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Anesthesia and Injections

Hand & UE anesthesia: diagnostic blocks, corticosteroid/PRP injections, and WALANT technique considerations for various pathologies.

Overview

Injection therapies serve as critical components in the management of various orthopaedic conditions, ranging from lateral epicondylitis to trigger finger and postoperative pain control. For lateral epicondylitis, patients treated with autologous blood, corticosteroid, or saline injections all demonstrate improved outcome scores over a 6-month period [1]. In the context of trigger finger, the injection approach does not affect patient pain perception scores or outcomes [2]. However, surgeons should exclude anesthetic from trigger finger corticosteroid injections to decrease injection pain, though they must discuss the trade-off of foregoing short-term anesthesia with patients [7].

Regional anesthesia and periarticular injections are pivotal in total joint arthroplasty. Regional anesthesia should be utilized whenever feasible, and when no contraindications are present, for total joint arthroplasty [6]. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks after total knee arthroplasty (TKA) [3]. For adductor canal block in TKA, the debate on the choice of anesthetic medication creates an opportunity for further collaborative research to establish standardization and guidelines for a multimodal pain management protocol that includes regional anesthesia and nerve blocks [12].

In shoulder surgery, the addition of a postoperative corticosteroid injection resulted in improved pain and function at an early time point for postmeniscectomy patients with osteoarthritis of the knee, but provided no lasting difference compared with only local anesthetic injection [8]. Given the equivalence in analgesia provided by continuous perineural catheter, liposomal bupivacaine, and dexamethasone as an adjuvant for interscalene block in total shoulder arthroplasty, providers should carefully consider the option that best fits each patient [25]. Surgeons may be free to choose where to inject analgesic agents (glenohumeral, subacromial, or combination) after rotator cuff repair according to each specific situation or their preferences [46].

Variations in corticosteroid/anesthetic doses and types among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians bespeak the need for additional investigations aimed at establishing uniform injection guidelines for painful shoulder conditions [5]. Additionally, a longer needle is required to increase the success of injections or aspirations through the posterior approach for glenohumeral joint penetration with a 21-gauge standard needle [26].

Anatomy & Pathophysiology

General Principles

Accurate diagnosis and management of hand and carpal fractures and dislocations require a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [42]. Hand surgery principles emphasize balancing the restoration of function with the maintenance of aesthetic appearance [55].

Carpal Tunnel Syndrome

Endoscopic Release: Endoscopic carpal tunnel release is more complex than standard open procedures [70]. However, it is a useful and safe alternative when performed by a surgeon familiar with hand anatomy and trained in endoscopic techniques [70].

Thenar Reconstruction: In patients with severe or long-term carpal tunnel syndrome affecting pinch due to thenar muscle atrophy, the modified Camitz technique restores thumb opposition, correcting abduction and improving flexion and pronation compared with the original technique [78].

Classification

Injection Modalities: Autologous blood, corticosteroid, and saline injections for lateral epicondylitis result in improved outcome scores over a 6-month period [1]. A single intra-articular injection has no value in pain relief regardless of the types of drugs used after anterior cruciate ligament reconstruction [14].

Trigger Finger Protocols: The injection approach for trigger finger does not affect patient pain perception scores or outcomes [2]. Surgeons should exclude anesthetic from trigger finger corticosteroid injections to decrease injection pain, though the trade-off of foregoing short-term anesthesia must be discussed with patients [7].

Diagnostic Utility: Injections of anesthetic agents help clinicians locate the source of pain when physical examination and imaging results are inconclusive [4].

Shoulder Management: Variations exist in corticosteroid/anesthetic doses and types among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians for painful shoulder conditions [5]. Continuous perineural catheter, liposomal bupivacaine, and dexamethasone as an adjuvant for interscalene block provide equivalent analgesia in total shoulder arthroplasty [25]. Periarticular injection of a local anesthetic solution provides reliable and consistent pain control with a trend toward less immediate postoperative opioid use after total shoulder arthroplasty compared with regional blocks [49].

Procedural Pain and Anesthesia Principles: Most patients undergoing intra-articular or peri-articular injections, synovial fluid aspirations, and spine injections suffer from procedural pain [11]. Collaborative research is needed to establish standardization and guidelines for multimodal pain management protocols that include regional anesthesia and nerve blocks, such as for adductor canal block in total knee arthroplasty [12]. Anesthesiology principles include preoperative assessment using the ASA classification system, anesthetic planning, monitoring, positioning, and management of complications such as malignant hyperthermia and local anesthetic systemic toxicity [43].

