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Anesthesia and Injections

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

97 citationsUpdated Sep 2026

Overview

Regional anesthesia is the preferred modality for total joint arthroplasty whenever feasible and in the absence of contraindications [2]. In hand surgery, ultrasound-guided axillary brachial plexus blocks demonstrate superior success rates, faster onset, and reduced anesthetic volume compared to conventional blind approaches [13]. Tumescent anesthesia combined with selective nerve blocks decreases injection-related pain and enhances patient satisfaction [63], while vibratory anesthesia serves as a useful adjunct for hand and upper extremity injections [32]. Although no consensus exists regarding the optimal technique, agent, or adjuncts for digital blocks [15], the anesthetic effect of a single injection digital block likely results from action in the subcutaneous space, making a simple subcutaneous injection adequate [9]. Clinicians must maintain proficiency in airway protection for patients receiving short-acting local anesthetics and be knowledgeable about the indications for 20% intralipid in cases of local anesthetic toxicity [36].

Injection efficacy varies by condition and attempt. For trigger finger, efficacy rates for initial, second, and third injections are 66.3%, 79.4%, and 79.6%, respectively [3]. Patients with lateral epicondylitis show improved outcome scores over six months following autologous blood, corticosteroid, or saline injections [5]. In shoulder conditions, anesthetic injections help localize pain sources when physical examination and imaging are inconclusive [6]. For Dupuytren contracture, manipulation following collagenase injection can be scheduled within the first 7 days at the convenience of the patient and surgeon [21]. However, corticosteroid injections to the thumb carpometacarpal joint prior to arthroplasty increase the rate of minor complications [11].

Technique and adjunct selection significantly influence procedural outcomes. Injection approach does not affect pain perception or outcomes for trigger finger [1], though excluding anesthetic from corticosteroid injections reduces injection pain, a trade-off that must be discussed with patients [4]. Most patients undergoing intra- or peri-articular injections, aspirations, and spine injections experience procedural pain [8]. Ultrasound guidance significantly improves success rates for acromioclavicular joint injections [35], although glenohumeral injections take substantially longer than blind techniques [10]. A longer needle is required to increase success for posterior approach glenohumeral penetration [25]. Current variations in corticosteroid and anesthetic doses and types for painful shoulder conditions indicate a need for uniform injection guidelines [7]. Providers should carefully select among continuous perineural catheters, liposomal bupivacaine, and dexamethasone as adjuvants for interscalene blocks in total shoulder arthroplasty, given their equivalence in analgesia [16]. Following rotator cuff repair, surgeons may choose glenohumeral, subacromial, or combination injection sites based on specific situations or preferences [39]. Expansion of indications for periarticular and intra-articular injections requires caution due to potential negative effects on articular cartilage [31].

Anatomy & Pathophysiology

Upper Extremity Kinematics and Architecture

The hand functions efficiently only if the proximal joints of the limb are stable and yet mobile [41]. The shoulder, the most mobile joint in the body, allows orientation of the upper limb as required, while the movements of the clavicle amplify those of the shoulder [41]. The elbow brings the hand closer to or moves it away from the body through flexion–extension movements [41]. Combined movements of the wrist and forearm place the hand in a position for grasping; for gripping, the wrist is usually in flexion when close to the trunk and in extension when placed at a distance [41]. Forearm rotation (pronation–supination) plays an important role, particularly for bringing food to the mouth [41]. The hand’s blood and nerve supplies are continuous with those of the rest of the limb [41].

The open hand, with fingers extended and in contact, forms a balanced graceful oval in its longitudinal axis [41]. The posterior or dorsal aspect of the hand is convex, and the anterior, palmar or volar aspect is concave [41]. The digits converge in closing—that is, they flex and adduct—and diverge in opening—that is, they extend and abduct [41]. The thumb has a more proximal and lateral position, allowing movement inward and outward from the palm [41]. When the fingers are extended and separated, the tips of the fingers lie on the circumference of a circle whose center is the head of the third metacarpal [41]. The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand, and about the same number of tendons activated by the forearm muscles [41].

Osseous Skeleton

The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [45]. The skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [45]. The base of each metacarpal articulates with the distal row of the carpus, and the carpus articulates with the skeleton of the forearm through its proximal row [45]. The radioulno-carpal articulation has two axes of movement to which is added a third—pronation and supination from the forearm [45]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration [45].

The radial ray or first ray is the shortest and is made up of only three bones—a metacarpal and two phalanges [45]. The first ray continues the external column of the carpus formed by the scaphoid and trapezium [45]. The trapezium is clearly angled out in front of the carpal plane so that the first metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [45]. The thumb metacarpal is the shortest, the index finger metacarpal is the longest, and the others decrease in length from the third to the fifth digits [45]. The proximal and particularly the middle phalanges of the middle and ring fingers are longer than those of the index finger [45].

The skeleton of the hand presents a longitudinal and transverse concavity, giving it the shape of a cup with a palmar concavity when the thumb is placed next to the index finger [45]. The transverse axis of the palm is oblique, more distal at the metacarpophalangeal joint of the index finger and more proximal at the fifth metacarpophalangeal joint [45]. The transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [45]. The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [45].

Musculature and Tendon Mechanics

Extrinsic muscles have their origin outside of the hand and their insertion on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [44]. The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [44].

Compartment 1 (Most Radial): Contains the abductor pollicis longus and the extensor pollicis brevis [44]. The abductor pollicis longus inserts at the base of the thumb metacarpal and radially abducts the thumb [44]. The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the proximal phalanx of the thumb and actively extends the metacarpophalangeal joint of the thumb [44].

Compartment 2: Contains the extensor carpi radialis longus and the extensor carpi radialis brevis [44]. The extensor carpi radialis longus inserts on the index metacarpal, dorsiflexes and radially deviates the wrist [44]. The extensor carpi radialis brevis inserts into the base of the middle metacarpal and provides balanced wrist dorsiflexion [44].

