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Joint and Soft Tissue Injections

Julie A. Creech-Organ, DO
Sarah E. Szybist, DO
Jacqueline L. Yurgil, DO

American Family Physician. 2023;108(2):151-158.

Author disclosure: No relevant financial relationships.

Patient information: See related handout on joint and soft tissue injections.

Diagnostic Injections

Therapeutic Injections

Preparation

Contraindications

Complications

Reference(s)

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Indications for Joint and Soft Tissue Injections

Therapeutic Injection Considerations for Common Musculoskeletal Conditions

Suggested Composition and Needle Size for Common Landmark-Guided Corticosteroid Injections

Landmark-based knee injection setup.

Supplies for Joint or Soft Tissue Injection

Tray setup and supplies for injection.

Indications for Referral for Joint or Soft Tissue Injections

Joint and soft tissue injections can be divided into two primary categories: diagnostic and therapeutic. Diagnostic injections facilitate a diagnosis by using a local anesthetic to identify the site of pain or through fluid aspiration for analysis. Therapeutic injections are categorized by the type of injectate and include corticosteroids, hyaluronic acid, dextrose prolotherapy, and platelet-rich plasma. Diagnostic and therapeutic injections are most accurate under direct visualization. Corticosteroid injections help treat adhesive capsulitis and tenosynovitis but are not recommended for intratendinous injections. Hyaluronic acid has limited benefits for knee osteoarthritis. Dextrose prolotherapy injections treat tendinopathy and degenerative joint pain. Platelet-rich plasma injections effectively treat common extensor tendinopathy and knee arthritis; however, the evidence does not support its use for other soft tissue injuries. Preparation for injections includes patient education, consent, proper patient positioning, and obtaining the necessary supplies. Local infection, fractures, and allergy to injection substrates are contraindications to joint and soft tissue injections. Potential complications include pain, swelling, and redness. Corticosteroid injections into soft tissue may cause atrophy and depigmentation, and repeated injections can cause cartilage and tendon degeneration. Optimizing conservative, noninjection treatments, such as oral and topical analgesics, activity modification, or rehabilitation, is also important.

Musculoskeletal conditions are reported by 48% of the population and are a significant component of primary care visits.1 Joint and soft tissue injections can serve as diagnostic aids and adjunctive treatments (Table 12 ). Injections can be categorized as diagnostic or therapeutic. A diagnostic injection clarifies the underlying pathology causing pain. Diagnostic injections introduce a local anesthetic with subsequent evaluation for symptom relief. Aspiration of synovial fluid for substrate analysis is classified as a diagnostic injection; however, it can also be therapeutic for joint effusion or a painful cyst.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Intrasheath corticosteroid injections may be effective for treatment of trigger finger and de Quervain tenosynovitis.14,15,17 B Inconsistent quality patient-oriented evidence
Dextrose prolotherapy is effective in the treatment of common extensor tendinopathy.43,44 A Consistent patient-oriented evidence
Intra-articular injection of dextrose prolotherapy improves pain and function in patients with knee osteoarthritis.45–48 A Consistent evidence from randomized controlled trials
Repeated and frequent intra-articular injections of triamcinolone acetonide decrease cartilage thickness.66,67 C Randomized controlled trials with disease-oriented outcomes

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

TABLE 1. Indications for Joint and Soft Tissue Injections

Joint conditions
Chondromalacia
Crystalloid arthropathies
Effusion
Inflammatory arthritis
Intra-articular derangement (e.g., meniscal injury)
Osteoarthritis
Synovitis
Soft tissue conditions
Bursitis
Masses (e.g., ganglion cysts, neuromas)
Nerve entrapment
Neuropathic pain
Tendinopathy
Tendon/ligament/muscle disruption
Tenosynovitis or tendinopathy
Trigger point

Adapted with permission from Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002;66(2):284.

Therapeutic injections provide clinical benefits by relieving pain, restoring function, or both. These injections commonly include corticosteroids, hyaluronic acid, dextrose prolotherapy, and platelet-rich plasma.

