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Aspiration or injection of the knee joint involves accessing the synovial joint cavity of the knee to remove fluid, administer medication, or both. It can facilitate both diagnosis and treatment of knee disease.
This guide provides a step-by-step approach to knee joint aspiration and injection in an OSCE setting. It is NOT intended to be used to guide patient care.
Indications
Diagnostic
Aspiration and laboratory examination of joint fluid aspirate can help in the diagnosis of unexplained joint effusions and monoarticular arthritides. This could include:1-2
- Septic arthritis
- Crystal arthropathy (gout, pseudogout)
- Haemarthrosis
- Inflammatory joint disease
Therapeutic
Therapeutic indications of joint aspiration and injection include:1-2
- Administration of corticosteroid (often mixed with local anaesthetic)
- Symptomatic relief of large effusions
- Repeated aspiration to limit joint damage in septic arthritis
Gather equipment
Collect the equipment required for the procedure and place it within reach, ensuring all items are visible:3
- 21G green needle
- Sterile syringe (30-60 mL for aspiration, 10 mL for injection)
- Alcohol skin wipes (2% chlorhexidine gluconate in 70% isopropyl alcohol)
- Non-sterile gloves
- Sharps bin
- Sterile gauze
- Dressing/plaster
- Blunt, drawing up needle (if applicable)
- Medication for injection (if applicable)
Pre-procedure
Contraindications
There are no absolute contraindications to joint aspiration, as untreated septic arthritis or haemarthrosis can lead to joint destruction. Relative contraindications include:2
- Prosthetic joint
- Overlying cellulitis or severe dermatitis
- Bacteraemia
- Inaccessible joint
- Major coagulopathy
Anticoagulation with joint aspiration and injection
Joint injections and aspirations are safe to do if a patient is taking antiplatelets or anticoagulation. For those on warfarin, there is no defined safe upper INR limit; however, if it is above the patient’s target range, it should be considered a relative contraindication.2, 4
Contraindications to intraarticular injection include the above points, plus:1-2
- Suspected joint infection
- Allergy
- Unstable joint or fracture
- Adjacent osteomyelitis
- Haemarthrosis
- Impending joint surgery (within days)
Risks
Risks of knee joint aspiration include:2
- Infection
- Bleeding
- Pain
- Failure
Risks of knee joint corticosteroid injection include:2
- Infection
- Bleeding
- Pain
- Failure
- Subcutaneous fat atrophy
- Skin depigmentation
- Facial flushing
- Post-injection flare of symptoms
Introduction
Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
Don PPE.
Introduce yourself to the patient, including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the procedure will involve using patient-friendly language.
Example explanation
“I plan to remove fluid from the knee joint that can be analysed to diagnose the cause of your symptoms” or “I plan to inject a solution of steroid and local anaesthetic into your knee joint to relieve the symptoms you are experiencing.”
“For the procedure, you will need to sit on the examination couch with your knee straight, and I will use a needle with a syringe to access the space around the joint. There will be some discomfort as this goes through the skin. If this is too much and you need me to stop, let me know.”
“The main risks include bleeding and infection. A sterile technique is used to prevent infection, but it is important to seek medical attention if you notice pain, swelling, or redness after the procedure.”
If injecting corticosteroid: “The steroid can cause thinning of the skin, reduction of fat in the surrounding area and a temporary flare of symptoms.”
Gain consent to proceed with the knee joint aspiration/injection.
Ensure there are no contraindications to the procedure.
Check if the patient has any allergies (e.g. latex, local anaesthetic).
Ask the patient if they have any pain before continuing with the clinical procedure.
