Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Joint aspiration or injection in adults: Complications

W Neal Roberts, Jr, MD
Howard W Hauptman, MD
Section Editor
Daniel E Furst, MD
Deputy Editor
Monica Ramirez Curtis, MD, MPH


A needle is inserted into a joint for two main indications: aspiration of fluid (arthrocentesis) for diagnosis or for relief of pressure, or injection of medications. In practical terms, almost all injections into joints consist of a glucocorticoid, a local anesthetic, or combinations of the two. Adverse outcomes from glucocorticoid injection are uncommon, but several are serious. These include iatrogenic infection and three serious types of atrophy (ie, tendon rupture, nerve damage, and inhibition of chondrocytes leading to glucocorticoid arthropathy) (table 1). The last of these is more of a theoretical than actual risk of glucocorticoid injection.

The complications of joint aspiration or injection in adults are discussed here. The technique and indications for joint aspiration and intraarticular and periarticular injections of glucocorticoids and intraarticular hyaluronate derivatives, as well as the choice and frequency of agents for injection, are discussed separately. (See "Joint aspiration or injection in adults: Technique and indications" and "Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?".)


Tendon rupture is most commonly encountered when undiluted glucocorticoid is injected near the rotator cuff or near the insertion of the long head of the biceps tendon. This complication may be more common with the posterior approach, which can be directed upward in the direction of the subdeltoid bursae and rotator cuff, than with the anterior approach, which is only intraarticular (figure 1). Tendon rupture can usually be avoided by sticking to one size of needle and syringe so as to be able to recognize the higher resistance that comes with injecting into a tendon.

Nerve atrophy or necrosis occurs when glucocorticoids enter the nerve sheath directly, an event which usually occurs only with carpal tunnel injections that come quite close to the median nerve. These injections should be performed by a subspecialist with specific training (eg, a hand surgeon or a rheumatologist). One would think that injection of the nerve would be quite painful and would, therefore, be uncommon. However, once the perineurium is pierced, the pain may be moderate and may be accompanied by a burning sensation. In the worst case, permanent nerve injury with a claw hand deformity ensues.

Other minor atrophies can also occur. These include skin atrophy, hypopigmentation, and dystrophic calcification around joint capsules. Hypopigmentation around the injection site is the most troublesome, especially on the wrist and hand of deeply pigmented individuals in whom it takes years to resolve (picture 1). Thus, such patients should be specifically advised about this complication. It may be possible to reduce the incidence of hypopigmentation by switching syringes and by flushing the needle with a small volume of lidocaine before withdrawing it.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Mar 15, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2003; 48:370.
  2. Mader R, Lavi I, Luboshitzky R. Evaluation of the pituitary-adrenal axis function following single intraarticular injection of methylprednisolone. Arthritis Rheum 2005; 52:924.
  3. Black DM, Filak AT. Hyperglycemia with non-insulin-dependent diabetes following intraarticular steroid injection. J Fam Pract 1989; 28:462.
  4. Sparling M, Malleson P, Wood B, Petty R. Radiographic followup of joints injected with triamcinolone hexacetonide for the management of childhood arthritis. Arthritis Rheum 1990; 33:821.
  5. Neidel J, Boehnke M, Küster RM. The efficacy and safety of intraarticular corticosteroid therapy for coxitis in juvenile rheumatoid arthritis. Arthritis Rheum 2002; 46:1620.
  6. Emkey RD, Lindsay R, Lyssy J, et al. The systemic effect of intraarticular administration of corticosteroid on markers of bone formation and bone resorption in patients with rheumatoid arthritis. Arthritis Rheum 1996; 39:277.
  7. Slotkoff, et al. Effects of soft-tissue corticosteroid injection on glucose control in diabetics (abstract). Arthritis Rheum 1994; 37:S347.
  8. Smith GN Jr, Myers SL, Brandt KD, Mickler EA. Effect of intraarticular hyaluronan injection in experimental canine osteoarthritis. Arthritis Rheum 1998; 41:976.
  9. Puttick MP, Wade JP, Chalmers A, et al. Acute local reactions after intraarticular hylan for osteoarthritis of the knee. J Rheumatol 1995; 22:1311.
  10. Pullman-Mooar S, Mooar P, Sieck M, et al. Are there distinctive inflammatory flares after hylan g-f 20 intraarticular injections? J Rheumatol 2002; 29:2611.
  11. Kroesen S, Schmid W, Theiler R. Induction of an acute attack of calcium pyrophosphate dihydrate arthritis by intra-articular injection of hylan G-F 20 (Synvisc). Clin Rheumatol 2000; 19:147.
  12. Geirsson AJ, Statkevicius S, Víkingsson A. Septic arthritis in Iceland 1990-2002: increasing incidence due to iatrogenic infections. Ann Rheum Dis 2008; 67:638.
  13. Smyth TT, Chirino-Trejo M, Carmalt JL. In vitro assessment of bacterial translocation during needle insertion through inoculated culture media as a model of arthrocentesis through cellulitic tissue. Am J Vet Res 2015; 76:877.
  14. Schmid FR. New developments in bacterial arthritis. Bull Rheum Dis 1992; 41:1.