Diagnostic and therapeutic injections can be performed with and without imaging guidance; however, imaging guidance increases injection accuracy and is warranted in specific anatomic locations, including the glenohumeral joint, femoroacetabular joint, and nerve hydrodissections.3 Knowledge of anatomy, proper patient positioning, and physician preparedness are essential for all injections. A patient's understanding of risks, benefits, and alternatives promotes patient-oriented outcomes.4,5

Diagnostic Injections

Diagnostic injections identify which structure is generating pain when nearby structures overlap the pattern of symptoms. For example, a diagnostic injection can accurately identify the cause of shoulder pain in a patient with both glenohumeral and acromioclavicular joint pain features or if conservative management has been ineffective.

Lidocaine, bupivacaine, and ropivacaine (Naropin) are commonly used in diagnostic injections. Anesthetic injections have a dose-dependent potential for cell damage, most prominently with lidocaine and bupivacaine.6,7 Evidence supports ultrasonography to improve the accuracy of injection of the acromioclavicular joint, biceps tendon sheath, glenohumeral joint, and hip joint.8–10 A targeted soft tissue diagnostic injection providing immediate relief of more than 50% of preprocedural pain clarifies the diagnosis.

Therapeutic Injections

Therapeutic injections should be used with injury-specific rehabilitation and modification of aggravating activities.11 Table 2 summarizes the evidence-based application of therapeutic injection for musculoskeletal conditions.12 Other therapeutic injections, such as botulinum toxin, sclerotherapy, mesenchymal signaling, and other cellular therapies are beyond the scope of this article.

TABLE 2. Therapeutic Injection Considerations for Common Musculoskeletal Conditions

Therapeutic injectate classMusculoskeletal pathology
CorticosteroidsAdhesive capsulitis
Degenerative joint disease*
Inflammatory arthropathy (e.g., gout)
Nerve entrapment
Shoulder impingement
Tenosynovitis
Dextrose prolotherapyDegenerative joint disease
Ligamentous pathology
Tendinopathy
Hyaluronic acidKnee osteoarthritis
Platelet-rich plasmaCommon extensor tendinopathy
Knee osteoarthritis

*—Corticosteroid injections administered more often than every three months is discouraged.

Information from reference 12.

CORTICOSTEROID

Indications. High-quality evidence supports the use of corticosteroid injections for adhesive capsulitis, de Quervain tenosynovitis, and trigger finger.13–17 In a systematic review and network meta-analysis evaluating pharmacologic treatments for adhesive capsulitis, the most significant benefit was found in patients with less than two months of symptoms who had intra-articular glenohumeral corticosteroid injections or corticosteroid injections and capsule distention.13 For de Quervain tenosynovitis, tendon sheath corticosteroid injections alone provided greater pain relief compared with corticosteroid injections with splinting, splinting alone, rest, or nonsteroidal anti-inflammatory drugs (NSAIDs) in patients 38 to 50 years of age.14 In patients who are pregnant and breastfeeding with de Quervain tenosynovitis, corticosteroid injection is superior to thumb spica splinting.17 In a double-blind, randomized controlled trial (RCT) of 50 patients, tendon sheath corticosteroid injections for trigger finger had a significantly higher success rate compared with normal saline injection in decreasing the frequency of triggering and severity of symptoms.15

Corticosteroids are also used to treat nerve entrapment (e.g., the median nerve at the carpal tunnel); however, evidence suggests that benefits may be attributed to corticosteroid and physical tissue distortion.18 Tendinopathies such as gluteus medius (greater trochanteric pain) and common extensor tendinopathy (lateral epicondylopathy, tennis elbow) were previously thought to benefit from corticosteroid injections, but extensive evidence shows that rehabilitation outperforms any combination of treatments, including corticosteroid injections.19–21 Table 3 offers composition and needle size guidance for commonly performed landmark-guided corticosteroid injections.12,22–24 Figure 1 provides an example of a setup for a knee injection.

