
ticular steroid injections. BMJ. 1993;307:1329. Schmerling RH, Delbanco TL, Tosteson ANA, et al. Synovial fluid tests:
Juni P, Hari R, Rutjes AW, Fischer R, Silletta MG, et al. Intraarticu- what should be ordered? JAMA. 1990;264:1009.
lar corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. Scott WA. Injection techniques and use in the treatment of sports injuries.
2015;3:CD005328. Sports Med. 1996;22:406.
Kamm GL, Hagmeyer KO. Allergic-type reactions to corticosteroids. Ann Sibbitt Jr WL, Peisajovich A, Michael AA, et al. Does sonographic needle
Pharmacother. 1999;33:451. guidance affect the clinical outcome of intraarticular injections? J Rheu-
Karpie J, Chi C. Lidocaine exhibits dose and time dependent cytotoxic ef- matol. 2009;36:1892.
fects on bovine chondrocytes in vitro. Am J Sports Med. 2007;35:10. Slotkoff AT, Clauw DJ, Nashel DJ. Effects of soft tissue corticosteroid injec-
Kendall H. Local corticosteroid injection therapy. Ann Phys Med. 1963;7:31. tion on glucose control in diabetics. Arthritis Rheum. 1994;37:S347.
Khohadee M. Common superficial bursitis. Am Fam Physician. Smith DL, McAfee JH, Lucas LM, et al. Treatment of nonseptic olecra-
2017;95(4):224–231. non bursitis: a controlled, blinded prospective trial. Arch Intern Med.
Kim SR, Stitik TP, Foye PM, et al. Critical review of prolotherapy for osteo- 1989;149:2527.
arthritis, low back pain, and other musculoskeletal conditions: a physiat- Stahl S, Kaufman T. The efficacy of an injection of steroids for medial ep-
ric perspective. Am J Phys Med Rehabil. 2004;83:379. icondylitis. A prospective study of sixty elbows. J Bone Joint Surg Am.
Kotz R, Kolarz G. Intraarticular hyaluronic acid: duration of effect and results 1997;79(11):1648–1652.
of repeated treatment cycles. Am J Orthop. 1999;28:5. Stefanich RJ. Intraarticular corticosteroids in treatment of osteoarthritis. Or-
Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of in- thop Rev. 1986;15:65.
jection therapies in lateral epicondylitis: a systematic review and net- Stitik TP, Kumar A, Foye PM. Corticosteroid injections for osteoarthritis.
work metaanalysis of randomized controlled trials. Am J Sports Med. Am J Phys Med Rehabil. 2006;85(suppl):S51.
2013;41(6):1435–1446. Tramèr MR, Moore RA, Reynolds DJ, McQuay HJ. Quantitative estimation
Lavelle W. Intraarticular injections. Med Clin North Am. 2007;91:241. of rare adverse events which follow a biological progression: a new model
Leversee JH. Aspiration of joints and soft tissue injections. Prim Care. applied to chronic NSAID use. Pain. 2001;91:401.
1986;13:572. Troum OM. Office-based diagnostic needle arthroscopic lavage. In: Pfen-
Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for car- ninger JL, ed. Joint Injection Techniques Clin Atlas Office Proc. 2002;5:4.
pal tunnel syndrome. Cochrane Database of Syst Rev. 2007;2:CD001554. Walker-Bone K, Javaid K, Arden N, et al. Medical management of osteoar-
McNabb JW. A Practical Guide to Joint and Soft Tissue Injections. 3rd ed. Phila- thritis. BMJ. 2000;321:936.
delphia: Lippincott Williams & Wilkins Wolters Kluwer; 2014. Wen DY. Intraarticular hyaluronic acid injections for knee osteoarthritis.
Moraes VY, Lenza M, Tamaoki M, Faloppa F, Belloti J. Platelet-rich thera- Am Fam Physician. 2000;62:565.
pies for musculoskeletal soft tissue injuries. Cochrane Database of Syst Rev. Wiggins ME, Fadale PD, Ehrlich MG, et al. Effects of corticosteroids on the
2014;3:CD010071. healing of ligaments. J Bone Joint Surg. 1995;77-A:1682.
Nouette-Gaulain K, Sirvent P, Canal-Raffin M, et al. Effects of intermit- Wise CM. Arthrocentesis and injection of joints and soft tissue. In: Firestein
tent femoral nerve injections of bupivacaine, levobupivacaine, and ropi- GS, Budd RS, Harris ED, et al., eds. Kelley’s Textbook of Rheumatology. 8th
vacaine on mitochondrial energy metabolism and intracellular calcium ed. Philadelphia: Saunders; 2008:721.
homeostasis in rat psoas muscle. Anesthesiology. 2007;106:1026. Young CC, Rutherford DS, Neidfeldt MW. Treatment of plantar fasciitis.
Peters-Veluthamaningal C, van der Windt DA, Winters JC, Meyboom- Am Fam Physician. 2001;63:467.
de Jong B. Corticosteroid injection for de Quervain’s tenosynovitis. Zink W, Missler G, Sinner B, et al. Differential effects of bupivacaine and
Cochrane Database Syst Rev. 2009;2:CD005616. ropivacaine enantiomers on intracellular Ca2+ regulation in murine skel-
Peters-Veluthamaningal C, van der Windt DAWM, Winters JC, Meyboom- etal muscle fibers. Anesthesiology. 2005;102:793.
de Jong B. Corticosteroid injection for trigger finger in adults. Cochrane Zuckerman JD, Meislin RJ, Rothberg M. Injections for joint and soft tissue
Database Syst Rev. 2009;2:CD005617. disorders; when and how to use them. Geriatrics. 1990;45:45.
Pfenninger JL. Injections of joints and soft tissue. Part I. General guidelines.
Am Fam Physician. 1991;44:1196.