Technical Accuracy and Technique: Injection accuracy using anatomic landmarks for carpal tunnel syndrome is 75.7%, which is less than previously reported rates of 82% to 100% [24]. A simple subcutaneous injection is adequate for digital block, as the anaesthetic effects are likely due to the agent acting in the subcutaneous space [44].

Clinical Presentation

Diagnostic Utility: Injections of anesthetic agents assist clinicians in locating the pain source when physical examination and imaging are inconclusive for shoulder conditions [4]. For diagnostic hip injections, clinical and imaging findings are unreliable predictors of response; however, nonresponse to injection is a strong negative predictor of surgical outcome [10].

Procedural Pain Management: Most patients undergoing intra-articular, peri-articular, synovial fluid aspiration, or spine injections suffer from procedural pain [11]. There is no consensus regarding the optimal technique, anesthetic agent, or adjuncts for digital block anesthesia [16]. For trigger finger injections, surgeons should exclude anesthetic to decrease injection pain, though the trade-off of foregoing short-term anesthesia must be discussed with patients [7]. Injections do not affect patient pain perception scores or outcomes for trigger finger [2].

Regional and Periarticular Anesthesia: Regional anesthesia should be utilized whenever feasible for total joint arthroplasty when no contraindications are present [6]. Periarticular injections provide adequate pain relief and are simple to use, avoiding potential complications associated with nerve blocks after total knee arthroplasty (TKA) [3]. The debate over anesthetic medication choice for adductor canal block in TKA creates an opportunity for further collaborative research to establish standardization and guidelines for multimodal pain management protocols [12].

Condition-Specific Outcomes: Patients within each injection group (autologous blood, corticosteroid, and saline) demonstrated improved outcome scores over a 6-month period in the treatment of lateral epicondylitis [1]. Patients receiving intra-articular corticosteroid injections for symptomatic knee osteoarthritis had improved pain and function [17]. The addition of a postoperative corticosteroid injection resulted in improved pain and function at an early time point for postmeniscectomy patients with osteoarthritis of the knee, but provided no lasting difference compared with only local anesthetic injection [8]. A single intra-articular injection has no value in pain relief after anterior cruciate ligament reconstruction, regardless of the types of drugs used [14].

Trigger Finger and Morton’s Neuroma: Although most patients ultimately require surgical release for trigger finger, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief [30]. In the presence of a clear diagnosis, a trained clinician may perform a corticosteroid injection for Morton’s neuroma without ultrasound guidance with good and safe results [13].

Complications and Variations: Variations exist in corticosteroid/anesthetic doses and types among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians for painful shoulder conditions [5]. Providers should be aware of the adverse effects and potential complications of intra-articular corticosteroid injections when using them in clinical practice for symptomatic knee osteoarthritis [31]. Myofibrosis and joint contractures can be caused by injections of pentazocine, and the diagnosis can be challenging if the history of repeated injections is initially denied [9].

Investigations

Plain radiography: Plain radiographs are standard initial imaging but have specific limitations in diagnostic injection contexts. Clinical and imaging findings are unreliable predictors of injection response for diagnostic hip injections [10].

MRI: MRI findings in patients who did not respond to diagnostic hip injection did not differ from those who responded, implying false-negative results render the technique not 100% reliable [54].

Aspiration: In-office ultrasound-guided hip injections were more convenient and less painful than fluoroscopy-guided hospital-based injections [57]. Patients who have undergone both in-office ultrasound-guided and fluoroscopy-guided hip injections prefer the ultrasound-guided approach [57]. Ultrasonography-guided hip injections have diagnostic and therapeutic value for orthopedic practice [58].

Laboratory: Laboratory analysis is not explicitly covered by the provided evidence base for this section.

Other Considerations: Injection Efficacy and Safety: Autologous blood, corticosteroid, and saline injections for lateral epicondylitis result in improved outcome scores over a 6-month period [1]. The injection approach for trigger finger does not affect patient pain perception scores or outcomes [2]. Periarticular injections provide adequate pain relief after total knee arthroplasty (TKA) [3]. Periarticular injections are simple to use after total knee arthroplasty (TKA) [3]. Periarticular injections avoid potential complications associated with nerve blocks after total knee arthroplasty (TKA) [3]. Injections of anesthetic agents help clinicians locate the source of pain when physical examination and imaging results are inconclusive [4]. Most patients undergoing intra-articular or peri-articular injections, synovial fluid aspirations, and spine injections suffer from procedural pain [11].