TABLE 3. Suggested Composition and Needle Size for Common Landmark-Guided Corticosteroid Injections

Anatomic siteInjectate doseNeedle size
1% lidocaine (mL)Triamcinolone acetonide (mg)*Betamethasone (mg)GaugeLength (in)
Intra-articular knee3 to 4206251.5 to 2
Acromioclavicular joint0.5 to 110 to 203 to 6251 to 1.5
Glenohumeral joint4 to 620622 or 251.5 to 2
Subacromial space4 to 6206251.5 to 2
de Quervain tenosynovitis1 to 2206251 to 1.5
Trigger finger110 to 20325 or 271 to 1.5
Trochanteric bursa4 to 6206221.5 to 2
Carpal tunnel0.5 to 1203 to 625 or 271 to 1.5
Morton neuroma1 to 2203 to 6251 to 1.5

Note: Triamcinolone acetonide dosing is equivalent to methylprednisolone dosing.

*—To ensure appropriate volume of injectate, this table assumes the use of triamcinolone acetonide, 40 mg per mL. Recent studies suggest lower doses of corticosteroid (20 mg of triamcinolone acetonide) are as effective as higher doses (40 mg of triamcinolone acetonide).22–24

Information from references 12 and 22–24.

FIGURE 1. Landmark-based knee injection setup.

Timing. Corticosteroid injections are appropriate when pain prohibits activities of daily living, leisure activities, or fitness. They may be performed as an adjunct to rehabilitation.25 For patients with knee osteoarthritis, rehabilitation outperforms corticosteroid injections at one year,26 and corticosteroid injection plus rehabilitation provides no greater pain relief than placebo injection plus rehabilitation.27

Corticosteroid injections provide temporary relief from trochanteric bursitis, adhesive capsulitis, de Quervain tenosynovitis, carpal tunnel syndrome, and shoulder impingement syndrome.13,14,16,28–30 These injections should not be performed more frequently than every three months because of their association with cartilage loss and tendon damage.11,31–34

HYALURONIC ACID

Indications. Hyaluronic acid, usually used for knee osteoarthritis, has limited evidence of benefit. The U.S. Department of Veterans Affairs and Department of Defense clinical practice guideline issued a weak recommendation for hyaluronic acid.35 The Osteoarthritis Research Society International supports hyaluronic acid use in knee osteoarthritis in patients with comorbid conditions and the general population.36 The American Academy of Orthopaedic Surgeons recommends against the routine use of hyaluronic acid.37 A recent systematic review and meta-analysis showed minimal clinically significant improvement in pain or function and significant adverse reactions with hyaluronic acid knee injections.38 Similarly, the American College of Rheumatology recommends against hyaluronic acid injections for knee osteoarthritis, noting that it can be considered in patients who have not been treated successfully with topical NSAIDs or corticosteroids.39 Another subanalysis found hyaluronic acid beneficial for patients with mild to moderate knee osteoarthritis and a body mass index of less than 30 kg per m2.40

Timing. Hyaluronic acid injections are often used in early to moderate knee osteoarthritis, with a peak response at six to eight weeks and less benefit by six months postinjection.41 However, most insurance requires failure of three months of conservative therapy and contraindication to or failure of corticosteroid injections. Hyaluronic acid injections may be single- or multidose. Multidose formulations are commonly performed for consecutive weeks.42

DEXTROSE PROLOTHERAPY

Indications. Prolotherapy is dextrose diluted with anesthetic to yield concentrations of 5% to 25% dextrose and is used as soft tissue treatment in tendinopathy and ligamentous pathology and intra-articularly for degenerative joint pain. A three-injection series of dextrose prolotherapy outperformed saline injections in adults with more than six months of lateral elbow pain refractory to rehabilitation, NSAIDs, and two corticosteroid injections.43 In a case-control study, tendons without tears had a more significant reduction in pain with a series of three prolotherapy injections; however, all tendons (with and without tears) had statistically significant improvements in pain.44 Prolotherapy for common extensor tendinopathy is more effective in patients younger than 45 years and with less than 12 months of pain.44 Dextrose prolotherapy decreases pain and improves function in patients with knee osteoarthritis.45–47

Timing. Prolotherapy should be timed every four to eight weeks, generally for a series of at least three injections.43,45–48

