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Joint steroid injection


Cortisone is a synthetic version of cortisol, a steroid produced by the body's adrenal glands. Read What Is Cortisone? These injections provide temporary relief. Patients who are seeking long-term relief are typically advised to:. These steps can improve a joint's biomechanics and possibly decrease or eliminate the need for additional cortisone shots. Without other treatments, joint pain will probably worsen over time Patients who have repeated cortisone shots may notice that the period of pain relief becomes shorter and shorter over time.

This is not necessarily because the patient has built up a tolerance to the medication but because the joint is degrading. Again, physical therapy, weight loss, and changes in day-to-day lifestyle can help slow down or stop joint degradation. It may take a few days for the benefits of the cortisone medication to take full effect. During this time, patients are usually told to rest and cut back on normal activities.

Once the joint pain is relieved, a well-intentioned patient may be tempted to jump right into an exercise routine. However, in order to avoid injuries or possibly making the condition worse, a doctor typically advises a patient to resume normal activities gradually and add intensity over time. See Exercising with Arthritis. Too many injections over a short period of time can cause damage to the tendons, ligaments, and articular cartilage at the injection site.

Tendons are particularly prone to degeneration and injury after a cortisone injection. Because of this risk, a doctor will not inject cortisone medication directly into a tendon, even if a tendon is suspected to be the root of the pain. Because cortisone works locally, an injected placed near a tendon can still reduce its inflammation.

In fact, the Achilles and patella tendons are particularly prone to injury post-injection, even if an injection is directed near, rather than in, the tendon. For this reason, doctors avoid cortisone injections for Achilles and patella tendinopathies. Often, you can receive one at your doctor's office. Because of potential side effects, the number of shots you can get in a year generally is limited. Cortisone shots might be most effective in treating inflammatory arthritis, such as rheumatoid arthritis.

They can also be part of treatment for other conditions, including:. Potential side effects of cortisone shots increase with larger doses and repeated use. Side effects can include:. There's concern that repeated cortisone shots might damage the cartilage within a joint.

So doctors typically limit the number of cortisone shots into a joint. In general, you shouldn't get cortisone injections more often than every six weeks and usually not more than three or four times a year. If you take blood thinners, you might need to stop taking them for several days before your cortisone shot to reduce bleeding or bruising risk.

Some dietary supplements also have a blood-thinning effect. Ask your doctor what medications and supplements you should avoid before your cortisone shot. Tell your doctor if you've had a temperature of Your doctor might ask you to change into a gown. You'll then be positioned so that your doctor can easily insert the needle.

The area around the injection site is cleaned. Your doctor might also apply an anesthetic spray to numb the area where the needle will be inserted. In some cases, your doctor might use ultrasound or a type of X-ray called fluoroscopy to watch the needle's progress inside your body — so as to place it in the right spot. You'll likely feel some pressure when the needle is inserted.

Let your doctor know if you have a lot of discomfort. The medication is then released into the injection site. Typically, cortisone shots include a corticosteroid medication to relieve pain and inflammation over time and an anesthetic to provide immediate pain relief.

Some people have redness and a feeling of warmth of the chest and face after a cortisone shot. If you have diabetes, a cortisone shot might temporarily increase your blood sugar levels. Results of cortisone shots typically depend on the reason for the treatment. Cortisone shots commonly cause a temporary flare in pain and inflammation for up to 48 hours after the injection.

After that, your pain and inflammation of the affected joint should decrease, and can last up to several months. Mayo Clinic does not endorse companies or products.

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They're usually given by a specially trained doctor in a GP's surgery or hospital clinic. In an emergency, medical staff may give higher dose hydrocortisone injections to treat severe asthma, allergic reactions, severe shock due to injury or infection, or failure of the adrenal glands.

As long as you have no symptoms of coronavirus infection, carry on taking your prescribed steroid medicine as usual. If you develop any coronavirus symptoms, do not stop taking your steroid medicine suddenly. Ask your doctor about whether you need to stop taking it or not. Find out more about other ways you can use hydrocortisone for different health conditions.

Hydrocortisone injections are not suitable for some people. Tell your doctor before starting the medicine if you:. Hydrocortisone injections can make some health problems worse so it's important that your doctor monitors you. If you have diabetes and monitor your own blood sugar, you will need to do this more often. Hydrocortisone injections can affect your blood sugar control. If the injection is for pain, it may contain a local anaesthetic. You might also have a local anaesthetic by spray or injection to numb the skin before the hydrocortisone injection.

You can go home after the injection, but you may need to rest the area that was treated for a few days. You may be able to have a hydrocortisone injection into the same joint up to 4 times in a year. The number of injections you need depends on the area being treated and how strong the dose is. If you have arthritis, this type of treatment is only used when just a few joints are affected.

