1. Dr. TAREKNASRALA, MD,
Department of RHEUMATOLOGY
ALAZHARUniversity

2. • Hollander introduced local
corticosteroid injection therapy for
treatment of inflammatory arthritis in
1951
• Reported medical benefits of intra-
articular injection inconsistent

3. • Pain relieve
• Evaluate spontaneous, unexplained
joint effusion with/without associated
trauma
• Analysis of synovial fluid (especially if
septic arthritis suspected)
• Limit joint damage from infectious
process and provide relief from large
effusion

4. Conditions Often Treated
with Local Injection therapy
• Articular conditions
• Rheumatoid arthritis
• Seronegative spondyloarthropathies
• Ankylosing spondylitis
• Arthritis associated with inflammatory bowel
disease
• Psoriasis
• Reiter’s syndrome
• Crystal-induced arthritis
• Gout
• Pseudogout
• Osteoarthritis (acute exacerbation)Adapted from Pfenninger, 1991 and Cardone, 2002

5. Conditions Often Treated
with Local Injection therapy
• Nonarticular disorders
• Fibrositis
• Bursitis
• Subacromial
• Trochanteric
• Anserine
• Prepatellar
• Tenosynovitis/tendinitis
• DeQuervain’s disease
• Stenosing tenosynovitis (Trigger finger)
• Bicipital
• Lateral epicondylitis (Tennis elbow)
• Medial epicondylitis (Golfer’s elbow)
• Plantar fasciitis
• Neuritis
• Carpal tunnel syndrome ; Tarsal tunnel syndrome
Adapte d fro m Pfe nning e r, 1 9 9 1 and Cardo ne , 20 0 2

6. Contraindications
Overlying cellulitis*
Severe coagulopathy ; Anticoagulant therapy
Septic effusion
More than three injections per year in a weight-bearing joint
Lack of response after two to four injections
Bacteremia*
Unstable joints
Inaccessible joints (i.e. facet joints of spine)
Joint prosthesis*
Evidence of surrounding osteoporosis
Recent intra-articular joint osteoporosis
History of allergy or anaphylaxis to injectable pharmaceuticals
*absolute contraindications
Adapte d fro m Pfe nning e r, 1 9 9 1 and Cardo ne , 20 0 2

7. • Materials and Equipment
• Pharmacologic Agents
• Site Preparation
• Post-injection Care

8. • Alcohol wipes
• Gloves
• 20 – 25 gauge 1.0 – 1.5 inch needle
• 1 mL to 10 mL syringe*
• Local anesthetic
• Corticosteroid preparation
• Adhesive bandage dressing
*Larger syringe may be required for aspiration of a large joint (i.e.
knee).

9. • Corticosteroids
• Modify local inflammatory response
• Increase viscosity of synovial fluid
• Alter production of hyaluronic acid synthesis
• Change synovial fluid leukocyte activity
Short-term benefit of intra-articular corticosteroids in
treatment of knee OA well established; longer term
benefits not confirmed. Cochrane Collaboration, 2006

10. Relative Potency
Corticosteroid Preparations
Corticosteroid Relative anti-
inflammatory
potency
Approximate
equivalent
dose (mg)
Short-acting preparations
Cortisone 0.8 25
Hydrocortisone 1.0 20
Intermediate-acting preparations
Prednisone 3.5 5
Methylprednisolone acetate (Depo-
Medrol)
5 4
Long-acting preparations
Dexamethasone sodium phosphate
(Decadron)
25 0.6
Betamethasone (Celestone Soluspan) 25 00.6

11. Dosages
Corticosteroid Preparations
Corticosteroid Preparation
strength
(mg per mL)
Common dosage
for site (mg)
Tendon sheaths
and bursae
Small
joints
Large
joints
Hydrocortisone 25, 50 8-40 10-25 50-125
Methylprednisolo
ne
(Depo-Medrol)
20, 40, 80 4-10 2-5 10-25
Betamethasone
(Celestone
Soluspan)
6 1.5-3.0 0.8-1.0 2-4

12. • Hyaluronic Acid
• Used to treat pain associated with OA of knee
• Safe and effective (Grade of Recommendation: A)
“Hyaluronic acid products had more prolonged
effects than intra-articular corticosteroids.”
Cochrane Collaboration, 2007

13. • Autologous blood
• Polidocanol
• Prolotherapy
•Dextrose
•Morrhuate sodium

15. • is an increasingly popular therapy for chronic
musculoskeletal and arthritic pain in which a
small volume of an irritant solution is injected
at multiple sites on painful ligament and
tendon insertions (enthesis) and in adjacent
joint spaces..
• Injected substances (proliferants) are
purported to initiate a local inflammatory
response with resultant hypertrophy and
strengthening of collagenous structures

