I. Diagnostic use--synovial fluid analysis

  1. Bloody vs. amber
  2. Clear vs. turbid
  3. Cell count
  4. Cx & sensitivity
  5. Crystals

II. Therapeutic use--relieve pain

  1. Remove exudate
  2. Inject lidocaine, saline, and/or steroid provides symptomatic relief and assists rehab
  1. Lido/marcaine 1:1 mix plus steroid works well

III. Conditions shown to improve with local steroid injection:

  1. Articular disease:
  1. Rheumatoid arthritis
  2. Seronegative arthropathies including ankylosing spondylitis, IBD, psoriasis, Reiter's
  3. Crystal-induced arthritis (gout, pseudogout)
  1. Nonarticular
  1. Fibrositis
  2. Bursitis (subacromial, trochanteric, prepatellar, pes anserinus, etc.)
  3. Tendonitis/synovitis
  1. DeQuervain's, trigger finger, biceps tendonitis, plantar fasciitis, epicondylitis, etc.
  1. Neuritis/entrapment
  1. CTS, tarsal tunnel, cubital tunnel, meralgia paresthetia, costochondritis, etc.

IV. Contraindications

  1. Cellulitis over inj. site
  2. Septic periarticular bursa
  3. Suspected bacteremia (unless joint is suspected as source)
  4. Coagulopathy (e.g. on coumadin)
  5. >3 injections of wt bearing joint in last 12mos
  6. Lack of response to 2-3 previous injections
  7. Unstable joints (for steroid injections)
  8. Joint prostheses (refer if infection is suspected)

V. Risks:

  1. Postinjection flare in 2-5%
  2. Asymptomatic pericapsular calcification in 40%
  3. Tendon rupture in <1%
  4. Can traumatize cartilage & nerves
  5. Injection .001-.072%
  6. Skin atrophy/depigmentation <1%
  7. Inj. of artery/vein; hypersens. rxn; transient paresis distally; facial flushing (all rare)

VI. Equipment

  1. Iodine wipes
  2. Sterile gloves & drape
  3. 22-25g 1.5" needle for inj
  4. 18-20g 1.5" needle for aspiration
  5. Bupivacaine or 1% lido (single dose vials good; lack preservative); steroid if applicable
  6. Hemostat, if plan to aspirate/inject with same needle
  7. Tubes for lab work

VII. Technique

  1. Informed consent
  2. Identify path of least risk; mark entry site with thumbnail
  3. Prep; local anesth although not required (don?t do if doing cx); position pt. supine
  4. Insert needle gently to avoid cartilagenous damage
  5. Aspirate before injection
  6. Can do asp. then injection with 2 syringes; changing them with hemostat
  7. Inject slowly. Stop & reposition needle if sig. resistnce or c/o paresthesia
  8. May inject in >1 place
  9. Cover with bandaid for 12h; advise of signs of inf; NSAIDS x 2-3d; rest; rehab
  10. Can repeat up to 3x/yr in wt-bearing joints; 4x/yr in smaller joints