Steroid Injections in Adult Patients With Joint and Soft Tissue Conditions JCG0055v3 PDF

Joint Trust Guideline for the Management of:
Steroid injections in adult patients with joint and soft tissue conditions
A clinical guideline recommended for use

Norfolk and Norwich University Hospitals NHS
For use in: Foundation Trust and James Paget University
Hospitals NHS Foundation Trust
Doctors and physiotherapists who are deemed
By:
competent following supervised training
Intra-articular and soft tissue steroid injections in
For:
adult patients
Division responsible for
Division 1
document:
Name and job title of document
Dr Chulanie Desilver, Consultant in Rheumatology
author:
Name and job title of document
Dr Karl Gaffney, Consultant in Rheumatology ,NNUH
author’s Line Manager:
Dr Karl Gaffney, Mr John Nolan, Dr Andoni Toms, Ms
Carol Payne, NNUH. Dr Tarnya Marshall, Consultant
Supported by:
in Rheumatology NNUH. Drs Makkuni ,Thomas
JPUH
Clinical Guidelines Assessment Panel (CGAP)
Assessed and approved by:
Chairs action 
Date of approval: 13/11/2018
Reported as approved
Clinical Standards Group and Effectiveness Sub-board
to the:
To be reviewed before: 13/11/2021
To be reviewed by: Dr Tarnya Marshall
Trustdocs ID No: 8272 JCG0055
Version No: 3
Description of changes: Table added regarding different steroid formulations.
Compliance links: None
If Yes – does the strategy/policy
deviate from the
N/A
recommendations of NICE?
If so, why?
This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis
and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a
standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing
clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge
and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should
be documented in the patient's case notes.
The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the
quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for
any misunderstanding or misapplication of this document.
Joint Clinical Guideline for: Steroid injections in adult patients with joint and soft tissue conditions
Author/s: Dr Chulanie Desilva Author/s title: Consultant in Rheumatology
Approved by: CGAP Date approved: 13/11/ 2018 Review date: 13/11 2021
Available via Trust Docs Version: 3 Trust Docs ID: 8272 Page 1 of 18
Joint Trust Guideline for the Management of:
Introduction
Joint and soft tissue injections are commonly undertaken in patients with joint and soft
tissue pathology in both primary care and a hospital setting. This is an established therapy
which has been embedded in standard clinical practice for many years, but the evolving
evidence base and the improved access to radiological imaging for targeted injection
therapy has changed current practice and it is timely to unify practice across the Trust.
Medical staff from the following departments are trained in joint and soft tissue injections in
their speciality training posts:
 Orthopaedics
 Pain Team
 Radiology
 Rheumatology
Other health care professionals who may undertake joint and soft tissue injections having
undertaken the relevant courses are:
 Physiotherapists
This guideline does not intend to cover the training requirements, nor does it cover
the management pathways of each condition, for example investigations,
rehabilitation, biomechanical assessment, orthotic provision and exercises. For
doctors, training will be covered within the procedural competencies laid out by the
General Medical Council but does not exist specifically for intra-articular and soft
tissue injections.
Physiotherapists will hold a postgraduate qualification in injection therapy,

accredited by the Association for Chartered Physiotherapists with an interest in
orthopaedic medicine and Injection therapy or similar.
It does cover the evidence base for commonly undertaken soft tissue and joint injections.
A quick reference guide is not appropriate as the diagnosis and anatomical location are all
subject to individual factors.
Objective
To provide a contemporary, evidence-based approach to joint and soft tissue injections and
to unify practice across all departments in the Trust based on recent published and
nationally-driven best practice opinion. This guideline does not cover the treatment
pathways for joint/soft tissue aspiration but aims to cover the therapeutic indications for
steroid and local anaesthetic injections.
Rationale
Increasingly there is emerging evidence that the efficacy of some procedures is not as
strong as has been anecdotally reported and indeed there may be potential to cause harm.
This guideline summarises the current evidence base.
Trust Guideline for the Management of:
Broad recommendations
Joints which are synovitic should only be injected within the Rheumatology service or by
Radiologists following a request from Rheumatology after appropriate clinical assessment.
Lower limb joint injections should be pre-planned i.e. be followed by a period of 24 hours
absolute rest and transport home, such as currently provided in the Rheumatology Day Unit.
(1, 2)
Lower limb tenosynovitis injections around the foot and ankle should only be undertaken
following podiatry input and appropriate imaging, and only in cases of localised disease in
patients with inflammatory arthritis. (3)
Injections can only be administered by a medical practitioner or other health professional,

