What is the typical dosage ratio of lidocaine to triamcinolone (corticosteroid) for injections in various conditions, including knee, shoulder, plantar fasciitis, De Quervain's tenosynovitis, carpal tunnel syndrome, tennis elbow, golfer's elbow, CMC (carpometacarpal) joint, and hip bursitis?

Lidocaine to Triamcinolone Dosage Ratios for Joint and Soft Tissue Injections

For most joint and soft tissue injections, use 1-4 mL of 1% lidocaine combined with appropriate triamcinolone dosing based on the specific joint or condition being treated.

General Principles

• Aseptic technique is essential for all injections 1
• Local anesthetic should be offered to reduce discomfort during and after the procedure 1
• Consider warming lidocaine to 37°C to reduce injection pain 1

Specific Joint/Condition Recommendations

Knee Osteoarthritis

• Triamcinolone: 40 mg (can use 10 mg for reduced cartilage effects) 2
• Lidocaine: 2-4 mL of 1% solution 3
• Approach: Superolateral approach has highest accuracy (91%) 1
• Warning: Long-term triamcinolone may increase cartilage volume loss 4

Shoulder (Capsulitis/Arthritis)

• Triamcinolone: 40 mg (superior to 10 mg for pain relief) 5
• Lidocaine: 2-4 mL of 1% solution
• Note: Image guidance recommended for glenohumeral joint

Hip Bursitis/Osteoarthritis

• Triamcinolone: 40 mg
• Lidocaine: 2-4 mL of 1% solution
• Important: Image guidance strongly recommended for hip injections 1

De Quervain's Tenosynovitis

• Triamcinolone: 10-20 mg
• Lidocaine: 1 mL of 1% solution
• Efficacy: ~90% of patients respond to corticosteroid injection 6

Carpal Tunnel Syndrome

• Triamcinolone: 10-20 mg
• Lidocaine: 1 mL of 1% solution
• Technique: Inject between palmaris longus and flexor carpi radialis tendons

Tennis Elbow (Lateral Epicondylitis)

• Triamcinolone: 10-20 mg
• Lidocaine: 1-2 mL of 1% solution
• Technique: Inject at point of maximum tenderness

Golfer's Elbow (Medial Epicondylitis)

• Triamcinolone: 10-20 mg
• Lidocaine: 1-2 mL of 1% solution
• Technique: Inject at point of maximum tenderness

CMC Joint (First Carpometacarpal)

• Triamcinolone: 10-20 mg
• Lidocaine: 0.5-1 mL of 1% solution
• Approach: Dorsoradial approach recommended

Plantar Fasciitis

• Triamcinolone: 20-40 mg
• Lidocaine: 2 mL of 1% solution
• Technique: Inject at medial calcaneal tubercle

Safety Considerations

1. Maximum safe dose of lidocaine:

   • With epinephrine: 7 mg/kg (not to exceed 500 mg) 3
   • Without epinephrine: 4-5 mg/kg

2. Precautions:

   • Avoid injections within 3 months prior to joint replacement 1
   • Monitor diabetic patients for transient hyperglycemia for 1-3 days post-injection 1
   • Consider lower triamcinolone doses (10 mg) for knee OA to minimize cartilage effects 2

3. Potential adverse effects:

   • Post-injection flare (crystal-induced inflammation) 7
   • Local skin atrophy or depigmentation
   • Facial flushing
   • Tendon weakening or rupture with repeated injections

Practical Tips

• Draw up medications with one needle and inject with a new needle
• For knee injections, aspiration of synovial fluid helps confirm proper needle placement 1
• Consider ultrasound guidance for deeper joints (hip, shoulder) to improve accuracy 1
• Avoid mixing lidocaine with triamcinolone in the same syringe for small joint injections where volume matters
• For patients with diabetes, warn about potential blood glucose elevation for 1-3 days

Remember that while intra-articular corticosteroid injections provide short-term relief (typically 3 months), they should be part of a comprehensive treatment approach that includes other modalities for long-term management 1.