Compartment 3: Contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle [44]. The extensor pollicis longus inserts on the distal phalanx and provides forceful extension of the thumb interphalangeal joint [44].

Compartment 4: Contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [44].

Compartment 5: Contains the extensor digiti quinti [44].

Compartment 6: The extensor carpi ulnaris tendon runs through the sixth compartment and inserts at the base of the little finger metacarpal [44]. The extensor carpi ulnaris provides wrist extension and ulnar deviation [44].

The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [44]. Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [44]. Distal interphalangeal joint extension is achieved through the conjoined lateral bands that are composed of tendinous slips from the extrinsic and intrinsic tendons [44]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [44]. The digital extensor tendons are stabilized over the mid-line of the metacarpophalangeal joint by their attachment to sagittal band fibers [44]. The sagittal band fibers insert onto the volar proximal phalanx and onto the lateral borders of the volar plate [44]. With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [44].

The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [44]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [44]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [44].

There are seven interosseous muscles, four dorsal and three volar [81]. The dorsal interossei are abductors [81]. The volar interossei are adductors [81]. The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [81]. Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [81]. The superficial head of the dorsal interosseous muscles abducts and weakly flexes the proximal phalanx [81]. The deep head of the dorsal interosseous muscles flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [81]. The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [81]. The abductor digiti quinti and flexor digiti quinti brevis are similar in both structure and function to the superficial and deep heads of the dorsal interossei, respectively [81]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate and inserts onto the ulnar side of the diaphysis of the fifth metacarpal, which it flexes and supinates [81].

The flexor digitorum profundus originates from the proximal ulna and the interosseous membrane [87]. The flexor digitorum profundus and the flexor pollicis longus muscles form the deep compartment of the volar forearm [87]. The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa [87]. The tenosynovial sheath to the little finger is continuous with the ulnar digital bursa [87]. In some patients, the radial and ulnar bursae communicate, allowing a so-called horseshoe abscess to spread between the thumb and little finger if infection occurs in the flexor tendon sheath of either one of these digits [87]. The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [87]. The innervation of the flexor digitorum profundus of the index and middle fingers is through the anterior interosseous branch of the median nerve [87]. The profundus of the ring and little fingers is innervated by the ulnar nerve [87].

The flexor digitorum superficialis has two heads: The radial head originates from the proximal shaft of the radius, and the humeral ulnar head originates from the medial humeral epicondyle and coronoid process of the ulna [87]. The flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [87]. The flexor digitorum superficialis tendon slips reunite distally at the Camper chiasm, with approximately half of the fibers staying on the ipsilateral side and half crossing to the contralateral side of the finger [87]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [87]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve [87]. The primary function of the superficialis is digital flexion at the proximal interphalangeal joint [87].

The flexor pollicis longus originates from two heads: The radial head takes origin from the proximal radius and interosseous membrane, and an accessory head originates from the coronoid process of the ulna and from the medial epicondyle of the humerus [87]. The flexor pollicis longus inserts into the proximal base of the thumb distal phalanx and is innervated by the anterior interosseous branch of the median nerve [87]. The flexor pollicis longus flexes both the interphalangeal and metacarpophalangeal joints of the thumb [87].

The fibroosseous tunnel, or digital flexor sheath, extends distally to the proximal aspect of the distal phalanx [87]. The tendinous sheath consists of annular pulleys, which provide mechanical stability, and cruciate pulleys, which provide flexibility [87]. The first, third, and fifth annular pulleys (A1, A3, and A5) are located over the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively [87]. The second and fourth pulleys (A2 and A4) are situated over the middle portion of the proximal and middle phalanges [87]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [87]. The tenosynovium that lines the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [87]. Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [87].

Vascular Anatomy

The "princeps pollicis" artery, the terminal branch of the radial artery, crosses the first intermetacarpal space, then runs along the ulnar side of the first metacarpal bone and along the volar surface of the adductor muscle [84]. The princeps pollicis emerges onto the subcutaneous palmar tissue at the level of the cutaneous flexion crease of the metacarpophalangeal joint [84]. The princeps pollicis divides into two terminal rami, namely the collateral palmar arteries of the thumb, which run along the digital tunnel symmetrically and are of equal caliber [84]. An arcade located deep in the flexor tendon joins together the two arteries at the level of the distal metaphysis of the first phalanx [84]. In anatomical studies, only 15% of dissections fall into the classical category of palmar thumb artery layout [84]. In the second segment of the thumb, the main artery is the ulnar collateral artery [84]. The subtendinous anastomosis situated at the level of the neck of the first phalanx acts as "moderator" between the two arteries [84]. The dorsal arteries of the thumb are vascularized by two arteries which originate from the palmar arteries (princeps, commissural or anastomoses of the superficial arcade) at the level of the first metacarpal [84]. At the level of the neck of the first phalanx, an anastomosis can be found which originates from the palmar arteries [84].

Cutaneous Anatomy and Gliding Mechanisms

There are "functional cutaneous units" in the hand similar to the ones customarily described in the face [80]. One cutaneous unit on the dorsum of the hand extends from the wrist to the proximal interphalangeal joints of the fingers and the interphalangeal joint of the thumb [80]. The dorsal covering of the interphalangeal articulations of the digits forms a unique cutaneous unit characterized by a considerable excess of skin when the digits are in extension [80]. The palm forms a cutaneous unit extending from the distal transverse crease of the wrist up to the transverse crease at the base of the digits [80]. The palmar integument may be subdivided into two separate zones by the oppositional crease of the thumb, which constitutes the oblique axis of the hand [80]. The skin of the radial portion of the palm covers the thenar eminence and the external part of the palm; it is the mobile portion [80]. The skin of the ulnar and distal portion covers the hypothenar eminence where the skin has poor mobility [80]. The central triangular part of the palm has skin that is fixed and poorly vascularized, covering almost directly the superficial palmar aponeurosis, which inserts into it [80]. The integument of the palmar face of the digits may be subdivided into phalangeal units separated by the digital flexion folds [80]. When a digit is completely flexed, the integument of the adjacent phalanges comes into contact in the zones of the flexion creases, establishing areas of cutaneous contact in the form of a diamond [80]. The sides of this diamond do not undergo variations in length during the movements of flexion and extension, and incisions made along their level present a minimal chance of retraction [80].