Preparation
Identifying an insertion site
There are many ways to access the synovial joint of the knee, guided by surface anatomy. Lateral approaches are commonly used, given their accuracy and avoidance of cartilaginous structures:3, 5
Lateral approach
1. Position the patient supine with the knee extended
2. Identify the surface borders of the patella and, dividing the patella into thirds, locate the junction of the proximal and middle thirds
3. Move along this line laterally until in the soft spot posterior to the patella
4. Direct the needle towards the opposite patellar mid-pole
Medial approach
1. Position the patient supine with the knee extended
2. Identify the surface borders of the patella and locate the midpoint
3. Move along this line medially until in the soft spot posterior to the patella
4. Direct the needle towards the opposite patellar mid-pole
Anterior approach
1. Position the patient supine or sitting with the knee flexed between 60-90°
2. Identify the surface borders of the patella, patellar ligament and tibial plateaus
3. The needle can be inserted either medially or laterally:
- Medial: soft spot within the inferomedial patellar border, patellar tendon and medial tibial plateau
- Lateral: soft spot within the inferolateral patellar border, patellar tendon and lateral tibial plateau
4. Direct the needle parallel to the tibial plateau at 45° towards the imaginary midpoint (intercondylar notch) of the knee
Medication for injection
The precise practice may vary, but a standard approach is to use 40 mg of steroid (40 mg/mL concentration of triamcinolone or methylprednisolone) with 3-5 mL of 1% lidocaine.1, 6
1. Wash your hands
2. Check the medication, expiry date and integrity of the equipment and medication vials
3. Open the lidocaine ampoule by holding the bottle with the dot facing towards you and breaking the top away from yourself
4. Remove the cap from the corticosteroid vial, clean the top with an alcohol swab for approximately 30 seconds and allow to dry
5. Attach a sterile drawing-up needle to the 10 mL syringe
6. Draw up the lidocaine and steroid solution into the syringe
7. Remove the drawing-up needle and immediately dispose of it into a sharps bin, then attach the needle to be used for performing the injection. Leave the protective cap on until immediately before injecting
Perform the procedure
1. Wash your hands and don non-sterile gloves
2. Identify the site for needle insertion and mark the area by firmly holding the needle cap against the skin for 10 seconds
3. Clean the insertion site with an alcohol swab for 30 seconds and allow to dry for 30 seconds
4. Prepare your needle and syringe, as above if injecting or with an empty syringe and 21G needle if aspirating only
5. Wash your hands and change your gloves
6. Using an aseptic non-touch technique, insert the needle to access the synovial joint
- This is approximately 3 cm deep but can vary
- A ‘give’ should be felt as you enter the joint capsule
7. Withdraw the plunger on the syringe to aspirate synovial fluid
- If injecting, aspiration should be performed to ensure the needle is not within a vascular structure
8. If a joint injection is to be performed, slowly inject the contents of the syringe into the joint space
- If resistance is felt, the needle is unlikely to be in the joint capsule and should be adjusted by either advancing or withdrawing slightly
- Ensure to re-aspirate if the position of the needle is changed
9. Withdraw the needle and immediately dispose of it into a sharps bin
10. Apply a plaster or dressing 2, 5-6
To complete the procedure…
If applicable, transfer the synovial fluid into a sterile specimen container and label it with the patient’s details. This should be sent to the laboratory with a request for the type of analysis required (e.g. microscopy, culture and sensitivity or crystal analysis).
Explain to the patient that the procedure is now complete.
Thank the patient for their time.
Dispose of PPE and other clinical waste into an appropriate clinical waste bin.
Wash your hands.
Inform the patient to monitor for signs of infection.
Document details of the procedure in the patient’s notes including:
- Your personal details including your name, job role and GMC number
- The date and time the procedure was performed
- That you have explained the risks and gained informed consent
- The indication for joint aspiration/injection
- The site of injection and whether this was a single attempt or multiple
- The colour and volume of the synovial fluid drained
- Medications administered, including the concentration, volume and batch number of vials/ampoules
- What investigations have been requested, and who is responsible for checking the results
Editor
Dr Jamie Scriven
References
- Zuber TJ. Knee Joint Aspiration and Injection. American Family Physician. 2002. Available from: [LINK].
- HCP Live. Joint Aspiration and Injection: A Look at the Basics. 2011. Available from: [LINK].
- Cardone DA, Tallia AF. Diagnostic and Therapeutic Injection of the Hip and Knee. American Family Physician. 2003. Available from: [LINK].
- Kotecha J, Gration B, Hunt BJ, et al. The Safety of Continued Oral Anticoagulation Therapy in Joint Injections and Aspirations: A Qualitative Review of the Current Evidence. Journal of Clinical Rheumatology. 2022. Available from: [LINK].
- Maricar N, Parkes MJ, Callaghan MJ, et al. Where and how to inject the knee—A systematic review. Seminars in Arthritis and Rheumatism. 2013. Available from: [LINK].
- Cardone DA, Tallia AF. Joint and Soft Tissue Injection. American Family Physician. 2002. Available from: [LINK].
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