What is the recommended dose and protocol for a knee intra-articular (in the joint) steroid injection?

From the Guidelines

The recommended dose for a knee intra-articular steroid injection typically involves 40mg of triamcinolone acetonide or methylprednisolone acetate, though doses may range from 20-80mg depending on joint size and inflammation severity, as supported by the most recent and highest quality study 1.

Key Considerations for Knee Intra-Articular Steroid Injections

• The protocol begins with patient positioning (knee slightly flexed), followed by sterile preparation of the injection site.
• Using aseptic technique, the clinician should identify the appropriate entry point (commonly lateral or medial approach), and after local anesthesia with 1% lidocaine, insert a 21-22 gauge needle into the joint space.
• Prior to steroid injection, any significant effusion should be aspirated.
• The steroid is then slowly injected, often mixed with 2-5ml of 1% lidocaine for immediate pain relief.
• Post-injection, patients should rest the joint for 24-48 hours and avoid strenuous activity for 1-2 weeks.

Rationale and Evidence

The use of intra-articular corticosteroids for knee osteoarthritis is supported by several studies, including a 2022 guideline summary from the American Academy of Orthopaedic Surgeons 1, which found considerable evidence supporting the use of intra-articular corticosteroid injections, although the duration of benefits was often only 3 months.

Important Considerations

• Injections should generally be limited to 3-4 per year in the same joint to minimize potential side effects such as cartilage damage, infection risk, and temporary blood glucose elevation in diabetic patients.
• The potential long-term negative effects on bone health, joint structure, and meniscal thickness associated with repeat intra-articular corticosteroid administration should be taken into account 1.
• There is no notable difference in the risk of gastrointestinal adverse events with nonselective NSAIDs compared to selective cyclooxygenase-2 oral NSAIDs 1.

From the FDA Drug Label

The dose for intra-articular administration depends upon the size of the joint and varies with the severity of the condition in the individual patient. In chronic cases, injections may be repeated at intervals ranging from one to five or more weeks, depending upon the degree of relief obtained from the initial injection The doses in the following table are given as a general guide: Size of Joint Examples Range of Dosage Large Knees Ankles Shoulders 20 mg to 80 mg Medium Elbows Wrists 10 mg to 40 mg Small Metacarpophalangeal Interphalangeal Sternoclavicular Acromioclavicular 4 mg to 10 mg

The recommended dose for a knee intra-articular steroid injection is between 20 mg to 80 mg of methylprednisolone acetate, depending on the severity of the condition in the individual patient 2.

• The injection should be made into the synovial space.
• The procedure involves inserting a sterile needle into the synovial cavity and aspirating a few drops of joint fluid to confirm the joint space has been entered.
• After injection, the joint should be moved gently a few times to aid mixing of the synovial fluid and the suspension.
• Injections may be repeated at intervals ranging from one to five or more weeks, depending upon the degree of relief obtained from the initial injection.

From the Research

Recommended Dose and Protocol for Knee Intra-Articular Steroid Injection

The recommended dose and protocol for a knee intra-articular steroid injection can vary depending on the specific condition being treated and the steroid used.

• The dose of steroid used can range from 40 mg to 80 mg per injection, with some studies using triamcinolone hexacetonide (TH) or triamcinolone acetonide (TA) at a dose of 40 mg or 80 mg, respectively 3, 4.
• Methylprednisolone acetate (MPA) has also been used at a dose of 80 mg per injection 3.
• The frequency of injections can vary, with some studies using a single injection and others using multiple injections spaced several weeks apart 5.
• The choice of steroid and dose may depend on the specific condition being treated, with some studies suggesting that TH may be more effective than TA or MPA for certain conditions 6, 4.

Efficacy of Different Steroids

• Studies have compared the efficacy of different steroids for knee intra-articular injections, including TH, TA, and MPA 3, 4.
• One study found that TH and MPA were equally effective in reducing pain and improving function in patients with knee osteoarthritis, with improvements sustained for up to 24 weeks 4.
• Another study found that TA and MPA were equally effective in reducing pain and swelling in patients with chronic inflammatory arthritis, with no significant differences in efficacy between the two steroids 3.

Safety and Adverse Effects

• Knee intra-articular steroid injections are generally considered safe, with few adverse effects reported in clinical trials 3, 4.
• However, as with any injection, there is a risk of infection, hematoma, or other local adverse effects 3.
• Systemic adverse effects, such as changes in blood sugar or blood pressure, can also occur, especially with repeated injections 5.