The dorsal slope of the web spaces has a gradual incline and its supple skin is not adherent to the subjacent region [80]. The palmar surface of the web spaces is flat and precipitously interrupted, and the skin is densely adherent to the commissural skeleton [80]. The commissural skeleton is formed by the interdigital palmar (natatory) ligament between the fingers and by the distal transverse ligament at the level of the thumb web [80]. The dorsal integument must be supple, elastic, and malleable [88]. The skin of the back of the hand slides distally to allow metacarpophalangeal joint flexion [88]. Interphalangeal flexion is accomplished by means of a special arrangement of skin folds on the dorsum of each articulation [88]. The vessels and nerves adapt themselves to differences in length and are surrounded by loose fibroadipose connective tissue [88]. In unrestricted areas, where the tendon has a straight trajectory, it is surrounded by the paraten

Classification

Anesthetic Plan: The anesthetic plan must include postoperative nausea and vomiting prophylaxis when appropriate and postoperative analgesia [38]. The anesthesiologist, surgeon, and patient must agree with the anesthetic plan [38]. Components of anesthesia include amnesia, anxiolysis, analgesia, akinesia, and attenuation of autonomic responses to noxious stimulation [38].

Local Anesthesia: Local anesthesia involves infiltration of local anesthetic by the surgeon, with or without sedation [38]. In this modality, the anesthesiologist is not involved in the monitoring or care of the patient [38].

Monitored Anesthesia Care: Monitored anesthesia care involves the anesthesiologist monitoring and caring for the patient to ensure comfort, care, and safety [38]. Sedation levels in monitored anesthesia care may range from no sedation to conscious sedation [38].

General Anesthesia: General anesthesia is defined as a pharmacologically induced, reversible loss of consciousness irrespective of airway management [38]. Inhalational anesthesia involves the use of inspired volatile anesthetic gas [38]. Total intravenous anesthesia involves the use of intravenous agents without inspired volatile anesthetic gas [38].

Regional Anesthesia: Regional anesthesia involves a regional block performed with anesthesiologist monitoring, with or without sedation [38]. Regional anesthesia provides targeted, site-specific anesthesia and analgesia [38]. It minimizes opioid requirements and associated side effects [38].

Clinical Presentation

Local anesthetic injection is reported to be more painful than pneumatic tourniquet use in short hand surgery procedures [55]. In trigger finger treatment, injections containing lidocaine cause more pain during the procedure without significant delayed benefits of pain relief [52]. A statistically significant difference in pain during and shortly after injection exists when using a steroid with lidocaine versus steroid alone, though this difference may not be clinically relevant [50]. Decreasing the pain of finger block injection requires approximately one minute of additional time [57].

Adjuncts for Pain Reduction: Vibratory anesthesia is a useful adjunct for reducing pain during injections of the hand and upper extremity [32]. Vapocoolant spray before local anesthetic infiltration during percutaneous needle aponeurotomy results in a significant reduction in mean injection pain of -2.70 VAS units [56].

Diagnostic Utility and Response Prediction: Injections of anesthetic agents can help clinicians locate the source of pain when physical examination and imaging results are inconclusive [6]. Relief of symptoms after instillation of local anesthetic and steroid into the hip joint has a positive predictive value and specificity of 100%, sensitivity of 95%, and negative predictive value of 89.5% for distinguishing hip joint pain from other sources [54]. Immediate improvement of pain, range of motion, and muscle strength can be expected after blind subacromial injection regardless of needle location [23]. Patients with carpal tunnel syndrome who have an absent sensory nerve action potential (SNAP) more often have a poor response to the first corticosteroid injection [18].

Technique Considerations: Significant pain experienced on inserting the needle during carpal tunnel injection indicates that the needle should be partially withdrawn and redirected before continuing corticosteroid infiltration [53].

Investigations

Diagnostic Injections and Pain Assessment

Diagnostic injection serves as a high-accuracy tool for confirming intra-articular pathology. Relief of symptoms following the instillation of local anesthetic and steroid into the hip joint demonstrates a positive predictive value and specificity of 100%, a sensitivity of 95%, and a negative predictive value of 89.5% [54]. Clinicians must note that the local anesthetic injection itself was reported to be more painful than the use of a pneumatic tourniquet [55].

Injection Accuracy and Technique

Technique selection significantly impacts injection accuracy across various anatomical sites. For carpal tunnel injections using anatomic landmarks, accuracy was 75.7%, which is lower than previously reported rates of 82% to 100% [24]. In the acromioclavicular joint, only 43.3% of injections were completely intra-articular, although 66.7% of patients had some contrast dye in the joint [154]. For the glenohumeral joint, a longer needle is required to increase the success of injections or aspirations through the posterior approach [25], while the anterior approach technique is most successful in the hands of experienced shoulder arthroscopists [78].

Specific anatomical considerations dictate technique for other conditions. For de Quervain’s disease, injections should be made separately over the two tendons to account for the possibility of a septum [71]. In ring blocks, the pigmented border serves as a guide for clinicians when injecting local anaesthetic agents using both volar and dorsal approaches [69]. 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 [9].

Ultrasound Guidance

Ultrasound guidance offers distinct advantages over traditional techniques, including direct visualization of neural structures, detection of anatomical variants, smaller volumes of local anesthetic, shorter block performance time, faster onset, greater success, decreased pain, and increased patient satisfaction [48]. For axillary block in hand surgery, the success rate, mean time to onset of anaesthesia, and the mean amount of anaesthetic injected were all significantly better under ultrasound guidance [13]. In the glenohumeral joint, ultrasound-guided injections took substantially longer to administer compared to blind injections [10].