Technique and Accuracy: There is no consensus regarding the optimal technique, anesthetic agent, or adjuncts for digital block anesthesia [16]. Injection accuracy using anatomic landmarks for carpal tunnel syndrome is 75.7% [24]. The 75.7% accuracy rate for carpal tunnel injection using anatomic landmarks is less than previously reported rates of 82% to 100% [24]. A longer needle is required to increase the success of glenohumeral joint injections or aspirations through the posterior approach [26]. Ultrasound-guided glenohumeral injections take substantially longer to administer than blind injections in a cadaveric study [28]. There is a 60.6% potential for acromioclavicular joint (ACJ) injections to be out of the joint if performed by palpation alone [59]. Routine use of image intensification guidance is recommended for ACJ injections due to the high potential for inaccurate placement by palpation [59].

Diagnostic Limitations and Complications: Variations in corticosteroid/anesthetic doses and types among orthopaedic surgeons, rheumatologists, and primary-care physicians indicate a need for uniform injection guidelines [5]. Myofibrosis and joint contractures can be caused by injections of pentazocine [9]. The diagnosis of myofibrosis and joint contractures caused by injections can be challenging if the history of repeated injections is initially denied [9]. Nonresponse to diagnostic hip injection is a strong negative predictor of surgical outcome [10]. Concurrent administration of intra-articular gadolinium with diagnostic intra-articular hip injections may result in a false-negative response to anesthetic [45]. A trained clinician may perform corticosteroid injection for Morton’s neuroma without ultrasound guidance with good and safe results if the diagnosis is clear [13].

Treatment

Non-Operative

Conservative management options vary by pathology but generally include pharmacologic and interventional strategies. For lateral epicondylitis, autologous blood, corticosteroid, and saline injections all demonstrate improved outcome scores over a 6-month period [1]. Intra-articular corticosteroid injections for symptomatic knee osteoarthritis experience improved pain and function [17]. Corticosteroid injection should be regarded as a primary option for Morton’s neuroma, with hyaluronic acid indicated only when corticosteroid is contraindicated [39]. Nonoperative management with corticosteroid injection can be used as a therapeutic measure with potential long-term benefits in the treatment of radial tunnel syndrome [47]. For trigger finger, extracorporeal shock wave therapy (ESWT) shows no between-group differences for cure rates, pain, and functional status compared to corticosteroid injection, suggesting ESWT is a non-invasive option for patients wishing to avoid steroid injections [48].

Pain Management

Regional and Local Anesthesia: Regional anesthesia should be utilized whenever feasible for total joint arthroplasty when no contraindications are present [6]. Ultrasound guidance for axillary block in hand surgery results in significantly better success rates, mean time to onset of anesthesia, and mean amount of anesthetic injected compared with the conventional blind approach [15]. Ultrasound guidance significantly improves the success rate of acromioclavicular joint injection and is recommended for therapeutic ACJ injections in routine clinical practice [36]. Injections of anesthetic agents help clinicians locate the source of pain when physical examination and imaging results are inconclusive [4]. Practitioners should be knowledgeable about the indications for and use of 20% intralipid for local anesthetic toxicity, as airway protection is critically important when using short-acting local anesthetics in hand surgery [40].

Periarticular and Multimodal Injections: Periarticular injections provide adequate pain relief after total knee arthroplasty (TKA) and avoid potential complications associated with nerve blocks [3]. Periarticular injection with a multimodal protocol decreases pain and improves functional recovery compared with conventional pain control modalities after total hip and knee arthroplasty [32]. Multimodal surgical-site injection as an adjunct to postoperative pain management in operatively treated ankle fractures results in slightly lower mean VAS scores over the first 48 hours postoperatively [33]. Local infusion analgesia using intra-articular double lumen catheter provides clinically significant analgesic effects and rapid recovery after total knee arthroplasty, although larger studies are needed to examine its safety [38]. Periarticular steroid injections reduce post-operative pain and inflammation following unicondylar knee arthroplasty, improving short-term functional recovery and clinical parameters without major complications [22]. The addition of a postoperative corticosteroid injection to local anesthetic in postmeniscectomy patients with knee osteoarthritis improves pain and function at an early time point but provides no lasting difference compared with local anesthetic alone [8].

Trigger Finger and Hand Pathology: The injection approach for trigger finger does not affect patient pain perception scores or outcomes [2]. Surgeons should exclude anesthetic from trigger finger corticosteroid injections to decrease injection pain, after discussing the trade-off of foregoing short-term anesthesia with patients [7]. High-dose triamcinolone injections outperform low-dose injections for soft tissue pathology of the hand across most metrics, including estimated time of relief, rate of repeat injection, and rate of surgery [41]. Performing finger manipulation on Day 2 after collagenase injection for Dupuytren’s contracture is comparable with manipulation on Day 1 in terms of efficacy and safety [29].

