Evidence based Injection dosages grid

Recommended doses of triamciniolone acetonide / Hydrocortisone and lidocaine injection in the treatment of musculoskeletal disorders

To be used in conjunction with the relevant PSD for administration of Triamcinolone acetonide / Hydrocortisone injection and lidocaine injection for peri-articular or intraarticular Injection for musculoskeletal conditions in Northwood MSK Physio Clinic

Lidocaine 0.5%, 1% and 2% injection are not licensed to be given by the intra-articular or peri-articular route, but this is in line with the Chartered Society of Physiotherapy guidance1 and accepted clinical practice2,3

For multiple joint treatment in a single episode, no more than a total dose of 80mg of Triamcinolone acetonide should be given in one session.

The smallest effective dose of the appropriate drug should be used in the selected area for the appropriately chosen patient. With respect to the flexibility of dosages allowed in this PGD any clinician decision on dose amount should take into account patient age, size, previous & current research evidence, mentor feedback, audit report feedback on compliance and clinical outcomes, annual evidence-based practice review information, national recommendations from specialist interest groups and the area to be injected. For larger joints (joint, knee joint, ankle joint, subtalar joint, midtarsal joint, hip and bursa only) a larger volume of injection may be required to ensure greater dispersal of medication in the joint. For these areas, Adcortyl® (triamcinolone acetonide 10mg/ml) may be preferred over Kenalog® (triamcinolone acetonide 40mg/ml) to provide a larger total volume of injection. The most suitable preparation will be determined by the size of the joint or lesions to be injected. Where Adcortyl, Kenalog and Hydrocortistab are stated under dose recommendations in Appendix 1, any may be chosen following patient assessment to determine most suitable choice. Throughout the table below, the preparation stated must be used unless a choice of Adcortyl®, Kenalog® or Hydrocortistab is stated.

