Journal CME January 2026: Identification of factors related to pain from musculoskeletal injections-PM R - 2025 - Faust - Identification of factors related to pain from musculoskeletal injections

PM R - 2025 - Faust - Identification of factors related to pain from musculoskeletal injections

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This retrospective cross-sectional study analyzed factors related to patient-perceived pain during musculoskeletal injections among 1,371 injections in 935 adult patients at outpatient orthopedic clinics. The main goal was to identify clinical, demographic, and procedural variables influencing intraprocedural pain to better counsel patients and potentially reduce pain. Patients self-reported pain on a 0–10 numerical scale before, during, and after injection.<br /><br />Key findings from multivariate linear regression revealed that female gender, use of ultrasound image guidance, presence of a trainee during the procedure, and higher body mass index (BMI) were significantly associated with higher intraprocedural pain scores. Conversely, use of sodium bicarbonate to buffer local anesthetic, older patient age, and larger injectate volumes correlated with lower pain scores, though the effects of age, BMI, and injectate volume were minimal. Logistic regression confirmed that trainee presence increased the odds of reporting any pain (score ≥1).<br /><br />Notably, female patients reported nearly half a point greater pain on average than males, a finding consistent with prior studies on sex differences in pain perception. The study also found that buffering lidocaine with sodium bicarbonate significantly reduced pain by approximately 0.68 points, suggesting a beneficial clinical practice. Ultrasound-guided injections were surprisingly associated with greater pain, possibly due to selection bias as more complex or technically challenging injections often require ultrasound. Trainee involvement was linked to increased pain, potentially reflecting longer procedure times or greater technical difficulty, but the retrospective design limits causal inference.<br /><br />The study’s limitations include its retrospective, nonrandomized nature, potential selection and reporting biases, incomplete postprocedural pain data, and variability in injection techniques and locations. Despite these, the findings highlight important factors affecting injection pain and recommend considering sodium bicarbonate use and careful communication regarding trainee involvement and procedure expectations. Future prospective, randomized research is needed to further clarify these associations and develop strategies to minimize musculoskeletal injection pain.

Keywords

musculoskeletal injections

intraprocedural pain

patient-perceived pain

ultrasound-guided injections

sodium bicarbonate buffering

local anesthetic pain reduction

trainee involvement

body mass index (BMI)

sex differences in pain perception

retrospective cross-sectional study