Intra-articular glucocorticoid injections can be considered for short-term (2- to 6-week) management of pain in patients with knee osteoarthritis1,2
These injections provide modest relief (on average, an absolute reduction in pain of 3 points on a 0 to 10 scale3), with a peak response at 1 to 2 weeks2 and an expected response in 44% of patients.3 To support long-term symptom relief, injections and other analgesics should be used alongside disease education, exercise, and weight management.2
A dose of 20 to 40 mg of triamcinolone or 40 to 80 mg of methylprednisolone is recommended4
Mixing with up to 2 mL of local anesthetic (e.g., 1% to 2% lidocaine) can provide immediate analgesic effects.5 Aseptic no-touch technique (or sterile conditions) should be used. A 25G 1.5-in needle can be used to minimize trauma. Different injection approaches have similar accuracy (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.250719/tab-related-content).5
Intra-articular glucocorticoids are relatively safe5
Risks include postinjection flare, or transient increase in inflammation, which occurs in 2% to 25% of patients and resolves in 1 to 2 days.4 Serious bleeding or joint infection following injection are uncommon.4,5 Blood glucose and blood pressure may transiently increase.5 Although no evidence-based recommendations exist for repeat injection number and frequency, given potential risks to joint structures, decisions should be guided by prior response and repeat injections generally limited to 3 to 4 times per year, per joint.5
Contraindications to intra-articular injection include prosthetic joints, overlying cellulitis, concern of joint infection, acute injury, or periarticular fracture4
Injections should be avoided at least 3 months before joint replacement owing to risk of periprosthetic joint infection.5 Anticoagulant use is not an absolute contraindication (0% to 2% bleeding risk).5
Other intra-articular therapies such as hyaluronic acid, platele-trich plasma, stem cells, or prolotherapy are not recommended by major professional societies (American College of Rheumatology, European Alliance of Associations for Rheumatology)5
High-quality studies have not consistently found intra-articular injections of hyaluronic acid or autologous therapies to be superior to placebo for symptom management.1
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Supplementary Information
Footnotes
Competing interests: Lauren King reports receipt of the Arthritis Society Canada Stars Career Development Award and royalties from UpToDate (Wolters Kluwer). No other competing interests were declared.
This article has been peer reviewed.
References
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