What type of corticosteroid is recommended for injection in an adult patient with bursitis, considering potential conditions such as diabetes, osteoporosis, or recent joint infection?

Corticosteroid Selection for Bursitis Injection

For bursitis injection, use triamcinolone acetonide 5-15 mg for smaller joints/bursae or up to 40 mg for larger areas, or betamethasone 6-24 mg, mixed with 1% lidocaine for immediate pain relief. 1, 2, 3

Specific Corticosteroid Preparations and Dosing

Triamcinolone Acetonide (Preferred Agent)

• Dose range: 2.5-5 mg for smaller joints, 5-15 mg for larger joints, up to 40 mg for larger areas 1
• For trochanteric bursitis specifically: 10 mg triamcinolone combined with 2.5 ml of 0.5% lidocaine has demonstrated complete pain relief 4
• FDA-approved for intra-articular and soft tissue administration in acute and subacute bursitis 1
• Single injections are often sufficient, though several may be needed for adequate symptom relief 1

Betamethasone (Alternative Agent)

• Dose range: 6-24 mg for trochanteric bursitis, mixed with 4 ml of 1% lidocaine 2, 3
• Higher doses (24 mg) show superior efficacy compared to lower doses (6-12 mg) with 77.1% of patients reporting improvement at 1 week 3
• Provides prolonged benefit with 61.3% of patients maintaining improvement at 26 weeks 3

Critical Technical Considerations

Injection Technique Requirements

• Strict aseptic technique is mandatory to minimize infection risk (0.035% or 3 per 7,900 procedures) 5
• Use surgical gloves, prepare skin with alcohol/iodine/chlorhexidine, and change needles between drawing medication and injecting 5
• Inject deeply into the bursa; avoid subcutaneous injection as this causes fat atrophy 1
• Shake vial before use and inspect for agglomeration (white precipitate); discard if present 1

Anatomical Approach

• For trochanteric bursitis: inject at the point of maximal tenderness over the greater trochanter 2, 6
• Ultrasound guidance improves accuracy but is not mandatory for superficial bursae 5
• For deep bursae (e.g., obturator internus): ultrasound guidance with trans-tendinous approach may be necessary 4

Special Population Considerations

Diabetes Mellitus

• Patients with diabetes should closely monitor blood glucose for 2 weeks following injection due to risk of hyperglycemia 7
• The risk of hyperglycemia does not contraindicate injection but requires enhanced monitoring 8

Osteoporosis

• No specific contraindication exists for local corticosteroid injection in osteoporosis patients 8
• Systemic effects from single local injections are minimal compared to oral corticosteroids 7

Recent or Active Joint Infection

• Absolute contraindication: do not inject if active infection is present or suspected 8
• Avoid injection within 3 months preceding joint replacement surgery due to theoretical infection risk 9
• Rule out infection before administering intra-articular steroids 8

Treatment Algorithm

First-Line Approach

• Conservative therapy (rest, NSAIDs, stretching) should be attempted first 2
• If symptoms persist despite 2-4 weeks of conservative management, proceed to corticosteroid injection 2, 7

Injection Protocol

• Single injection is effective in 77% of patients at 1 week 3
• 29.9% of patients require only one injection for sustained relief 6
• If inadequate response, repeat injection after 4-6 weeks 6
• Maximum of 3-5 injections may be given for refractory cases 6

Post-Injection Management

• Avoid overuse of injected area for 24 hours; however, immobilization is discouraged 8
• Physical therapy following injection improves outcomes in 49% of patients versus 39% with injection alone 6

Common Pitfalls to Avoid

• Never inject peri-tendon around Achilles, patellar, or quadriceps tendons due to rupture risk 8
• Avoid injecting into tendon substance itself; ensure injection is into tendon sheath or bursa 1
• Do not inject if agglomeration (white precipitate) is visible in the vial 1
• Avoid subcutaneous injection as this causes tissue atrophy 1