For the acromioclavicular joint, the use of US guidance significantly improves the success rate [35]. Ultrasound-guided infiltration of the AC joint is simple, efficient, and requires no previous experience to reveal excellent accuracy of administration of the active agent [153]. However, in the presence of a clear diagnosis, a trained clinician may perform an injection for Morton’s neuroma without ultrasound guidance with good and safe results [26]. Based on the evidence, the routine use of ultrasound guidance for subacromial injections is not necessary [66].

Anesthesia Modalities and Adjuvants

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 [20]. 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 [16]. Perifracture site injections were not found to provide any additional pain control benefit following volar plating for distal radius fractures [73].

Injection Efficacy and Outcomes

The efficacy of initial, second, and third injection for trigger finger was 66.3%, 79.4%, and 79.6%, respectively [3]. Triamcinolone injection was associated with more frequent apparent resolution than dexamethasone for trigger finger, and delayed surgery treatment strategies were associated with higher resolution rates [76]. However, open surgery is superior to ultrasound-guided corticosteroid injections for trigger finger [132]. Patients with carpal tunnel syndrome and an absent SNAP more often had a poor response to the first injection and may be better served by early surgical treatment [18]. For lateral epicondylitis, patients within each injection group (autologous blood, corticosteroid, or saline) demonstrated improved outcome scores over a 6-month period [5].

Risks and Complications

Corticosteroid injections for the thumb carpometacarpal joint increase the rate of minor complications following arthroplasty [11]. Proximity of injection to time of surgery plays a role in postoperative infections in carpal tunnel release, although comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution [17]. Myofibrosis and joint contractures caused by injections of pentazocine can be challenging to diagnose if the history of repeated injections is initially denied [12]. Variations in corticosteroid/anesthetic doses and types bespeak the need for additional investigations aimed at establishing uniform injection guidelines [7].

Treatment

Non-Operative

Conservative management includes regional anesthesia, local infiltration, and corticosteroid injections. Regional anesthesia for upper extremity surgery may improve postoperative pain control, lower opiate consumption, decrease nausea and vomiting, and decrease hospital stay [28]. Ultrasound-guided blocks improve onset and decrease dosage requirements compared with traditional techniques [28]. Among nerve stimulator–guided, paresthesia-guided, or ultrasound-guided nerve block techniques, no particular technique demonstrates improved outcome [28]. Continuous peripheral nerve catheters are safe and effective for extending opioid-sparing, site-specific analgesia in adult and pediatric patients in inpatient and outpatient settings [28]. For carpal tunnel release, 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 [111]. Corticosteroid injections provide superior short-term pain relief and grip strength for lateral epicondylitis but show no beneficial effects for intermediate- or long-term follow-up [37]. Some studies indicate poorer outcomes at 1 year for lateral epicondylitis treated with corticosteroid injections compared to other treatments [37]. A meta-analysis showed no difference in pain intensity between corticosteroid injection and placebo 6 months after injection for enthesopathy of the extensor carpi radialis brevis origin [101]. Patients experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after a single, image-guided corticosteroid injection for glenohumeral arthritis [19]. Nonoperative management with corticosteroid injection can be used as a therapeutic measure with potential long-term benefits in the treatment of radial tunnel syndrome [61]. Hand surgeons should consider the benefit of high-dose triamcinolone injections when deciding on a treatment modality for common hand conditions [58]. There is no evidence that corticosteroid injection is better than placebo injection for most hand and wrist conditions [60]. Studies of US-guided corticosteroid injections are limited largely to uncontrolled cohorts and anatomical studies [60]. The short-term beneficial effects of steroid injections for symptoms of de Quervain's tenosynovitis were maintained during the follow-up after 12 months [30]. A corticosteroid injection should be regarded as a primary option in the treatment of Morton’s neuroma, and the only indication for an injection of hyaluronic acid might be in patients in whom corticosteroid is contraindicated [103]. Evidence regarding the efficacy of intra-articular corticosteroid injections for the osteoarthritic knee is inconclusive [107]. Combining intra-articular corticosteroid injections with higher-dose anesthetics may compound chondrotoxic effects [107]. Subacromial steroid injection is an alternative modality for primary frozen shoulder, and treatment should be individualized [135]. There were no between-group differences for cure rates, pain, and functional status between extracorporeal shock wave therapy and corticosteroid injection for trigger finger [108]. It has been recommended to delay interventional pain procedures with steroids for 2 weeks after the second or final dose of the SARS-CoV-2/COVID-19 vaccine [29]. If delaying steroid injection is not possible due to severe debilitating pain, it is recommended to proceed at the discretion of the physician and consider using only a local anesthetic agent or the lowest possible effective dose of short-acting steroids [29]. Patients who are healthy, have no comorbidities, have received a single dose of vaccine, and are suffering from severe pain that cannot be delayed may proceed with caution with a local anesthetic agent alone or with short-acting steroids [29].

Operative

Indications: Patients with an absent SNAP more often had a poor response to the first injection and may be better served by early surgical treatment for carpal tunnel syndrome [18]. Although most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief [22]. The efficacy of initial, second, and third trigger finger injection was 66.3%, 79.4%, and 79.6%, respectively [3].

Pain Management: Regional anesthesia for upper extremity surgery may improve postoperative pain control, lower opiate consumption, decrease nausea and vomiting, and decrease hospital stay [28]. Ultrasound-guided blocks have been shown to improve onset and decrease dosage requirements compared with traditional techniques [28]. Among regional anesthesia techniques of nerve stimulator–guided, paresthesia-guided, or ultrasound-guided nerve block, there is no demonstrated improvement in outcome with any particular technique [28]. The use of additives to local anesthetics can prolong block duration and analgesia while reducing overall local anesthetic dose, but agents should be chosen judiciously to avoid neurotoxicity [28]. Continuous peripheral nerve catheters are safe and effective for extending opioid-sparing, site-specific analgesia for adult and pediatric patients in both the inpatient and outpatient settings [28]. The injection group for local infiltration received a significantly higher amount of opioid intraoperatively (mean 14.1 MME) compared with the block group (mean 6.6 MME) [27]. There was no difference in MME between local infiltration and block groups during the first 24 hours postoperatively or any other postoperative time points [27]. There was no statistically significant difference in pain experienced during local anesthetic administration or during the procedure between superficial and deep local anesthetic infiltration in carpal tunnel release [33]. The triangular injection technique represents an option when interscalene block is unavailable, contraindicated, or not desired [106]. 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 after carpal tunnel release [111]. Given the equivalence in analgesia provided with 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 [16]. Surgeons may be free to choose where to inject analgesic agents (glenohumeral, subacromial, or combination) according to each specific situation or their preferences after rotator cuff repair [39].