following appropriate training, and for non-prescribers, this can only be done under the remit
of a Patient Group Directive (PGD). Physiotherapists and Rheumatology practitioners have
a more stringent list of contraindications outlined in their PGDs. See Appendices.
Relative contraindications
Injection in the presence of the following must only be undertaken by a medical practitioner
or after discussion with a medical consultant. These include:
 bleeding diathesis/ anticoagulation

 prosthetic joint
 infection in overlying skin
 lack of response to previous injection
Frequency of injections
 Soft tissue – every 3-6 weeks

 Joints – every 3-4 months
There is no upper limit to the number of injections that can be undertaken although
physiotherapists are more restricted in their PGDs than medical staff. See appendices
Anticoagulation
For patients who are taking warfarin, an INR of 3 or less is not a contraindication for joint
injection. For patients on low molecular weight heparins and Direct Oral Anticoagulants
(DOACS) no other precautions are necessary.
Local anaesthetic
1 - 4mL of 1% or 2% lidocaine can be mixed with depomedrone. Non medical practitioners

who administer injections should not mix lidocaine and steroid, in line with national guidance
(4) and local PGD.
Bupivacaine is a long acting local anaesthetic and is preferred for diagnostic injections
undertaken in the Radiology Department.
Steroid
Depomedrone is the steroid preparation which is listed for the majority of injections, but an
equivalent dose of another corticosteroid for example triamcinolone would be acceptable
and can be used at the clinician’s discretion.
Procedure
This covers “blind” injections (not those undertaken under radiological guidance where
antiseptic techniques cover the equipment used for imaging)
A “no touch” technique is utilised, ensuring the skin is not touched once it has been cleaned.
 Ensure no drug allergies

