What is typically mixed with Kenalog (triamcinolone acetonide) for a trigger point injection?

Trigger Point Injection Preparation with Kenalog

For trigger point injections, Kenalog (triamcinolone acetonide) is typically mixed with a local anesthetic such as lidocaine, though recent evidence suggests using Kenalog alone may actually be preferable to reduce injection pain. 1

Standard Mixing Protocols

Traditional Approach

• Kenalog is commonly combined with 1% lidocaine in equal volumes (e.g., 1 mL triamcinolone 40 mg/mL mixed with 1 mL lidocaine 1%) 1, 2
• Some practitioners use 0.25% lidocaine as a lower concentration alternative 3
• The addition of epinephrine to lidocaine is not recommended, as it significantly increases injection pain (VAS 3.5 vs 2.0 without epinephrine) 1

Evidence-Based Alternative: Kenalog Alone

• Using triamcinolone without any local anesthetic produces less injection pain compared to mixing with lidocaine (VAS 2.0 vs 3.5) 1
• This approach is simpler, more efficient, and safer by eliminating potential anesthetic-related complications 1
• The trade-off is foregoing immediate short-term anesthesia at the injection site 1

Important Clinical Considerations

Regarding Corticosteroid Use in Trigger Points

• The American College of Occupational and Environmental Medicine (2021) recommends against adding glucocorticosteroids to trigger point injections for chronic low back pain, suggesting local anesthetic alone when trigger point injections are indicated 4
• This represents a significant divergence from traditional practice and reflects concerns about the evidence base for steroid use in myofascial trigger points 4

Technique Matters More Than Solution

• Eliciting a local twitch response (LTR) during needle insertion is essential for therapeutic effect, regardless of whether you inject medication or perform dry needling 5
• Without eliciting an LTR, there is minimal improvement in pain, tenderness, or muscle tightness 5

Post-Injection Effects

• Dry needling (no medication) causes significantly more post-injection soreness than lidocaine injection, with 100% of dry needling patients experiencing soreness versus 42% with lidocaine 5
• When lidocaine is used, it reduces both the intensity and duration of post-injection soreness 5
• Adding corticosteroid to lidocaine reduces post-injection sensitivity compared to lidocaine alone 3

Practical Recommendation Algorithm

For most trigger point injections:

1. Use triamcinolone acetonide 40 mg/mL (1 mL) alone if minimizing injection pain is the priority 1
2. Mix triamcinolone 40 mg/mL (1 mL) with 0.25-1% lidocaine (1 mL) if reducing post-injection soreness is more important 5, 3
3. Never add epinephrine to the mixture 1
4. Always attempt to elicit a local twitch response during injection for therapeutic efficacy 5

Critical Caveat

Be aware that severe postinjection flares can occur with triamcinolone, mimicking septic arthritis with intense pain, swelling, and inability to ambulate within hours of injection 6. While rare, this represents an acute crystal-induced inflammatory response that requires aspiration and synovial fluid analysis to rule out infection 6.