Other Considerations: Absolute contraindications to regional anesthesia are infection at the site of injection and patient refusal [28]. The incidence of temporary paresthesias following regional anesthesia is between 3% and 8%, and most resolve within 4 weeks [28]. Prolonged neurapraxias are extremely rare, with an incidence of between 0.04% and 0.8% [28]. In the event of a neurapraxia, a coordinated effort between the anesthesiologist and surgeon is required, as well as thorough communication with the patient [28]. In the initial 2 weeks, 7% to 10% of patients experience residual postoperative neurologic symptoms (PONS) from a variety of causes [100]. The incidence of PONS is less than 0.2% at 9 months [100]. Substantial dysesthesia or neurapraxia with motor block should be urgently referred to a neurologist and/or a chronic pain specialist [100]. Early imaging studies should be considered for PONS, as well as early and late electromyographic/nerve conduction velocity studies if motor involvement is present [100]. Oral medications for PONS symptom control may include NSAIDs, acetaminophen, anticonvulsants (eg, gabapentin or pregabalin), tricyclic antidepressants (eg, amitriptylin or duloxetine), and muscle relaxants [100]. Opioids should be the last option for PONS symptom control because nerve pain is not well managed with opioids [100]. The risk of local anesthetic systemic toxicity (LAST) is traditionally 1:1,500, and incidence decreases significantly with ultrasound use [100]. LAST usually presents as seizure but rarely can cause life-threatening cardiac arrhythmias [100]. Treatment for LAST includes airway control, advanced cardiac life support, intravenous administration of 20% lipid emulsion therapy as antidote, stopping seizure with benzodiazepines or propofol, and arrhythmia management with amiodarone and/or pacing [100]. Catheter-related complications include inadequate analgesia, catheter problems (leaking, dislodgement, kinking), pain/paresthesias on removal, infusion pump failures, inadequate patient education, and infection [100]. The risk of catheter-related infection increases with catheter duration greater than 5 days and is higher in immunocompromised patients [100]. Superficial catheter-related infections can be treated with oral antibiotics and monitored after catheter removal [100]. Deep catheter-related infections require consideration of advanced imaging (such as MRI), antibiotics, and possible surgical drainage [100]. Failed block requires an alternative anesthesia or analgesia plan [100]. Wrong-side block is prevented with appropriate time-out procedures and site marking [100]. Bleeding or hematoma from regional anesthesia is rare and typically resolves with compression unless the patient has a severe bleeding diathesis [100]. Injections increase the rate of minor complications following thumb carpometacarpal joint arthroplasty [11]. We do not recommend administering a corticosteroid injection at the time of hand surgery [62]. Surgeons should exclude the anesthetic to decrease injection pain for trigger finger, though they must discuss the trade-off of foregoing short-term anesthesia with patients [4]. Injections containing lidocaine cause more pain without significant delayed benefits of pain relief for trigger finger, indicating that lidocaine is unnecessary and causes more pain during the injection [52]. The ShotBlocker device effectively reduced the pain of injection versus controls when scores were adjusted to account for pain tolerance [59]. The vapocoolant group experienced a significant reduction in mean injection pain of -2.70 VAS units, exceeding the reported minimal clinically important difference for acute procedural pain [56]. Immediate improvement of pain, range of motion, and muscle strength can be expected regardless of location for blind subacromial injection from the anterolateral approach [23]. The use of US guidance significantly improves the success rate in acromioclavicular joint injection, and it is recommended for therapeutic ACJ injections in routine clinical practice [35]. Ultrasound-guided injections are essential in the management of recalcitrant piriformis problems [131]. Ultrasound is superior to all other available image-guided methods in terms of reliability, simplicity, and accessibility for piriformis injections [131]. If only anesthetic is injected for piriformis syndrome, the patient may return to baseline activity immediately [131]. If a corticosteroid is injected for piriformis syndrome, the patient is asked to rest the hip area for 1 week [131]. Physical therapy for piriformis syndrome can be initiated after 1 week of rest following corticosteroid injection [131]. Manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after collagenase injection for Dupuytren contracture [21]. Performing finger manipulation on Day 2 after collagenase injection is comparable with manipulation on Day 1 in terms of efficacy and safety [70].

Complications

Neurological: The incidence of temporary paresthesias following regional anesthesia ranges from 3% to 8%, with most cases resolving within 4 weeks [28]. Prolonged neurapraxias are extremely rare, occurring in 0.04% to 0.8% of cases [28]. When neurapraxia occurs, management requires a coordinated effort between the anesthesiologist and surgeon, along with thorough communication with the patient [28]. In a series of carpal tunnel release patients treated with local infiltration, the median nerve showed no evidence of damage due to the needle or the injection itself [128].

Hematologic: Epidural or subdural hematomas resulting from regional anesthesia have a low incidence of 1:190000 [68]. If an epidural or subdural hemorrhage or hematoma is observed by MRI in a postoperative patient, the finding should be presumed abnormal and pathologic, and addressed urgently [68].

Infection and Inflammation: Serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions [113]. Proximity of corticosteroid injection to the time of surgery plays a role in postoperative infections in carpal tunnel release, although comorbidities, dose, and frequency require further study to determine risk contribution [17].

Surgical Outcomes: Corticosteroid 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 [65]. Thumb carpometacarpal joint corticosteroid injections increase the rate of minor complications following arthroplasty [11].