Diagnostic and Specific Pathologies: Clinical and imaging findings are unreliable predictors of injection response, and nonresponse to diagnostic hip injection is a strong negative predictor of surgical outcome [10]. There is no difference in pain intensity between corticosteroid injection and placebo for enthesopathy of the extensor carpi radialis brevis origin at 6 months [37]. Variations in corticosteroid/anesthetic doses and types among different physician specialties indicate a need for additional investigations to establish uniform injection guidelines [5]. Meticulous evaluation of indications is crucial for percutaneous interlaminar endoscopic lumbar discectomy due to potential risks associated with local anesthesia [35].

Postoperative Analgesia: Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications after carpal tunnel release, with similar patient satisfaction and functional outcomes [52].

Complications

Infection (PJI): The incidence of serious infectious complications following knee joint injections ranges widely, potentially as high as 1 in 3,000 and potentially far higher in high-risk patients [53]. For carpal tunnel release, the proximity of injection to the time of surgery plays a role in postoperative infections, though comorbidities, corticosteroid dose, and frequency of injection require further study to determine risk contribution [27].

Stiffness / Arthrofibrosis: Repeated injections of pentazocine can cause myofibrosis and joint contractures [9]. The diagnosis of myofibrosis and joint contractures caused by injections can be challenging if the history of repeated injections is initially denied [9].

Other Considerations: Periarticular injections avoid the potential complications associated with nerve blocks [3]. Steroid injections performed within 6 months of index surgical procedure are correlated with a greater likelihood of revision rotator cuff surgery [51].

Recovery

Light activity (weeks): Periarticular injections provide adequate pain relief after total knee arthroplasty (TKA) [3]. These injections are simple to use [3] and avoid potential complications associated with nerve blocks [3]. Regional anesthesia should be utilized whenever feasible and when no contraindications are present for total joint arthroplasty [6]. For unicondylar knee arthroplasty, periarticular steroid injections reduce post-operative pain and inflammation [22], improve short-term functional recovery and clinical parameters [22], and result in better outcomes for patients without major complications [22]. In postmeniscectomy patients with knee osteoarthritis, the addition of a postoperative corticosteroid injection to local anesthetic resulted in improved pain and function at an early time point [8].

Full activity (months): Corticosteroid injections provide superior short-term pain relief and grip strength for lateral epicondylitis [23]. However, these injections show no beneficial effects for intermediate- or long-term follow-up in lateral epicondylitis [23], and some studies indicate poorer outcomes at 1 year for lateral epicondylitis with corticosteroid injections compared to other treatments [23]. Patients within autologous blood, corticosteroid, and saline injection groups for lateral epicondylitis demonstrated improved outcome scores over a 6-month period [1]. For de Quervain's tenosynovitis, short-term beneficial effects of steroid injections were maintained during follow-up after 12 months [19]. In trigger finger, patients who continue to experience symptom relief two years after a single corticosteroid injection are likely to maintain long-term success [20]. Triamcinolone injection was associated with more frequent apparent resolution of idiopathic trigger finger than dexamethasone [62]. Delayed surgery treatment strategies were associated with higher resolution rates for idiopathic trigger finger [62].

Complete recovery / outcome plateau (months): Postoperative corticosteroid injection provided no lasting difference in pain and function compared with only local anesthetic injection in postmeniscectomy patients [8]. Studies should assess whether local anaesthetic infiltration can prevent long-term pain after total hip and knee replacement [18]. The optimal dose and long-term effects of steroid injection in total knee or hip arthroplasty still require numerous studies [21].

Rehabilitation protocol: Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week [56]. Bupivacaine with lidocaine provides good long-term anesthesia for digital nerve blocks [50] and may reduce the need for postprocedural anesthesia in digital nerve blocks [50]. Manipulation following collagenase injection for Dupuytren contracture can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection [64].

Functional milestones: The risk for postoperative deep infection in trigger finger release surgery is time dependent [60]. The risk for postoperative deep infection in trigger finger release surgery is greater when injections are performed within 90 days of surgery [60], and is especially greater in the 31- to 90-day postinjection period [60]. Proximity of injection to the time of surgery plays a role in postoperative infections in carpal tunnel release [27]. Comorbidities, corticosteroid dose, and frequency of injection require further study to determine risk contribution for postoperative infections in carpal tunnel release [27].

