Basic Principles of Joint and Soft Tissue Injection Procedures

  • Todd P. StitikEmail author
  • Jong H. Kim
  • Gregory Gazzillo


Joint and soft tissue injection procedures are commonly performed as part of a musculoskeletal medicine practice [1]. These procedures are very valuable diagnostic and therapeutic patient management tools. This chapter, along with Chap. 2, will review the basic principles behind these injection procedures and serve as the ­general framework from which these procedures are taught throughout this book.


Local Anesthetic Senior Author Target Structure Corticosteroid Injection Tendon Sheath 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Liddell WC, Carmichael CR, McHugh NJ. Joint and soft tissue injections: a survey of general practitioners. Rheumatology 2005; 44:1043–1046.CrossRefPubMedGoogle Scholar
  2. 2.
    Bliddal H. Placement of intra-articular injections verified by mini-air arthrography. Ann Rheum Dis 1999; 58:641–643.CrossRefPubMedGoogle Scholar
  3. 3.
    Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement of intra-articular steroid injections. J Bone Joint Surgery Am 2002; 84:1522–1527.Google Scholar
  4. 4.
    Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. BMJ 1993; 307:1329–1330.CrossRefPubMedGoogle Scholar
  5. 5.
    Partington PF, Broome GH. Diagnostic injection around the shoulder: hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 1998; 7(2):147–150.CrossRefPubMedGoogle Scholar
  6. 6.
    Williams MJ. Local Anesthetics. In Raj PP, ed. Pain Medicine: A Comprehensive Review. St. Louis: Mosby; 1996:162–175.Google Scholar
  7. 7.
    Cohen SP, Narvaez JC, Lebovits AH, Stojanovic MP. Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. Br J Anaesth 2005; 94(1):100–106.CrossRefPubMedGoogle Scholar
  8. 8.
    Brandt, KD. Synovial fluid analysis. An Atlas of Osteoarthritis. New York: The Parthenon Publishing Group Inc.; 2001:60.Google Scholar
  9. 9.
    Canoso JJ, D, Yood RA Acute gouty bursitis: report of 15 cases. Ann Rheum Dis 1979; 38:326–328.CrossRefPubMedGoogle Scholar
  10. 10.
    Vegter J. The influence of joint posture on intra-articular pressure. J Bone Joint Surg 1987; 69-B(1):71–74.Google Scholar
  11. 11.
    Carbonell AM, Harold KL, Mahmutovic AJ, Hassan R, Matthews BD, Kercher KW et al. Local injection for the treatment of suture site pain after laparoscopic ventral hernia repair. Am Surg 2003; 69(8):688–691.PubMedGoogle Scholar
  12. 12.
    Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006; (2):CD005321.PubMedGoogle Scholar
  13. 13.
    Lo GH, LaValley M, McAlindon T, Felson DT. Intra-articular hyaluronic acid in treatment of knee osteoarthritis. JAMA 2003; 290:3115–3121.CrossRefPubMedGoogle Scholar
  14. 14.
    Wang CT, Lin J, Chang CJ, Lin YT, Hou SM. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee: a meta-analysis of randomized controlled trials. J Bone Joint Surg 2004; 86A:538–545.Google Scholar
  15. 15.
    Arrich J, Piribauer F, Mad P, Schmid D, Klaushofer K, Mullner M. Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis. CMAJ 2005; 172:1039–1041.PubMedGoogle Scholar
  16. 16.
    Matura M, Goossens A. Contact allergy to corticosteroids. Allergy 2000; 55:698–704.CrossRefPubMedGoogle Scholar
  17. 17.
    Hernigou P, Bachir D, Galacteros F. Avascular necrosis of the femoral head in sickle-cell disease. Treatment of collapse by the injection of acrylic cement. J Bone Joint Surg Br 1993; 75(6):875–880.PubMedGoogle Scholar
  18. 18.
    Vanderwilde RS, Morrey BF, Melberg MW, Vinh TN. Inflammatory arthritis after failure of silicone rubber replacement of the radial head. J Bone Joint Surg Br 1994; 76(1):78–81.PubMedGoogle Scholar
  19. 19.