Usually, no more than 3 joints are injected at a time. The dose of hydrocortisone depends on the size of the joint. It can vary between 5mg and 50mg of hydrocortisone. If you need a follow-up injection, the amount of hydrocortisone could go up or down. It depends on how well the previous injection worked, how long the benefits lasted and whether you had any side effects.

Most people do not have any side effects after a hydrocortisone injection. Side effects are less likely if only one part of the body is injected. The most common side effect is intense pain and swelling in the joint where the injection was given.

This usually gets better after a day or two. You may also get some bruising where the injection was given. This should go away after a few days. It helps to rest the joint for 24 hours after the injection and avoid heavy exercise. It's safe to take everyday painkillers such as paracetamol or ibuprofen. With hydrocortisone injections, the medicine is placed directly into the painful or swollen joint. It does not travel through the rest of your body.

That means, it's less likely to cause side effects. Sometimes, though, hydrocortisone from a joint injection can get into your blood. This is more likely to happen if you've had several injections. If hydrocortisone gets into your blood, it can travel around your body and there's a very small chance that you may have a serious side effect.

Some of these side effects, such as mood changes, can happen after a few days. Others, such as getting a rounder face, can happen weeks or months after treatment. In rare cases, if your child or teenager has hydrocortisone injections over many months or years, it can slow down their normal growth. Your child's doctor will monitor their height and weight carefully for as long as they're having treatment with hydrocortisone.

This will help them spot any slowing down of your child's growth and change their treatment if needed. Even if your child's growth slows down, it does not seem to have much effect on their overall adult height. Talk to your doctor if you're worried. They will be able to explain the benefits and risks of giving your child hydrocortisone injections.

It's extremely rare to have an allergic reaction anaphylaxis to a hydrocortisone injection. Your doctor will only prescribe hydrocortisone injections for you while you're pregnant or breastfeeding if the benefits of the medicine outweigh the chances of it being harmful. Tell your doctor if you're trying to get pregnant or if you're already pregnant before having a hydrocortisone injection.

Only very small amounts of hydrocortisone get into breast milk, so it's unlikely to be harmful. For more information about how hydrocortisone can affect you and your baby during pregnancy, read this leaflet on the Best Use of Medicines in Pregnancy BUMPs website. It's very important to check with your doctor or pharmacist that a medicine is safe to mix with hydrocortisone injections before you start having them.

This includes prescription medicines and ones that you buy like paracetamol , ibuprofen and aspirin. It also includes herbal remedies and supplements. Tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements. Hydrocortisone injections contain the active ingredient hydrocortisone.

This is a steroid or corticosteroid. The injection releases the hydrocortisone slowly into the part of your body that is painful or swollen. Like other steroids, it works by calming down your immune system. This reduces inflammation and helps to relieve the pain and swelling. A hydrocortisone injection usually takes a few days to start working — although sometimes they work in just a few hours.

If your pain and swelling gets better after a single hydrocortisone injection, you may not need another one. If you have a long-term problem and hydrocortisone injections work well, you may carry on having them. Doctors usually recommend waiting at least 3 months before having another hydrocortisone injection in the same joint. The injection can be a little uncomfortable, but many people say they're not as bad as they thought they would be.

Hydrocortisone injections usually help with pain and swelling for around 2 months. They can also make movement easier. If you have a short-term joint injury, an injection will often help you start to move again so that your body can heal itself.

For long-term joint pain, an injection should help for a few months, but you may need further injections. Hydrocortisone injections can sometimes affect your immune system, so you're more likely to catch infections such as flu , the common cold and chest infections. Keep away from people with infectious diseases, especially chickenpox , shingles or measles. If you've never had these illnesses they could make you very ill.

Tell your doctor straight away if you come into contact with someone who has chickenpox, shingles or measles. Your doctor may be able to prescribe a medicine to protect you. Before you have a vaccination, mention to the healthcare professional that you're taking a steroid.

It's possible that if you have a "live" vaccine around the time that you have a hydrocortisone injection, your immune system might not be strong enough to handle it. This could lead to you getting an infection. Inactive vaccinations, like the injected flu vaccine , are safe.

If you have regular hydrocortisone injections, your doctor may give you a blue steroid card. Carry this with you all the time. The card is the size of a credit card and fits into your wallet or purse. It gives advice on how you can reduce the risks of side effects.

Injection technique requires knowledge of anatomy of the targeted area and a thorough understanding of the agents used. In this overview, the indications, contraindications, potential side effects, timing, proper technique, necessary materials, pharmaceuticals used and their actions, and post-procedure care of patients are presented.