 Confirm is the patient is not taking anticoagulants.
 Take verbal consent (see below) and record this in the health record
 Skin preparation – Medi swabs/Alcohol
 Local anaesthetic can be administered to the skin and underlying tissue prior to the
injection being administered, if the injection is
technically difficult or particularly uncomfortable. 2mL of 1% lidocaine is
usually sufficient for this purpose.
Complications of corticosteroid injections and verbal consent
Verbal consent must always be taken prior to injection having discussed the potential risks
and this must be documented in the medical record. :
Risks of injections include
1. Pain
2. Worsening of symptoms eg carpal tunnel syndrome
3. Infection (<0.001%)
4. Fat atrophy or hypopigmentation
5. Post injection steroid flare for 24-48 hours (10%)
6. Tendon rupture ( 0.1%)
7. Transient blood sugar elevation in patients with diabetes
8. May not work
9. Risk of bleeding, especially if on anticoagulants
10. Flushing (40%)
Post procedure advice should cover duration of rest which includes limiting weight bearing
for lower limb joints for 24 hours. rest.
Recommendation by process and anatomical location
Index Page
1. Joint disease 7
 Osteoarthritis 7
o glenohumeral joint 7
o acromioclavicular joint 7
o sternoclavicular joint 7
o the elbow capsule 7
o wrist 8
o distal radioulnar joint 8
o thumb carpometacarpal joint 8
o hip 8
o knee 8
o ankle mortice joint 9
o subtalar joint and midtarsal joints 9
o first metatarsal interphalangeal joint 9
 Capsulitits 9
 Synovitis 10
2. Soft tissue 10
 Bursitis 10
o Subacromial space and rotator cuff 10
o Subscapularis bursa 10
o Olecranon bursa 10
o Trochanteric bursa 10
o Ischial bursa 11
o Iliotibial band bursa 11
o Infrapatellar bursa 11
o Anserine bursa 11
o Achilles tendon and bursa 11
 Tendinopathy 12
 Tenosynovitis 12
o De Quervain’s tenosynovitis 12
o Trigger finger 12
o Adductor tendinitis 12
o Patellar tendinitis 12
o Peroneal tendinitis 12
o Achilles tendon and bursa 13
 Tendon insertions 13
 Entrapment neuropathies 13
o Carpal tunnel syndrome 13
o Suprascapular nerve block 13
o Morton’s neuroma 14
 Ganglia 14
 Ligaments 14
 Plantar fasciitis 14
1. Joint disease:
Osteoarthritis
There is data indicating that 1 in 4 patients with osteoarthritis of the knee respond to an
intra-articular steroid injection (5,6). Other osteoarthritic joints can be injected but there is
less evidence to support efficacy.
Glenohumeral joint
Osteoarthritis of the shoulder joint is uncommon and imaging is required to confirm the
diagnosis prior to injection. The glenohumeral joint is most easily accessed from the
posterior approach. From behind, palpate the tip of the acromion and identify the coracoid
process. The needle should be inserted perpendicular to the skin, 2.5 cm inferiorly and
2.5cm medially to the tip of the acromion, with the tip of the needle aiming towards the
coracoid process.
 The anterior approach requires the needle to be inserted just medially to the coracoid
process. The anterior approach is less commonly use than the posterior due to the
relative proximity of the large vessels and brachial plexus.
 Needle: 21G, inserted to a depth of approximately 4cm.
 Steroid: depomedrone 40 mg
Acromioclavicular joint
Where there is diagnostic uncertainty, this injection should be undertaken under ultrasound
guidance to aid accurate placement of the injection.
 The acromioclavicular joint is identified 1cm medially from the tip of the acromion. It
can be felt to move when the shoulder is shrugged. The patient sits with their arm
hanging by their side and the needle is inserted at an angle of 30º medially as the
joint sits at an angle. This can be a difficult joint to inject, but ‘walking’ the needle
slowly and gently across the acromion can help in identifying the acromioclavicular
joint.
 Needle: 25G, inserted 1cm
 Steroid: depomedrone 20mg.
Sternoclavicular joint
Due to close proximity of the underlying major vessels and pleura, this should only be
undertaken under ultrasound guidance.
 Needle: 25G, inserted 1cm.
The elbow capsule

Elbow osteoarthritis is uncommon and injection of the joint should only be undertaken
following appropriate imaging.
 The elbow capsule houses the radio-humeral, radio-ulnar and humero-ulnar joints.
The joint is most easily accessed from a lateral approach. The patient sits with the
elbow at 90º of flexion. The needle is inserted into the space between the head of the
radius and the olecranon process of the humerus, with the needle parallel to the top
of the radius.
Wrist
 The hand is placed palm down, and just proximal to the capitate is a hollow, within
the mid-carpus bones. The needle is inserted into the hollow.
Distal radioulnar joint
 The hand is placed palm down, and the joint line identified midway between the
radial and ulnar styloids. The needle is inserted perpendicular to the skin.
 Needle: 25G, inserted by 1.5cm.
Thumb carpometacarpal joint
 The arm is positioned on the ulnar border of the forearm with the thumb uppermost.
The joint space between the trapezium and the metacarpal is easily identified.
Traction on the thumb helps to open up the joint space. The needle may be inserted
in to the joint.
 Needle: 25G, inserted 0.5cm.
 Steroid: hydrocortisone 10mg.
The hip
The hip is a deep joint and should only be injected under radiological guidance, followed by
a period of 24 hours absolute rest. These injections should therefore be pre-planned with
appropriate post injection rest and transport to the car, such as is currently provided in the
Rheumatology Day Unit.
 Needle: 21G, inserted by around 4cm.
The knee
As there is evidence that patients have the best clinical response to a steroid injection if
they have at least 24 hours of absolute rest these injections should be pre-planned with
 The patient is positioned lying on their back with the knee in slight flexion and
supported. Either a medial or a lateral approach can be taken. The medial approach
requires identification of the midpoint of the patellar and insertion of the needle under
the patella and above the femoral condyle. In the lateral approach, the same
technique is applied, but from the lateral aspect.
 Needle: 21G, inserted 3-4cm.