    Neth OW, Bajaj-Elliott M, Turner MW, Klein NJ. Susceptibility to infection in patients with neutropenia: the role of the innate immune system. Br J Haematol 2005; 129(6):713.CrossRefPubMedGoogle Scholar
  20. 20.
    Finucane BT. Allergies to local anesthetics – the real truth/Les allergies aux anesthésiques locaux – la vraie vérité. Can J Anesth 2003; 50:869–874.CrossRefPubMedGoogle Scholar
  21. 21.
    Dance D, Basti S, Koch DD. Use of preservative-free lidocaine for cataract surgery in a patient allergic to “caines.” J Cataract Refract Surg 2005; 31(4):848–850.CrossRefPubMedGoogle Scholar
  22. 22.
    Achar S, Kundu S. Principles of office anesthesia: Part I. Infiltrative anesthesia. Am Fam Physician 2002; 66(1):91–94.PubMedGoogle Scholar
  23. 23.
    Rydberg J, Charles J, Aspelin P. Frequency of late allergy-like adverse reactions following injection of intravascular non-ionic contrast media: a retrospective study comparing a non-ionic monomeric contrast medium with a non-ionic dimeric contrast medium. Acta Radio 1998; 39(3):219–222.Google Scholar
  24. 24.
    Bettmann MA. Frequently asked questions: iodinated contrast agents. RadioGraphics 2004; 24:S3–S10.CrossRefPubMedGoogle Scholar
  25. 25.
    Lehrer SB, Ayuso R, Reese G. Seafood allergy and allergens: a review. Mar Biotechnol 2003; 5(4):339–348.CrossRefPubMedGoogle Scholar
  26. 26.
    Mortele KJ, Oliva MR, Ondategui S, Ros PR, Silverman SG. Universal use of nonionic iodinated contrast medium for CT: evaluation of safety in a large urban teaching hospital. AJR 2005; 184:31–34.PubMedGoogle Scholar
  27. 27.
    Charalambous CP, Tryfonidis M, Sadiq S, Hirst P, Paul A. Septic arthritis following intra-­articular steroid injection of the knee – a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol 2003; 22(6):386–390.CrossRefPubMedGoogle Scholar
  28. 28.
    Muller LM, Gorter KJ, Hak E, Goudzwaard WL, Schellevis FG, Hoepelman AI Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis 2005; 41:281–288.CrossRefPubMedGoogle Scholar
  29. 29.
    Hammesfahr R, Knopf AB, Stitik TP. Safety of Intra-articular Hyaluronates for Pain Associated with Osteoarthritis of the Knee. Am J Orthop 2003; 32(6):277–283.PubMedGoogle Scholar
  30. 30.
    Hamburger M, Settles M, Teutsch J. Identification of an immunogenic candidate for the elicitation of severe acute inflammatory reactions (SAIRs) to hylan G-F 20. Osteoarthr Cartil 2005; 13(3):266–268.CrossRefPubMedGoogle Scholar
  31. 31.
    Hamburger MI, Lakhanpal S, Mooar PA, Oster D. Intra-articular hyaluronans: a review of product-specific safety profiles. Semin Arthritis Rheum 2003; 32(5):296–309.CrossRefPubMedGoogle Scholar
  32. 32.
    Goldberg VM, Coutts, RD. Pseudoseptic reactions to Hylan viscosupplementation: diagnosis and management. Clin Orthop 2004; 419:130–137.CrossRefPubMedGoogle Scholar
  33. 33.
    Hsieh HF, Chiu HH, Lee FP. Surgical hand scrubs in relation to microbial counts: systematic literature review. J Adv Nurs 2006; 55(1):68–78.CrossRefPubMedGoogle Scholar
  34. 34.
    Roberts WN. Primer: pitfalls of aspiration and injection. Nat Clin Pract Rheumatol 2007; 3(8):464–472.CrossRefPubMedGoogle Scholar
  35. 35.
    Cox B, Durieux ME, Marcus MAE. Toxicity of local anaesthetics. Best Pract Res Clin Anaesth 2003; 17(1):111–136.CrossRefGoogle Scholar
  36. 36.