Injection of joints, bursae, tendon sheaths, and soft tissues of the human body is a useful diagnostic and therapeutic skill for family physicians. With training, physicians can incorporate joint and soft tissue injection into daily practice, yielding many benefits. For example, a lidocaine Xylocaine injection into the subacromial space can help in the diagnosis of shoulder impingement syndromes, and the injection of corticosteroids into the subacromial space can be a useful therapeutic technique for subacromial impingement syndromes and rotator cuff tendinopathies.

Evidence-based reviews of joint and soft tissue injection procedures have found few studies that support or refute the efficacy of common joint interventions in medical practice. These injections are most useful in instances of joint or tissue injury and inflammation. History of pain, local and referred, will provide important clues to the underlying pathology.

Physical examination is extremely helpful in ascertaining the diagnosis. Knowledge of the anatomy of the area to be injected is essential. Intratendinous injection should be avoided because of the likelihood of weakening the tendon. Corticosteroid injections also should be avoided in cases of Achilles or patella tendinopathies. Therapeutic responses to corticosteroid injections are variable. Most patients, if they are going to respond, will respond after the first injection.

If the patient has achieved significant benefit after the first injection, an argument can be made to give a second injection if symptoms recur. However, patients who have gained no symptom relief or functional improvement after two injections should probably not have any additional injections, because a subsequent positive outcome is low.

If therapeutic effect is achieved, a maximum of four injections per year is recommended. There is some concern that corticosteroid preparations, with repeated use, may accelerate normal, aging-related articular cartilage atrophy or may weaken tendons or ligaments. When symptoms are resistant, or when there is a history of trauma, a radiograph or other imaging study should be performed to help assist in the diagnosis.

The indications for joint or soft tissue aspiration and injection fall into two categories: diagnostic and therapeutic. A common diagnostic indication for placing a needle in a joint is the aspiration of synovial fluid for evaluation. Synovial fluid evaluation can differentiate among various joint disease etiologies including infection, inflammation, and trauma. A second diagnostic indication involves the injection of a local anesthetic to confirm the presumptive diagnosis through symptom relief of the affected body part.

Therapeutic indications for joint or soft tissue aspiration and injection include decreased mobility and pain, and the injection of medication as a therapeutic adjunct to other forms of treatment. Also, early reaccumulation of fluid can occur in many cases. Therapeutic injection with corticosteroids should always be viewed as adjuvant therapy.

These injections should never be undertaken without diagnostic definition and a specific treatment plan in place. Physicians should resist external pressure for a quick return of athletes to playing sports by the use of joint or soft tissue injections. Table 1 lists soft tissue and joint condition indications for diagnostic and therapeutic injections. As with any invasive diagnostic or therapeutic injection procedure, there are absolute and relative contraindications Table 2.

Relative contraindications are less well defined and should be considered on a case-by-case basis. Physicians should be aware that the contraindications listed are for therapeutic injection and do not apply for diagnostic aspiration of joints or soft tissue areas. For instance, suspected septic arthritis is a contraindication for therapeutic injection, but an indication for joint aspiration. Local cellulitis Septic arthritis Acute fracture Bacteremia Joint prosthesis Achilles or patella tendinopathies History of allergy or anaphylaxis to injectable pharmaceuticals or constituents.

Minimal relief after two previous corticosteroid injections Underlying coagulopathy Anticoagulation therapy Evidence of surrounding joint osteoporosis Anatomically inaccessible joints Uncontrolled diabetes mellitus. Appropriate timing can minimize complications and allow a clear diagnosis or therapeutic response. For diagnostic injections, the procedure should be performed when acute or chronic symptoms are present, when the diagnosis is unclear or needs to be confirmed, when consideration has been given to other diagnostic modalities, and when septic arthritis has been ruled out by aspiration and fluid analysis.

For therapeutic injections, the procedure should be performed when acute or chronic symptoms are present, after the diagnosis and therapeutic plan have been made, and after consideration has been given to obtaining radiographs. Therapeutic injection should be performed only with or after the initiation of other therapeutic modalities e. In the absence of an underlying chronic inflammatory arthritis, any joint with an effusion should be radiographed to rule out a fracture or other intra-articular pathologic process.

After intra-articular injection, corticosteroids function to suppress inflammation and decrease erythema, swelling, heat, and tenderness of the inflamed joint. These effects are believed to result from several mechanisms, including alterations in neutrophil chemotaxis and function, increases in viscosity of synovial fluid, stabilization of cellular lysosomal membranes, alterations in hyaluronic acid synthesis, transient decreases in synovial fluid complements, alterations in synovial permeability, and changes in synovial fluid leukocyte count and activity.