PLATELET-RICH PLASMA

Indications. Although platelet-rich plasma is generally accepted as safe, variability in procedure techniques has resulted in unclear effectiveness and reproducibility in studies. Current evidence does not support the use of platelet-rich plasma in tendinopathies except for common extensor tendinopathy.49,50 Compared with placebo, platelet-rich plasma showed no significant difference in pain or function in Achilles, patellar, and rotator cuff tendinopathy.51–54 Conflicting evidence indicates a possible benefit in plantar fasciopathy.55,56 A 2017 systematic review and meta-analysis of 14 RCTs of adults with symptomatic knee osteoarthritis found that compared with hyaluronic acid, saline, ozone, and corticosteroid injections, platelet-rich plasma was more effective at improving pain and function at three, six, and 12 months after injection without increasing adverse events.57 A 2021 meta-analysis of 34 RCTs confirmed the superiority of platelet-rich plasma over other injections for knee osteoarthritis but did not meet the authors' prespecified minimal clinically significant difference.58,59

Timing. Platelet-rich plasma injections are costly; therefore, they are typically used after other therapeutic interventions have not worked. In studies showing benefits from platelet-rich plasma, single- and multidose regimens can provide pain relief or improved function.56,57,60

Preparation

Patient and injection preparation is important for procedural success.4,5 Patient preparation involves a detailed overview of the procedure, informed consent, and proper positioning. The available evidence suggests that washing hands, using nonsterile gloves, and cleansing the skin with alcohol before an injection is safe and inexpensive, with safety outcomes comparable to a sterile technique.61 Table 4 provides a basic supply list.2 Figure 2 provides a visual example of a tray setup for injection. Sterility of injection supplies should be maintained by avoiding direct manipulation of needle and syringe hubs.

TABLE 4. Supplies for Joint or Soft Tissue Injection

Syringe
Needle
Alcohol, povidone-iodine, or chlorhexidine swabs
Gauze pads
Bandage
Ethyl chloride spray (optional)
Pillow, wedge, other devices for patient comfort and positioning

Information from reference 2.

FIGURE 2. Tray setup and supplies for injection.

Contraindications

Absolute contraindications to soft tissue and joint injections include infection at the injection site, fracture, and a history of a serious allergy to the injection substrate or local anesthetics. Relative contraindications include systemic infection, history of vasovagal reaction, and current anticoagulation therapy.34 Contraindications to platelet-rich plasma injections include coagulopathies, hematologic malignancy, and platelet function disorders.62

Complications

Immediate complications may include pain, swelling, redness, stiffness, or soreness involving the injection site. These reactions can last from a few hours to several days and have been noted in 3% to 25% of patients receiving intra-articular corticosteroids and 2% to 6% of patients receiving intra-articular hyaluronic acid for knee osteoarthritis.11,63 Risk of infection is mitigated by using a clean technique. Patients should be counseled about potential complications and signs and symptoms of infection.

Intra-articular corticosteroid injections are associated with transient hyperglycemia that may last a few hours to almost two weeks.64 Patients who have insulin-dependent diabetes mellitus should monitor their blood glucose more frequently to determine if insulin dose adjustments are necessary.64,65

Cartilage damage from corticosteroid injections is time-dependent and dose-dependent.66,67 One study found that repeated treatments (every three months) with intra-articular triamcinolone acetonide contributed to higher rates of cartilage loss and progressive joint space narrowing over two years compared with placebo.31 However, this study does not reflect routine care because patients were treated with corticosteroid injections regardless of symptoms.31,66 A population-based cohort study followed patients with symptomatic knee osteoarthritis over five years who received intra-articular corticosteroid or hyaluronic acid injections only when symptomatic; there was no significant change in cartilage thickness when corticosteroid injections were used only for symptomatic treatment of osteoarthritis flare-ups.67

Corticosteroid injections into soft tissue can cause depigmentation and atrophy, which usually develop days to weeks following injection.11,34 Inaccurate placement of the needle and injectate can lead to injury of adjacent structures and potential tendon trauma.3 Plantar fascia rupture and heel pad atrophy are rare complications associated with corticosteroid injections for plantar fasciitis.