Ankle mortice joint
As there is evidence that patients have the best clinical response to a steroid injection if
they have at least 24 hours of absolute rest these injections should be pre-planned with
 The foot is supported in neutral. The ankle joint lies between the lateral and medial
malleoli, and the ankle joint may be followed laterally, and identified by passively
flexing and extending the ankle. The needle is inserted directly into the joint, passing
through the capsule.
Subtalar joint and midtarsal joints
The subtalar and midtarsal joints are difficult to access “blindly” and should therefore be
injected under ultrasound guidance.
 Needle: 25G
First metatarsal interphalangeal joint
 The patient lies with the foot supported. The joint line can be palpated and identified
by passively moving the great toe. The needle is inserted perpendicularly, avoiding
the extensor tendon in the midline.
 Steroid: hydrocortisone 25mg
Capsulitis
Capsulitis most commonly occurs in the shoulder joint but is also reported in the wrist.
There is little evidence to support steroid injections in this condition (7).
Intra-articular steroid injection may be administered as current best practice advocates early
intervention for both primary and secondary contracted frozen shoulder (7,8). Patients
should be advised that this will not be curative but may alleviate some symptoms in the
short term pending spontaneous resolution of the capsulitis.
Hydrodistension of the shoulder may be useful, at least in the short term but must be
undertaken with imaging in Radiology (9).
Synovitis
All patients with synovitis should be referred to the Rheumatology service for an
assessment.
2. Soft tissue:
Bursitis
Non-infective bursitis responds to steroid injections. Only those bursa discussed here can
be injected routinely and those where ultrasound guidance is recommended should not be
injected “blindly”.
Subacromial space and rotator cuff
 The patient sits with the arm hanging by their side. This opens up the subacromial
space between the acromion and humeral head. The lateral edge of the acromion
should be palpated and the needle inserted below the midpoint of the acromion.
Subscapularis bursa
This should only be injected in the Radiology department under ultrasound guidance.
 The patient sits supported with arm by their side and held in 45 degrees lateral
rotation. The medial edge of the lesser tuberosity should be palpated lateral to the
coracoid process. The needle is angled slightly laterally.
Olecranon bursa
This should only be injected following Rheumatology input for as the underlying diagnosis
needs to be confirmed to inform medical management e.g. gout
 The patient sits with the elbow flexed to 90º. The area of the tenderness is palpated
and the needle inserted into the central tenderness.
Trochanteric bursa
 The patient lies on their side with the painful hip uppermost. The site of the maximum
tenderness is palpated over the greater trochanter. The needle is injected
perpendicular to the skin and the steroid and local anaesthetic mixture injected in a
fan like approach in the tender region.
Ischial bursa
This should only be injected in the Radiology department under ultrasound guidance and
after MRI.
 Patient lies on the unaffected side with upper leg flexed. Palpate Ischial tuberosity
and insert needle into mid point angled upwards.
liotibial band bursa
 Patient sits with knee supported; tender area is marked on lateral side of femur.
Needle is inserted into bursa and solution is deposited in a bolus.
 Steroid: depomedrone 20mg
Infrapatellar bursa
 The knee is slightly flexed and supported. The deep infrapatellar burse sits beneath
the patellar tendon and the needle is inserted beneath the tendon, either from a
medial or a lateral approach. It is important not to insert the needle into the patellar
tendon.
Pes anserine bursa
 The knee is supported in extension. The pes anserine tendon is identified by flexing
the knee against resistance. The point of insertion can be palpated on the tibia, and
the bursa lies deep to this, and is tender. The needle is inserted into the central area
of tenderness, and onto the bone.
Achilles tendon and bursa
The Achilles tendon should not be injected as there is no tendon sheath, and injection may
result in rupture (10). The achilles bursa lies in the triangular space anterior to the tendon
and posterior to the base of the upper part of the calcaneus. This should only be injected in
the Radiology department and under ultrasound guidance. The safest approach is from the
lateral side to avoid the posterior tibial artery and nerve.
Tendinopathy
There is no evidence base supporting the practice of injecting degenerate tendons and as
these may rupture, as a consequence of the degenerative process, or as a result of the
anaesthetic effect, injections should be avoided.
Tenosynovitis
In the lower limb there is increasing concern that tenosynovitis in patients without an
underlying systemic inflammatory disease may result in tendon rupture, so these should not
routinely be undertaken.
In the upper limb, there is evidence that steroid injections are beneficial in De Quervain’s
tenosynovitis (11). Flexor tenosynovitis should only be injected after Rheumatological
assessment to exclude the presence of an underlying systemic inflammatory disease.
De Quervain’s tenosynovitis
 The arm is positioned on the ulnar border of the forearm with the thumb uppermost.
The abductor pollicis longus and extensor pollicis brevis tendons run together in one
tendon sheath. The gap between the tendons is identified and the needle inserted
into the gap. As the injection is administered, there may be a swelling as the fluid
moves out of the opposite end of the tendon sheath.
Trigger finger
There is good evidence to support the use of corticosteroids in the management of trigger
finger (12).
 A nodule is often palpable at the base of the finger in the flexor tendon sheath. The
nodule is directly injected with the steroid.
Adductor tendinitis
These are currently only undertaken following diagnosis with MRI and are injected under
ultrasound guidance in the Radiology department.
 Needle: 20mg, inserted 3cm.
Patellar tendinitis
In view of the risk of rupture, this should not be undertaken routinely.
Peroneal tendinitis
In view of the risk of rupture, this should not be undertaken routinely and not without
podiatry and orthotic input, and only in patients with inflammatory arthritis (3).
The Achilles tendon and bursa
The Achilles tendon should not be injected as there is no tendon sheath, and injection may
result in rupture (9). This should only be injected in the Radiology department and under
ultrasound guidance. The achilles bursa lies in the triangular space anterior to the tendon
and posterior to the base of the upper part of the calcaneus. The safest approach is from
the lateral side to avoid the posterior tibial artery and nerve.
Tendon insertions
Injections are not recommended routinely for insertional tendinopathies as these are
overuse / degenerative pathologies; patients should be advised that an injection may impair
the healing process (13).
There is no indication to inject the patellofemoral or the achilles tendon insertion, and these
are not routinely undertaken.
Entrapment neuropathies
Injections that may be undertaken in clinical practice are for carpal tunnel syndrome (14),
suprascapular nerve block (15, 16) and Morton’s neuroma (17). Local anaesthetic is
normally administered at the same time, except in carpal tunnel syndrome due to an
increase in short term paraesthesia.
Carpal tunnel syndrome
 The hand is placed with the palm facing up. Identify the proximal wrist crease. The
palmaris longus tendon should be identified. The needle should be inserted on the
ulnar side of the palmaris longus tendon at an angle of 45º with the needle aiming
towards the tip of the middle finger. If there is acute worsening of pain and numbness
in the distribution of the median nerve, the needle should be removed and
repositioned as it is likely to be in the median nerve. Patients should be warned that
the symptoms may deteriorate in severe carpal tunnel due to increase in pressure
around the nerve. Local anaesthetic is not normally administered as local anaesthetic
may worsen the paraesthesia in the short term.
Suprascapular nerve block

