Abstract
Introduction
This review article addresses the best evidence currently available for the effectiveness of injection therapy for musculoskeletal conditions involving the peripheral joints. The research is presented by anatomical region and areas of controversy and the need for additional research are identified.
Discussion
Randomized controlled trials, meta-analyses and systematic reviews are lacking that address the effectiveness of therapeutic injections to the sternoclavicular, acromioclavicular, ankle and foot joints. No research studies of any kind have been reported for therapeutic injections of the sternoclavicular joint. With the exception of the knee, possibly the hip and patients with inflammatory arthropathies, research does not unequivocally support the use of therapeutic joint injections for most of the peripheral joints, including the shoulder. Additionally, controversy exists in some areas as to whether or not corticosteroids provide better outcomes compared to local anesthetic injections alone.
Conclusion
When viscosupplementation injections are compared to corticosteroids in patients with osteoarthritis of the knee, the evidence supports the use of viscosupplementation for more prolonged improvement in outcomes, with corticosteroids being good for short-term relief.
Similar content being viewed by others
References
Airaksinen O, Brox JI, Cedraschi C, et al. European guidelines for the management of chronic nonspecific low back pain, chapter 4. Eur Spine J. 2006;15(suppl 20):S192–300.
Rupert MP, Lee M, Manchikanti L, Datta S, Cohen SP. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009;12:399–418.
Falco FJE, Erhart S, Wargo BW, Bryce DA, Atluri S, Datta S, et al. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician. 2009;12:323–44.
Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007;10:229–53.
Sehgal N, Dunbar EE, Shah RV, Colson J. Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update. Pain Physician. 2007;10:213–28.
Atluri S, Datta S, Falco FJE, Lee M. Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. Pain Physician. 2008;11:611–29.
Furtado RNV, Oliveira LM, Natour J. Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study. J Rheumatol. 2005;32:1691–8.
Klint E, Grundtman C, Engstrom M, Catrina AI, Makrygiannakis D, Klareskog L, et al. Intraarticular glucocorticoid treatment reduces inflammation in synovial cell infiltrations more efficiently than in synovial blood vessels. Arthritis Rheum. 2005;52:3880–9.
Stephens MB, Beutler AI, O’Connor FG. Musculoskeletal injections: a review of the evidence. Am Fam Physician. 2008;78:971–6.
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;25(1):CD002824.
Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD004016. doi:10.1002/14651858.CD004016.
Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomized controlled trials. Ann Rheum Dis. published online 3 Dec 2008. doi:10.1136/ard.2008.099572
Koester MC, Dunn WR, Kuhn JE, Spindler KP. The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: a systematic review. J Am Acad Orthop Surg. 2007;15:3–11.
Arroll B, Goodyear-Smith F. Corticosteroid injections for painful shoulder: a meta-analysis. Br J Gen Pract. 2005;55:224–8.
Alvarez CM, Litchfield R, Jackowski D, Griffin S, Kirkley A. A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med. 2005;33:255–62.
Hossain S, Jacobs LGH, Hashmi R. The long-term effectiveness of steroid injections in primary acromioclavicular joint arthritis: a five-year prospective study. J Shoulder Elbow Surg. 2008;17:535–8.
Strobel K, Pfirrmann CWA, Zanetti M, Nagy L, Hodler J. MRI features of the acromioclavicular joint that predict pain relief from intra-articular injection. AJR. 2003;181:755–69.
Kurta I, Datir S, Dove M, Rahmatalla A, Wynn-Jones C, Maffulli N. The short term effects of a single corticosteroid injection on the range of motion of the shoulder in patients with isolated acromioclavicular joint arthropathy. Acta Orthop Belg. 2005;71:656–61.
Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Int J Clin Pract. 2007;61:240–6.
Dogramaci Y, Kalaci A, Savas N, Duman IG, Yanat AN. Treatment of lateral epicondilitis using three different local injection modalities: a randomized prospective clinical trial. Arch Orthop Trauma Surg. 2009; published on-line 14 February 2009. doi:10.1007/s00402-009-0832-x.
Lindenhovius A, Henket M, Gilligan BP, Lozano-Calderon S, Jupiter JB, Ring D. Injection of dexamethasone versus placebo for lateral elbow pain: a prospective, double-blind, randomized clinical trail. J Hand Surg. 2008;33A:909–19.
Manchikanti L, Singh V, Valco FJE, Cash KA, Pampati V. Lumbar facet joint nerve blocks in managing chronic facet joint pain: one-year follow-up of a randomized, double-blind controlled trial: Clinical Trial NCT00355914. Pain Physician. 2008;11:121–32.
Manchikanti L, Singh V, Falco FJE, Cash KM. Fellows B. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine. 2008;33:1813–20.
Marti P, Molinari L, Bolt IB, Seger R, Saurenmann RK. Factors influencing the efficacy of intra-articular steroid injections in patients with juvenile idiopathic arthritis. Eur J Pediatr. 2008;167:425–30.
