Which cortisone (corticosteroid) preparation is preferred for intra‑articular injections and what are the typical doses for large versus small joints?

Preferred Corticosteroid for Intra-Articular Injections

Triamcinolone hexacetonide is the strongly preferred corticosteroid for intra-articular injections, providing more complete and longer-lasting clinical responses than triamcinolone acetonide or other preparations. 1, 2

First-Line Agent

• Triamcinolone hexacetonide demonstrates superior efficacy with more durable symptom control lasting several months compared to other formulations in both juvenile idiopathic arthritis and rheumatoid arthritis. 1, 3, 4
• This agent has been consistently observed by expert panels to produce more complete clinical responses without increased adverse effects compared to triamcinolone acetonide. 1
• The recommendation for triamcinolone hexacetonide over acetonide is strong and based on moderate-quality evidence. 1

Critical Availability Issue

• Triamcinolone hexacetonide has been commercially unavailable in the United States for several years, forcing clinicians to use less effective alternatives. 2
• The FDA recently allowed importation of one specific formulation to address this unmet medical need. 2
• Important caveat: Triamcinolone hexacetonide may cause local tissue necrosis when injected outside a synovial cavity and should only be used by experienced clinicians. 3, 4

Alternative Agents When Hexacetonide Unavailable

When triamcinolone hexacetonide is not available, use these alternatives:

For Large Joints (Knee, Hip, Shoulder)

• Methylprednisolone acetate 40 mg is recommended for large joints including knee and hip. 5, 6
• Methylprednisolone demonstrates superior pain and functional improvement at 4 weeks and 24 weeks compared to triamcinolone acetonide, suggesting longer duration of effect. 2, 6
• Triamcinolone acetonide 40 mg is the standard alternative, providing pain relief at 6 weeks but not sustained at 12 weeks. 2
• For shoulder injections, 20 mg triamcinolone is as effective as 40 mg for both intra-articular and subacromial subdeltoid bursa injections. 7
• For knee injections, triamcinolone 40 mg is as effective as 80 mg. 7

For Small Joints (Hand, Wrist, Foot)

• 2.5 to 5 mg triamcinolone acetonide for smaller joints. 8
• 5 to 15 mg triamcinolone acetonide for larger small joints, depending on the specific joint. 8
• Doses up to 10 mg for smaller areas have usually been sufficient. 8

Dosing Summary by Joint

Joint Size	Recommended Dose
Large joints (knee, hip, shoulder)	Methylprednisolone 40 mg OR Triamcinolone acetonide 40 mg [5,6,7]
Shoulder (alternative)	Triamcinolone 20 mg (equally effective as 40 mg) [7]
Small joints	Triamcinolone acetonide 2.5-5 mg [8]
Larger small joints	Triamcinolone acetonide 5-15 mg [8]

Clinical Indications

• Strongly recommended for knee and hip osteoarthritis to achieve short-term pain relief. 1, 6
• Conditionally recommended for hand osteoarthritis (lower quality evidence). 1, 6
• Particularly indicated for acute flares of knee pain, especially when accompanied by effusion. 1, 6
• Consider when arthritis is preventing ambulation or interfering with important daily activities requiring more prompt disease control. 1

Expected Duration of Benefit

• Clinical benefit is detectable at 1 week after injection. 6
• Effect typically persists 1-4 weeks for most patients. 1, 6
• Triamcinolone hexacetonide provides the longest clinical effect, with mean duration up to several months. 3, 4
• No improvement in pain, function, or radiographic progression is observed at 2-year follow-up. 6

Administration Technique

Knee Injections

• Use the superolateral (lateral mid-patellar) approach, which achieves approximately 92% accuracy with anatomical landmarks alone. 6
• Ultrasound guidance is optional but improves accuracy to approximately 96% versus 78% with landmark technique. 6, 7
• Strict aseptic technique is mandatory: surgical gloves, skin preparation with alcohol/iodine/chlorhexidine, and separate needles for medication draw and injection. 6, 8

Hip Injections

• Image guidance (ultrasound or fluoroscopy) is mandatory for hip injections—this is a strong recommendation. 1, 5, 6
• Use 40 mg methylprednisolone for hip intra-articular injection. 5, 6, 7

General Technique

• Inject deeply into the synovial space for full anti-inflammatory effect. 2
• If excessive synovial fluid is present, aspirate some (but not all) to aid pain relief and prevent undue dilution of the steroid. 8
• Avoid injecting into surrounding tissues, particularly in the deltoid region, as this may lead to tissue atrophy. 8

Safety Considerations and Precautions

Frequency Limitations

• Limit injections to one injection every 6 weeks and no more than 3-4 injections per year in the same joint. 3, 4
• The decision to reinject should consider benefits from previous injections and individualized factors including treatment options, compound used, and comorbidities. 2

Timing Relative to Surgery

• Avoid intra-articular injections within 3 months before planned joint replacement surgery due to theoretical infection risk. 5, 2, 6

Post-Injection Instructions

• Patients should avoid overuse of the injected joint for 24 hours, but complete immobilization is discouraged. 5, 2, 6

Potential Adverse Effects

• Recent MRI data suggest intra-articular corticosteroids may be associated with cartilage thickness loss, but the ACR notes this finding lacks clinical significance because it does not correlate with worsening pain, function, or radiographic deterioration. 1, 6
• Repeated injections may pose long-term risks to bone health, joint structure, and meniscal thickness. 2, 6
• Other adverse events include increased blood glucose, adrenal suppression, and reduction of bone mineral density. 7
• The risk of glucocorticoid-induced cartilage damage is probably less than that of untreated joint inflammation. 3

Comparison to Other Intra-Articular Therapies

• Intra-articular corticosteroids are conditionally recommended over hyaluronic acid preparations for knee, hip, and hand osteoarthritis because the quality of evidence supporting glucocorticoid efficacy is substantially higher. 1, 2, 6
• Hyaluronic acid has slower onset of action and requires a course of 3-5 weekly injections with associated logistical and cost issues. 1

Common Pitfalls to Avoid

• Do not use triamcinolone hexacetonide unless you are experienced, as extravasation outside the joint can cause tissue necrosis. 3, 4
• Do not inject into the tendon substance itself when treating tenosynovitis—inject into the tendon sheath. 8
• Do not perform hip injections without image guidance. 1, 5, 6
• Do not exceed recommended dosing—lower doses are as effective (e.g., 20 mg vs 40 mg for shoulder, 40 mg vs 80 mg for knee). 7
• Always rule out infection before injecting, as strict aseptic technique is essential to avoid iatrogenic septic arthritis. 4