J S T A I (A) : Oint and Oft Issue Spiration and Njection Rthrocentesis

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

J S T A I (A) : Oint and Oft Issue Spiration and Njection Rthrocentesis

Uploaded by

Copyright:

Available Formats

CHAPTER 180

Joint and Soft Tissue Aspiration

anticipated, sterile gloves are more customary. Masks are unnecessary.

Hydrocortisone acetate 25, 50 40–100 20–40 8–20 20–40 20–50 40–90

‡Such as metacarpophalangeal, interphalangeal, acromioclavicular, temporomandibular.

TABLE 180.3 Steroid Solubility TABLE 180.4 Adverse Effects of Local Corticosteroid

TABLE 180.5 Needle Size and Drug Dosage for Injection Therapy

Palmaris longus tendon

Median nerve Palmaris Ulnar artery Flexor

A Posterior view Anterior view

A Infrapatellar Pes anserine

Joint space Popliteal

• T ypically used in areas of degenerative tissue (i.e., tendinosis).

BOX 180.2 Possible Complications of Intraarticular or

20526 Injection: therapeutic (e.g., local anesthetic,

ICD-10-CM Diagnostic Codes Online Resources

You might also like

J S T A I (A) : Oint and Oft Issue Spiration and Njection Rthrocentesis

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

J S T A I (A) : Oint and Oft Issue Spiration and Njection Rthrocentesis

Uploaded by

Copyright:

Available Formats

CHAPTER 180

Joint and Soft Tissue Aspiration

anticipated, sterile gloves are more customary. Masks are unnecessary.

Hydrocortisone acetate 25, 50 40–100 20–40 8–20 20–40 20–50 40–90

‡Such as metacarpophalangeal, interphalangeal, acromioclavicular, temporomandibular.

TABLE 180.3 Steroid Solubility TABLE 180.4 Adverse Effects of Local Corticosteroid

TABLE 180.5 Needle Size and Drug Dosage for Injection Therapy

Palmaris longus tendon

Median nerve Palmaris Ulnar artery Flexor

A Posterior view Anterior view

A Infrapatellar Pes anserine

Joint space Popliteal

• T ypically used in areas of degenerative tissue (i.e., tendinosis).

BOX 180.2 Possible Complications of Intraarticular or

20526 Injection: therapeutic (e.g., local anesthetic,

ICD-10-CM Diagnostic Codes Online Resources

You might also like

TABLE 180.3 Steroid Solubility TABLE 180.4 Adverse Effects of Local Corticosteroid

TABLE 180.5 Needle Size and Drug Dosage for Injection Therapy

• T ypically used in areas of degenerative tissue (i.e., tendinosis).