A suprascapular nerve block has been shown to be a safe and efficacious treatment for the
treatment of shoulder pain in degenerative disease and/or arthritis (16). This should only be
carried out in Rheumatology, Radiology or by the Pain Team.
 The patient sits with their arm in the neutral position . Identifying the lateral end of
the spine of the scapula, move one-third along medially and mark a spot superiorly in
the supraspinous fossa. Insert needle perpendicular to the fossa and touch bone.
Morton’s neuroma
A nerve block has been shown to be superior to shoe modifications alone for burning
pain/paraesthesia, most commonly at the first or second interspace between or slightly
distal to the metatarsal heads (17,18). This injection should only be done under ultrasound
guidance.
 The patient sits supported with the foot placed flat on a table. The tender area
between MT heads is marked. The needle is inserted perpendicularly through the
dorsal skin at this point. If a sharp burning sensation is reported the needle tip is
withdrawn slightly. Steroid is deposited around neuroma.
 Steroid depomedrone 20mg.
Ganglia
These may be deep within the tissues and these should be aspirated and injected under
radiological guidance. Superficial, easily palpable ganglia may be aspirated if not next to
vital structures (nerve, artery).
Ligaments
There is no indication to routinely inject ligaments. In the foot and ankle, injection around
ligament insertions should only be undertaken by the orthopaedic foot surgeons or, by
physiotherapists working closely with this team and following discussion.
 Patient lies supported on table. Identify and mark anterior inferior edge of lateral
malleolus. Insert needle to touch bone and pepper the solution.
 Needle: 25G
 Steroid Depomedrone 10 mg.
Plantar Fasciitis
The evidence base for steroid injections for plantar fasciitis is evolving and these should
only be undertaken in patients with refractory symptoms and in whom a podiatry
assessment has been undertaken. Patients should be warned that response may be short
lived and there is a risk of rupture (19). If these are undertaken, a medial approach should
be used.
Preparations and properties of injectable corticosteroid
Corticosteroid Supplied Dosing Potency using

