What is the recommended dose of Kenalog (triamcinolone) and lidocaine for a knee injection?

Recommended Dosing for Kenalog and Lidocaine in Knee Injections

For knee injections, the recommended dose is 40 mg of triamcinolone acetonide (Kenalog) mixed with 2-4 mL of 1% lidocaine.

Dosing Guidelines

Triamcinolone (Kenalog) Dosing:

• Standard dose: 40 mg for knee joint injections 1
• Lower dose option: 10-20 mg may be equally effective with potentially fewer side effects 2, 3
  • A recent randomized controlled trial showed 10 mg was non-inferior to 40 mg for pain relief in knee osteoarthritis 2

Lidocaine Dosing:

• 1-4 mL of 1% lidocaine is typically used 4
• Calculate based on patient's ideal body weight (not to exceed safe dosing limits) 1
• Maximum safe dose: 7 mg/kg when used with epinephrine, lower without epinephrine 5

Administration Technique

1. Preparation:

   • Draw up medications separately then combine in the same syringe
   • Consider buffering lidocaine with sodium bicarbonate (1:9 ratio) to decrease injection pain 5
   • Warming the solution to approximately 40°C can reduce injection pain 5

2. Injection approach:

   • Ensure proper sterile technique
   • Consider ultrasound guidance for accurate placement (though not mandatory for knee as it is for hip injections) 1
   • Inject into the joint space using an appropriate gauge needle

Safety Considerations

• Avoid concurrent local anesthetics:

  • Do not use intravenous lidocaine within 4 hours of the injection 1
  • Do not perform additional nerve blocks within 4 hours 1

• Monitor for adverse reactions:

  • Post-injection flares can occur, ranging from mild effusion to severe pain 4
  • Rare but severe crystal-induced inflammatory responses can mimic septic arthritis 4
  • Early signs of lidocaine toxicity include perioral tingling, tinnitus, and light-headedness 5

• Contraindications:

  • Avoid in patients weighing <40 kg 1
  • Use caution in patients with cardiac disease, electrolyte disorders, or seizure disorders 1

Clinical Efficacy

• Intra-articular glucocorticoid injections are strongly recommended for knee osteoarthritis by the American College of Rheumatology 1
• The combination provides both immediate pain relief (from lidocaine) and longer-term anti-inflammatory effects (from triamcinolone)
• Duration of effect typically lasts 1-3 months, with some patients experiencing relief for up to 6 months 3

Key Pitfalls to Avoid

• Overdosing: Using more than the recommended dose increases risk of systemic effects without improving efficacy
• Misplacement: Ensure proper intra-articular placement to maximize effectiveness
• Ignoring contraindications: Screen for allergies to either medication
• Repeated injections: Limit frequency to no more than every 3 months to prevent cartilage damage 1

This evidence-based approach balances efficacy with safety considerations to provide optimal pain management for patients with knee conditions requiring intra-articular injections.