    Klein SM, Greengrass RA, Gleason DH, Nunley JA, Steele SM. Major ambulatory surgery with continuous regional anesthesia and a disposable infusion pump. Anesthesiology 1999; 91:563–565.CrossRefPubMedGoogle Scholar
  37. 37.
    Stitik TP, Klecz R, Greenwald B. Pharmacotherapy of Disability. In DeLisa JA, ed. Rehabilitation Medicine: Principles and Practices. Fourth edition. Philadelphia, PA: JB Lippincott Co; 2005:1205–1252.Google Scholar
  38. 38.
    Schumacher HR, Chen LX. Injectable corticosteroids in treatment of arthritis of the knee. Am J Med 2005; 118(11):1208–1214.CrossRefPubMedGoogle Scholar
  39. 39.
    Chakravarty K, Scott DGI. A randomized controlled study of post-injection rest following intra-articular steroid therapy for knee synovitis. Br J Rheumatol 1994; 33:464–468.CrossRefPubMedGoogle Scholar
  40. 40.
    Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury. Am J Sports Med 2004; 32:251–261.CrossRefPubMedGoogle Scholar
  41. 41.
    Stitik TP, Nadler SF. Sports injuries: when-and how-to use cold most effectively. Consult Consult Prim Care 1999; 39(1):2881–2890.Google Scholar
  42. 42.
    Kesson M, Atkins E, Davies I, eds. Essential Equipment, Safety Cautions and Emergency Situations. In Musculoskeletal Injection Skills. Section I: Principles of Musculoskeletal Injections. Philadelphia, PA: Elsevier Science; 2003:10–17.Google Scholar
  43. 43.
    Katz JN, Simmons BP. Carpal tunnel syndrome. N Eng J Med 2002; 346(23):1807–1812.CrossRefGoogle Scholar
  44. 44.
    Beary JP. Osteoarthritis. In Beary JP, Christian CL, Johanson NA, eds. Manual of Rheumatology and Outpatient Orthopedic Disorders: Diagnosis and Therapy. Boston, MA: Little, Brown and Company; 1987:187–198.Google Scholar
  45. 45.
    Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier Jet al Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2003; 48(2):370–377.CrossRefPubMedGoogle Scholar
  46. 46.
    Mitchell M. Patient anxiety and modern elective surgery: a literature review. J Clin Nurs 2003; 12:806–815.CrossRefPubMedGoogle Scholar
  47. 47.
    Fung D, Cohen M. What do out-patients value most in their anesthesia care? Can J Anesth 2001; 48(1):12–19.CrossRefPubMedGoogle Scholar
  48. 48.
    Voulgari A, Papanikolaou MN, Lykouras L, Alevizos B, Alexiou E, Christodoulou GN. Prevention of postoperative anxiety and depression. Bibl Psychiatr 1994; 165:49–55.PubMedGoogle Scholar
  49. 49.
    Zervou E, Ziciadis K, Karabini F, Xanthi E, Chrisostomou E, Tzolou A. Vasovagal reactions in blood donors during or immediately after blood donation. Transfus Med 2005; 15(5):389–394.CrossRefPubMedGoogle Scholar
  50. 50.
    Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Hanna A, Rittenberg J et al. Complications of fluoroscopically guided caudal epidural injections. Am J Phys Med Rehabil 2001; 80(6):416–424.CrossRefPubMedGoogle Scholar
  51. 51.
    Botwin K P, Castellanos R, Rao S, Hanna AF, Torres-Ramos FM, Gruber RD et al. Complications of Fluoroscopically Guided Interlaminar Cervical Epidural Injections. Arch Phys Med Rehabil 2003; 84:627–633.PubMedGoogle Scholar
  52. 52.
    Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten WK. Complications of Fluoroscopically Guided Transforaminal Lumbar Epidural Injections Arch Phys Med Rehabil 2000; 81:1045–1050.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of Physical Medicine and RehabilitationNew Jersey Medical SchoolNewarkUSA

Personalised recommendations