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Anesthesia and Injections

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

Overview

Injection therapy serves as a versatile modality for managing musculoskeletal pain and facilitating recovery across diverse orthopaedic conditions. For lateral epicondylitis, 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 influence patient pain perception or outcomes [2], though surgeons may exclude anesthetic from corticosteroid injections to reduce pain, provided they discuss the trade-off of foregoing short-term anesthesia with patients [7].

Regional anesthesia and periarticular injections are critical components of pain management for major joint procedures. Periarticular injections provide adequate pain relief after total knee arthroplasty (TKA) while avoiding complications associated with nerve blocks [3], and regional anesthesia should be utilized whenever feasible for total joint arthroplasty in the absence of contraindications [6]. For postmeniscectomy patients with knee osteoarthritis, adding a postoperative corticosteroid injection to local anesthetic improves pain and function at early time points [8]. Similarly, continuous perineural catheters, liposomal bupivacaine, and dexamethasone as an adjuvant for interscalene block provide equivalent analgesia in total shoulder arthroplasty [25].

Standardization remains a challenge due to significant variations in corticosteroid and anesthetic doses and types among orthopaedic surgeons, rheumatologists, and primary-care physicians [5]. This variability underscores the need for further investigations to establish uniform guidelines, particularly regarding the debate on anesthetic medication choice for adductor canal blocks in TKA [12]. Technical considerations also vary by procedure; a longer needle is required to increase the success of glenohumeral joint injections or aspirations through the posterior approach [26], and surgeons may choose to inject analgesic agents into the glenohumeral joint, subacromial space, or a combination of both after rotator cuff repair based on specific situations or preferences [46].

Anatomy & Pathophysiology

Anesthetic Modalities: Surgeons can be confident in choosing either general anesthesia or wide awake local anesthesia for Zone II flexor tendon repair if rigorous patient selection, sound surgical technique, and proper hand therapy are employed [66]. Wide awake local anesthesia no tourniquet (WALANT) hand surgery was generally well tolerated with excellent surgical outcomes [67]. Further research is warranted to determine the appropriateness of distal peripheral nerve blocks in the forearm as an alternative to proximal brachial plexus blockade in patients undergoing surgery in the thumb or proximal to the hand [61].

Injection Efficacy and Indications: Corticosteroid injection is not superior to placebo for most hand and wrist conditions [68], though studies of ultrasound-guided corticosteroid injections remain limited to uncontrolled cohorts and anatomical studies [68]. For trigger finger and thumb, the success incidence of corticosteroid injections may reach 69% at long-term follow-up, with efficacy increasing when treating the thumb compared with other digits [71]. However, the presence of a proximal interphalangeal joint contracture is associated with a reduced clinical response to corticosteroid injection in trigger fingers [76]. Botulinum toxin injection significantly improved hand function and symptoms in patients with Raynaud's syndrome associated with scleroderma, with the majority recommending the treatment [77]. A patient experienced complete pain resolution and regained wrist extension strength by 3 months following botulinum toxin injection to the extensor carpi radialis brevis for tennis elbow [75]. Blind subacromial injection from the anterolateral approach yields immediate improvement of pain, range of motion, and muscle strength regardless of location [72].

Surgical and Procedural Considerations: Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [42]. Aggressive surgical excision may be necessary to avoid a prolonged clinical course and secondary functional limitations of the hand following accidental injection of Freund complete adjuvant with Mycobacterium tuberculosis [63]. The technique for intra-articular injections of the glenohumeral joint through an anterior approach is most successful in the hands of experienced shoulder arthroscopists [65]. 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 [70]. The modified Camitz technique enables restoration of thumb opposition, correcting abduction and improving flexion and pronation compared with the original technique in patients with severe or long-term carpal tunnel syndrome affecting pinch due to atrophy of the thenar muscle [78].