Most injections administered in the primary care office are performed by palpation of landmarks to determine the placement of the injectate. The use of imaging guidance, such as ultrasonography, may increase the accuracy of needle placement and is recommended for specific anatomic locations.3

Joint and soft tissue injections are useful adjuncts for diagnosing and treating common musculoskeletal conditions. However, there are times when injection in the primary care office may not be appropriate. Table 5 lists indications for referral to primary care sports medicine, orthopedic surgery, or pain medicine.8–10

TABLE 5. Indications for Referral for Joint or Soft Tissue Injections

Desired injectate unavailable
Family physician is untrained in procedure
Image-guidance required
 Nerve hydrodissections
 Specific anatomic locations: glenohumeral joint, acromioclavicular joint, biceps tendon sheath, femoro-acetabular joint
Patient-oriented response not achieved after intervention by family physician

Information from references 8–10.

This article updates a previous article on this topic by Cardone and Tallia.2

Data Sources: A PubMed search was completed in Clinical Queries using the key terms injection, tendinopathy, tendinitis, degenerative, joint, and osteoarthritis. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. The Cochrane database, Essential Evidence Plus, National Center for Complementary and Integrative Health, U.S. Preventive Services Task Force, and Agency for Healthcare Research and Quality were also searched. Search dates: September 11, 2022, and May 30, 2023.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force, the U.S. Department of Defense, or the U.S. government.

JULIE A. CREECH-ORGAN, DO, CAQSM, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md., and a faculty physician at the Saint Louis University (Southwest Illinois)/Scott Air Force Base Family Medicine Residency, O'Fallon, Ill.

SARAH E. SZYBIST, DO, is a chief resident at Offutt Air Force Base/University of Nebraska Family Medicine Residency.

JACQUELINE L. YURGIL, DO, CAQSM, FAAFP, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences and an associate program director at the Primary Care Sports Medicine Fellowship at Alexander T. Augusta Military Medical Center, Fort Belvoir, Va.

Address correspondence to Jacqueline L. Yurgil, DO, CAQSM, FAAFP, Department of Sports Medicine, 9300 DeWitt Loop, Fort Belvoir, VA 22060 (email: jacqueline.l.yurgil.mil@health.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