Bliddal H, Terslev L, Qvistgaard E, Holm KM, CC RH, Boesen M, et al. A randomized, controlled study of a single intra-articular injection of etanercept or glucocorticosteroids in patients with rheumatoid arthritis. Scand J Rheumatol. 2006;35:341–5.
Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.:CD001554. doi:10.1002/14651858.CD001554.pub2.
Sevim S, Dogu O, Camdeviren H, Kaleagasi H, Aral M, Arslan E, et al. Long-term effectiveness of steroid injections and splinting in mild and moderate carpal tunnel syndrome. Neurol Sci. 2004;25:48–52.
Richie CA III, Briner W Jr. Corticosteroid injection for treatment of de Quervain’s tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. 2003;16:102–6.
Jirarattanaphochai K, Saengnipanthkul S, Vipulakorn K, Jianmongkol S, Chatuparisute P, Jung S. Treatment of de Quervain disease with triamcinolone injection with or without nimesulide: a randomized, double-blind, placebo-controlled trial. J Bone Joint Surg Am. 2004;86:2700–6.
Goldfarb CA, Gelberman RH, McKeon K, Chia B, Boyer MI. Extra-articular steroid injection: early patient response and the incidence of flare reaction. J Hand Surg. 2007;32A:1513–20.
Fuchs S, Mönikes R, Wohlmeiner A, Heyse T. Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis. Osteoarthritis Cartilage. 2006;14:82–8.
Stahl S, Karsh-Zafrir I, Ratzon N, Rosenberg N. Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints. J Clin Rheumatol. 2005;11:299–302.
Qvistgaard E, Christensen R, Torp-Pedersen S, Bliddal H. Intra-articular treatment of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid, and isotonic saline. Osteoarthritis Cartilage. 2006;14:163–70.
Kullenberg B, Runesson R, Tuvhag R, Olsson C, Resch S. Intraarticular corticosteroid injections: pain relief in osteoarthritis of the hip? J Rheumatol. 2004;31:2265–8.
Lambert RGW, Hutchings EJ, Brace MGA, Jhangri GS, Conner-Spady B, Maksymowych WP. Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2007;56:2278–87.
Plant MJ, Borg AA, Dziedzic K, Saklatvala J, Dawes PT. Radiographic patterns and response to corticosteroid hip injection. Ann Rheum Dis. 1997;56:476–80.
Harvey WF, Hunter DJ. The role of analgesics and intra-articular injections in disease management. Rheum Dis Clin N Am. 2008;34:777–88.
van den Bekeron MPJ, Lamme B, Sermon A, Mulier M. What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature. Arch Orthop Trauma Surg. 2008;128:815–23.
Bellamy N, Campbell J. Welch V, Gee TL, Bourne R, Wells GA. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.:CD005328. doi:10.1002/14651858.CD005328.pub2.
Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2006; Issue 2. Art. No.:CD005321. doi:10.1002/14651858.CD005321.pub2.
Divine JG, Zazulak BT, Hewett TE. Viscosupplementation for knee osteoarthritis: a systematic review. Clin Orthop Relat Res. 2007;455:113–22.
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 Am. 2004;86-A:538–45.
Middleton F, Coakes J, Umarji S, Palmer S, Venn R, Panayiotou S. The efficacy of intra-articular bupivacaine for relief of pain following arthroscopy of the ankle. J Bone Joint Surg (Br). 2006;88-B:1603–5.
Ward ST, Williams PL, Purkayastha S. Intra-articular corticosteroid injections in the foot and ankle: a prospective 1-year follow-up investigation. J Foot Ankle Surg. 2008;47:138–44.
Sun SF, Chou YJ, Hsu CW, Hwang CW, Hsu PR, Wang JL, et al. Efficacy of intra-articular hyaluronic acid in patients with osteoarthritis of the ankle: a prospective study. Osteoarthritis Cartilage. 2006;14:867–74.
Munteanu SE, Menz HB, Zammit GV, Landorf KB, Handley CJ, ElZarka A, et al. Efficacy of intra-articular hyaluronan (Synvisc) for the treatment of osteoarthritis affecting the first metatarsophalangeal joint of the foot (hallux limitus): study protocol for a randomised placebo controlled trial. J Foot Ankle Res. 2009;2:2.
Pons M, Alvarez F, Solana J, Viladot R, Varela L. Sodium hyaluronate in the treatment of hallux rigidus: a single-blind, randomized study. Foot Ankle Int. 2007;28:38–42.
Hartrick CT. Quality assessment in clinical trials: considerations for outcomes research in interventional pain medicine. Pain Practice. 2008;6:433–8.
Bolton JE. Sensitivity and specificity of outcome measures in patients with neck pain: detecting clinically significant improvement. Spine. 2004;29:2410–7.
Bolton JE. The evidence in evidence-based practice: What counts and what doesn’t count? J Manipulative Physiol Ther. 2001;24:362–6.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Peterson, C., Hodler, J. Evidence-based radiology (part 2): Is there sufficient research to support the use of therapeutic injections into the peripheral joints?. Skeletal Radiol 39, 11–18 (2010). https://doi.org/10.1007/s00256-009-0784-9
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00256-009-0784-9