Rehabilitation and Outcomes: Performing finger manipulation on Day 2 after collagenase injection is comparable with manipulation on Day 1 in terms of efficacy and safety [29]. Hand function was significantly improved, with 70% achieving a functional range of motion at 5 years after treatment with collagenase Clostridium histolyticum injection for Dupuytren's disease [34]. The relative motion extension (RME) program supports safe earlier recovery of hand function and motion when compared to a controlled active motion (CAM) program following repair of zones V and VI extensor tendons [69]. Current clinical practice guidelines for reconstruction of congenital hand differences are appropriate from a developmental standpoint, and in the absence of compelling evidence demonstrating a causal relationship between general anesthetic exposure and neurocognitive defects, established treatment timelines are rarely deviated from [74]. The chapter provides a comprehensive overview of hand anatomy, diagnosis, and treatment principles for various disorders, emphasizing the balance between restoring function and maintaining aesthetic appearance [55]. The clinical importance of the amount of increased motion following intra-articular injection of bupivacaine in knee-replacement operations is questionable and needs longer-term monitoring [73].

Classification

Anesthetic Role in Diagnosis: Injections of anesthetic agents can help clinicians locate the source of pain when physical examination and imaging results are inconclusive [4]. Most patients undergoing intra-or peri-articular injections, synovial fluid aspirations, and spine injections suffer from procedural pain [11].

Trigger Finger Injection Strategy: 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]. Injection approach does not affect patient pain perception scores or outcomes for trigger finger [2].

Corticosteroid Dosing Variability: Variations in corticosteroid/anesthetic doses and types exist among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians [5].

Intra-articular Efficacy: A single intra-articular injection has no value in pain relief regardless of the types of drugs used [14].

Carpal Tunnel Injection Accuracy: Injection accuracy using anatomic landmarks for carpal tunnel was 75.7%, which is less than previously reported rates of 82% to 100% [24].

Digital Block Mechanism: The anaesthetic effects of a single injection digital block are likely due to the agent acting in the subcutaneous space, making a simple subcutaneous injection adequate [44].

Shoulder Arthroplasty Analgesia: There is equivalence in analgesia provided by continuous perineural catheter, liposomal bupivacaine, and dexamethasone as an adjuvant for interscalene block 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].

Adductor Canal Block Standardization: The debate over anesthetic medication choice for adductor canal block creates an opportunity for further collaborative research to establish standardization and guidelines for a multimodal pain management protocol [12].

Lateral Epicondylitis Outcomes: Patients within each injection group for lateral epicondylitis demonstrated improved outcome scores over a 6-month period [1].

General Anesthetic Principles: 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].

Clinical Presentation

Diagnostic utility of injections varies by joint and clinical context. When physical examination and imaging are inconclusive, anesthetic injections can help clinicians locate the pain source [4]. However, for diagnostic hip injections, clinical and imaging findings are unreliable predictors of response, whereas nonresponse to injection serves as a strong negative predictor of surgical outcome [10]. In contrast, patients with symptomatic knee osteoarthritis receiving intra-articular corticosteroid injections demonstrate improved pain and function [17]. For Morton's neuroma, a trained clinician may perform a corticosteroid injection without ultrasound guidance if the diagnosis is clear, yielding good and safe results [13].

Procedural pain is a common experience, with most patients undergoing intra- or peri-articular injections, synovial fluid aspirations, and spine injections suffering from discomfort [11]. To mitigate this, surgeons should exclude anesthetic from trigger finger corticosteroid injections to decrease injection pain, though this involves a trade-off of foregoing short-term anesthesia [7]. For trigger finger specifically, the injection approach does not affect patient pain perception scores or outcomes [2]. Variations in corticosteroid and anesthetic doses and types exist among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians [5].

Outcomes for lateral epicondylitis show improved scores over a 6-month period within each injection group [1]. For postmeniscectomy patients with knee osteoarthritis, adding a postoperative corticosteroid injection improves pain and function at an early time point, yet provides no lasting difference compared with local anesthetic alone [8]. Conversely, a single intra-articular injection offers no value in pain relief regardless of drug type after anterior cruciate ligament reconstruction [14]. Regarding digital block anesthesia, there is no consensus regarding the optimal technique, anesthetic agent, or adjuncts [16].

Anesthesia Strategy: Regional anesthesia should be utilized whenever feasible for total joint arthroplasty when no contraindications are present [6]. Periarticular injections provide adequate pain relief after total knee arthroplasty and are simple to use while avoiding potential complications associated with nerve blocks [3]. For patients with Morton's neuroma, ultrasound guidance is not strictly required if the diagnosis is clear [13].