  1. 1.United States Bone and Joint Initiative. The burden of musculoskeletal diseases in the United States. Accessed May 30, 2023. https://www.boneandjointburden.org
  2. 2.Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002;66(2):283-288.
  3. 3.Peterson C, Hodler J. Adverse events from diagnostic and therapeutic joint injections: a literature review. Skeletal Radiol. 2011;40(1):5-12.
  4. 4.Ibrahim M, Lau GJ, Smirnow N, et al. A multidisciplinary preoperative teaching session for women awaiting breast cancer surgery: a quality improvement initiative. Rehabil Process Outcome. 2018;7:1179572718790937.
  5. 5.Seeman K. The importance of quality perioperative patient education. J Consum Health Internet. 2019;23(1):94-101.
  6. 6.Jacob B, Zippelius T, Kloss N, et al. Local anesthetics' toxicity toward human cultured chondrocytes: a comparative study between lidocaine, bupivacaine, and ropivacaine. Cartilage. 2019;10(3):364-369.
  7. 7.Kreuz PC, Steinwachs M, Angele P. Single-dose local anesthetics exhibit a type-, dose-, and time-dependent chondrotoxic effect on chondrocytes and cartilage: a systematic review of the current literature. Knee Surg Sports Traumatol Arthrosc. 2018;26(3):819-830.
  8. 8.Aly AR, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med. 2015;49(16):1042-1049.
  9. 9.Hoeber S, Aly AR, Ashworth N, et al. Ultrasound-guided hip joint injections are more accurate than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med. 2016;50(7):392-396.
  10. 10.Daniels EW, Cole D, Jacobs B, et al. Existing evidence on ultrasound-guided injections in sports medicine. Orthop J Sports Med. 2018;6(2):2325967118756576.
  11. 11.Levy DM, Petersen KA, Scalley Vaught M, et al. Injections for knee osteoarthritis: corticosteroids, viscosupplementation, platelet-rich plasma, and autologous stem cells. Arthroscopy. 2018;34(5):1730-1743.
  12. 12.Malanga GA, Mautner KR. Atlas of Ultrasound-Guided Musculoskeletal Injections. 1st ed. McGraw-Hill Education; 2014.
  13. 13.Kitridis D, Tsikopoulos K, Bisbinas I, et al. Efficacy of pharmacological therapies for adhesive capsulitis of the shoulder: a systematic review and network meta-analysis. Am J Sports Med. 2019;47(14):3552-3560.
  14. 14.Richie CA, Briner WW. Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. 2003;16(2):102-106.
  15. 15.Peters-Veluthamaningal C, Winters JC, Groenier KH, et al. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial. Ann Rheum Dis. 2008;67(9):1262-1266.
  16. 16.Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009;68(12):1843-1849.
  17. 17.Peters-Veluthamaningal C, van der Windt DA, Winters JC, et al. Corticosteroid injection for de Quervain's tenosynovitis. Cochrane Database Syst Rev. 2009(3):CD005616.
  18. 18.Wu YT, Ke MJ, Ho TY, et al. Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol. 2018;84(4):601-610.
  19. 19.Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.
  20. 20.Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018;361:k1662.
  21. 21.Coombes BK, Bisset L, Brooks P, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-469.
  22. 22.Weitoft T, Öberg K. Dosing of intra-articular triamcinolone hexacetonide for knee synovitis in chronic polyarthritis: a randomized controlled study. Scand J Rheumatol. 2019;48(4):279-283.
  23. 23.Kim KH, Park JW, Kim SJ. High- vs low-dose corticosteroid injection in the treatment of adhesive capsulitis with severe pain: a randomized controlled double-blind study. Pain Med. 2018;19(4):735-741.
  24. 24.Kim YS, Lee HJ, Lee DH, et al. Comparison of high- and low-dose intra-articular triamcinolone acetonide injection for treatment of primary shoulder stiffness: a prospective randomized trial. J Shoulder Elbow Surg. 2017;26(2):209-215.
  25. 25.Crawshaw DP, Helliwell PS, Hensor EM, et al. Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial. BMJ. 2010;340:c3037.
  26. 26.Henriksen M, Christensen R, Klokker L, et al. Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee. JAMA Intern Med. 2015;175(6):923-930.
  27. 27.Deyle GD, Allen CS, Allison SC, et al. Physical therapy versus glucocorticoid injection for osteoarthritis of the knee. N Engl J Med. 2020;382(15):1420-1429.
  28. 28.Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care [published correction appears in Ann Fam Med. 2011;9(3):371]. Ann Fam Med. 2011;9(3):226-234.
  29. 29.Ly-Pen D, Andréu JL, de Blas G, et al. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005;52(2):612-619.
  30. 30.Rhon DI, Boyles RB, Cleland JA. One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: a pragmatic randomized trial. Ann Intern Med. 2014;161(3):161-169.
  31. 31.McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs. saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967-1975.
  32. 32.Kompel AJ, Roemer FW, Murakami AM, et al. Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought?. Radiology. 2019;293(3):656-663.
  33. 33.Brinks A, Koes BW, Volkers AC, et al. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord. 2010;11:206.
  34. 34.Jacobs JW, Michels-van Amelsfort JM. How to perform local soft-tissue glucocorticoid injections?. Best Pract Res Clin Rheumatol. 2013;27(2):171-194.