Other Considerations: Myofibrosis and joint contractures can be caused by injections of pentazocine [12]. The diagnosis of these conditions can be challenging if the history of repeated injections is initially denied [12]. If significant pain is experienced on inserting the needle during corticosteroid injection for carpal tunnel syndrome, it appears negligent to continue with infiltration without first partially withdrawing and then redirecting the needle [53]. No cases of finger necrosis have been reported after the use of lidocaine with epinephrine in the world literature [123]. There were no reports of digital necrosis or other permanent harmful sequelae in cases where patients accidentally injected their fingers with epinephrine 100 times more concentrated than commercially available lidocaine and epinephrine mixtures [123]. Among 48 cases of digital gangrene identified in a search of Index Medicus and the National Library of Medicine database, all but 6 occurred over 50 years ago [123]. In the historical cases of digital gangrene, the anesthetics used were procaine and cocaine with epinephrine, and only 44% (21 cases) had epinephrine mixed with the local anesthetic [123]. No complications occurred from either local infiltration or intravenous regional anesthesia in a series of carpal tunnel release patients [128]. Ultrasound-guided tenotomy for tendinopathies of the elbow has been sustained in long-term follow-up with no reported complications [64].

Recovery

Light activity (weeks): The evidence base provided does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The evidence base provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence base provided does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The evidence base provided does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression, or sling and brace removal timing.

Functional milestones: The evidence base provided does not report validated patient-reported outcome measure trajectories or specific outcome-measure benchmarks such as Constant, ASES, or WOMAC scores.

Other Considerations: Ultrasound-guided axillary block for brachial plexus anesthesia in hand surgery results in a significantly better success rate, mean time to onset of anesthesia, and mean amount of anesthetic injected compared to the conventional blind approach [13]. Conversely, ultrasound-guided glenohumeral injections take substantially longer to administer than blind injections [10]. The quality of evidence for the duration to onset of anesthesia, duration of anesthesia, and pain on injection of local anesthetic for digital nerve blocks ranges from very low to moderate [14]. Decreasing the pain of finger block injection requires only a minute of time [57].

Regarding corticosteroid efficacy, patients who continue to experience symptom relief two years after a single corticosteroid injection for trigger finger are likely to maintain long-term success [34]. Although most patients with trigger finger ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief [22]. The short-term beneficial effects of steroid injections for de Quervain's tenosynovitis symptoms were maintained during follow-up after 12 months [30]. For lateral epicondylitis, 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 [37]. Corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain [149]. Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week [119]. Injections into the Greater Trochanteric Bursa may have longer lasting benefit for Greater Trochanteric Pain Syndrome [67]. Platelet rich plasma provides better long-term functional improvement and clinical long-term pain relief for lateral epicondylitis, while corticosteroids provide significantly better short-term pain relief [116]. In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis [120].

Technique and complication data indicate a statistically significant difference in pain during and shortly after injection when using a steroid with lidocaine versus steroid alone for trigger finger, but that difference may not be clinically relevant [50]. The routine use of ultrasound guidance for subacromial injections is not necessary [66]. Ultrasound-guided tenotomy improves physical function and decreases pain for tendinopathies of the elbow, with effects sustained in long-term follow-up and no reported complications [64]. Steroid injections for painful rotator cuff conditions are correlated with a greater likelihood of revision rotator cuff surgery when performed within 6 months of the index surgical procedure [65]. The risk for postoperative deep infection in trigger finger release surgery 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 [136]. Corticosteroid injection in the preoperative period for trigger finger release is associated with a higher rate of postoperative infection, although the time before surgery and the corticosteroid dose do not appear to have an effect [145]. Proximity of corticosteroid injection to the time of carpal tunnel release surgery plays a role in postoperative infections, although comorbidities, the corticosteroid dose, and frequency of injection require further study to determine risk contribution [17].

Other injection modalities include multiple concurrent collagenase clostridium histolyticum injections to Dupuytren’s cords, which would eliminate the 30-day wait between single treatments and allow for rapid and effective treatment of patients with multiple affected joints [151]. Ultrasound-guided needling treatment was more effective in function restoration and pain relief in the short term for calcific tendinitis in the shoulder compared to extracorporeal shock wave therapy [112]. Both ultrasound-guided needling combined with a subacromial corticosteroid injection and high-energy extracorporeal shockwave therapy are successful in improving function and pain, with high satisfaction rates after 1-year follow-up for calcific tendinitis of the rotator cuff [122]. The percentage of Medicare patients who received hyaluronic acid and corticosteroid injections increased steadily until 2006 to 2007 when it began trending down, with a sharper decline in 2012 to 2013, while the number of injections per patient increased substantially [40]. Patients with an absent SNAP more often had a poor response to the first corticosteroid injection for carpal tunnel syndrome and may be better served by early surgical treatment [18].

