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Am Fam Physician. 2023;108(2):151-158

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

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

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

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

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.810 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.

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


Indications. High-quality evidence supports the use of corticosteroid injections for adhesive capsulitis, de Quervain tenosynovitis, and trigger finger.1317 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.1921 Table 3 offers composition and needle size guidance for commonly performed landmark-guided corticosteroid injections.12,2224 Figure 1 provides an example of a setup for a knee injection.

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