Key Evidence

  • [L2] Patients within each injection group demonstrated improved outcome scores over a 6-month period. (10.1016/j.jhsa.2011.05.014)
  • [L3] Our data suggest that injection approach does not affect patient pain perception scores or outcomes. (10.1177/1558944717703134)
  • [L1] Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks. (10.1007/s11999-014-3603-0)
  • [L4] Injections of anesthetic agents can help clinicians locate the source of pain when physical examination and imaging results are inconclusive. (10.5435/jaaos-d-16-00076)
  • [L4] Variations in corticosteroid/anesthetic doses and types bespeak the need for additional investigations aimed at establishing uniform injection guidelines. (10.1186/1471-2474-8-63)
  • [L2] Regional anesthesia should be utilized whenever feasible, and when no contraindications are present. (10.1016/j.arth.2024.10.082)
  • [L1] Surgeons should exclude the anesthetic to decrease injection pain, though they must discuss the trade-off of foregoing short-term anesthesia with patients. (10.1177/1558944719884663)
  • [L1] The addition of a postoperative corticosteroid injection resulted in improved pain and function at an early time point; however, it provided no lasting difference compared with only local anesthetic injection. (10.1177/0363546508331204)
  • [Case_report] The diagnosis can be challenging if the history of repeated injections is initially denied. (10.2106/00004623-198365070-00017)
  • [L4] Clinical and imaging findings are unreliable predictors of injection response, and nonresponse to injection is a strong negative predictor of surgical outcome. (10.1016/j.arthro.2016.02.027)
  • [L4] Most patients undergoing intra-or peri-articular injections, synovial fluid aspirations and spine injections suffer from procedural pain. (10.1186/1471-2474-11-16)
  • [L5] The debate creates an opportunity for further collaborative research to establish standardization and guidelines for a multimodal pain management protocol that includes regional anesthesia and nerve blocks. (10.1016/j.arth.2025.10.001)
  • [L1] In the presence of a clear diagnosis, a trained clinician may perform an injection without ultrasound guidance with good and safe results. (10.1302/0301-620x.98b4.36880)
  • [L1] In addition, a single IA injection would have no value in pain relief, regardless of types of drugs. (10.1016/j.arthro.2011.10.015)
  • [L2] The success rate, mean time to onset of anaesthesia, and the mean amount of anaesthetic injected were all significantly better under ultrasound guidance. (10.1177/1753193411413664)
  • [L4] There is no consensus regarding the optimal technique, anesthetic agent, or adjuncts for digital block anesthesia. (10.1016/j.jhsa.2008.10.010)
  • [L2] Patients receiving intra-articular corticosteroid injections had improved pain and function. (10.5435/jaaos-d-16-00541)
  • [L1] Studies should assess whether local anaesthetic infiltration can prevent long-term pain. (10.1186/1471-2474-15-220)
  • [L1] The short-term beneficial effects of steroid injections for symptoms were maintained during the follow-up after 12 months. (10.1186/1471-2474-10-131)
  • [L4] Patients who continue to experience symptom relief two years after injection are likely to maintain long-term success. (10.2106/jbjs.n.00004)
  • [L2] The optimal dose and long-term effects of steroid injection still require numerous studies. (10.1007/s00167-014-3049-7)
  • [L1] Periarticular steroid injections reduce post-operative pain and inflammation, and are clinically relevant as they improve short-term functional recovery and clinical parameters, resulting in better outcomes for patients without having major complications. (10.1007/s00167-010-1126-0)
  • [L5] Corticosteroid injections provide superior short-term pain relief and grip strength but show no beneficial effects for intermediate- or long-term follow-up, with some studies indicating poorer outcomes at 1 year compared to other treatments. (10.1016/j.jhsa.2008.10.011)
  • [L4] Injection accuracy using anatomic landmarks was 75.7%, which is less than previously reported rates of 82% to 100%, suggesting the procedure may be less reliable than thought. (10.1177/1558944718787330)
  • [L2] Given the equivalence in analgesia provided with these 3 modalities, providers should carefully consider the option that best fits each patient. (10.1016/j.jse.2024.06.014)
  • [L4] A longer needle is required to increase the success of injections or aspirations through the posterior approach. (10.1016/j.jse.2011.11.034)
  • [L3] Proximity of injection to time of surgery plays a role, although comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution. (10.1016/j.jhsa.2021.06.022)
  • [L5] The ultrasound-guided injections took substantially longer to administer. (10.1016/j.jse.2011.11.026)
  • [L4] Performing finger manipulation on Day 2 after collagenase injection is comparable with manipulation on Day 1 in terms of efficacy and safety. (10.1177/1753193413490899)
  • [L4] Although most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief. (10.1016/j.jhsa.2017.02.001)
  • [L5] Providers should be aware of the adverse effects and potential complications of these injections when using them in clinical practice. (10.5435/jaaos-d-18-00106)
  • [L1] Periarticular injection with a multimodal protocol was shown to decrease pain and improve functional recovery compared with conventional pain control modalities. (10.1016/j.arth.2006.12.027)
  • [L1] The study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with operatively treated ankle fractures, finding slightly lower mean VAS scores in the injection group compared with the control group over the first 48 hours postoperatively. (10.2106/jbjs.19.00293)