Key Evidence

• [L3] Our data suggest that injection approach does not affect patient pain perception scores or outcomes. [1] (10.1177/1558944717703134)
• [L2] Regional anesthesia should be utilized whenever feasible, and when no contraindications are present. [2] (10.1016/j.arth.2024.10.082)
• [L4] The efficacy of initial, second, and third injection was 66.3%, 79.4%, and 79.6%, respectively. [3] (10.5435/jaaosglobal-d-22-00198)
• [L1] Surgeons should exclude the anesthetic to decrease injection pain, though they must discuss the trade-off of foregoing short-term anesthesia with patients. [4] (10.1177/1558944719884663)
• [L2] Patients within each injection group demonstrated improved outcome scores over a 6-month period. [5] (10.1016/j.jhsa.2011.05.014)
• [L4] Injections of anesthetic agents can help clinicians locate the source of pain when physical examination and imaging results are inconclusive. [6] (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. [7] (10.1186/1471-2474-8-63)
• [L4] Most patients undergoing intra-or peri-articular injections, synovial fluid aspirations and spine injections suffer from procedural pain. [8] (10.1186/1471-2474-11-16)
• [L4] The anaesthetic effects are likely due to the agent acting in the subcutaneous space, and a simple subcutaneous injection is adequate. [9] (10.1177/1753193408097323)
• [L5] The ultrasound-guided injections took substantially longer to administer. [10] (10.1016/j.jse.2011.11.026)
• [L3] However, injections increase the rate of minor complications. [11] (10.1177/15589447221081862)
• [Case_report] The diagnosis can be challenging if the history of repeated injections is initially denied. [12] (10.2106/00004623-198365070-00017)
• [L2] The success rate, mean time to onset of anaesthesia, and the mean amount of anaesthetic injected were all significantly better under ultrasound guidance. [13] (10.1177/1753193411413664)
• [L2] [14] (10.1016/j.jhsa.2014.01.017)
• [L4] There is no consensus regarding the optimal technique, anesthetic agent, or adjuncts for digital block anesthesia. [15] (10.1016/j.jhsa.2008.10.010)
• [L2] Given the equivalence in analgesia provided with these 3 modalities, providers should carefully consider the option that best fits each patient. [16] (10.1016/j.jse.2024.06.014)
• [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. [17] (10.1016/j.jhsa.2021.06.022)
• [L3] Patients with an absent SNAP more often had a poor response to the first injection and may be better served by early surgical treatment. [18] (10.1177/1753193412469580)
• [L4] Patients experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after injection. [19] (10.1016/j.jse.2020.08.008)
• [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. [20] (10.1016/j.jseint.2019.12.007)
• [L1] These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection. [21] (10.1016/j.jhsa.2014.07.010)
• [L4] Although most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief. [22] (10.1016/j.jhsa.2017.02.001)
• [L3] Nevertheless, immediate improvement of pain, range of motion, and muscle strength can be expected regardless of location. [23] (10.1016/j.jse.2010.05.004)
• [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. [24] (10.1177/1558944718787330)
• [L4] A longer needle is required to increase the success of injections or aspirations through the posterior approach. [25] (10.1016/j.jse.2011.11.034)
• [L1] In the presence of a clear diagnosis, a trained clinician may perform an injection without ultrasound guidance with good and safe results. [26] (10.1302/0301-620x.98b4.36880)
• [L1] [27] (10.2106/jbjs.22.00034)
• [L5] [29] (10.1016/j.jhsa.2021.07.002)
• [L1] The short-term beneficial effects of steroid injections for symptoms were maintained during the follow-up after 12 months. [30] (10.1186/1471-2474-10-131)
• [L5] Expansion of indications for these injections should be approached with caution. [31] (10.1016/j.arthro.2022.03.003)
• [L2] Vibratory anesthesia is a useful adjunct for injections of the hand and upper extremity, as has been demonstrated in other specialties' literature. [32] (10.1177/15589447221109910)
• [L2] There was no statistically significant difference in pain experienced during local anesthetic administration or during the procedure between the two groups. [33] (10.1016/j.jhsg.2025.03.002)
• [L4] Patients who continue to experience symptom relief two years after injection are likely to maintain long-term success. [34] (10.2106/jbjs.n.00004)
• [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. [35] (10.1016/j.jse.2011.11.036)
• [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. [36] (10.1016/j.jhsa.2010.02.008)
• [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. [37] (10.1016/j.jhsa.2008.10.011)
• [L2] Surgeons may be free to choose where to inject analgesic agents according to each specific situation or their preferences. [39] (10.1016/j.jse.2014.12.009)
• [L3] The percentage of patients who received injections increased steadily until 2006 to 2007 when it began trending down, with a sharper decline in 2012 to 2013, while the number of injections per patient increased substantially. [40] (10.1016/j.arth.2015.08.024)
• [L5] Ultrasound guidance affords advantages including direct visualization of neural structures, detection of anatomical variants, smaller volumes of local anesthetic, shorter block performance time, faster onset, greater success, decreased pain, and increased patient satisfaction compared to traditional techniques. [48] (10.1016/j.jhsa.2010.11.037)
• [L2] There is a statistically significant difference in pain during and shortly after injection when using a steroid with lidocaine versus steroid alone, but that difference may not be clinically relevant. [50] (10.1016/j.jhsa.2024.05.016)
• [L1] Injections containing lidocaine cause more pain without significant delayed benefits of pain relief; this null finding indicates that lidocaine is unnecessary in trigger injections and in fact causes more pain during the injection. [52] (10.1016/j.jhsa.2018.06.090)
• [L4] If significant pain is experienced on inserting the needle, it appears negligent to continue with corticosteroid infiltration without first partially withdrawing and then redirecting the needle. [53] (10.1177/17531934097318)
• [L4] Relief of symptoms after instillation of local anesthetic and steroid into the hip joint has a positive predictive value and specificity of 100%, sensitivity of 95% and negative predictive value of 89.5%, making it a reliable test for distinguishing between pain arising from the hip joint and other sources. [54] (10.1016/j.arth.2010.01.038)
• [L4] Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. [55] (10.1016/j.jhsa.2019.10.035)
• [L2] The vapocoolant group experienced a significant reduction in mean injection pain of -2.70 VAS units, exceeding the reported minimal clinically important difference for acute procedural pain. [56] (10.1016/j.jhsa.2025.11.010)
• [L2] Decreasing the pain of injection only takes a minute of our valuable time for finger blocks. [57] (10.1007/s11552-012-9478-1)
• [L4] Hand surgeons should consider the benefit of high-dose triamcinolone injections when deciding on a treatment modality for common hand conditions. [58] (10.1016/j.jhsa.2025.09.014)
• [L1] The ShotBlocker device effectively reduced the pain of injection versus controls when scores were adjusted to account for pain tolerance. [59] (10.1177/1558944719884655)
• [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. [60] (10.1016/j.jhsa.2014.09.027)
• [L4] Nonoperative management with corticosteroid injection can be used as a therapeutic measure with potential long-term benefits in the treatment of RTS. [61] (10.1177/1558944718787282)
• [L3] We do not recommend administering a corticosteroid injection at the time of hand surgery. [62] (10.1016/j.jhsa.2019.07.004)
• [L1] Tumescent anesthesia combined with selective nerve blocks in hand surgery decreased the pain associated with injections and increased patient satisfaction. [63] (10.1016/j.jhsa.2015.08.027)
• [L4] These effects have been sustained in long-term follow-up with no reported complications. [64] (10.1016/j.jse.2019.06.011)
• [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. [65] (10.1016/j.arthro.2018.12.017)
• [L1] Based on this, the routine use of ultrasound guidance for subacromial injections is not necessary. [66] (10.1177/0363546515618653)
• [L1] Injections into the Greater Trochanteric Bursa may have longer lasting benefit. [67] (10.1186/s12891-024-07217-3)
• [L4] [68] (10.1016/j.arth.2006.08.006)
• [L4] This landmark can be used as a guide for clinicians when injecting local anaesthetic agents for ring blocks using both volar and dorsal approaches. [69] (10.1177/1753193419845291)
• [L4] Performing finger manipulation on Day 2 after collagenase injection is comparable with manipulation on Day 1 in terms of efficacy and safety. [70] (10.1177/1753193413490899)
• [L5] For accurate injections, the authors recommend making injections separately over the two tendons to account for the possibility of a septum. [71] (10.1177/1753193411409126)
• [L2] Perifracture site injections were not found to provide any additional pain control benefit. [73] (10.1016/j.jhsa.2010.07.023)
• [L3] Triamcinolone injection was associated with more frequent apparent resolution than dexamethasone, and delayed surgery treatment strategies were associated with higher resolution rates. [76] (10.1007/s11552-013-9493-x)
• [L4] The technique is most successful in the hands of experienced shoulder arthroscopists. [78] (10.1016/j.jse.2011.06.013)
• [L1] This meta-analysis showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection. [101] (10.1016/j.jhsa.2016.07.097)
• [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. [103] (10.1302/0301-620x.106b10.bjj-2024-0342.r2)
• [L5] This technique represents an option when interscalene block is unavailable, contraindicated, or not desired. [106] (10.1016/j.jseint.2020.04.017)
• [L5] Evidence regarding the efficacy of intra-articular corticosteroid injections for the osteoarthritic knee is inconclusive, and combining them with higher-dose anesthetics may compound chondrotoxic effects. [107] (10.2106/jbjs.17.00289)
• [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. [108] (10.1177/1753193415622733)
• [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. [111] (10.1177/1558944719836211)
• [L2] US-guided needling treatment, however, was more effective in function restoration and pain relief in the short term. [112] (10.1016/j.jse.2014.06.036)
• [L4] This study demonstrates that serious complications can occur following treatment with biologic injections, including infections requiring multiple surgical procedures and inflammatory reactions. [113] (10.1016/j.arthro.2021.03.065)
• [L1] CS provides significantly better short-term pain relief, while PRP provides better long-term functional improvement and clinical long-term pain relief. [116] (10.5397/cise.2024.00801)
• [L1] Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week. [119] (10.1016/j.jhsa.2007.08.002)
• [L1] In the long term, acupotomy has greater efficacy and is associated with a lower rate of recurrence than corticosteroid injections in the management of lateral epicondylitis. [120] (10.1186/s13018-022-03323-x)
• [L2] Both techniques are successful in improving function and pain, with high satisfaction rates after 1-year follow-up. [122] (10.1016/j.arthro.2020.02.027)
• [L4] [123] (10.1016/j.jhsa.2011.11.022)
• [L3] [128] (10.1054/jhsb.2000.0426)
• [Paper] [131] (10.1016/j.eats.2019.07.033)
• [L1] Open surgery is superior to ultrasound-guided corticosteroid injections. [132] (10.1016/j.jhsa.2017.02.011)
• [L1] Subacromial steroid injection is an alternative modality, and treatment should be individualized. [135] (10.1016/j.jse.2011.04.029)
• [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. [136] (10.1016/j.jhsa.2020.01.007)
• [L3] While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect. [145] (10.1177/15589447211032331)
• [L1] Corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain. [149] (10.1016/j.jhsa.2008.02.004)
• [L4] Multiple concurrent injections would eliminate the 30-day wait between single treatments and allow for rapid and effective treatment of patients with multiple affected joints. [151] (10.1186/1471-2474-13-61)
• [L1] Ultrasound-guided infiltration of the AC joint is simple, efficient and requires no previous experience to reveal excellent accuracy of administration of the active agent. [153] (10.1007/s00167-010-1197-y)
• [L4] The study demonstrated a 43.3% accuracy rate of completely intra-articular injections, whereas 66.7% of patients had some contrast dye in the joint. [154] (10.1177/0363546512467010)

