Joint and extremity injection covers the non-spinal targets: shoulder, elbow, wrist and hand, hip, knee, ankle and foot, plus peripheral nerves and trigger points. It is the part of interventional pain practice most accessible to clinicians without fluoroscopy, because most of these injections are performed on palpation and anatomical landmarks.
This reference follows the teaching of Gisele J. Girault, MD, a Yale-educated anaesthesiologist and interventional pain specialist who completed a Pain Medicine Fellowship at Dartmouth-Hitchcock, served as Medical Director of its Pain Medicine Fellowship, and has practised in South Carolina since 2002.
It sits under our clinical reference to interventional pain procedures.
Landmark technique, and where guidance is added
Most of the injections in this category are performed by palpation. As Girault frames it, they are “based solely on palpation and anatomical landmarks” — though the same targets can be approached under ultrasound or fluoroscopy where the anatomy is difficult or the target is deep.
That accessibility is what makes joint and extremity work the usual entry point into procedural pain practice. It also means the examination carries more weight than it does when an image confirms position, which is why the assessment sections below are not preamble.
The five patient populations that change the plan
Girault identifies the groups that most often require the approach to be modified, and they are the ones a busy clinic sees constantly: diabetics, patients on antibiotics, patients on anticoagulants, patients already taking oral steroids, and obese patients.
Diabetic patients get the most attention. Before injecting steroid she wants haemoglobin A1c and fasting glucose under good control. Where they are not, her answer is not to cancel but to substitute: several of these injections “can be done with local anaesthetic alone, leaving out the steroid, because steroids can increase blood sugars.”
That is a more useful position than a blanket rule. The steroid is one component of the injection, not the whole of it, and it can be omitted where the risk outweighs the benefit.
Patients already on oral steroids matter for the same reason from the other direction — the injected dose adds to an existing systemic burden.
Which steroid, and the two classes that get confused
A distinction worth being precise about, because getting it wrong means injecting a drug chosen for the wrong property.
Glucocorticoids are what is injected: hydrocortisone, prednisone, methylprednisolone, triamcinolone and betamethasone. They have, in Girault's words, “greater anti-inflammatory properties, which is why we want to use them in our injections to begin with.”
Mineralocorticoids — fludrocortisone and cortisone — are not used for injection. Their effects are predominantly on fluid and electrolyte balance, which is not what the injection is for.
Within the glucocorticoids, the particulate question matters as much here as in the spine. Girault's test is visual and practical: hold the vial up and look at it. Intermediate-potency steroids such as triamcinolone and methylprednisolone are cloudy — that cloudiness is undissolved particles in suspension. Dexamethasone is clear, because it is non-particulate.
For spinal work she uses non-particulate dexamethasone specifically, because particles “can get into small blood vessels.” She adds a supply-chain note that will be familiar to anyone ordering it: dexamethasone is in high demand and is the cheapest, so it goes out of stock frequently — she keeps a second steroid on hand as a matter of routine.
The local anaesthetic rule that has no exceptions
Girault's position on local anaesthetic containing epinephrine is absolute, and the reasoning is worth stating in full because the risk is catastrophic and entirely avoidable.
Epinephrine causes vasoconstriction. Injected into or near an end-artery supplying a digit or other appendage, the tissue supplied can become ischaemic and necrose.
Her mitigation is not careful labelling but removal: do not have it in the office at all. As she puts it, she does not keep local anaesthetic with epinephrine even in her own practice, because “I don't want there to be an accidental mix up… there could be a mixup.”
A vial that is not in the building cannot be drawn up by mistake at the end of a long clinic. That is the entire argument, and it is a good one.
Most reported local anaesthetic allergy is not allergy
A related point that changes how you take a history, and one of the more immediately useful things in the course.
When a patient reports having reacted to local anaesthetic, Girault asks what actually happened. The typical account is tachycardia, flushing and light-headedness — and the typical setting is a dental chair.
Dentists commonly use local anaesthetic with epinephrine. An inadvertent intravascular injection of epinephrine produces exactly that picture, sometimes followed by a vasovagal episode. In her words: “That's not an allergy to local anaesthetics.”
So the question is not are you allergic but what happened, and where were you. A patient labelled allergic on the basis of a dental epinephrine reaction is being denied a useful drug for no reason. This is covered in local anaesthetic allergy, or epinephrine.
What the procedure room needs
Girault's list is short and specific, which is itself instructive — this is not an equipment-heavy discipline.
- 25 or 22 gauge, 1.5 inch needles for the majority of injections
- 18 gauge, 1.5 inch as the drawing-up needle
- 30 gauge, half inch for dry needling
- 4×4 sterile gauze, alcohol or Betadine skin prep, latex-free plasters
- Sharps box, hand sanitiser, skin marker
- Local anaesthetic, steroid, sterile and non-sterile gloves
Two items are easily overlooked and matter more than they sound. A table that sits up into a beach-chair position, because several of these injections are performed with the patient seated rather than lying. And bolsters and rolls, because positioning is frequently what makes a landmark palpable.
Steroid flare, and what to tell the patient before they leave
Girault warns every patient about this, and the warning prevents a predictable phone call.
Increased pain over the 24 to 48 hours after injection occurs in roughly one in ten injections. It is a steroid flare, it settles over the following day or two, and it is not a reason to attend the emergency department — though the patient should feel free to ring the office.
Told in advance, it is an expected event. Discovered afterwards, it reads as a complication.
The systemic effects of injected steroid she lists as facial flushing, raised blood sugar, raised blood pressure, insomnia, increased appetite, mood swings and adrenal suppression. Of these, the two she watches are blood sugar and adrenal suppression.
The common syndromes by site
The shoulder illustrates the approach. It comprises two joints — the acromioclavicular and the glenohumeral — surrounded by the rotator cuff muscles. The syndromes Girault treats there are rotator cuff tears, rotator cuff tendonitis and tendinosis, subacromial bursitis, and osteoarthritis of either joint.
Her instruction before any of it: know the anatomy, and perform a thorough examination including range of motion and palpation. Which structure is tender, and which movement reproduces the pain, is what selects the target. Shoulder injection is covered in shoulder injection.
Trigger points and the occipital nerves are handled separately, in trigger point injections and occipital nerve block.
Coding, and why it is local
Girault teaches the billing alongside the technique, with a caution that the detail is jurisdictional: her comments apply to South Carolina, and codes “differ from state to state and sometimes from area to area.”
The three families used across this work are trigger point codes, joint injection codes split by small, medium and large joint, and peripheral nerve codes. She notes that some peripheral nerve blocks — carpal tunnel and occipital among them — carry different codes in her state despite being peripheral nerves.
Her recommended reference is the CMS Physician Fee Schedule Lookup Tool, on the practical grounds that many commercial insurers follow Medicare's lead. Verify locally before building a service around an assumed reimbursement.
For clinicians
These injections are learned under supervision with a proctor watching your hands. Empire teaches them in Joint and Extremity Injection Training, with image guidance covered separately across the pain management academy.
Learn blocks with your hands, not from a page
Empire’s Pain Management Training (THE Pain Show) is accredited for 25.25 AMA PRA Category 1 Credits™, jointly provided by AKH, Inc, and Empire Medical Training. For narrower peripheral work, Joint, Extremity and Non-Spinal Injection Training carries 6.75 credits for the complete in-person hybrid program, and Advanced Musculoskeletal Ultrasound Guided Injections builds the guidance skills above.
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