  35. 35.U.S. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for the non-surgical management of hip and knee osteoarthritis. July 2020. Accessed December 14, 2022. https://www.healthquality.va.gov/guidelines/CD/OA/VADoDOACPG.pdf
  36. 36.Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-1589.
  37. 37.American Academy of Orthopaedic Surgeons. Management of osteoarthritis of the knee (non-arthroplasty). Evidence-based clinical practice guideline. August 30, 2021. Accessed December 15, 2022. https://www.aaos.org/oak3cpg
  38. 38.Pereira TV, Jüni P, Saadat P, et al. Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis. BMJ. 2022;378:e069722.
  39. 39.Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee [published correction appears in Arthritis Rheumatol. 2021;73(5):799]. Arthritis Rheumatol. 2020;72(2):220-233.
  40. 40.Migliore A, Gigliucci G, Alekseeva L, et al. Systematic literature review and expert opinion for the use of viscosupplementation with hyaluronic acid in different localizations of osteoarthritis. Orthop Res Rev. 2021;13:255-273.
  41. 41.Trigkilidas D, Anand A. The effectiveness of hyaluronic acid intra-articular injections in managing osteoarthritic knee pain. Ann R Coll Surg Engl. 2013;95(8):545-551.
  42. 42.Jevsevar D, Donnelly P, Brown GA, et al. Viscosupplementation for osteoarthritis of the knee: a systematic review of the evidence. J Bone Joint Surg Am. 2015;97(24):2047-2060.
  43. 43.Scarpone M, Rabago DP, Zgierska A, et al. The efficacy of prolotherapy for lateral epicondylosis: a pilot study. Clin J Sport Med. 2008;18(3):248-254.
  44. 44.Shin JY, Seo KM, Kim DK, et al. The effect of prolotherapy on lateral epicondylitis of elbow. J Korean Acad Rehabil Med. 2002;26(6):764-768.
  45. 45.Sit RWS, Wu RWK, Rabago D, et al. Efficacy of intra-articular hypertonic dextrose (prolotherapy) for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2020;18(3):235-242.
  46. 46.Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis [published correction appears in Ann Fam Med. 2013; 11(5): 480]. Ann Fam Med. 2013;11(3):229-237.
  47. 47.Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Altern Ther Health Med. 2000;6(2):68-74.
  48. 48.Rabago D, Patterson JJ, Mundt M, et al. Dextrose and morrhuate sodium injections (prolotherapy) for knee osteoarthritis: a prospective open-label trial. J Altern Complement Med. 2014;20(5):383-391.
  49. 49.Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multi-center, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463-471.
  50. 50.Lim W, Park SH, Kim B, et al. Relationship of cytokine levels and clinical effect on platelet-rich plasma-treated lateral epicondylitis. J Orthop Res. 2018;36(3):913-920.
  51. 51.Scott A, LaPrade RF, Harmon KG, et al. Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline. Am J Sports Med. 2019;47(7):1654-1661.
  52. 52.de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303(2):144-149.
  53. 53.de Jonge S, de Vos RJ, Weir A, et al. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011;39(8):1623-1629.
  54. 54.Hurley ET, Hannon CP, Pauzenberger L, et al. Nonoperative treatment of rotator cuff disease with platelet-rich plasma: a systematic review of randomized controlled trials. Arthroscopy. 2019;35(5):1584-1591.
  55. 55.Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014(4):CD010071.
  56. 56.Hohmann E, Tetsworth K, Glatt V. Platelet-rich plasma versus corticosteroids for the treatment of plantar fasciitis: a systematic review and meta-analysis. Am J Sports Med. 2021;49(5):1381-1393.
  57. 57.Shen L, Yuan T, Chen S, et al. The temporal effect of platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2017;12(1):16.
  58. 58.Filardo G, Previtali D, Napoli F, et al. PRP injections for the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials. Cartilage. 2021;13(1 suppl):364S-375S.
  59. 59.Angst F, Aeschlimann A, Stucki G. Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities. Arthritis Rheum. 2001;45(4):384-391.
  60. 60.Khoshbin A, Leroux T, Wasserstein D, et al. The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis. Arthroscopy. 2013;29(12):2037-2048.
  61. 61.Baima J, Isaac Z. Clean versus sterile technique for common joint injections: a review from the physiatry perspective. Curr Rev Musculoskelet Med. 2008;1(2):88-91.
  62. 62.Jain NK, Gulati M. Platelet-rich plasma: a healing virtuoso. Blood Res. 2016;51(1):3-5.
  63. 63.Legré-Boyer V. Viscosupplementation: techniques, indications, results. Orthop Traumatol Surg Res. 2015;101(1 suppl):S101-S108.
  64. 64.Choudhry MN, Malik RA, Charalambous CP. Blood glucose levels following intra-articular steroid injections in patients with diabetes: a systematic review. JBJS Rev. 2016;4(3):e5.
  65. 65.Veronese N, Cooper C, Reginster JY, et al. Type 2 diabetes mellitus and osteoarthritis. Semin Arthritis Rheum. 2019;49(1):9-19.
  66. 66.Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthop J Sports Med. 2015;3(5):2325967115581163.
  67. 67.Latourte A, Rat AC, Omorou A, et al. Do glucocorticoid injections increase the risk of knee osteoarthritis progression over 5 years? Arthritis Rheumatol. 2022;74(8):1343-1351.
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