  • [L3] However, it is crucial to meticulously evaluate the indications due to potential risks associated with this form of anesthesia. (10.1186/s12891-024-07898-w)
  • [L5] The use of US guidance significantly improves the success rate in ACJ injection, and we recommend it for therapeutic ACJ injections in routine clinical practice. (10.1016/j.jse.2011.11.036)
  • [L1] This meta-analysis showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection. (10.1016/j.jhsa.2016.07.097)
  • [L1] The local infusion analgesia alone provided clinically significant analgesic effects and rapid recovery in total knee arthroplasty, although larger studies are needed to examine its safety. (10.1007/s00167-012-2004-8)
  • [L1] Thus, a corticosteroid injection should be regarded as a primary option in the treatment of these patients, and the only indication for an injection of hyaluronic acid might be in patients in whom corticosteroid is contraindicated. (10.1302/0301-620x.106b10.bjj-2024-0342.r2)
  • [L5] The authors agree that airway protection is critically important and that practitioners should be knowledgeable about the indications for and use of 20% intralipid for local anesthetic toxicity. (10.1016/j.jhsa.2010.02.008)
  • [L4] High-dose triamcinolone injections outperformed low-dose injections across most metrics including estimated time of relief, rate of repeat injection, and rate of surgery. (10.1016/j.jhsa.2025.09.014)
  • [L4] The anaesthetic effects are likely due to the agent acting in the subcutaneous space, and a simple subcutaneous injection is adequate. (10.1177/1753193408097323)
  • [L3] Concurrent administration of intra-articular gadolinium with diagnostic intra-articular hip injections may result in a false-negative response to anesthetic. (10.1007/s00167-023-07392-1)
  • [L2] Surgeons may be free to choose where to inject analgesic agents according to each specific situation or their preferences. (10.1016/j.jse.2014.12.009)
  • [L4] Nonoperative management with corticosteroid injection can be used as a therapeutic measure with potential long-term benefits in the treatment of RTS. (10.1177/1558944718787282)
  • [L2] There were no between-group differences for cure rates, pain, and functional status, suggesting ESWT is a non-invasive option for patients wishing to avoid steroid injections. (10.1177/1753193415622733)
  • [L3] Periarticular injection of a local anesthetic solution provides reliable and consistent pain control with a trend toward less immediate postoperative opioid use after TSA compared with regional blocks. (10.1016/j.jseint.2019.12.007)
  • [L2] Bupivacaine with lidocaine provides good long-term anesthesia and may reduce the need for postprocedural anesthesia. (10.1016/j.jhsa.2014.01.017)
  • [L5] The historical treatment paradigm of steroid injections for painful rotator cuff conditions warrants reconsideration as they are correlated with a greater likelihood of revision rotator cuff surgery when performed within 6 months of the index surgical procedure. (10.1016/j.arthro.2018.12.017)
  • [L1] Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications with similar patient satisfaction and functional outcomes. (10.1177/1558944719836211)
  • [L2] The incidence of serious infectious complications following knee joint injections ranges widely, and may be as high as 1 in 3,000 and potentially far higher in high-risk patients. (10.1007/s00167-010-1380-1)
  • [L4] Intra-articular findings in patients who did not respond to the diagnostic injection did not differ from those who responded, implying false-negative results render the technique not 100% reliable. (10.1016/j.arthro.2013.11.023)
  • [L1] Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week. (10.1016/j.jhsa.2007.08.002)
  • [L3] In-office ultrasound-guided injections of the hip were more convenient and less painful than fluoroscopy-guided hospital-based injections and were preferred by patients who have undergone both. (10.1016/j.arthro.2013.09.083)
  • [L5] This article highlights the diagnostic and therapeutic value of ultrasonography-guided hip injections for an orthopedic practice, focusing on sonographic anatomy, technique, indications, and procedural pearls. (10.5435/jaaos-d-17-00908)
  • [L4] There is a 60.6% potential for ACJ injections to be out of the joint if performed by palpation alone, and the authors recommend the routine use of image intensification guidance. (10.1007/s00167-006-0038-5)
  • [L4] The risk for postoperative deep infection seems to be time dependent and greater when injections are performed within 90 days of surgery, especially in the 31- to 90-day postinjection period. (10.1016/j.jhsa.2020.01.007)
  • [L3] Triamcinolone injection was associated with more frequent apparent resolution than dexamethasone, and delayed surgery treatment strategies were associated with higher resolution rates. (10.1007/s11552-013-9493-x)
  • [L1] These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection. (10.1016/j.jhsa.2014.07.010)
  • [L4] Endoscopic carpal tunnel release is a useful and safe alternative when performed by a surgeon familiar with hand anatomy and trained in endoscopic techniques, though it is more complex than standard open procedures. (10.1007/s001670050097)
  • [L4] In patients with severe or long-term CTS affecting pinch due to atrophy of the thenar muscle, the modified Camitz technique enables restoration of thumb opposition, correcting abduction and improving flexion and pronation compared with the original technique. (10.1177/1753193418790499)

