Guidelines for Administering Steroid Injection to the Knee
Intraarticular corticosteroid injections are strongly recommended for patients with knee osteoarthritis who have inadequate response to initial pharmacologic management. 1
Indications and Patient Selection
Appropriate for patients with:
- Symptomatic knee osteoarthritis
- Inadequate response to first-line treatments (acetaminophen, oral/topical NSAIDs)
- Pain and inflammation requiring targeted therapy
Contraindications:
- Active joint infection or sepsis
- Fracture around the joint
- Significant skin infection over injection site
- Prosthetic joint (relative contraindication) 2
Injection Procedure Guidelines
Pre-injection Considerations
- Review patient's medical history for:
- Bleeding disorders or anticoagulant use
- Diabetes (may cause transient hyperglycemia)
- Previous allergic reactions to corticosteroids
- Recent joint injections (avoid frequent repeated injections)
Technique
Patient positioning: Seated with knee flexed at 90 degrees
Approach options:
- Anterolateral approach (between patella and femur)
- Anteromedial approach (between patella and femur)
- Superolateral approach (above and lateral to patella)
Procedural steps:
- Sterile preparation of the injection site
- Local anesthetic (optional)
- Aspiration of joint fluid if effusion present (for diagnostic purposes)
- Injection of corticosteroid preparation
Accuracy considerations:
Post-injection Care
- Rest the joint for 24 hours after injection (evidence suggests this improves outcomes) 4
- Avoid strenuous activity for 1-2 days
- Monitor for immediate side effects (pain flare, facial flushing)
Medication Selection
Recommended Corticosteroid Options
- Triamcinolone acetonide (20-40 mg)
- Methylprednisolone acetate (20-80 mg)
- Betamethasone (6-12 mg)
Dosing Considerations
- Use lowest effective dose to minimize side effects 5
- Duration of effect typically 3-12 weeks 1
- Methylprednisolone may provide longer relief (up to 24 weeks) compared to triamcinolone (up to 12 weeks) 1
Frequency and Timing Guidelines
- Limit injections to 3-4 per year in the same joint
- Allow at least 3 months between injections when possible
- Avoid corticosteroid injections within 3 months before planned knee replacement surgery 1
- Note: Evidence is mixed regarding infection risk, with some studies showing no increased risk 6
Potential Complications and Management
Local Complications
- Post-injection flare (temporary pain increase 24-48 hours after injection)
- Skin hypopigmentation or atrophy
- Infection (estimated risk of 1 in 3,000 injections) 3
- Accelerated progression of osteoarthritis with frequent injections 7, 2
Systemic Complications
- Transient hyperglycemia in diabetic patients
- Facial flushing
- Adrenal suppression (rare with isolated injections)
- Potential cartilage loss with repeated injections 1
Special Considerations
- Diabetic patients: Monitor blood glucose for 1-3 days post-injection
- Immunocompromised patients: Higher risk of infection; consider alternative treatments
- Patients on anticoagulants: Increased risk of bleeding; apply pressure after injection
- Obesity: May require longer needle and consideration of anatomical landmarks
Follow-up Recommendations
- Assess response at 2-4 weeks post-injection
- Document duration of symptom relief
- Consider alternative treatments if inadequate response to two consecutive injections
- Consider referral for surgical evaluation if repeated injections provide diminishing returns
Remember that while corticosteroid injections provide effective short-term pain relief, they should be part of a comprehensive treatment plan that includes weight management and appropriate exercise for optimal long-term outcomes 1.