Pain a few days after an intramuscular (IM) injection could mean it wasn’t done properly. Question lacks the critical detail of injection site since there are four major sites of IM injection (see below from 1), and each has specific pros and cons, and different propensity for complications such as post-injection pain.
It’s the responsibility of the doctor who administered the injection to prescribe medications and/or other treatment to reduce post-injection pain.
Longer answer below for those interested in learning about IM injections in general, and sources of and approaches to minimize post-injection pain.
Brief Background On Intramuscular (IM) Injection Techniques
There are two main techniques used in IM injections to try to ensure injection is deposited in the muscle, and that injected material stays locked in it and doesn’t seep out into surrounding area along the needle track. They are the Z-track (see below from 2, 3) and air-lock techniques.
In the air-lock technique (3), a small amount of air is drawn up into the syringe along with the medication, the skin is stretched flat between two fingers and held taut, needle is plunged in at a right angle, injection includes medication followed by air, needle is withdrawn and taut skin is released. Rationale is the air locks in the medication in the muscle, hence air-lock, preventing it from seeping out into surrounding tissue along the needle track.
Possible Sources Of Pain After IM Injection
- Aspiration is when the injector pushes the needle in but pulls back the syringe plunger before injecting the medication, rationale being to see if blood appears in the syringe meaning a blood vessel got punctured, i.e., need to try again. However, problems with aspiration are
- No scientific support (4).
- Can cause local tissue trauma and lingering pain (5, 6, , ).
- Is frequently done far too quickly to even be effective (4).
- Isn’t recommended by National Immunization Technical Advisory Committees ( ).
- Inexperienced and/or unskilled injectors may end up injecting subcutaneously (SC) rather than IM, and cause undue local tissue trauma (10, 11).
- Wrong choice of needle length can also increase chance of SC rather than IM injection. This is because ratio of subcutaneous to muscle varies by gender, age and weight, being higher in women (12, , 14, 15, , ), older people and the obese ( , , 20, , ). For example, a study infers a 12 to 25mm needle suffices for a thin person while a very obese person requires 76mm long needle for an IM injection ( ).
- Wiping needle with alcohol before injecting tracks it through the subcutaneous layer, which can be painful ( ).
How To Minimize Pain After IM Injection
- For something that’s a mainstay of routine medicine, shocking really that few sufficiently large, carefully controlled studies have compared different sites and techniques for their capacity to minimize pain after IM injection ( ).
- Consensus is slowly building that Ventrogluteal may cause less pain.
- It isn’t close to large blood vessels, nerves, bone (1, 2, 10, 11, , 26, , 28, 29).
- Being covered by relatively less subcutaneous tissue (15, 30) is another advantage since this reduces chances of accidental subcutaneous delivery (2, , 28).
- However, there’s still insufficient conclusive data supporting it over Dorsogluteal ( ).
- OTOH, Dorsogluteal, though still much more commonly used compared to Ventrogluteal, has known risks such as
- Sciatic nerve injury (26, 29).
- Proximity to major blood vessels.
- Increased thickness of subcutaneous tissue in this area compared to others ( ), especially ventrogluteal (15, 30).
- Injection techniques: A couple of small controlled studies (n=90 females aged between 18 and 60 years of age, ; n=60; ) suggest the air-lock technique can reduce tissue trauma and pain from IM injections.
- Relaxed muscles can reduce injection site discomfort and pain (
). This means appropriately positioning the body, particularly the limbs, before IM injection. Studies (33, 34) suggest
- Placing the hand on the hip relaxes the deltoid muscle.
- Internal rotation of the femur relaxes the gluteal muscles.
- No pain at initial point of needle contact on skin ( , 35). If there is pain, better to move needle 2 to 3mm at a time until reaching a painless point on the skin. Rationale is differential skin innervation, i.e., hitting upon a skin site with fewer or no pain receptors.
- A randomized study (n=100) showed that changing needle after drawing up the medication and before injecting can minimize pain by ensuring needle tip used for injection remains sharp and free of medicine residue ( ).
- Briefly applying manual pressure to injection site before IM injection can minimize post-injection pain (6; n=48, 45 experimental and control, respectively, 37; n=74, one injection per arm, manual pressure randomly assigned, 38; n=63, 60 experimental and control, respectively, 39).
1. Ogston-Tuck, Sherri. “Intramuscular injection technique: an evidence-based approach.” Nursing Standard 29.4 (2014): 52-59.
2. Chadwick, Angelina, and Neil Withnell. “How to administer intramuscular injections.” Nursing Standard 30.8 (2015): 36-39.
3. Gabhann, L’am Mac. “A comparison of two depot injection techniques.” Nursing Standard 12.37 (1998): 39-41.
4. Ipp, Moshe, Jonathan Sam, and Patricia C. Parkin. “Needle aspiration and intramuscular vaccination.” Archives of pediatrics & adolescent medicine 160.4 (2006): 451-451.
5. Ipp, Moshe, et al. “Vaccine-related pain: randomised controlled trial of two injection techniques.” Archives of disease in childhood 92.12 (2007): 1105-1108.
6. Taddio, Anna, et al. “Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials.” Clinical Therapeutics 31 (2009): S48-S76.
7. Taddio, Anna, et al. “Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline.” Canadian Medical Association Journal 182.18 (2010): E843-E855.
8. Davidson, Kathleen Marie, and Liam Rourke. “Teaching best-evidence: Deltoid intramuscular injection technique.” Journal of Nursing Education and Practice 3.7 (2013): 120.
9. Cook, Ian F. “Best vaccination practice and medically attended injection site events following deltoid intramuscular injection.” Human vaccines & immunotherapeutics 11.5 (2015): 1184-1191.