Complications and Long-term Outcomes: Providers must be aware of adverse effects and potential complications of intra-articular corticosteroid injections [31]. Repeated injections of pentazocine can cause myofibrosis and joint contractures, which are challenging to diagnose if the history of repeated injections is initially denied [9]. Although most trigger finger patients ultimately require surgical release, 50% of those receiving repeat injections realize one year or more of symptomatic relief [30].

Investigations

Plain radiography: While plain radiography is a standard initial step, clinical and imaging findings alone are unreliable predictors of injection response [10]. Intra-articular findings in patients who did not respond to a diagnostic injection did not differ from those who responded [54]. False-negative results render the technique of intra-articular hip injections not 100% reliable [54].

MRI: Concurrent administration of intra-articular gadolinium with diagnostic intra-articular hip injections may result in a false-negative response to anesthetic [45].

Aspiration: Most patients undergoing intra-or peri-articular injections, synovial fluid aspirations, and spine injections suffer from procedural pain [11]. Injections of anesthetic agents can help clinicians locate the source of pain when physical examination and imaging results are inconclusive [4]. Patients within each injection group demonstrated improved outcome scores over a 6-month period [1]. Injection approach does not affect patient pain perception scores or outcomes [2]. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks [3]. Nonresponse to injection is a strong negative predictor of surgical outcome [10].

Other Considerations: Variations in corticosteroid/anesthetic doses and types bespeak the need for additional investigations aimed at establishing uniform injection guidelines [5]. The diagnosis of myofibrosis and joint contractures caused by injections of pentazocine can be challenging if the history of repeated injections is initially denied [9]. There is no consensus regarding the optimal technique, anesthetic agent, or adjuncts for digital block anesthesia [16]. Injection accuracy using anatomic landmarks was 75.7% [24], a rate less than previously reported rates of 82% to 100% [24]. A longer needle is required to increase the success of injections or aspirations through the posterior approach [26]. Ultrasound-guided injections took substantially longer to administer [28]. In the presence of a clear diagnosis, a trained clinician may perform an injection without ultrasound guidance with good and safe results [13]. There is a 60.6% potential for ACJ injections to be out of the joint if performed by palpation alone [59], leading authors to recommend the routine use of image intensification guidance for ACJ injections [59]. In-office ultrasound-guided injections of the hip were more convenient and less painful than fluoroscopy-guided hospital-based injections [57], and patients who have undergone both approaches preferred the ultrasound-guided approach [57].

Treatment

Non-Operative

Injections serve as a primary therapeutic option for various musculoskeletal pathologies, including lateral epicondylitis, trigger finger, Morton's neuroma, and radial tunnel syndrome [1, 2, 39, 47]. For symptomatic knee osteoarthritis and enthesopathy of the extensor carpi radialis brevis origin, intra-articular or periarticular corticosteroid injections improve pain and function, though no difference in pain intensity exists compared to placebo at six months for the latter [17, 37]. High-dose triamcinolone injections outperform low-dose regimens for soft tissue pathology of the hand regarding relief duration and surgical rates [41]. For trigger finger, extracorporeal shock wave therapy offers a non-invasive alternative with comparable cure rates and functional status to corticosteroid injection [48]. Diagnostic utility is established when anesthetic agents help locate pain sources in inconclusive cases, although clinical and imaging findings remain unreliable predictors for hip injection response [4, 10].

Pain Management

Periarticular Infiltration: Multimodal protocols utilizing periarticular injections decrease pain and improve functional recovery compared to conventional modalities after total hip and knee arthroplasty [32]. Specific applications include reduced post-operative pain and inflammation following unicondylar knee arthroplasty [22] and slightly lower mean VAS scores over the first 48 hours for operatively treated ankle fractures [33]. For total knee arthroplasty, periarticular injections provide adequate pain relief while avoiding nerve block complications [3]. Additionally, adding a postoperative corticosteroid injection to local anesthetic improves early pain and function in postmeniscectomy patients with osteoarthritis, though this benefit does not persist long-term [8].