hydrocortisone as
reference agent
Short acting
Hydrocortisone 25 mg/ml, 50 mg/ml Tendon Sheath and 1.0 (20 mg)
acetate (licensed but bursas: 8-40 mg
not currently Small Joints: 8-20
available) mg
Large Joints: 40-100
mg
Intermediate-Acting
Prednisolone 25mg/ml 5-25mg depending 3.5 (5 mg)
(Deltastab®) on joint size
Prednisolone 20 mg/ml Tendon Sheath and 4 (5 mg)
tebutate (Hydeltra®) bursas: 4-10 mg
.Small Joints: 2-5 mg
Large Joints: 10-25
mg
Triamcinolone Adcortyl 10 mg/ml, Tendon Sheath and 5 (4 mg)
(Adcortyl ®Aristocort, Kenalog 40 mg/ml bursas: 4-10 mg
Aristospan, Small Joints: 2-5 mg
Kenalog®) (use Adcortyl)
Large Joints: 10-25
mg( use Kenalog)
Methylprednisolone 40mg/ml, 80mg/2ml Tendon Sheath and 5 (4 mg)
acetate (Depo- bursas: 20-40 mg
Medrone®l) Small Joints: 20 mg
Large Joints: 80 mg
Depo-Medrone with Lidocaine Tendon Sheath and 5 (4 mg)
Lidocaine® hydrochloride bursas: 20-40 mg
10mg/ml Small Joints: 20 mg
Methylprednisolone Large Joints: 80 mg
acetate 40mg/ml
Triamcinolone 20mg/ml Tendon Sheath and

hexacetonide bursas: 2-10mg
Small Joints:2-10mg
Large Joints: 20mg
Long acting
Betamethasone 4 mg/ml, 6 mg/ml, Tendon Sheath 25 (0.6 mg)
sodium phosphate 8 mg/ml and bursas: 1.5-3.0
(Betnesol® mg
Small Joints: 0.8-
1.0 mg
Large Joints: 2-4
mg
Clinical audit standards
Each department should keep data about the indication for and procedure that is
undertaken, and should therefore be responsible for their own audit.
Physiotherapists undertake the following monitoring processes to determine levels of

compliance with Trust PGDs:
1. All physiotherapy IT practitioners are entered on the live departmental register.

