Joint & Soft-Tissue Injection

General technique, equipment, contraindications and complications for a corticosteroid injection in general practice. Condition-specific dosing and site detail — subacromial, trochanteric, de Quervain — stays on that condition’s own page.

Indications

Injection can be diagnostic, definitive treatment, or a pain-free window to allow rehabilitation. Corticosteroid injection is the preferred initial treatment for de Quervain tenosynovitis, and is safe and highly effective for trochanteric pain, often after a single injection. Subacromial injection gives short-term pain relief at least equal to an oral NSAID. Intra-articular injection reduces pain and swelling in knee osteoarthritis. Lateral epicondylitis responds in the short term (under six weeks), but physiotherapy outperforms injection beyond that — set that expectation with the patient at the time of injection, not just when it wears off.

Contraindications

• Broken skin or infection over the injection site.
• Known hypersensitivity to the intended agent.
• Osteochondral or intra-articular fracture.
• Severe joint destruction.
• Unstable coagulopathy.
• A prosthetic joint (relative — low threshold to discuss with the surgical team first, given the consequences of introducing infection).

If the underlying diagnosis is unclear, aspirate and send synovial fluid for analysis before or instead of injecting.

Technique

Standard anatomic landmarks give correct needle placement in most straightforward cases — ultrasound guidance helps but isn’t required for a typical primary-care joint. A 1.5 inch 21-gauge needle suits a large joint (knee, shoulder); a smaller 23- or 25-gauge, 0.5 inch needle suffices for a small joint, though a viscous steroid preparation may not pass through the finer bore.

1. Confirm the indication and obtain informed consent — discuss risks, benefits and alternatives.
2. Prepare equipment: needles, syringes, medication, and pathology request forms if aspirating.
3. Mark the anatomic landmarks before skin prep obscures them.
4. Clean the skin with isopropyl alcohol or povidone-iodine.
5. Use a cooling spray or local anaesthetic for comfort if needed.
6. Advance the needle into the joint or target space — this should not be painful; stop and reposition if it is.
7. If aspirating first, anchor the needle with a hemostat once in place, then swap the aspirating syringe for the one containing steroid and/or anaesthetic without moving the needle.
8. Inject — fluid should flow freely; resistance means repositioning before continuing, not pushing through it.
9. Remove the needle, apply a dressing, and give post-procedure advice.

Choosing an agent

Less-soluble corticosteroid preparations (e.g. triamcinolone hexacetonide) stay at the injection site longer and suit an intra-articular injection; they also carry a higher rate of cutaneous side effects, which makes them a poor choice for a soft-tissue or periarticular injection where they can cause visible skin or fat atrophy. A local anaesthetic mixed with the steroid gives faster relief and helps confirm the diagnosis if the pain resolves immediately.

Complications

Complication	Approximate incidence
Post-injection flare	2–10%
Vasovagal reaction	10–20%
Facial flushing	<1–12%
Steroid arthropathy	0.8%
Skin/fat atrophy or depigmentation	<1%
Pericapsular calcification	up to 43%
Tendon rupture	<1%
Joint infection	<0.001–0.072%

Tendon rupture risk is highest with soft-tissue injection around the Achilles tendon or plantar fascia — avoid direct tendon injection. Warn every patient about a possible post-injection flare and facial flushing, which are common but self-limiting, and about the much rarer signs of joint infection that need urgent review.

Diabetes and repeat injections

A single intra-articular injection has little effect on glycaemic control, but a soft-tissue or peritendinous injection can raise blood glucose for 5–21 days — warn patients with diabetes to monitor more closely for two to three weeks afterwards. Repeat injections into the same joint appear safe; a three-month interval between injections to the same site is the usual recommendation, adjusted by response, other treatment options, and clinical judgement rather than followed rigidly.