Regional and Local Anesthesia: Regional anesthesia is recommended whenever feasible for total joint arthroplasty in the absence of contraindications [6]. Ultrasound guidance significantly enhances the success rate, reduces time to onset, and optimizes anesthetic volume for axillary blocks in hand surgery compared to the blind approach [15]. For acromioclavicular joint injections, ultrasound guidance is recommended for therapeutic procedures due to improved success rates [36]. Surgeons should exclude anesthetic from trigger finger corticosteroid injections to reduce pain, provided the trade-off of foregoing short-term anesthesia is discussed with the patient [7]. Local infusion analgesia via intra-articular double lumen catheters offers significant analgesic effects and rapid recovery after total knee arthroplasty, pending further safety data [38].

Pharmacologic Strategy: Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioids after carpal tunnel release, with similar satisfaction and functional outcomes [52]. Practitioners must be proficient in using 20% intralipid for local anesthetic toxicity, prioritizing airway protection when employing short-acting local anesthetics in hand surgery [40]. Variations in corticosteroid and anesthetic doses and types among specialties highlight the need for uniform injection guidelines [5].

Complications

Stiffness / Arthrofibrosis: Injections of pentazocine can cause myofibrosis and joint contractures, a diagnosis that may be challenging if the history of repeated injections is initially denied [9]. Additionally, while corticosteroid injections for lateral epicondylitis provide superior short-term pain relief and grip strength, they show no beneficial effects for intermediate- or long-term follow-up, with some studies indicating poorer outcomes at 1 year compared to other treatments [23].

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]. Proximity of a corticosteroid injection to the time of carpal tunnel release surgery plays a role in postoperative infection risk, though comorbidities, the corticosteroid dose, and frequency of injection require further study to determine their specific contribution to this risk [27].

Other Considerations: Steroid injections prior to arthroscopic rotator cuff repair are correlated with a greater likelihood of revision rotator cuff surgery when performed within 6 months of the index surgical procedure [51]. The addition of a postoperative corticosteroid injection to local anesthetic in postmeniscectomy patients with osteoarthritis of the knee resulted in improved pain and function at an early time point but provided no lasting difference compared with only local anesthetic injection [8]. Ultrasound-guided glenohumeral injections take substantially longer to administer than blind injections [28]. The optimal dose and long-term effects of steroid injection in total knee or hip arthroplasty still require numerous studies, and studies should assess whether local anaesthetic infiltration can prevent long-term pain after total hip and knee replacement [21, 18].

Recovery

Light activity (weeks): Patients typically resume light activities, including desk work and driving, within the first week following extra-articular steroid injections, as symptom relief begins to manifest gradually during this period [56]. For hand surgery procedures involving axillary blocks, the mean time to onset of anesthesia is significantly faster under ultrasound guidance compared to the conventional blind approach, facilitating earlier mobilization [15].

Full activity (months): Functional recovery and clinical parameters improve in the short term following unicondylar knee arthroplasty with periarticular steroid injections [22]. Patients treated for lateral epicondylitis demonstrate improved outcome scores over a 6-month period regardless of whether they received autologous blood, corticosteroid, or saline injections [1]. For trigger finger, patients who experience symptom relief two years after a single corticosteroid injection are likely to maintain long-term success [20]. Similarly, the short-term beneficial effects of steroid injections for de Quervain's tenosynovitis symptoms are maintained during follow-up at 12 months [19].

Complete recovery / outcome plateau (months): While corticosteroid injections provide superior short-term pain relief and grip strength for lateral epicondylitis, they show no beneficial effects for intermediate- or long-term follow-up [23]. Some studies indicate poorer outcomes at 1 year for lateral epicondylitis with corticosteroid injections compared to other treatments [23]. For postmeniscectomy patients with osteoarthritis of the knee, the addition of a postoperative corticosteroid injection resulted in improved pain and function at an early time point but provided no lasting difference compared with only local anesthetic injection [8].

Rehabilitation protocol: Regional anesthesia should be utilized whenever feasible and when no contraindications are present for total joint arthroplasty [6]. Periarticular injections are simple to use and avoid the potential complications associated with nerve blocks [3]. 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]. Bupivacaine with lidocaine provides good long-term anesthesia for digital nerve blocks and may reduce the need for postprocedural anesthesia [50].