See Also

References

[1] Comparison of Autologous Blood, Corticosteroid, and Saline Injection in the Treatment of Lateral Epicondylitis: A Prospective, Randomized, Controlled Multicenter Study. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.014

[2] The Effect of Trigger Finger Injection Site on Injection-Related Pain. HAND. 2017. DOI: 10.1177/1558944717703134

[3] The Chitranjan Ranawat Award: Periarticular Injections and Femoral & Sciatic Blocks Provide Similar Pain Relief After TKA: A Randomized Clinical Trial. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-014-3603-0

[4] Diagnostic Injections About the Shoulder. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00076

[5] Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians. BMC Musculoskeletal Disorders. 2007. DOI: 10.1186/1471-2474-8-63

[6] Is There a Difference in Outcome of Total Joint Arthroplasty When Regional Versus General Anesthesia Are Used?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.082

[7] Trigger Finger Corticosteroid Injection With and Without Local Anesthetic: A Randomized, Double-Blind Controlled Trial. HAND. 2019. DOI: 10.1177/1558944719884663

[8] A Randomized, Prospective, Double-Blind Study to Investigate the Effectiveness of Adding DepoMedrol to a Local Anesthetic Injection in Postmeniscectomy Patients With Osteoarthritis of the Knee. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546508331204

[9] Myofibrosis and joint contractures caused by injections of pentazocine. A case report.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365070-00017

[10] Outcomes After Diagnostic Hip Injection. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.02.027

[11] Are joint and soft tissue injections painful? Results of a national French cross-sectional study of procedural pain in rheumatological practice. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-16

[12] Can We Achieve Consensus on the Choice of Anesthetic Medication for Adductor Canal Block in Total Knee Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.001

[13] Corticosteroid injection for Morton’s neuroma with or without ultrasound guidance. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b4.36880

[14] Pain Management by Periarticular Multimodal Drug Injection After Anterior Cruciate Ligament Reconstruction: A Randomized, Controlled Study. Arthroscopy. 2012. DOI: 10.1016/j.arthro.2011.10.015

[15] What benefits does ultrasound-guided axillary block for brachial plexus anaesthesia offer over the conventional blind approach in hand surgery?. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411413664

[16] Digital Block Anesthesia. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.10.010

[17] Efficacy and Treatment Response of Intra-articular Corticosteroid Injections in Patients With Symptomatic Knee Osteoarthritis. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00541

[18] Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-220

[19] Randomised controlled trial of local corticosteroid injections for de Quervain's tenosynovitis in general practice. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-131

[20] Long-Term Outcomes Following a Single Corticosteroid Injection for Trigger Finger. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.n.00004

[21] The efficacy of steroid injection in total knee or hip arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3049-7

[22] Effects of periarticular steroid injection on knee function and the inflammatory response following unicondylar knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1126-0

[23] Steroid Injection for Lateral Epicondylitis. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.10.011

[24] Accuracy of Carpal Tunnel Injection: A Prospective Evaluation of 756 Patients. HAND. 2018. DOI: 10.1177/1558944718787330

[25] Comparison of analgesic efficacy of continuous perineural catheter, liposomal bupivacaine, and dexamethasone as an adjuvant for interscalene block in total shoulder arthroplasty: a triple-blinded randomized controlled trial. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.06.014

