Joint aspiration

Indications for joint aspiration

Joint aspiration is indicated in a number of joint conditions where it can be either therapeutic or diagnostic, or both:

• Septic arthritis: sampling synovial fluid for culture and sensitivity (also pus is destructive of joint structures)
• Haemarthrosis: blood in aspirate is diagnostic and blood itself is inflammatory
• Crystal arthropathy: identifies crystal involved
• Large joint effusions: rapidly relieves pain and improves mobility

Joint injection

Indications for joint injection

Corticosteroid is usually injected to reduce inflammation in acutely inflamed structures:

• Rheumatoid arthritis (RA)¹
• Osteoarthritis of the knee (although hyaluronic acid injections may have a more durable effect but are not recommended by the National Institute for Clinical Excellence (NICE)^2,3

Often beneficial in one or two joints in RA where the joint is warm and swollen with morning stiffness. Other conditions where it is widely used include psoriatic arthritis, ankylosing spondylitis and pyrophosphate arthritis.
Benefit is experienced within a few days if successful, and can last for months, but is often short-lived. Injection can be repeated, but effect is diminished. Failure may be due to not entering the joint or an incorrect diagnosis.

Contra-indications to joint injection

• Sepsis, or risk of it
• Skin lesions, broken skin over injection site or evidence of cellulitis
• Bleeding disorder or anticoagulant use

Soft tissue injection

Therapeutic injections (lidocaine plus a corticosteroid) are useful both because they are therapeutic and also because they can help differentiate impingement from other problems. For example, if a patient does not improve after a subacromial injection, has normal X-rays and an inconclusive examination, the rotator cuff may not be the problem.

Indications for soft tissue injection

• Shoulder impingement:^4,5 there are several entry points for shoulder injections, but the posterior subacromial approach is perhaps the easiest.
• Synovitis.
• Tenosynovitis.
• Bursitis, e.g. housemaid's knee, Achilles bursitis.
• Tendinitis, e.g. tennis elbow,^6,7,8 Achilles tendinitis - use is controversial and evidence clarifying the risk:benefit ratio is lacking.⁹ Injections in close proximity to the Achilles tendon should be undertaken by a specialist since relief tends to be temporary and there is a risk of tendon rupture and subsequent litigation. Such injections are not discussed further in this article.
• Nerve compression, e.g. carpal tunnel syndrome.

Complications of steroid injection

• Worsening of pain next day
• Local skin atrophy
• Facial flushing
• Bleeding (rare)¹⁰
• Infection (1/10,000)
• Joint injury (do not move the needle from side-to-side within the joint)
• Tendon rupture (<1%): avoid direct tendon injection. May be seen after injection in athletic injury¹¹
• Acceleration of septic joint
• Subcutaneous fat atrophy (<1%)
• Fistula formation
• Steroid flare and worsening of symptoms (2-5%)
• Cartilage damage and osteoporosis: avoid repeated injections (no more than three injections in each location per year)
• Allergy or hypersensitivity reaction
• Pericapsular calcification(>40%)

Technique for ankle joint injection

• Sit patient either in a supine position with the ankle relaxed, or seated with shin vertical and foot horizontal.
• Use an aseptic technique.
• Sterilise the skin.
• The ankle joint is injected using an anterior approach.
• Landmarks: identify the space between the anterior border of the medial malleolus and the medial border of the tibialis anterior tendon. Palpate for the articulation of the talus and tibia. See Reference¹³ for illustrations.
• Inject local anaesthetic to area.
• Insert needle containing steroid.
• Reduced resistance should be felt on entering joint space. Confirm position by aspirating fluid.
• Inject 1 ml methylprednisolone acetate (40 mg/ml).
• Remove needle and syringe and apply sterile dressing.
• Passive foot movement helps to distribute the injection.
• The patient should remain lying or sitting for several minutes after injection.
• Some advise the patient should be monitored for a further 30 minutes to ensure no adverse reactions, but this is probably unnecessary.
• Access to ultrasound or fluoroscopic guidance to enable better targeting of steroid injections may improve efficacy.^14,15,16

Patient advice

• Avoid any strenuous activity for 48 hours.
• Avoid stress to foot for two weeks after injection.
• Advise the patient that they may experience a 'steroid flare' with worsening symptoms over the subsequent 24-48 hours, which should be treated with ice and non-steroidal anti-inflammatory drugs.
• Arrange appropriate follow-up.

Document references

1. Wallen M, Gillies D; Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD002824. [abstract]
2. Bellamy N, Campbell J, Robinson V, et al; Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD005328. [abstract]
3. Lockman LE; Knee joint injections and aspirations: The triangle technique. Canadian Family Physician. November 2006
4. Fongemie AE, Buss DD, Rolnick SJ; Impingement syndromes and injection technique; American Family Physician 15th February 1998
5. Bandolier. Steroid injection for shoulder disorders; July 1999
6. Cardone DA, Tallia DF; Diagnostic and Therapeutic Injection of the Elbow Region; American Family Physician; 1 December 2002.
7. Bandolier. Corticosteroid injections for lateral epicondylitis (tennis elbow, July 1999
8. Bisset L, Beller E, Jull G, et al; Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Sep 29;. [abstract]
9. Shrier I, Matheson GO, Kohl HW 3rd; Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med. 1996 Oct;6(4):245-50. [abstract]
10. Rifat SF, Moeller JL; Basics of joint injection. General techniques and tips for safe, effective use. Postgrad Med. 2001 Jan;109(1):157-60, 165-6. [abstract]
11. Nichols AW; Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005 Sep;15(5):370-5. [abstract]
12. Rifat SF, Moeller JL; Site-specific techniques of joint injection. Useful additions to your treatment repertoire. Postgrad Med. 2001 Mar;109(3):123-6, 129-30, 135-6. [abstract]
13. Tallia AF, Cardone DA; Diagnostic and therapeutic injection of the ankle and foot. Am Fam Physician. 2003 Oct 1;68(7):1356-62. [abstract]
14. Tynjala P, Honkanen V, Lahdenne P; Intra-articular steroids in radiologically confirmed tarsal and hip synovitis of juvenile idiopathic arthritis.; Clin Exp Rheumatol. 2004 Sep-Oct;22(5):643-8. [abstract]
15. Lucas PE, Hurwitz SR, Kaplan PA, et al; Fluoroscopically guided injections into the foot and ankle: localization of the source of pain as a guide to treatment--prospective study. Radiology. 1997 Aug;204(2):411-5. [abstract]
16. Ekeberg OM, Bautz-Holter E, Tveita EK, et al; Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. BMJ. 2009 Jan 23;338:a3112. doi: 10.1136/bmj.a3112. [abstract]

Internet and further reading

• Arthritis Research UK; Home page
• British Society for Rheumatology; Professional society for those involved in treatment of rheumatological conditions.
• Primary Care Rheumatology society
• Codsi MJ; The painful shoulder: when to inject and when to refer. Cleve Clin J Med. 2007 Jul;74(7):473-4, 477-8, 480-2 passim. [abstract]

Acknowledgements