Functional milestones: Periarticular injections provide adequate pain relief after total knee arthroplasty [3]. Periarticular steroid injections reduce post-operative pain and inflammation, improve short-term functional recovery, and result in better outcomes for patients without major complications following unicondylar knee arthroplasty [22]. The success rate of axillary block for brachial plexus anesthesia in hand surgery is significantly better under ultrasound guidance compared to the conventional blind approach [15].

Other Considerations: The diagnosis of myofibrosis and joint contractures caused by injections of pentazocine can be challenging if the history of repeated injections is initially denied [9]. The risk for postoperative deep infection following trigger finger release surgery is time dependent, being especially greater in the 31- to 90-day postinjection period [60]. The proximity of corticosteroid injection to the time of surgery plays a role in the influence on postoperative infections in carpal tunnel release [27]. Comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution for postoperative infections in carpal tunnel release [27]. 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]. Studies should assess whether local anesthetic infiltration can prevent long-term pain after total hip and knee replacement [18], and the optimal dose and long-term effects of steroid injection in total knee or hip arthroplasty still require numerous studies [21].

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)
  • [L4] Hand function was significantly improved, with 70% achieving a functional range of motion at 5 years. (10.1177/17531934211002383)
  • [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)
  • [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)
  • [L2] Further research is warranted to determine the appropriateness of these techniques in patients undergoing surgery in the thumb or proximal to the hand. (10.1016/j.jhsa.2016.07.092)
  • [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)
  • [L4] Aggressive surgical excision may be necessary to avoid a prolonged clinical course and secondary functional limitations of the hand. (10.1016/j.jhsa.2018.02.008)
  • [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] The technique is most successful in the hands of experienced shoulder arthroscopists. (10.1016/j.jse.2011.06.013)
  • [L1] Surgeons can be confident in choosing either technique if rigorous patient selection, sound surgical technique, and proper hand therapy are employed. (10.1016/j.jhsa.2024.06.008)
  • [L4] WALANT hand surgery was generally well tolerated with excellent surgical outcomes. (10.1177/15589447211058838)
  • [L5] There is no evidence that corticosteroid injection is better than placebo injection for most hand and wrist conditions, and studies of US-guided injections are limited largely to uncontrolled cohorts and anatomical studies. (10.1016/j.jhsa.2014.09.027)
  • [L1] The RME program supports safe earlier recovery of hand function and motion when compared to a CAM program following repair of zones V and VI extensor tendons. (10.1016/j.jht.2018.10.003)
  • [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] At long-term follow-up, the success incidence may be as high as 69%, with efficacy increasing when treating the thumb compared with other digits. (10.1016/j.jhsa.2014.09.006)
  • [L3] Nevertheless, immediate improvement of pain, range of motion, and muscle strength can be expected regardless of location. (10.1016/j.jse.2010.05.004)
  • [L1] The clinical importance of the amount of increased motion is questionable and needs longer-term monitoring. (10.2106/00004623-199605000-00013)
  • [L5] Current clinical practice guidelines for reconstruction of congenital hand differences are appropriate from a developmental standpoint, and in the absence of compelling evidence demonstrating a causal relationship between general anesthetic exposure and neurocognitive defects, established treatment timelines are rarely deviated from. (10.1016/j.jhsa.2017.04.011)
  • [L4] The patient experienced complete pain resolution and regained wrist extension strength by 3 months. (10.1177/1753193410383600)
  • [L4] The presence of a proximal interphalangeal joint contracture was associated with a reduced clinical response to corticosteroid injection. (10.1177/1753193415596497)
  • [L4] The majority of patients showed improvement in their symptoms, botulinum toxin injection significantly improved their hand function, and they would recommend the treatment to other patients. (10.1177/1753193413516242)
  • [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

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[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

[34] Hand function 5 years after treatment with collagenase Clostridium histolyticum injection for Dupuytren’s disease. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211002383

[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

[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

[61] Distal Peripheral Nerve Blocks in the Forearm as an Alternative to Proximal Brachial Plexus Blockade in Patients Undergoing Hand Surgery: A Prospective and Randomized Pilot Study. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.092

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

[63] Accidental Injection of Freund Complete Adjuvant With Mycobacterium Tuberculosis. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.02.008

[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

[65] Accuracy of intra-articular injections of the glenohumeral joint through an anterior approach: arthroscopic correlation. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.06.013

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