Who performs joint injections?

Who Performs Joint Injections

Joint injections are primarily performed by rheumatologists, orthopedic surgeons, physical medicine and rehabilitation physicians, and primary care sports medicine physicians, with each specialty bringing different expertise and approaches to this procedure. 1, 2

Types of Specialists Who Perform Joint Injections

• Rheumatologists: Specialists in diagnosing and treating arthritis and other musculoskeletal conditions. They commonly perform joint injections as part of their comprehensive management of conditions like osteoarthritis and inflammatory arthritis 1

• Orthopedic Surgeons: Frequently perform joint injections, particularly in patients who may eventually need surgical intervention. They tend to use larger volumes of anesthetic compared to other specialists 2

• Physical Medicine and Rehabilitation (PM&R) Physicians: Regularly perform joint injections as part of their practice in treating musculoskeletal conditions 2

• Primary Care Sports Medicine Physicians: Often perform joint injections, particularly for sports-related injuries and conditions 2

Joint-Specific Considerations

Hip Joint Injections

• Imaging guidance strongly recommended: The 2020 American College of Rheumatology guidelines strongly recommend ultrasound guidance for hip joint injections to ensure accurate placement 1
• Studies show that blind hip injections have only a 65.1% success rate, with higher failure rates in obese patients, those with severe arthritis, and those with flexion deformities 3

Knee and Hand Joint Injections

• Ultrasound guidance is beneficial but not mandatory for knee and hand joint injections 1
• These joints are more accessible and have anatomical landmarks that make accurate injection possible without imaging in many cases

Injection Techniques and Medications

Corticosteroid Injections

• Intra-articular corticosteroid injections are strongly recommended for knee and hip osteoarthritis and conditionally recommended for hand osteoarthritis 1
• For knee osteoarthritis, intra-articular corticosteroid injections are indicated for flares of knee pain, especially if accompanied by effusion 1
• Common corticosteroids used include:
  • Triamcinolone acetonide (Kenalog)
  • Methylprednisolone acetate (Depo-Medrol) 2

Dosing Considerations

• For smaller joints: 2.5-5 mg of triamcinolone
• For larger joints: 5-15 mg of triamcinolone
• For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas are typically sufficient 4

Special Populations and Considerations

Pediatric Patients

• In juvenile idiopathic arthritis, intra-articular glucocorticoid injections are recommended for all patients with active arthritis, regardless of disease activity level 1
• Triamcinolone hexacetonide is the preferred agent for pediatric joint injections 1

Timing of Injections

• Recent guidelines from the American College of Rheumatology and American Association of Hip and Knee Surgeons (2023) conditionally recommend proceeding to total joint arthroplasty without delay over delaying for a trial of intra-articular glucocorticoid injections in patients with symptomatic moderate-to-severe osteoarthritis for whom nonoperative therapy is ineffective 1
• There is concern about increased risk of joint infection if surgery is performed within 3 months of an intra-articular injection 1

Practical Implications

• The choice of specialist for joint injections may depend on:

  • The specific joint involved
  • The underlying condition
  • The need for imaging guidance
  • The potential need for surgical intervention

• Collaboration between specialties is common, with rheumatologists often working closely with orthopedic surgeons for patients who may eventually need surgical intervention 1

Joint injections remain an important tool in the management of various joint conditions, with different medical specialists bringing their unique expertise to this procedure.