Intra‑Articular Corticosteroid Injection of the Knee – Evidence‑Based Recommendations

Indications

Intra‑articular corticosteroid injection is strongly indicated for acute exacerbations of knee pain, especially when joint effusion is present, and provides short‑term pain relief lasting weeks to months. 1
Acute exacerbation of knee osteoarthritis with effusion is the primary indication. 1
Inflammatory arthritis (e.g., rheumatoid arthritis) with one or a few residual active knee joints despite optimal systemic therapy may be treated with injection. 1
Acute gouty arthritis of the knee can be managed as a first‑line option with intra‑articular corticosteroid. 1
Injection should not be performed until a definitive diagnosis has been established and all contraindications have been ruled out. 1

Injection performed within 3 months before a planned total knee arthroplasty increases postoperative infection risk from 0.5 % to 1.0 %. 3
Uncontrolled diabetes with severe hyperglycemia is a contraindication. 3
High bleeding risk is a relative contraindication; it is not absolute for patients on anticoagulation. 1

Strict aseptic technique is mandatory. 1
The procedure should be performed in a professional, clean, quiet, private, and well‑lit room. 1
The patient must be positioned supine on an examination table, able to lie flat. 1
All equipment needed for aseptic procedures must be readily available, and resuscitation equipment should be within reach. 1

Ultrasound guidance improves injection accuracy and reduces procedural pain, but it is not required for knee injections. 1
Offering a local anesthetic together with an explanation of its benefits and risks is recommended. 1
Imaging guidance is strongly recommended for hip injections but remains optional for the knee. 2
Assistance from another qualified healthcare professional is optimal during the procedure. 1

Patients should avoid overuse of the injected knee for the first 24 hours; immobilization is discouraged. 1
Normal activity may resume after 24 hours; bed rest or splinting provides no additional benefit. 3

Patients with suboptimal glycemic control must be counseled about the risk of transient hyperglycemia and advised to monitor blood glucose, especially from day 1 to day 3 after injection. 3
Peak glucose elevations occur during days 1‑3 post‑injection, but no severe adverse events such as hyperosmolar state or ketoacidosis have been reported. 3

Intra‑articular corticosteroid injection is not contraindicated in patients receiving antithrombotic medications unless they have a high bleeding risk. 1

The decision to repeat an injection should weigh the benefits obtained from prior injections, alternative therapeutic options, and individual patient factors. 1
Studies of injections every 3 months for 2 years show conflicting outcomes: one trial reported no deleterious cartilage effects, while another demonstrated greater cartilage volume loss. 3
Recent reports suggest that certain injection frequencies may contribute to cartilage loss, although the clinical significance remains uncertain. 2

Routine injection of prosthetic knee joints should be avoided; infection occurs in approximately 0.6 % of such injections (≈ 1 in 625). 3
If injection of a prosthetic knee is contemplated, referral to orthopedic surgery after strict infection screening is required. 3

A definitive diagnosis must be confirmed before performing an intra‑articular corticosteroid injection; the procedure should not be used as a diagnostic tool without first excluding infection. 1