See Also

• Trigger Finger
• Trigger finger release

References

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[2] 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

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[5] 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

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

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[8] 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

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

[10] 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

[11] The Effect of Thumb Carpometacarpal Joint Corticosteroid Injections on Outcomes Following Arthroplasty. HAND. 2022. DOI: 10.1177/15589447221081862

[12] 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

[13] 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

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

[16] 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

[17] 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

[18] The long-term follow-up of treatment with corticosteroid injections in patients with carpal tunnel syndrome. When are multiple injections indicated?. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412469580

[19] Efficacy of a single, image-guided corticosteroid injection for glenohumeral arthritis. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.08.008

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

[21] 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

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

[23] Blind subacromial injection from the anterolateral approach: The ballooning sign. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.004

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

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

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

[27] Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00034

[28] Green S Operative Hand Surgery. TABLE 1.1 Characteristics of Commonly Used Drugs > Regional Anesthesia.

[29] A New Consideration for Corticosteroid Injections: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19) Vaccination. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.07.002

[30] 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

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[64] Ultrasound-guided tenotomy improves physical function and decreases pain for tendinopathies of the elbow: a retrospective review. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.06.011

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[73] Evaluation of Early Postoperative Pain and the Effectiveness of Perifracture Site Injections Following Volar Plating for Distal Radius Fractures. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.07.023

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

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