16. • mesotherapy involves injecting various types of
medications and plant extracts into layers of fat and
connective tissue under the skin with the object of
dissolving fat.
• In the same way using other medical drugs in minute
amounts injected in the affected site to relief symptoms
without side effects

17. • Homeopathy is a distinct, comprehensive and deep healing
system originally developed by Samuel Hahnemann about
200 years ago.
• It uses small doses of specially prepared (“potentized”)
remedies to set the body’s systems back in order and
stimulate a persons own energies toward a natural healing
process.
• It is entirely distinct in both theory and in practice from other
healing systems – most notably from ordinary or main-
stream (“allopathic”) medicine, but also from acupuncture,
chiropractics, naturopathy, etc., although some
homeopathy often finds its way into these other fields of
practice.

18. Sterile ethyl chloride
Aseptic technique
• Injection site clearly identified
• Immediate injection site cleaned
with alcohol swab
• Use of local anesthetic on skin /
subcutaneous tissues overlying the
injection site optional
•Sterile ethyl chloride
• Immediate injection site cleaned
with alcohol swab

19. Injection
•Do not inject directly into tendon
or ligament
•Reposition needle if resistance
encountered
•Aspirate to avoid intravascular
deposition of medicine

20. • Pain relief following joint or soft tissue
injection with local anesthetic may
indicate appropriate structure
infiltrated.
• Avoid poly-injection syndrome
•Not be performed more than three times
per year
•Separated by six or more weeks.

21. Complications Estimated prevalence
Postinjection flare 2-5%
Steroid arthropathy 0.8%
Tendon rupture <1%
Facial flushing <1%
Skin atrophy, depigmentation <1%
Iatrogenic infectious arthritis <0.001 to 0.072%
Transient paresis of injected extremity Rare
Hypersensitivity reaction Rare
Asymptomatic pericapsular calcification 43%
Acceleration of cartilage attrition Unknown

22. • Most commonly associate with
injection of steroids other than
triamcinolone or methylprednisolone
(Binder, 1983; Kumar, 1999)
• Occurs and resolves within 48 hrs
• Flares occur more frequently in soft
tissue injections (Roberts, 2005)

23. • Common sites
• Shoulder
• Elbow
• Hand and wrist
• Hip
• Knee
• Ankle

24. • With the jaw fully opened, enter the joint 1⁄4 to
3⁄8 inch directly anterior to the tragus in the
depression formed over the joint;
• Angle perpendicular to the skin
• Needle: 5⁄8-inch, 25-gauge
• Depth: 1⁄4 to 1⁄2 inch into the joint
• Volume: 0.5 to 1 mL anesthetic, 0.5 mL K40, or
both
• NOTE: Identify the temporal artery by palpation,
mark its course, and enter the skin on either
side of it.
• Gently advance the needle into the joint. If
arterial blood enters the syringe, exit the skin,

25. • Corticosteroid injection of shoulder may
be utilized for treatment of such
conditions as subacromial bursitis, rotator
cuff tendonitis, adhesive capsulitis, and
biceps tendonitis (Grade o f
Re co m m e ndatio n: D).
•Subacromial bursa
•Glenohumeral joint
•Biceps tendon

28. • Enter 1 to 11⁄2 inches below the midpoint
of the acromial process; parallel the angle
of the acromion to the subacromial bursa
• Needle: 11⁄2-inch, 22-gauge
• Depth: 1 to 11⁄2 inches to 31⁄2 inches
(obese patient)
• Volume: 2 to 3 mL anesthetic and 1 mL
D80
• NOTE: Never inject under pressure or if
the patient experiences dramatic pain
(intratendinous or periosteal);
• if pain develops or resistance to injection
is encountered, withdraw 1⁄2 inch and
redirect

30. Needle inserted 1 – 2 cm below
midpoint of lateral edge of acromion
Needle inserted 1 - 2 cm below
posterior lateral aspect of acromion

31. Needle placement accuracy (Kang, 2008)
•60 shoulders with impingement
•70% Subacromial accuracy rate
•No differences among injection approaches
•Clinical improvement did not correlate with
accuracy

32. (a) Preferred needle gauge; length;
type: 22-gauge; 3½-in.; spinal
(b) Recommended dosage: Total
volume of up to 100 mL have been
injected

33. • The joint can be injected from a posterior
approach with the patient seated.
• The arm is positioned in front of the trunk and is
medially (internally) rotated, with the forearm
across the abdomen, in order to help open the
posterior aspect of the joint space.
• The injection site can be localized by palpating
the mediastinal posterolateral corner of the
scapular spine; one can also identify the
coracoid process anteriorly.
• pierce the skin just below the scapular spine
insertion site and direct the needle toward the
anterior coracoid process until it reaches the
articular surfaces.