2. All physiotherapy IT practitioners have evidence of attendance at annual mandatory
training recorded on the live departmental register.
3. All physiotherapy IT practitioners maintain a log of injections performed.
4. All injections performed have the following detailed on the IT log sheet:
 date of administration injection
 patient identifier
 patient diagnosis
 pain score (pre injection)
 pain score (post injection)
 patient reported clinical outcome
 patient satisfaction
5. All physiotherapy IT practitioners perform one witnessed injection every two years as
recorded on the IT log sheet.
Summary of development and consultation process undertaken before registration

and dissemination
The author listed above drafted this guideline on behalf of the Rheumatology Department,
Orthopaedic Department, Radiology Department, Pain Team and Physiotherapy
Department, who have agreed the final content.
During its development it was circulated for comment to: Dr Karl Gaffney, Mr John Nolan, Dr
Andoni Toms, Dr Mark Sanders, Dr Peter Woodhouse, Dr Jennie Wimperis, Ms Carol
Payne and Ms Sue Christie.
The comments were aimed at evidence base and current practice. Some are based on
current best practice.
The physiotherapy injection protocol, which reflects existing physiotherapy practice, was
used as the basis for the development of this clinical guideline.
This version has been endorsed by the Clinical Guidelines Assessment Panel.
Distribution list/ dissemination method
This will be disseminated to each department via the clinical leads.
References
1. Randomized controlled study of post-injection rest following intra-articular steroid

therapy for knee synovitis. Chakravarty K et al. British Journal of Rheumatology.
33(5):464-8, 1994 May.
2. Where should patients rest following intra-articular steroid therapy for knee synovitis?
Gaffney K et al. Rheumatology 2000:39 (suppl 1):87
3. Best practice as discussed recently with foot surgeons, rheumatology, radiology,

physiotherapy and podiatry September 2011 NNUH.
4. The use of medicines in physiotherapy injection therapy in NHS settings. 3 rd ed.

Chartered Society of Physiotherapy, London. 2010.
5. Safety and efficacy of long term intra-articular steroid injections in osteoarthritis of the
knee: a randomised, double-blind, placebo controlled trial. Raynauld JP et al. Arthritis
Rheum. 2003:48:370-7
6. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. Arroll B et al. BMJ
2004;328:869
7. Corticosteroid injections for shoulder pain. Buchbinder R. Green S. Youd JM. Cochrane
Database of Systematic Reviews. 2003
8. Hanchard N, Goodchild L, Thompson J, O’Brien T, Richardson C, Davison D, Watson
H, Wragg M, Mtopo S, Scott M. (2011) Evidence-based clinical guidelines for the
diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder
v.1.5, ‘standard’ physiotherapy, Chartered Society of Physiotherapy, London.
9. Arthrographic distension of the shoulder joint in the management of frozen shoulder.

Khan AA. Mowla A. Shakoor MA. Rahman MR. Mymensingh Medical Journal: MMJ.
14(1):67-70, 2005 Jan.
10. Achilles tendonitis: are corticosteroid injections useful or harmful? Shrier I.

Matheson GO. Kohl HW 3rd. Clinical Journal of Sport Medicine. 6(4):245-50, 1996 Oct.
11. Randomised controlled trial of local corticosteroid injections for de Quervain's

tenosynovitis in general practice. Peters-Veluthamaningal C. Winters JC. Groenier KH.
Meyboom-DeJong B. BMC Musculoskeletal Disorders. 10:131, 2009.
12. Corticosteroid injection for trigger finger in adults. Peters-Veluthamaningal C. van der
Windt DA. Winters JC. Meyboom-de Jong B. Cochrane Database of Systematic
Reviews. (1):CD005617, 2009.
13. Efficacy and safety of corticosteroid injections and other injections for management of
tendinopathy: a systematic review of randomised controlled trials. Coombes BK. Bisset
L. Vicenzino B. Lancet. 376(9754):1751-67, 2010 Nov 20.
14. Local corticosteroid injection for carpal tunnel syndrome. Update of Cochrane Database
Syst Rev. 2002;(4):CD001554; Marshall S. Tardif G. Ashworth N. Cochrane Database
of Systematic Reviews. (2):CD001554, 2007.
15. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in

