What is the recommended assessment prior to administering a steroid injection for knee treatment?

Knee Physical Assessment Prior to Steroid Injection

Prior to administering a knee steroid injection, a thorough physical assessment should be performed to confirm the diagnosis, identify the presence of inflammation or effusion, and determine the appropriate injection approach based on the patient's specific condition.

Essential Assessment Components

Pain Assessment

• Document the location, severity, duration, and character of pain using a validated scale (e.g., visual analog scale) 1, 2
• Determine if pain is exacerbated by specific movements or activities 1
• Assess if there are any mechanical symptoms (locking, catching, giving way) that might suggest meniscal pathology 2

Physical Examination

• Inspect for visible swelling, erythema, or deformity 1
• Palpate for effusion, warmth, and areas of localized tenderness along the joint line 1
• Assess range of motion (both active and passive) and document any limitations or pain with movement 1, 2
• Perform specific tests to evaluate joint stability:
  • Ligamentous stability tests (anterior/posterior drawer, varus/valgus stress) 2
  • McMurray's test for meniscal pathology 2
  • Patellar tracking and apprehension 2

Inflammation Assessment

• Document the presence or absence of effusion, as this may predict response to steroid injection 1, 2
• Note any signs of acute inflammation that would indicate a potential flare requiring more urgent intervention 1

Imaging Considerations

• Review recent radiographic findings to assess the degree of structural damage 1, 2
• Consider point-of-care ultrasound to confirm effusion and identify specific pain-generating pathologies, particularly for targeted approaches like the anteromedial joint line approach for medial compartment issues 3

Pre-Injection Planning

• Determine the most appropriate injection approach based on the location of pathology:

  • Standard superolateral approach for general knee osteoarthritis 1, 2
  • Anteromedial joint line approach for specific medial compartment pathology 3
  • Consider ultrasound guidance for more accurate placement, especially in obese patients or those with complex anatomy 1

• Document any contraindications to steroid injection:

  • Local or systemic infection 1
  • Significant bleeding risk (though not an absolute contraindication per EULAR recommendations) 1
  • Planned joint replacement surgery within 3 months 1, 2
  • Poorly controlled diabetes 1, 2

Patient Education and Consent

• Inform patients about expected benefits and potential risks of the procedure 1, 2
• For diabetic patients, specifically advise about the risk of transient hyperglycemia for 1-3 days post-injection 1, 2
• Instruct patients to avoid overuse of the injected joint for 24 hours following the injection 1, 4
• Consider discussing the potential benefit of 24-hour rest following injection, as this may prolong clinical response 4

Documentation Requirements

• Record baseline pain and functional status to assess treatment response at follow-up 1, 2
• Document previous treatments attempted and their outcomes 1, 2
• Note any previous injections, including timing and response 1, 2

Clinical Pearls

• The presence of effusion may predict a better response to intra-articular steroids, though evidence is mixed 1, 2
• Consider combining the injection with a referral for physical therapy, as this combination may improve overall outcomes and increase adherence to physical therapy 5
• For patients with primarily medial compartment pain who have failed standard superolateral injections, consider the anteromedial joint line approach 3
• Remember that steroid injections provide relatively short-term relief (1-12 weeks) and should be part of a comprehensive treatment plan 1, 2

By following this structured assessment approach, clinicians can optimize the safety and efficacy of knee steroid injections while tailoring the treatment to each patient's specific condition.