Shoulder Treatments
Area of a
Administration / Condition / Lidocaine 1% / Triamcinolone Acetonide
Use Kenalog® 40mg/ml unless choice is stated / Advice and Aftercare
Shoulder (glen humeral) joint / Acute or Chronic Capsulitis (‘Frozen shoulder’) / 1-4 ml Lidocaine 1% / 20-40mg/ml triamcinolone (Kenalog) / Maintenance of mobility with pendular and stretching exercises within the pain free range, with stronger stretching when pain reduced. Strong passive stretching of the capsule can be given when the pain is abated. A strengthening and stabilizing programme is often required, together with postural correction.
Acromion-Clavicular joint / Acute or Chronic Capsulitis / 0.75ml / Kenalog® 40mg/ml Dose: 10mg (0.25ml) / Rest for 1 week then begin gentle mobilising exercises. Acutely inflamed joints are helped by the application of ice, taping to stabilise the joint and by oral pain killers.
Sub acromial or Subscapularis bursa / Bursitis / 1-5ml of 1% Lidocaine / 20-40mg/ml triamcinolone (adcortyl or kenalog) / Maintain retraction and depression of the shoulders and avoid elevation of the arm above the shoulder level for up to 2 weeks. When pain free, the patient commences resisted lateral rotation and retraction exercises, followed by strengthening of abduction. Retaining of over arm activities to avoid recurrence is essential.
Long Head of Biceps / Tendinopathy / 0.75ml
Kenalog® 40mg/ml Dose: 10mg (0.25ml) / Relative rest for 1 week then address the causes of the lesion
Elbow Treatments
Common extensor tendon / Chronic Tendinopathy (Tennis elbow) / 0.75ml1.25ml 1% lidocaine / 10mg Kenalog / Relative rest for 1 week, then stretching and strengthening exercises can be started
Common flexor tendon / Chronic Tendinitis (Golfer’s elbow) / 0.75ml1.25ml 1% lidocaine / 10mg Kenalog / Relative rest for 1 week, then stretching and strengthening exercises can be started.
Wrist Treatments
Wrist / Carpal Tunnel Syndrome / Kenalog® 40mg/ml Dose: 20mg (0.5ml) / The patient rests for 1 week and then resumes normal activities. A night splint helps in the early stages after the infiltration and the patient is advised to avoid sleeping with the wrists held in full flexion
Fingers Flexor / Tendon Nodule
Trigger finger / 0.25 1.0ml Lidocaine 1% / 10-20mg/ml triamcinolone (kenalog) / The patient is advised to maintain a period of relative rest for approximately 2 weeks following injection
Thumb Flexor Tendon / Nodule
Trigger thumb / 0.251.0ml Lidocaine 1% / 10-20mg/ml triamcinolone (kenalog) / The patient is advised to maintain a period of relative rest for approximately 2 weeks following injection.
Thumb tendon / De Quervain’s tenosynovitis / 0.75ml1.25ml 1% lidocaine / 10mg Kenalog / The patient should rest the hand for a week with taping of the tendons. This is followed by avoidance of the provoking activity and a graded strengthening regime if necessary
Wrist / Acute capsulitis / 1.5ml / Kenalog® 40mg/ml Dose: 20mg (0.5ml) / The patient is advised to maintain a period of relative rest for approximately 2 weeks following injection.1
Carpometacarpal (CMC) joint (Thumb) / Acute or chronic capsulitis / 0.75ml / Kenalog® 40mg/ml Dose: 10mg (0.25ml) / The patient is advised to maintain a period of relative rest for approximately 2 weeks following injection
Hip Treatments
Trochanteric bursa / Acute or Chronic Bursitis / 4.5ml (if using Kenalog® only) / Kenalog® 40mg/ml Dose: 20mg (0.5ml) / Avoid overuse for 1 week and then gradually return to normal activity.
Knee Treatments
Knee Joint / Acute or Chronic Capsulitis / 1-3ml Lidocaine 1% / 20-80mg/ml triamcinolone (adcortyl or kenalog) / Avoid undue weight bearing activity for 1 week. Give strengthening & mobilising exercises to do at home
Pes Anserine bursa / Chronic bursitis / 1.5ml / Kenalog® 40mg/ml Dose: 20mg (0.5mls) / The patient should avoid overuse activities for at least 1 week, when graded strengthening exercises are started.
Iliotibial Band Bursa / Chronic bursitis / 1.5ml / Kenalog® 40mg/ml Dose: 20mg (0.5mls) / Absolute rest must be maintained for 10 days. Then begin stretching and strengthening programme. Footwear and running technique should be checked and corrected if necessary
Infrapatellar tendon / Chronic Tendinitis / 1.5ml / Kenalog® 40mg/ml Dose: 20mg (0.5mls) / Absolute rest is recommended for at least 10 days before a stretching and strengthening programme is initiated.
Ankle Treatments
Ankle Joint / Chronic Capsulitis / 1.75ml / Kenalog® 40mg/ml Dose: 30mg (0.75mls) / Avoid excessive weight bearing activities for at least a week. The patient should be warned that heavy overuse of the foot will cause a recurrence of symptoms and therefore long distance running should also be avoided. Weight control is also advised and footwear should be checked to ensure correct support.
Achilles bursa / Chronic Bursitis / 1.5ml / Kenalog® 40mg/ml Dose: 20mg (0.5mls) / Avoid overuse activities for at least 10 days, then start a stretching and eccentric exercise programme.
Foot Treatments
Plantar Fascia / Acute / chronic fasciitis / 0.75ml1.25ml 1% lidocaine / 20mg Kenalog / A heel support is used for at least a week after the injection, followed by intrinsic muscle exercise and stretching of the fascia. Standing on a golf ball to apply deep friction can be helpful and Orthotics can be applied. Taping can also be used
Morton’s Neuroma / Acute or Chronic Neuroma symptoms / 20mg Kenalog / Avoid overuse for 1 week. Resolution of symptoms should then lead to consideration of change in footwear, orthotics and strengthening of the evertors.
Mid Tarsal Joints / Acute or Chronic Capsulitis / 1.5ml / Kenalog® 40mg/ml Dose: 10-20mg (0.250.5mls) / Avoid excessive weight bearing activities for at least 1 week Orthotics and weight control if necessary
Peroneal Tendon and Tib-post Tendons / Acute or Chronic Tendinopathy / 0.75ml / Kenalog® 40mg/ml Dose: 10mg (0.25mls) / Avoid excessive weight bearing activities for at least 1 week. Mobilizing and strengthening exercises and retaining of causal activities follow. Orthotics and weight control if necessary
Hallux / Acute or Chronic capsulitis / 0.5-1ml / Kenalog® 40mg/ml Dose: 10-20mg (0.250.5mls) / Avoidance of excessive weight-bearing activities for at least 1 week, together with taping of the joint and a toe pad between the toes. Care in choice of footwear and orthotics might be necessary.
Other Toes (Metatarsal and metacarpal phalangeal joints) / Acute or Chronic capsulitis / 0.5-1ml / Kenalog® 40mg/ml Dose: 10-20mg (0.250.5mls) / Avoidance of excessive weight-bearing activities for at least 1 week, together with taping of the joint and a toe pad between the toes. Care in choice of footwear and orthotics might be necessary.
Sinus Tarsi / Acute or Chronic Irritation / 0.5-1ml / Kenalog® 40mg/ml Dose: 10-20mg (0.250.5mls) / Avoid overuse for 1 week. Resolution of symptoms should then lead to consideration of change in footwear or activity modification.
Tarsal Tunnel / Acute or Chronic nerve compression / 0.5-1ml / Kenalog® 40mg/ml Dose: 10-20mg (0.250.5mls) / Avoid overuse for 1 week. Resolution of symptoms should then lead to consideration of change in footwear or activity modification.

The Chartered Society of Physiotherapy. The use of medicines in physiotherapy injection-therapy in

NHS settings. 3rd Edition. July 2010 2 Atkins E, Kerr J and Goodlad E. A practical approach to orthopaedic medicine: assessment, diagnosis and treatment. 3rd Edition. Churchill Livingstone 2010.

Saunders S and Longworth S. Injection Techniques in Musculoskeletal Medicine: A practical manual for clinicians in primary and secondary care. 4th Edition. Churchill Livingstone 2013

Further information: British National Formulary and Summary of Product Characteristics available at

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