A joint or soft tissue injection is a procedure in which a needle is used to place medication into, or draw fluid from, a joint, bursa or soft tissue, and safe practice rests on three decisions: the right patient, the right target and the right agent, supported by informed consent, an aseptic technique and a clear aftercare plan. Injections are useful but they are one part of management rather than a stand-alone cure, and most work best alongside rehabilitation. For the sport and exercise medicine (SEM) clinician the core tasks are knowing when an injection is and is not indicated, understanding how it is delivered safely, and recognising and managing the risks. This page covers why and when injections are used, how they are performed safely, and the risks and aftercare, including the anti-doping considerations that apply to a competing athlete.
Why and when are injections used?
Injections serve two broad purposes. Diagnostic injections help work out where pain is coming from: placing a small volume of local anaesthetic into a specific structure should give meaningful relief if that structure is contributing to the pain, which supports rather than proves that it is the source, and aspiration of joint fluid allows the fluid to be analysed. Therapeutic injections deliver a treatment, most commonly a corticosteroid to reduce inflammation, and sometimes hyaluronic acid or other agents. A helpful way to frame every injection is to answer three questions: who to inject, meaning is the diagnosis right and is an injection the best option; how to inject, meaning the correct target, technique and guidance; and what to inject, meaning the most appropriate agent and dose.
Injections are either diagnostic (a local anaesthetic to localise pain, or aspiration of fluid for analysis) or therapeutic (such as corticosteroid or hyaluronic acid). Good practice answers who, how and what to inject, and respects the contraindications and cautions.
The decision to inject depends on indications and contraindications. Injections are considered when a condition is likely to respond, when simpler measures have not worked or need support, or when fluid is needed for diagnosis. The main absolute contraindications are infection or broken skin over the injection site, and a known serious allergy to the agent or to local anaesthetic. Important cautions include a significant bleeding tendency or anticoagulation, a prosthetic joint (which is not injected in clinic and is discussed with orthopaedics), poorly controlled diabetes, pregnancy where relevant, and an uncertain diagnosis, since injecting without a clear reason rarely helps. Needle choice follows the target: a wider-bore needle such as a twenty-one gauge is used for larger joints or to aspirate thick fluid, and finer needles for small joints and superficial soft tissue.
How is an injection performed safely?
Safe delivery starts with consent and preparation. Informed consent covers the indication, the alternatives including doing nothing, the expected benefit and that it may be short-lived, and the risks, and it is documented. The clinician confirms the diagnosis, checks allergies, medication and anticoagulation, and identifies the correct landmark or uses ultrasound. An aseptic non-touch technique is essential: the skin is cleaned and allowed to dry, single-use equipment is used, and the needle and syringe tips are not touched or allowed to touch non-sterile surfaces. Before injecting, the clinician draws back on the syringe to check for blood or fluid, while recognising that a negative aspirate does not reliably confirm the needle is outside a vessel; where a local anaesthetic is used, it is given slowly in small increments with the patient observed.
Guidance and record-keeping complete safe practice. Many large joints can be injected accurately by palpating landmarks, while ultrasound guidance generally improves the accuracy of needle placement and is preferred for deeper or smaller targets and where precise placement matters, though it does not necessarily improve the clinical outcome for every injection. Whatever the guidance, the agent, dose, site, side and batch number are recorded, along with consent and any immediate reaction. Anticoagulation is handled individually: low-bleeding-risk superficial injections can usually proceed without interrupting anticoagulation, after checking the indication, the bleeding risk, that anticoagulation is at a therapeutic rather than supratherapeutic level, and local policy, while for higher-risk or deeper injections the bleeding risk is weighed against the thrombotic risk of stopping, and anticoagulation is not stopped without good reason. People with diabetes are warned that blood glucose can rise, particularly in the first one to three days after a corticosteroid injection, and are advised to monitor it more closely, for longer if readings stay high.
What are the risks, and what is the aftercare?
Injections are generally safe, but the risks are discussed and planned for. The most common is a post-injection flare of pain in the first day or two, which settles with simple analgesia. Serious infection, including septic arthritis, is rare but important, which is why aseptic technique matters and why any hot, increasingly painful, swollen joint with fever after an injection needs urgent assessment. Other risks include bleeding or bruising, a vasovagal (fainting) episode, allergic reaction, and, when a local anaesthetic is used, the rare risk of local anaesthetic systemic toxicity. Corticosteroid injections carry additional effects: depigmentation of the overlying skin and atrophy of the fat beneath it at the site, facial flushing, a temporary rise in blood glucose, and, if injected into the body of a tendon, tendon rupture, which is why intratendinous corticosteroid is avoided. There is no single universal limit on how often a joint can be injected; decisions depend on the site, diagnosis, previous injections and response, and repeated injections are used cautiously.
Recognised risks include a short-lived post-injection flare, rare infection, bleeding, a vasovagal episode, allergy and local anaesthetic toxicity; corticosteroid can also cause skin and fat changes, facial flushing, a temporary rise in blood glucose, and tendon rupture if injected into a tendon. Safety-net advice covers increasing pain, redness, swelling or fever.
Aftercare is straightforward but important. The athlete is advised on relative rest and given clear safety-net advice: to seek urgent review for increasing pain, spreading redness, swelling, fever or feeling systemically unwell, since these can signal infection. In a competing athlete, anti-doping is a central consideration. Under the World Anti-Doping Agency (WADA) rules, injectable glucocorticoids are prohibited in-competition, so the exact agent, formulation, route, date and competition period are checked against the current Prohibited List and washout guidance, and the timing is planned around competition with records kept. Where treatment is needed, a therapeutic use exemption (TUE) is applied for prospectively; retrospective applications are permitted only under defined criteria and are not guaranteed, and sustained-release preparations may remain detectable beyond the standard washout period.
Exam Tips
•Injections are diagnostic (a local anaesthetic to localise pain, or aspiration for fluid analysis) or therapeutic (corticosteroid, hyaluronic acid and others), and are one part of management alongside rehabilitation.
•Frame every injection as who to inject (right diagnosis), how to inject (correct target, technique and guidance) and what to inject (appropriate agent and dose).
•Absolute contraindications are infection or broken skin over the site and serious allergy to the agent or local anaesthetic; cautions include bleeding risk or anticoagulation, a prosthetic joint, poorly controlled diabetes and an uncertain diagnosis.
•Use informed consent, an aseptic non-touch technique and clear documentation; ultrasound guidance improves accuracy for deeper or smaller targets, while landmark injection suffices for many large joints.
•Recognised risks include a post-injection flare, rare infection, bleeding, a vasovagal episode and allergy; corticosteroid can also cause skin and fat changes, a temporary rise in blood glucose, and tendon rupture if injected into a tendon.
•Injectable glucocorticoids are prohibited in-competition, so check the exact agent, route and timing against the current World Anti-Doping Agency Prohibited List and washout guidance, and apply prospectively for a therapeutic use exemption where treatment is needed; retrospective exemptions are not guaranteed.