10. Wynaden, Dianne, et al. “Establishing best practice guidelines for administration of intra muscular injections in the adult: a systematic review of the literature.” Contemporary nurse 20.2 (2005): 267-277.
11. Cocoman, A., and J. Murray. “Intramuscular injections: a review of best practice for mental health nurses.” Journal of psychiatric and mental health nursing 15.5 (2008): 424-434.
12. Haramati, Nogah, et al. “Injection granulomas. Intramuscle or intrafat?.” Archives of family medicine 3.2 (1994): 146-148.
13. Poland, Gregory A., et al. “Determination of deltoid fat pad thickness: implications for needle length in adult immunization.” Jama 277.21 (1997): 1709-1711.
14. Cook, I. F., M. Williamson, and D. Pond. “Definition of needle length required for intramuscular deltoid injection in elderly adults: an ultrasonographic study.” Vaccine 24.7 (2006): 937-940.
15. Chan, V. O., et al. “Intramuscular injections into the buttocks: are they truly intramuscular?.” European journal of radiology 58.3 (2006): 480-484.
16. Burbridge, Brent E. “Computed tomographic measurement of gluteal subcutaneous fat thickness in reference to failure of gluteal intramuscular injections.” Canadian Association of Radiologists Journal 58.2 (2007): 72.
17. Shankar, Nachiket, et al. “Influence of skin-to-muscle and muscle-to-bone thickness on depth of needle penetration in adults at the deltoid intramuscular injection site.” medical journal armed forces india 70.4 (2014): 338-343.
18. Greenway, Kathleen. “Using the ventrogluteal site for intramuscular injection.” Nursing Standard 18.25 (2004): 39-42.
19. Nisbet, Andrew Charles. “Intramuscular gluteal injections in the increasingly obese population: retrospective study.” Bmj 332.7542 (2006): 637-638.
20. Zaybak, Ayten, et al. “Does obesity prevent the needle from reaching muscle in intramuscular injections?.” Journal of advanced nursing 58.6 (2007): 552-556.
21. Sakamaki, Sakiko, et al. “The relationship between body mass index, thickness of subcutaneous fat, and the gluteus muscle as the intramuscular injection site.” Health 2013 (2013).
22. Brown, Joe, Mark Gillespie, and Simon Chard. “The dorso–ventro debate: in search of empirical evidence.” British Journal of Nursing 24.22 (2015): 1132-1139.
23. Kaya, Nurten, et al. “The reliability of site determination methods in ventrogluteal area injection: A cross-sectional study.” International journal of nursing studies 52.1 (2015): 355-360.
24. Nicoll, Leslie H., and Amy Hesby. “Intramuscular injection: an integrative research review and guideline for evidence-based practice.” Applied Nursing Research 15.3 (2002): 149-162.
25. Malkin, Bridget. “Are techniques used for intramuscular injection based on research evidence.” Nursing times 104.50/51 (2008): 48-51.
26. Small, Sandra P. “Preventing sciatic nerve injury from intramuscular injections: literature review.” Journal of advanced nursing 47.3 (2004): 287-296.
27. Ferreira Oliveira, Laura, et al. “Ventrogluteal region, an alternative location to apply benzathine penicillin.” Revista Eletronica de Enfermagem 17.4 (2015).
28. Coskun, Halise, Cenk Kilic, and Cicek Senture. “The evaluation of dorsogluteal and ventrogluteal injection sites: a cadaver study.” Journal of clinical nursing (2016).
29. Mishra, P., and M. D. Stringer. “Sciatic nerve injury from intramuscular injection: a persistent and global problem.” International journal of clinical practice 64.11 (2010): 1573-1579.
30. Beecroft, P. C., and S. A. Redick. “Clarification of ventrogluteal site.” Pediatric nursing 16.4 (1989): 396-396.
31. Najafidolatabad, Shahla, Janmohamad Malekzadeh, and Zinat Mohebbinovbandegani. “Comparison of the pain severity, drug leakage and ecchymosis rates caused by the application on tramadol intramuscular injection in Z-track and Air-lock techniques.” Investigación y Educación en Enfermería 28.2 (2010): 24-33.
32. Yilmaz, Dilek K., et al. “The effect of air-lock technique on pain at the site of intramuscular injection.” Saudi medical journal 37.3 (2016): 304.
33. Kruszwski, Ann Z., Susan Havens Lang, and Jean E. Johnson. “Effect of positioning on discomfort from intramuscular injections in the dorsogluteal site.” Nursing Research 28.2 (1979): 103-105.
34. Rettig, Frannie M., and Janet R. Southby. “Using different body positions to reduce discomfort from dorsogluteal injection.” Nursing Research 31.4 (1982): 219-221.
35. Jablecki, C. K. “Alternative technique for medication injections.” Nursing research 49.5 (2000): 244.
36. Ağaç, Emine, and Ülkü Yapucu Güneş. “Effect on pain of changing the needle prior to administering medicine intramuscularly: a randomized controlled trial.” Journal of advanced nursing 67.3 (2011): 563-568.
37. Barnhill, Barbara J., et al. “Using pressure to decrease the pain of intramuscular injections.” Journal of pain and symptom management 12.1 (1996): 52-58.
38. Chung, Joanne WY, Winnie MY Ng, and Thomas KS Wong. “An experimental study on the use of manual pressure to reduce pain in intramuscular injections.” Journal of clinical nursing 11.4 (2002): 457-461.
39. Öztürk, Deniz, et al. “The effect of the application of manual pressure before the administration of intramuscular injections on students’ perceptions of postinjection pain: a semi‐experimental study.” Journal of Clinical Nursing (2016).