Maximum Number of Intra-Articular Corticosteroid Injections Per Year
The generally accepted limit is 3-4 corticosteroid injections in the same joint per year, though this recommendation is not based on strong research evidence. 1
Evidence-Based Frequency Recommendations
The 2021 EULAR (European League Against Rheumatism) guidelines explicitly state that while high-quality studies evaluating long-term effects of repeated intra-articular injections are scarce, the general accepted rule is to avoid more than 3-4 glucocorticoid injections in the same joint per year. 1 This recommendation is acknowledged as being based on expert consensus rather than robust research evidence. 1
Supporting Evidence for Frequency Limits
One research study from 1998 recommends limiting injections to no more frequently than every 6 weeks, with a maximum of 3-4 injections per year in the same joint. 2
A 2005 study demonstrated that intra-articular corticosteroid injections every 3 months for up to 2 years showed safety and efficacy with no joint space narrowing detected. 3
The American College of Rheumatology suggests limiting to 3-4 injections per year due to potential risks of accelerated cartilage loss and increased risk of requiring knee arthroplasty. 4
Rationale for Limiting Injection Frequency
Cartilage Safety Concerns
The evidence on cartilage effects is contradictory but concerning:
Two randomized controlled trials in knee osteoarthritis comparing injections every 3 months for 2 years showed conflicting results: one demonstrated no deleterious effect on cartilage volume, while the other showed greater progression of cartilage volume loss with glucocorticoids compared to saline. 1
Recent evidence suggests intra-articular corticosteroids might be associated with more MRI-assessed quantitative cartilage thickness loss than saline injections in the context of repeat injections. 5
Infection Risk
In prosthetic joints, the infection rate is 0.6% (1 infection per 625 injections). 1, 4
Injections should be avoided within 3 months prior to knee replacement surgery due to increased prosthetic infection risk (from 0.5% to 1.0%). 4, 6
Clinical Decision-Making for Reinjection
The decision to reinject should be individualized based on:
- Response to previous injections (duration and magnitude of benefit) 1
- Available alternative treatment options 1
- Specific corticosteroid compound used 1
- Concurrent systemic treatments 1
- Patient comorbidities (particularly diabetes mellitus and prosthetic joints) 1, 4
Special Population Considerations
Diabetic Patients
Blood glucose levels increase during days 1-3 post-injection, requiring close monitoring for 1-3 days. 1, 4, 6
No severe adverse events such as hyperosmolar hyperglycemic state or ketoacidosis have been reported in studies. 1
Prosthetic Joints
Routine injections should be avoided in prosthetic joints. 1, 7
Only consider after strict screening for prosthetic infection and consultation with the orthopedic surgeon. 1, 7
Common Pitfalls to Avoid
Do not exceed 3-4 injections per year in the same joint, even if individual injections provide only temporary relief. 1, 4, 2
Maintain minimum 6-week intervals between injections in the same joint. 2
Avoid injections within 3 months of planned joint replacement surgery. 4, 6
Do not routinely inject prosthetic joints without orthopedic consultation and infection screening. 1, 7