Which knee conditions can be treated with injections?

Knee Conditions Treatable with Injections

Intra-articular corticosteroid injections are strongly recommended for knee osteoarthritis, acute gouty arthritis, rheumatoid arthritis, and can be used for iliotibial band syndrome when conservative treatment fails.

Conditions Appropriate for Knee Injections

Osteoarthritis (OA) of the Knee

• Strong recommendation for corticosteroid injections 1
  • Indicated for acute exacerbations of knee pain, especially with effusion
  • Provides short-term pain relief (typically up to 3 months) 2
  • Should be considered when patients have failed conservative measures
  • Can be repeated when previous injections provided significant relief

Inflammatory Arthritis

• Rheumatoid Arthritis (RA) 3

  • Corticosteroid injections indicated as adjunctive therapy
  • Particularly useful for flares affecting specific joints
  • Can help tide patients over acute episodes

• Psoriatic Arthritis 2

  • Local injections of glucocorticoids should be considered as adjunctive therapy
  • Particularly helpful in monoarthritis/oligoarthritis presentations
  • Can be used during disease flares while systemic medications are being adjusted

• Acute Gouty Arthritis 3

  • Intra-articular corticosteroids indicated as adjunctive therapy
  • Provides rapid relief of pain and inflammation

Other Knee Conditions

• Iliotibial Band Syndrome 4

  • Corticosteroid injections should be considered if visible swelling or pain persists for more than three days after initiating conservative treatment
  • Most patients respond to conservative treatment first (stretching, strengthening)

• Bursitis and Tenosynovitis 3

  • Acute and subacute bursitis
  • Acute nonspecific tenosynovitis
  • Epicondylitis

Types of Injectable Treatments

Corticosteroid Injections

• First-line injectable therapy for most knee conditions 1
• Dosing: 5-15 mg for knee joints (up to 40 mg for larger areas) 3
• Provides short-term relief (typically up to 3 months) 2
• Special considerations for diabetic patients: monitor glucose levels for 1-3 days post-injection 2

Hyaluronic Acid (HA) Injections

• Conditionally recommended against in knee OA 2
• May be considered when:
  • Corticosteroid injections have failed
  • Other interventions have been exhausted
  • Patient has mild OA 5
• Evidence of benefit is limited to studies with higher risk of bias 2
• Recent research suggests HA may provide longer-term relief (up to 3 months) compared to corticosteroids 6

Platelet-Rich Plasma (PRP)

• Strongly recommended against in knee OA by ACR guidelines 2
• Concerns regarding heterogeneity and lack of standardization in preparations 2
• Recent research suggests PRP may be beneficial for pain relief in younger patients with mild OA 5, 7

Injection Technique Considerations

• Aseptic technique is mandatory for all injections 2, 3
• Ultrasound guidance:
  • Not required for knee injections 1
  • May help ensure accurate delivery but not routinely necessary 1
• Patient positioning: ideally on examination table, easy to lie flat 2
• Post-injection recommendations:
  • Avoid overuse of injected joints for 24 hours
  • Complete immobilization is discouraged 2

Contraindications and Cautions

• Not contraindicated in patients with clotting/bleeding disorders or taking antithrombotic medications, unless bleeding risk is high 2
• May be performed at least 3 months prior to joint replacement surgery 2
• Diabetic patients should monitor glucose levels for 1-3 days post-injection 2
• Avoid injection if infection is suspected

Clinical Decision-Making Algorithm

1. First-line treatment: Non-pharmacological approaches (weight loss, exercise)
2. Second-line: Oral analgesics (NSAIDs, acetaminophen)
3. Third-line: Intra-articular corticosteroid injection for:
   • Persistent moderate-to-severe pain
   • Failure of conservative measures
   • Presence of inflammation/effusion
4. Consider repeat injection if significant relief was achieved previously
5. Consider alternative injectables only after corticosteroids fail and in specific patient populations