[26] Glenohumeral joint penetration with a 21-gauge standard needle. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.034

[27] Influence of Corticosteroid Injections on Postoperative Infections in Carpal Tunnel Release. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.06.022

[28] Comparison of ultrasound-guided versus blind glenohumeral injections: a cadaveric study. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.026

[29] Efficacy and tolerability of Day 2 manipulation and local anaesthesia after collagenase injection in patients with Dupuytren’s contracture. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413490899

[30] Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.02.001

[31] Intra-articular Corticosteroid Injections for Symptomatic Knee Osteoarthritis: What the Orthopaedic Provider Needs to Know. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00106

[32] Controlling Pain After Total Hip And Knee Arthroplasty Using a Multimodal Protocol With Local Periarticular Injections: A Prospective, Randomized Study. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2006.12.027

[33] Efficacy of Multimodal Analgesic Injections in Operatively Treated Ankle Fractures. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00293

[35] Comparison of spinal anesthesia and local anesthesia in percutaneous interlaminar endoscopic lumbar discectomy for L5/S1 disc herniation: a retrospective cohort study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07898-w

[36] The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.036

[37] A Meta-Analysis of the Effect of Corticosteroid Injection for Enthesopathy of the Extensor Carpi Radialis Brevis Origin. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.097

[38] Local infusion analgesia using intra‐articular double lumen catheter after total knee arthroplasty: a double blinded randomized control study. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2004-8

[39] Ultrasound-guided infiltration with hyaluronic acid compared with corticosteroid for the treatment of Morton’s neuroma. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b10.bjj-2024-0342.r2

[40] Use of Short-Acting Local Anesthetics in Hand Surgery Patients. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.02.008

[41] Efficacy of Low-Dose Versus High-Dose Corticosteroid Injections for Soft Tissue Pathology of the Hand. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.09.014

[42] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[43] Chapter 6 Anesthesiology. 2019.

[44] Single Injection Digital Block: Is a Transthecal Injection Necessary?. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408097323

[45] Gadolinium injected concurrently with anesthetic can result in false‐negative diagnostic intra‐articular hip injections. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07392-1

[46] Administration of analgesics after rotator cuff repair: a prospective clinical trial comparing glenohumeral, subacromial, and a combination of glenohumeral and subacromial injections. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.12.009

[47] Prospective Evaluation of a Single Corticosteroid Injection in Radial Tunnel Syndrome. HAND. 2018. DOI: 10.1177/1558944718787282

[48] Extracorporeal shock wave therapy versus corticosteroid injection in the treatment of trigger finger: a randomized controlled study. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415622733

[49] Efficacy of local infiltration anesthesia versus interscalene nerve blockade for total shoulder arthroplasty. JSES International. 2020. DOI: 10.1016/j.jseint.2019.12.007

[50] Comparison of Local Anesthetics for Digital Nerve Blocks: A Systematic Review. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.017

[51] Editorial Commentary: Steroid Injections Prior to Arthroscopic Rotator Cuff Repair—Is It Time to Rethink a Conservative Treatment Paradigm?. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.12.017

[52] Opioid Versus Nonopioid Analgesia After Carpal Tunnel Release: A Randomized, Prospective Study. HAND. 2019. DOI: 10.1177/1558944719836211

[53] The efficacy, accuracy and complications of corticosteroid injections of the knee joint. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-010-1380-1

[54] The Role of Fluoroscopically Guided Intra‐Articular Hip Injections in Potential Candidates for Hip Arthroscopy: Experience at a UK Tertiary Referral Center Over 34 Months. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2013.11.023

[55] 9. Hand Surgery. 2013.

[56] Extra-Articular Steroid Injection: Early Patient Response and the Incidence of Flare Reaction. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.08.002

[57] Ultrasound‐Guided Hip Injections: A Comparative Study With Fluoroscopy‐Guided Injections. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2013.09.083

[58] Ultrasound-Guided Hip Injections. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00908

[59] Accuracy of needle placement in ACJ injections. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0038-5

[60] Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.01.007

[62] Resolution and Recurrence Rates of Idiopathic Trigger Finger after Corticosteroid Injection. HAND. 2013. DOI: 10.1007/s11552-013-9493-x

[64] Prospective Randomized Controlled Trial Comparing 1- Versus 7-Day Manipulation Following Collagenase Injection for Dupuytren Contracture. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.010

[70] Difficulties and early results of the endoscopic carpal tunnel release using the modified Chow technique. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050097

[78] Temporary tourniquet use after epinephrine injection to expedite wide awake emergency hand surgeries. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418790499

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