Needle gauge and patient pain in steroid injection of the knee: a prospective randomized controlled trial

John T. Schwartz; Matthew J. Hatter; Justin Harrington; Rex Saito; Jaspreet S. Sidhu; Eric G. Huish

doi:10.18203/issn.2455-4510.IntJResOrthop20260488

Authors

John T. Schwartz Orthopedic Surgery Residency, Valley Consortium for Medical Education, USA
Matthew J. Hatter Orthopedic Surgery Residency, Valley Consortium for Medical Education, USA
Justin Harrington Orthopedic Surgery Residency, Valley Consortium for Medical Education, USA
Rex Saito Orthopedic Surgery Residency, Valley Consortium for Medical Education, USA
Jaspreet S. Sidhu Orthopedic Surgery Residency, Valley Consortium for Medical Education, USA
Eric G. Huish Orthopedic Surgery Residency, Valley Consortium for Medical Education, USA

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20260488

Keywords:

Intra-articular, Corticosteroid injections, 22-gauge, 18-gauge, Patient pain, Knee osteoarthritis

Abstract

Background: Intra-articular corticosteroid injection (IACI) is a common conservative treatment modality for knee osteoarthritis (OA) but can cause procedural discomfort. Needle gauge is a modifiable factor that may influence patient pain perception, though evidence remains limited. This study compared 18- versus 22-gauge needles in knee IACIs.

Methods: The authors performed a single-blinded, prospective, randomized controlled trial at a public teaching hospital (San Joaquin General Hospital, in French Camp, CA) from May 10, 2023 to October 16, 2024. Adults with primary knee OA indicated for corticosteroid injection were randomized to receive injection with either an 18-gauge or 22-gauge needle. All injections were performed via the superolateral approach using triamcinolone acetonide and lidocaine. Pain scores were measured using a visual analogue scale (VAS). Secondary outcomes included anticipated pain, nervousness, and satisfaction.

Results: Twenty-six patients were randomized (14 in the 18-gauge group, 12 in the 22-gauge group). Median injection pain was similar between groups (median 2.5 vs 2.5, p=0.71). Post-injection pain was lower in the 18-gauge group (median 1.5 vs 3.5, p=0.21), but not statistically significant. Pre-injection nervousness correlated with both injection pain (ρ=0.50, p=0.011) and post-injection pain (ρ=0.55, p=0.004).

Conclusions: Needle gauge did not significantly affect pain or satisfaction during knee IACIs. Psychosocial factors appear to play a greater role in pain perception than needle size.

Metrics

Metrics Loading ...

References

Lawrence RC, Felson DT, Helmick CG, Lesley MA, Hyon C, Richard AD, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26-35. DOI: https://doi.org/10.1002/art.23176

Hunter DJ, March L, Chew M. Osteoarthritis in 2020 and beyond: a Lancet Commission. Lancet. 2020;396(10264):1711-2. DOI: https://doi.org/10.1016/S0140-6736(20)32230-3

Shumnalieva R, Kotov G, Monov S. Obesity-Related Knee Osteoarthritis-Current Concepts. Life (Basel). 2023;13(8):1650. DOI: https://doi.org/10.3390/life13081650

Weng Q, Chen Q, Jiang T, Yuqing Z, Weiya Z, Michael D, et al. Global burden of early-onset osteoarthritis, 1990-2019: results from the Global Burden of Disease Study 2019. Ann Rheum Dis. 2024;83(7):915-25. DOI: https://doi.org/10.1136/ard-2023-225324

Salis Z, Gallego B, Nguyen TV, Sainsbury A. Association of Decrease in Body Mass Index With Reduced Incidence and Progression of the Structural Defects of Knee Osteoarthritis: A Prospective Multi-Cohort Study. Arthritis Rheumatol. 2023;75(4):533-43. DOI: https://doi.org/10.1002/art.42307

He Q, Mei J, Xie C, Wang Z, Sun X, Xu M. The Relationship Between Central Obesity and Osteoarthritis in US Adults: The Mediating Role of Biological Aging Acceleration. J Am Nutr Assoc. 2025;44(1):29-39. DOI: https://doi.org/10.1080/27697061.2024.2389398

