PAIN RESEARCH 18（2003）157 − 161

Effect of local injection of 10% lidocaine hydrochloride

on painful osteoarthritis of the knee joint

Motohiro Kawasaki, Takahiro Ushida, Tatsunori Ikemoto,

Toshikazu Tani, and Hiroshi Yamamoto

Department of Orthopaedic Surgery, Kochi Medical School, Kochi, Japan

［Received 13 May 2003, Accepted 22 July 2003］

Abstract
The aim of this study was to investigate whether local injection of high-dose lidocaine could attenuate
tenderness and motion pain existing in the medial compartmental osteoarthritic knee. Seventeen patients who
had tenderness and pain during walking at the medial compartment of degenerative femorotibial joint for more
than 6 months were examined in this study. The knee pain during walking was assessed by the visual analog
scale (VAS) score and pressure pain thresholds for tenderness at the site of the injection were evaluated by
means of a hand-held pressure algometer. As for the treatment, 1 ml of 10% or 1% lidocaine was injected into
the periarticular tissue of the most painful tenderness point of the medial femorotibial joint. These pain intensities
were measured before (controls), 2 weeks and 4 weeks after the injection. Decreased VAS score (p<0.007)
during walking and increased pressure pain thresholds (p<0.004) were observed 2 weeks after injection of 10%
lidocaine and compared with respective controls. VAS score was significantly decreased throughout 4 weeks
after the injection. At the same time, there was no significant difference before and after injection of 1% lidocaine.
These results suggest that injection of 10% lidocaine may produce a more effective and long-term analgesia for
pain following osteoarthritis of the knee, as compared with the injection of 1% lidocaine.

Key words: osteoarthritis, knee joint, lidocaine, visual analog scale, pressure pain threshold

articular cartilage 10,13). In general, patients with the

INTRODUCTION
Osteoarthritis (OA) is known as the commonest
rheumatological disease of the knee joint in the
elderly 6). Most patients with OA of the knee joint
suffer from chronic pain at the medial part of the knee
joint. The mechanism by which OA causes pain is
complicated. All causes of pain in the OA are as-
sociated with deformation of subchondral bone 7) or
periarticular tissue 1), accompanied by destruction of
knee OA are treated with regular use of non-steroidal
anti-inflammatory drugs and intra-articular injection
of hyaluronic acid 2,11). In some cases, however, the
effect of conservative treatment is insufficient enough
to relieve OA pain.
Since low concentration of local anesthetics has
a relatively short period of action, we decided to use
the trigger point injection 20) or intra-articular injec-
tion of local anesthetics 4) to abolish the OA pain

