Dosing and administration of local corticosteroid injections for musculoskeletal pain

There is substantial variation in the doses used for intra-articular corticosteroid injections. Example doses for local corticosteroid injection by size of the joint for adults provides example doses for adults by the size of joint, and Example doses of triamcinolone hexacetonide injection for children and adolescents by size of joint provides example doses of triamcinolone hexacetonide for children and adolescents by size of joint, for practitioners to use as guidance.

Local corticosteroid injections should only be given through healthy, normal skin (avoid psoriatic plaques). Contraindications to local corticosteroid injection are:

infection of the skin at the injection site
systemic infection, because it may seed a deep infection
infection of the joint or soft tissue, because injection may worsen infection
injecting into a prosthetic joint or joint containing a foreign body
injecting into a joint that is due for joint replacement surgery in less than 3 (or for some indications 6) months.

Note: Local corticosteroid injections should only be given through healthy, normal skin.

Table 1. Example doses for local corticosteroid injection by size of the joint for adults
[NB1][NB2]
Joint or tissue	Corticosteroid dose	Local anaesthetic dose [NB3]
small joint (eg hand)	0.25 to 0.5 mL	0.25 to 0.5 mL—less local anaesthetic may be used in small joints to allow sufficient corticosteroid to be administered for the desired effect
medium joint (eg wrist)	0.5 to 1 mL	0.5 to 1 mL
large joint (eg knee)	1 mL	1 mL
soft tissue (eg bursa)	1 mL	1 mL
Note: NB1: These are example doses; the dose should be individualised for each person. See Overview of local corticosteroid injections for musculoskeletal pain for more details. NB2: The corticosteroids commonly used for intra-articular or soft-tissue injection are betamethasone sodium phosphate plus betamethasone acetate, methylprednisolone acetate, triamcinolone acetonide, and triamcinolone hexacetonide. NB3: The local anaesthetic of choice is lidocaine (lignocaine) injection; avoid preparations containing adrenaline (epinephrine).

Table 2. Example doses of triamcinolone hexacetonide injection for children and adolescents by size of joint
[NB1] [NB2]
Dose of triamcinolone hexacetonide 20 mg/mL
Small joint (eg hand)	Medium joint (eg wrist)	Large joint (eg knee)
0.03 to 0.05 mL for PIP joints 0.05 to 0.1 mL for MCP and MTP joints	0.025 mL/kg up to 0.5 mL	0.05 mL/kg up to 1 mL
Note: MCP = metacarpophalangeal; MTP = metatarsophalangeal; PIP = proximal interphalangeal NB1: These are example doses; the dose should be individualised for each person. See Overview of local corticosteroid injections for musculoskeletal pain for more details. NB2: Triamcinolone hexacetonide is not registered for use in Australia but is available via the Special Access Scheme.

Note: A maximum of 4 local corticosteroid injections per joint per year is recommended.

If local corticosteroid injection is effective for providing analgesia over an extended duration (eg months), and in the absence of a safer therapeutic alternative, the injection may be repeated. A maximum of 4 injections per joint per year is recommended because of the risk of local tissue atrophy and systemic adverse effects. Avoid multiple injections involving the major weightbearing tendons.

Radiological guidance does not increase the efficacy of local corticosteroid injections and is only required for joints that are difficult to access (eg hip joint).

Note: Radiological guidance does not increase the efficacy of local corticosteroid injections and is only required for joints that are difficult to access.