Zhu S, Qu W, He C. Evaluation and management of knee osteoarthritis. J Evid Based Med. 2024;17(3):675-87. DOI: https://doi.org/10.1111/jebm.12627

McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-88. DOI: https://doi.org/10.1016/j.joca.2014.01.003

American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty): Evidence-Based Clinical Practice Guideline. Rosemont, IL: American Academy of Orthopaedic Surgeons. 2021. Available at: https://www.aaos.org/oak3cpg. Accessed on 01 September 2025.

Crawford DC, Miller LE, Block JE. Conservative management of symptomatic knee osteoarthritis: a flawed strategy? Orthop Rev (Pavia). 2013;5(1):e2. DOI: https://doi.org/10.4081/or.2013.e2

Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am. 2002;84(9):1522-7. DOI: https://doi.org/10.2106/00004623-200209000-00003

Ayhan E, Kesmezacar H, Akgun I. Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop. 2014;5(3):351-61. DOI: https://doi.org/10.5312/wjo.v5.i3.351

Bensa A, Salerno M, Moraca G, Boffa A, McIlwraith CW, Filardo G. Intra-articular corticosteroids for the treatment of osteoarthritis: A systematic review and meta-analysis on the comparison of different molecules and doses. J Exp Orthop. 2024;11(3):e12060. DOI: https://doi.org/10.1002/jeo2.12060

Hermans J, Bierma-Zeinstra SMA, Bos PK, Verhaar JAN, Reijman M. The most accurate approach for intra-articular needle placement in the knee joint: a systematic review. Semin Arthritis Rheum. 2011;41(2):106-15. DOI: https://doi.org/10.1016/j.semarthrit.2011.02.007

Douglas RJ. Aspiration and injection of the knee joint: approach portal. Knee Surg Relat Res. 2014;26(1):1-6. DOI: https://doi.org/10.5792/ksrr.2014.26.1.1

Bae C, Chen E, Wong M. A Prospective Study on Pain Associated with Injection of Needles: PAIN Study. Arthritis Rheumatol. 2022;74(9):NA.

Tubach F, Ravaud P, Baron G, Falissard B, Logeart I, Bellamy N, et al. Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement. Ann Rheum Dis. 2005;64(1):29-33. DOI: https://doi.org/10.1136/ard.2004.022905

Van Rossum G, Drake FL. Python 3 Reference Manual. CreateSpace. 2009.

Virtanen P, Gommers R, Oliphant TE, Matt H, Tyler R, David C, et al. SciPy 1.0: fundamental algorithms for scientific computing in Python. Nat Methods. 2020;17(3):261-72. DOI: https://doi.org/10.1038/s41592-019-0686-2

Harris CR, Millman KJ, van der Walt SJ, Ralf G, Pauli V, David C, et al. Array programming with NumPy. Nature. 2020;585(7825):357-62. DOI: https://doi.org/10.1038/s41586-020-2649-2

McKinney W. Data Structures for Statistical Computing in Python. In: Proceedings of the Python in Science Conference. SciPy; 2010:56-61. DOI: https://doi.org/10.25080/Majora-92bf1922-00a

Rastogi AK, Davis KW, Ross A, Rosas HG. Fundamentals of Joint Injection. AJR Am J Roentgenol. 2016;207(3):484-94. DOI: https://doi.org/10.2214/AJR.16.16243

Charalambous CP, Tryfonidis M, Sadiq S, Hirst P, Paul A. Septic arthritis following intra-articular steroid injection of the knee--a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol. 2003;22(6):386-90. DOI: https://doi.org/10.1007/s10067-003-0757-7

Amoako AO, Pujalte GG, Kaushik N, Riley T. Patient Discomfort and Resident Confidence After Knee Intra-articular Injection Simulation Training: A Randomized Control Trial Study. Clin Med Insights Arthritis Musculoskelet Disord. 2018;11:1179544118782903. DOI: https://doi.org/10.1177/1179544118782903