43
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more effectively and quickly. Lidocaine is a safe and
effective anesthetic agent frequently used for local
anesthesia. It should be mentioned that high concen-
tration of lidocaine may produce neurological toxicity
after spinal anesthesia 15,18,19) and irreversible neuro-
logical deficits on the peripheral nervous system 3,8,12,
14). It is hypothesized that local neurological deficits
may result in a long-term relieving effect of chronic
OA pain at the medial compartment of the knee joint.
However, high concentration of lidocaine has not been
examined in the treatment for painful degenerative
joint diseases yet.
Therefore, we conducted a double-blind study to
reveal the effect of clinically used concentrations or
higher concentrations of lidocaine hydrochloride solu-
tions on the OA pain at the medial compartment of
degenerative femorotibial joint.
MATERIALS AND METHODS
Seventeen patients, 13 females and 4 males, aged
81 years (range: 67 to 91 years), who had tenderness
and pain during walking at the medial compartment of
degenerative femorotibial joint for more than 6 months,
were examined in this study. All patients were treated
with regular use of non-steroidal anti-inflammatory
drugs and intra-articular injection of hyaluronic acid
for over 3 months. They had definite radiographic
signs of osteoarthritic knee without previous injury.
Radiographic features of the knees were assessed by
the Kellgren-Lawrence grading scale 9), which were
determined for medial femorotibial compartment of
the knee joint on standing anteroposterior radiographs.
Patients with clinically meaningful cardiopulmonary,
hepatic, renal comorbidity or allergies against local
anesthetics were excluded.
This study was conducted in accordance with the
Declaration of Helsinki, approved by the local Ethics
Committee. Informed consent was obtained from all
participants enrolled in this study.
The most painful tender point of the medial
compartment of the femorotibial joint was determined
before the injection. One-milliliter volume of 1% or
10% lidocaine hydrochloride solution (Xylocaine®,
44
Fujisawa pharmaceutical co., Osaka, Japan) was
injected slowly into the periarticular tissue at the
tender point with a 27-gage needle in a double-blind
design. Pain intensity during walking and the follow-
ing examinations were measured before (controls), 2
and 4 weeks after the injection. All patients were
tested in the morning at the clinical visit to exclude the
known circadian influence on the OA patients.
The pain intensity was scored on a 0–10 visual
analog scale (VAS) where 0 cm indicated “ no pain”
and 10 cm indicated “ the worse pain imaginable” .
Pressure pain threshold for tenderness was measured
at the injection site with a hand-held algometer
(MICROFET2®, Hoggan Health Industries Inc., UT,
USA) mounted on a 1 cm2–rubber pad. The pressure
increased with approximately 2 N/s until the subject
felt tenderness. The pressure pain threshold at the
tender point was determined as the mean value of two
trials with an interval of approximately 5 min. Active
joint range of motion (ROM) of the treated knee was
examined in the supine position. Maximal flexion and
extension were assessed using a goniometer. Overall
satisfaction with the injection (verbal rating scale VRS:
0 = unsatisfactory, 1 = satisfactory, 2 = excellent) was
rated 4 weeks after the injection.
The results were expressed as means ± SD. The
paired data were analyzed with the Friedman test
(non-parametric repeated measures analysis of vari-
ance), and when it was found significant, it was
followed by a Bonferroni's multiple comparisons test
for post-hoc analysis. The comparison of satisfaction
between two groups was performed by Mann-
Whitney U-test. The significant threshold was p<0.05
in all tests.
RESULTS
Ten knee joints were treated with 10% lidocaine
(10% lidocaine group) and the others with 1% lidocaine
(1% lidocaine group). The mean age of the patients
was comparable between the two groups: 81 ± 5 vs
79 ± 8 in the 10% lidocaine and 1% lidocaine group,
respectively. Of the 10 patients in the 10% lidocaine
group, 2 (20%) were radiologically evaluated as grade

