Intra-Articular Knee Injection Guidelines

Corticosteroid and Lidocaine Administration

Lidocaine can be infiltrated along the needle path or injected directly into the joint, alone or mixed with corticosteroid, as recommended by the Annals of the Rheumatic Diseases 1, 2, 3
The maximum safe dose of lidocaine without epinephrine is 4.5 mg/kg in adults, according to Praxis Medical Insights 4
With epinephrine, the maximum lidocaine dose increases to 7.0 mg/kg, as stated by Praxis Medical Insights 4
It is crucial to avoid using lidocaine within 4 hours of other local anesthetic interventions to prevent cumulative toxicity, as advised by Praxis Medical Insights 4, 5

Warming the lidocaine to 37°C before injection reduces infiltration pain, as demonstrated in high-quality systematic reviews by the Annals of the Rheumatic Diseases 1, 2
Local anesthetics may be applied topically, infiltrated subcutaneously, along the needle path, or injected into the joint, as recommended by the Annals of the Rheumatic Diseases 1, 2, 3
Strict aseptic technique should always be used, including surgical gloves, skin preparation with alcohol/iodine/chlorhexidine, and changing needles between drawing the drug and injecting, as advised by the Annals of the Rheumatic Diseases 1, 2, 3

Diabetic patients should be warned about transient hyperglycemia and advised to monitor their glucose levels, as recommended by the Annals of the Rheumatic Diseases 1, 6
Patients with prosthetic joints should avoid routine injections due to a higher infection rate, as stated by the Annals of the Rheumatic Diseases 6
Pre-surgical patients should have injections performed at least 3 months before joint replacement surgery to avoid increased infection risk, as advised by the Annals of the Rheumatic Diseases 1, 6
Patients should be advised to avoid overuse for 24 hours after injection but discouraged from complete immobilization, as recommended by the Annals of the Rheumatic Diseases 6
The injection frequency should be limited to 3-4 injections per year in the same joint, as stated by the Annals of the Rheumatic Diseases 6

When lidocaine is combined with epinephrine, the recommended maximum dose increases to 7 mg per kilogram of body weight in adults, allowing a higher total amount than when lidocaine is used alone. This recommendation is based on the findings published in Anaesthesia (2019)【7】.

A single intra‑articular injection of lidocaine is not associated with damage to articular cartilage; experimental studies demonstrated no adverse effect on chondrocyte viability in both healthy and osteoarthritic knee joints. This safety evidence is reported in Anaesthesia (2019)【7】.