34. • Glenohumeral injection
• Injection point is 1 cm lateral of coracoid process

35. Patient positioning:
· Place the patient in a seated position,
generally with the affected arm hanging down to
the side.
Identification and marking of injection site:
· Palpate and locate the biceps tendon in the
bicipital groove.
· Mark the target using a marker or by
depressing the skin with a plastic needle cap.

37. Identification and marking of injection
site.
· Palpate laterally along the clavicle until
reaching an anterior curvature.
Move laterally beyond this until you feel a
distinct depression between the end of the
clavicle and the acromion.
· Adjust as necessary, and mark the
overlying skin by depressing it with a
plastic needle cap or a marker.

39. • Indications:
• (a) Adhesive capsulitis diagnosis as pain
generator
• (b) Differentiation of rotator cuff impingement
vs. rotator cuff tear
• (c) Rotator cuff impingement
• (d) Rotator cuff tendinitis, tendinosis
• (e) Subacromial region: diagnosis as pain
generator
• (f) Subacromial bursitis (sometimes referred
to as subdeltoid bursitis)

40. • Patient positioning:
• · The patient is seated on the exam table, with
the affected arm hanging
• down to the side.
• · If necessary, a weighted object may be
placed in the patient’s hand to
• distract the humerus inferiorly and thus increase
subacromial space.
• Identification and marking of injection site:
• Identify the posterolateral corner of the scapula
by palpating laterally along the scapular spine
until the discrete corner is appreciated.
• Identify a point that is one-finger-breadth below
this location .

45. • Corticosteroid injection of the elbow is
indicated in the management of lateral
epicondylitis and medial epicondylitis
•Lateral epicondyle
•Grade of Recommendation: A
•Medial epicondyle
•Grade of Recommendation: D

47. Step-by-step procedure:
Patient positioning: With the patient in a
seated position, the elbow resting on a flat
surface, the hand is in full pronation, and
the elbow is flexed to 60–90°.
Identification and marking of injection
site:
Identify the lateral epicondyles by direct
palpation and with palpation of the origin of
the common extensor tendon as the patient

49. Step-by-step procedure:
Patient positioning:
With the patient in a seated position, the elbow
resting on a flat surface, the hand is in full
pronation, and the elbow is flexed to 60–90°.
Identification and marking of injection site:
Identify the medial epicondyle by direct palpation
and with palpation of the origin of the common
flexor tendon as the patient flexes and relaxes the
wrist on the affected side.

51. Step-by-step procedure:
Patient positioning:
• Place the patient in a seated position with the
elbow resting on a flat surface, the hand in full
pronation, and the elbow flexed to 90°.
• Approaching the bursa from a posterolateral angle is
preferred to avoid potential injury to the ulnar nerve.
• Identification and marking of injection site:
• Identify the center of the distended, painful bursa,
or the olecranon process if the bursa is not significantly
distended. Care should be taken to select an injection
site slightly lateral to the area described earlier to
avoid the ulnar nerve.
• Mark the target using a marker or by depressing
the skin with a plastic needle cap.

55. • Step-by-step procedure:
• Patient positioning:
• · Place the patient in a seated position The
elbow is placed on a flat surface and positioned
in 50–90° of elbow flexion, with the palm facing
downward (pronated).
• Identification and marking of injection site:
• The capitellum and radial head are
palpated and identified. The space between the
capitellum and radial head is identified by
palpation.
• Mark the target using a marker or by depressing
the skin with a plastic needle cap.

57. • Step-by-step procedure:
• Patient positioning:
• · The elbow is placed on a flat surface and
positioned in 50–90° of elbow flexion, with the
palm facing downward (pronated).
• Identification and marking of injection site:
• The lateral epicondyle, radial head, and
posterior aspect of the olecranon are palpated
and identified.
• Identify the groove between the lateral
epicondyle and posterior olecranon; it is
palpated lateral to the radial head.

59. • Trigger finger.
•Corticosteroid injection appears to be effective
treatment option for trigger finger
• Grade of recommendation: C
• De Quervain’s tenosynovitis.
•De Quervain’s tenosynovitis can be effectively
treated with corticosteroid injections
• Strength of recommendation: C
• Carpal tunnel.
•For carpal tunnel syndrome, corticosteroid
injection provides temporary, short-term
improvement
• Grade of recommendation: A

60. • Identify a tender, palpable nodule along the
flexor tendon sheath, most commonly just
distal to the A1 pulley of the hand if the finger is
extended (near the distal end of the
metacarpal).
• The nodule may be proximal to the finger pulley
if the finger is locked in flexion.
• The injectate does not need to be deposited
into the nodule per se, though injection into the
peritendinous sheath close to the nodule is
appropriate

61. • The injection is generally performed with the
needle pointing toward the fingertip (proximal to
distal approach).
• Pierce the overlying skin and soft tissue and
angle the needle into the nodule and
subsequently into the tendinous sheath.
• When satisfactory needle position is achieved,
there should be mild resistance to injection
• Gentle passive finger flexion may also
precipitate needle movement, which can
suggest that the needle is in contact with or
lodged in the actual flexor tendon

63. Identification and marking of injection site:
Have the patient actively extend the thumb to
identify the two tendons noted previously.
Passively flex the thumb, and again note the
location of these tendons by palpation over the
base of the first metacarpal.
If possible, palpate a space between the tendons
and mark this as the ideal injection site.
Mark the target using a marker or by depressing
the skin with a plastic needle cap.

