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Joint Injection and Aspiration

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:

Often beneficial in one or two joints in RA where 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 joint or incorrect diagnosis.

Contraindications to joint injection

  • Sepsis, or risk of
  • Skin lesions
  • Bleeding disorder or anticoagulant use

Complications of steroid injection

  • Septic arthritis
  • Worsening of pain next day
  • Local skin atrophy
  • Facial flushing
  • Joint destruction is rare, but occasionally occurs after repeated injection (avoid weight bearing after injection). Allow at least 4 months between injections.
Soft tissue injection

Therapeutic injections (lignocaine 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 sub-acromial 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. housemaids knee
  • Tendinitis e.g. tennis elbow6,7,8
  • Nerve compression, e.g. carpal tunnel syndrome

Complications of steroid injection

  • Rupture of tendon with injection into tendon.9 May be seen after injection in athletic injury.
  • Worsening of pain next day
  • Local skin atrophy
  • Facial flushing

Injection procedures10,11
  • Before injecting steroid, be sure that joint infection has been excluded by aspirating before injecting.
  • Carefully palpate joint and mark entry point with thumb nail.
  • Prepare skin with 1% chlorhexidine in spirit or iodine solution, if available. No touch technique is usually adequate.
  • Consider giving local anaesthetic with adrenaline to infiltrate skin and tissues.
  • Have patient lying down on couch and relaxed.
  • Advise patient to rest the joint for 1-2 days and avoid strenuous use for 5 days.
  • Warn patient that joint may be painful for a while and advise on use of analgesics.


JOINT INJECTION - KNEE (OM1140a.jpg)


JOINT INJECTION (OM1142a.jpg)


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. 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]
  10. Rifat S & Moeller JL Basics of Joint injection. June 2001. Postgraduate Medicine on-line 109(1)
  11. 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]
Internet and further reading
  • Anderson BC; Patient information: Aftercare instructions for elbow tendinitis injection
  • Anderson BC; Patient information: Aftercare instructions for biceps tendonitis injection
  • A Practical Guide to Joint and Soft Tissue Injection and Aspiration. McNabb JW. Lippincott Williams and Wilkins 2004.
Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2349
Document Version: 21
DocRef: bgp1140
Last Updated: 2 Jul 2007
Review Date: 1 Jul 2009










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