chronic shoulder pain. Shanahan EM. Ahern M. Smith M. Wetherall M. Bresnihan B.
FitzGerald O, Annals of the Rheumatic Diseases. 62(5):400-6, 2003 May.
16. Safety and acceptability of suprascapular nerve block in rheumatology patients.

Shanahan EM, Shanahan KR, Hill CL, Ahern MJ, Smith MD. Clin Rheumatol. 2011 Jul
20.
17. Clinical Inquiry. What is the best way to treat Morton's neuroma? Schreiber K, Khodaee
M, Poddar S, Tweed EM. J Fam Pract. 2011 Mar;60(3):157-8, 168.
18. Best practice as discussed at the Association of Chartered Physiotherapists with an
Interest in Orthopaedic Medicine and Injection Therapy Annual Scientific Conference,
London, 2011.
19. Incidence of plantar fascia ruptures following corticosteroid injection. Kim C. Cashdollar
MR. Mendicino RW. Catanzariti AR. Fuge L. Foot & Ankle Specialist. 3(6):335-7, 2010
Dec.
Source document
Saunders, S & Longworth, S 2011, Injection Techniques in Musculoskeletal Medicine: A

Practical Manual for Clinicians in Primary and Secondary Care, 4th edn, Churchill
Livingstone, Edinburgh.
Appendices
 Patient Group Direction for the administration by injection of Methylprednisolone
Acetate (40mg) and Triamcinolone Acetonide (40mg), by Qualified Chartered
Physiotherapists (Ref 161.1)
 Patient Group Direction for the administration by injection of Lidocaine
Hydrochloride (1%) and Lidocaine Hydrochloride (2%), by Qualified Chartered
Physiotherapists (Ref 46.2)

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What is the purpose of the guideline?

What is the purpose of the guideline?

What conditions are covered in the guideline?

What conditions are covered in the guideline?

Joint Trust Guideline for the Management of:

A clinical guideline recommended for use

Physiotherapists will hold a postgraduate qualification in injection therapy,

Injections can only be administered by a medical practitioner or other health professional,

 bleeding diathesis/ anticoagulation

 Soft tissue – every 3-6 weeks

1 - 4mL of 1% or 2% lidocaine can be mixed with depomedrone. Non medical practitioners

 Ensure no drug allergies

Complications of corticosteroid injections and verbal consent

Risks of injections include

The elbow capsule

 Needle: 21G, inserted 3-4cm.

First metatarsal interphalangeal joint

Suprascapular nerve block

Preparations and properties of injectable corticosteroid

Corticosteroid Supplied Dosing Potency using

Triamcinolone 20mg/ml Tendon Sheath and

Physiotherapists undertake the following monitoring processes to determine levels of

1. All physiotherapy IT practitioners are entered on the live departmental register.

Summary of development and consultation process undertaken before registration

This will be disseminated to each department via the clinical leads.

1. Randomized controlled study of post-injection rest following intra-articular steroid

3. Best practice as discussed recently with foot surgeons, rheumatology, radiology,

4. The use of medicines in physiotherapy injection therapy in NHS settings. 3 rd ed.

9. Arthrographic distension of the shoulder joint in the management of frozen shoulder.

10. Achilles tendonitis: are corticosteroid injections useful or harmful? Shrier I.

11. Randomised controlled trial of local corticosteroid injections for de Quervain's

15. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in

16. Safety and acceptability of suprascapular nerve block in rheumatology patients.

Saunders, S & Longworth, S 2011, Injection Techniques in Musculoskeletal Medicine: A

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