65. • Identification and marking of injection site:
• •Palpate the radio-ulnar joint by feeling for
the mobility of the radius and ulnar and
identifying the joint space in-between.
• After localizing the separation of the
radius and ulna, the distal end of the ulna
is identified by palpating the prominent
distal tip. The joint space is generally
located just medial and proximal to this
most distal tip.

67. • The median nerve generally runs directly
under the palmaris longus tendon, which
can often be identified by having the
patient oppose the thumb to the tip of the
fifth finger.
• Once the palmaris longus has been
identified, the needle entry site can be
marked on the skin between the palmaris
longus tendon and the FCR tendon.
• Mark spot 4 cm proximal to distal palmar
crease and between tendons

69. • Palpate the carpal bones and locate a spot half-
way between the distal end of the radius and
ulna and the proximal aspect of the
metacarpals.
• Continue to palpate and identify locations
between the carpal bones as potential injection
sites.
• The joint can be accessed through anyone of
several sites.
• Choose the site that appears to provide the
easiest

71. • Patient positioning:
• Place the patient in a seated position with the
affected hand laying flat (palm-down) on the
table
• Identification and marking of injection site:
• Palpate the location of the first CMC joint by
feeling for the distal end of the trapezium where
it articulates with the first metacarpal in the
anatomical snuff box.
• Entry through the skin overlying the anatomical
snuff box is generally preferred. Active and
passive movement of the first digit in flexion and
extension while feeling for the trapezium-first
metacarpal articulation is also helpful

73. • Patient positioning:
• For MCP joint injections, the hand can be
positioned resting on the procedure table
with the palm down, to be accessed from
the dorsal aspect of the hand.
• For IP joint injections, the joints can be
accessed from either the medial or lateral
side of the joint

74. • Identification and marking of injection
site:
• The target joint space can be
identified by passively flexing and
extending the digit across the target
joint to identify the space between
the two bones

78. Trochanteric bursa
•For treatment of
trochanteric bursitis,
corticosteroid injection
is effective treatment
option
• Grade of
Recommendation: C

79. Injections of knee
recommended for treatment of
such conditions as OA and
bursitis (Grade o f
Re co m m e ndatio n: A).
•Intra-articular space
•Anserine bursa

80. Lateral approach
–Draw horizontal line
one fingerbreadth
above superior margin
of patella
–Draw vertical line at
lateral margin of patella
–Needle inserted at
intersection of these
lines and directed
parallel to floor (also
parallel to undersurface
Infrapatellar
approach
–Needle inserted 1
-2 cm lateral (or
medial) to patellar
tendon

83. • Pes anserine bursa

84. • Intra-articular
space

85. • Plantar fascia.
• Corticosteroid injection considered initial treatment option
for plantar fasciitis (Grade of Recommendation: D)
• Limited evidence that corticosteroid injection provides short-
term benefit.

86. Injection is on dorsum of
foot, in-between metatarsel
heads at point of maximum
tenderness

87. Grades of Recommendations
Selected Injections.
Injection Site / Diagnosis Grade of
Recommendation
Shoulder (subacromial bursitis, rotator cuff
tendonitis, adhesive capsulitis, and biceps
tendonitis)
D
Lateral epicondylitis A
Medial epicondylitis D
Trigger finger C
DeQuervain’s tenosynovitis C
Carpal tunnel A
Trochanteric bursitis C
Knee (osteoarthritis, bursitis) A
Plantar fasciitis D

88. • Joint and soft tissue injections should be used
in conditions that are clearly demarcated and
well diagnosed and in which the injector is
comfortable with the procedure. Some general
guidance follows:
• • exact location of the needle is not always
necessary as even the more experienced
injectors can obtain good response rates with
periarticular injections

89. • it is a clean, not sterile procedure; evidence suggests
that, despite wide variation in precaution against
sepsis, this is rare
• anatomical landmarks are important and using them
reduces the discomfort of scraping bone
• a drawing-up needle should be used that is separate
from the injecting needle (no touch technique)
• 24-48 hours rest is beneficial, especially in weight-
bearing joints
• they should be administered at a maximum of 3 a
year as they tend to lose their efficacy over time in
noninflammatory conditions