Many corticosteroid preparations are available for joint and soft tissue injection. The agents differ according to potency Table 3 , solubility, and crystalline structure. Potency is generally measured against hydrocortisone, and ranges from low-potency, short-acting agents such as cortisone, to high-potency, long-acting agents such as betamethasone Celestone.

Few studies have investigated the efficacy or duration of action of the various agents in joints or soft tissue sites. The duration of effect is inversely related to the solubility of the preparation: the less soluble an agent, the longer it remains in the joint and the more prolonged the effect.

Consequently, suspensions are longer acting. A short-acting solution, such as dexamethasone sodium phosphate Decadron , is less irritating and less likely to cause a postinjection flare than a long-acting dexamethasone suspension. Many clinicians use injectables that combine short-acting compounds with long-acting suspensions e.

Mixing the corticosteroid preparation with a local anesthetic is a common practice for avoiding the injection of a highly concentrated suspension into a single area. The anesthetic provides early relief of symptoms and helps confirm the diagnosis. Methylprednisolone acetate Depo-Medrol or triamcinolone acetonide Aristocort. Low-solubility agents, favored for joint injection, should not be used for soft tissue injection because of the increased risk of surrounding tissue atrophy. Methylprednisolone Depo-Medrol is often the agent selected for soft tissue injection.

Several precautions should be taken when using steroid injections. Care should be taken to avoid direct injection of tendons because of the danger of rupture. Avoid injection into adjacent nerves of the target area e. Allow adequate time between injections, generally a minimum of four to six weeks. Pay attention to the depth of needle insertion to avoid needle trauma to articular cartilage.

Finally, avoid injecting several large joints simultaneously because of the increased risk of hypothalamic-pituitary-adrenal suppression and other adverse effects. Dosing is site dependent. As a rule, larger joints require more corticosteroid.

Table 3 lists general corticosteroid dosing guidelines. Before injection of a joint or soft tissue, a small quantity of 1 percent lidocaine or 0. For the actual joint or soft tissue injection, most physicians mix an anesthetic with the corticosteroid preparation. This provides temporary analgesia, confirms the delivery of medication to the appropriate target, and dilutes the crystalline suspension so that it is better diffused within the injected region. Manufacturers advise against mixing corticosteroid preparations with lidocaine because of the risk of clumping and precipitation of steroid crystals.

However, the authors have never experienced this as a major problem. For most injections, 1 percent lidocaine or 0. The dose of anesthetic varies from 0. On rare occasions, patients exhibit signs of anesthetic toxicity, including flushing, hives, chest or abdominal discomfort, and nausea. It can take as long as 20 to 30 minutes following the injection for these symptoms to present. For this reason, and to monitor for allergic reactions, patients should be observed in the office for at least 30 minutes following the injection.

A number of potential complications can arise from use of joint and soft tissue procedures. Joint injections should always be performed using sterile procedure to prevent iatrogenic septic arthritis. Local reactions at the injection site may include swelling, tenderness, and warmth, all of which may develop a few hours after injection and can last up to two days. A postinjection steroid flare, thought to be a crystal-induced synovitis caused by preservatives in the injectable suspension, may occur within the first 24 to 36 hours after injection.

Soft tissue fat atrophy and local depigmentation are possible with any steroid injection into soft tissue, particularly at superficial sites e. Periarticular calcifications are described in the literature, but they are rare. Tendon rupture can be avoided by not injecting directly into the tendon itself.

Systemic effects are possible especially after triamcinolone acetonide [Aristocort] injection or injection into a vein or artery , and patients should always be acutely monitored for reactions. Alterations in taste have been reported for one to two days after steroid injection. Hyperglycemia is possible in patients who have diabetes. To avoid direct needle injury to articular cartilage or local nerves, attention should be paid to anatomic landmarks and depth of injection.

Other rare, but possible, complications include pneumothorax when injecting thoracic trigger points , perilymphatic depigmentation, steroid arthropathy, adrenal suppression, and abnormal uterine bleeding. Informed consent should always be obtained for any invasive procedure.

Discussion with the patient should include indications, potential risks, complications and side effects, alternatives, and potential outcomes from the injection procedure. Patients should sign documentation that informed consent for the procedure was given and understood. A third party should witness the patient's signing.

Documentation is kept as part of the patient's record. All joint and soft tissue injection or aspiration techniques should be performed wearing gloves. When injecting or aspirating a joint space, sterile technique should be used. Non-sterile gloves can be used when injecting or aspirating soft tissue regions. Necessary equipment for joint and soft tissue injection or aspiration is listed in Table 4. The entry point for injection or aspiration should be identified. The point of entry can be marked with an impression from a thumb-nail, a needle cap, or an indelible ink pen.

The important goal is to minimize risk of infection at the site. Prepare the area with an alcohol or povidone-iodine Betadine wipe.