Fig. 1 Changes in visual analog scale (VAS) scores
during walking before and after the injection. *p<0.05,
compared with control.
Fig. 3 Changes in active joint range of motion (ROM) of
the treated knee before and after the injection. There is no
significant difference between before and after the injection.
II, 4 (40%) as grade III, 4 (40%) as grade IV, whereas
1 (14%) was radiologically evaluated as grade II, 3
(43%) as grade III, 3 (43%) as grade IV in the 1%
lidocaine group. No allergic complications occurred
after the injection of lidocaine.
The average of VAS score during walking before
the injection was 5.4 ± 2.2 in 10% lidocaine group and
5.0 ± 2.2 in the 1% lidocaine group. VAS scores were
significantly decreased 2 and 4 weeks after the injec-
tion of 10% lidocaine, compared with controls (3.1 ±
1.4; p<0.007 and 3.5 ± 2.2; p<0.02, respectively). On
the other hand, there was no significant difference
between before and after the injection of 1% lidocaine
(Fig. 1).
The average of pressure pain threshold for
tenderness before the injection was 14.7 ± 5.3 N in
10% lidocaine group and 15.5 ± 6.3 N in the 1%
45
Local injection of 10% lidocaine on osteoarthritic knee 159
Fig. 2 Changes in pressure (Newton; N) at the tender
point before and after the injection when the subjects felt
tenderness. *p<0.05, compared with control.
Fig. 4 Comparison of overall satisfaction 4 weeks after
the injection between the two groups. *p<0.05 between
the two groups.
lidocaine group. Pressure pain threshold significantly
increased 2 weeks after the injection of 10% lidocaine,
but not 4 weeks after the injection, compared with
controls (26.7 ± 11.8 N; p<0.004 and 19.5 ± 8.7 N;
p>0.18, respectively). There was no significant differ-
ence before and after the injection of 1% lidocaine
(Fig. 2).
The average of active ROM before the injection
was from 8.5 ± 6.2 to 129.2 ± 20.5 in 10% lidocaine
group and 13.3 ± 8.7 to 127.3 ± 25.6 in the 1% lidocaine
group. There was no significant difference between
before and after injection in each group (Fig. 3).
Overall satisfaction with the injection was signifi-
cantly higher in the 10% lidocaine group than in the
1% lidocaine group (p<0.01). Five patients in the
10% lidocaine group were relieved of chronic knee
pain (Fig. 4).
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DISCUSSION
The present study shows significant increased
pressure pain threshold and decreased pain intensity
during walking after the injection of 10% lidocaine,
compared with controls. Patients in the 10% lidocaine
group were satisfied with the injection at the tender
point in spite of a little improvement of active ROM.
There is a possibility that high concentration of
lidocaine might cause irreversible neurological altera-
tions. Ready et al. reported that minimum irreversible
concentration of intrathecal lidocaine in rabbits is
7.6–10.6% 15). As to the effect of local anesthetics on
peripheral nervous system, Baiton et al. reported that
lidocaine-induced irreversible conduction loss in frog
nerve is concentration-dependent 3). Kalichman et al.
showed that local anesthetics produced a concentra-
tion-dependent increase of specific morphological
changes, such as formation of endoneurial edema and
axonal degeneration, in the rat sciatic nerve 8). Thus,
increased pressure pain threshold 2 weeks after the
injection of 10% lidocaine may be due to a degenera-
tion of regional afferent fibers mediated tenderness,
whereas no significant changes in pressure pain
threshold after the injection of 1% lidocaine show a
temporary anesthetic effect of lidocaine, such as
reversible conduction block of the fibers. The gradual
restoration to preinjection value 4 weeks after the
injection of 10% lidocaine may indicate that the
regeneration of afferent fibers at the injection site is
the primary pathophysiological mechanism involved
in this process.
A number of patients with the chronic knee OA
usually complain on the well-localized pain and
tenderness at the medial compartment of the
femorotibial joint, which may represent osteophyte
growth, degenerative meniscus or deformation of peri-
articular tissues. These degenerative changes, result-
ing in elevation and stretching of the richly innervated
periosteum 7) and periarticular tissues 1), are probably
major sources of pain in OA 10,13). In addition, a
large amount of neuropeptides was found in the
synovium of osteoarthritic knee 16,21). Moreover, a
46
considerable number of afferent fibers in articular
nerve, which consists of numerous unmyelinated
fibers, is non-responsive under normal condition, but
there is a potential for an acute injury or inflammation
to sensitize these fibers or to awake the “ silent
nociceptor” 17). Once peripheral sensitization occurred,
these fibers might keep responding to the normal joint
movement even when the original stimuli had been
removed. Changes in the pain intensity may imply
that periarticular injection of 10% lidocaine produced
degeneration of pain-sensitive fibers responsible to the
joint movement, and then reinnervated articular fibers
at the injection site were likely non-responsive.
Active ROM remained limited after the injection
regardless of the decreased pain intensity during
walking. Negative correlation between joint range of
motion and Kellgren-Lawrence scores in the patients
with knee osteoarthritis has been reported 5). Therefore,
a slight improvement of active ROM may be attributed
to the severe advanced deformation of the knee joint,
as indicated by radiographic findings. In spite of that,
however, patients in the 10% lidocaine group were
satisfied with periarticular injection. These results
may suggest that periarticular injection of 10% lidocaine
was more efficient in relieving knee OA pain than
intra-articular injection of hyaluronic acid as was the
case with the periarticular injection of 1% lidocaine.
It should be noticed that limitations of the
present study are small sample data, no observation
period before injection, and a short period of follow-
up. The treatment effect of lidocaine may be able to
relieve some kinds of chronic pain following osteo-
arthritis of the knee joint. There is, however, a pos-
sibility for the repeated periarticular injection causing
a regional neurological deficit and damaged peri-
articular tissue at the injection site. Further studies are
therefore needed to clarify the efficacy and local
histo-chemical and general cardio-vascular safeness of
high concentration local anesthetics for the treatment
of knee OA.
CONCLUSION
The periarticular injection of 10% lidocaine at

the medial compartment of the knee joint produces
more effective and long-term analgesia for chronic
pain associated with osteoarthritis of the knee
compared with the injection of 1% lidocaine. In
combination with previous treatment regimes, results
of the present study may contribute to establishing
new and more effective treatment strategies for
painful OA.
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Address for correspondence: Motohiro Kawasaki, M.D., Ph.D.
Department of Orthopaedic Surgery, Kochi Medical School
Kohasu Oko-cho, Nankoku city, Kochi 783-8505, Japan
Tel: +81-88-880-2387 Fax: +81-88-880-2388 E-mail: kawasaki-koc@umin.ac.jp
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