Ultrasound Guided
Joint
Femoroacetabular
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The accuracy of ultrasound-guided intra-articular (IA) hip injections is 97%–100% in the literature.
Pertinent Anatomy
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The hip joint is a ball and socket synovial joint formed by the femoral head and acetabulum.
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It is surrounded by a thick articulate capsule that is made up of the iliofemoral, ischiofemoral (Y ligament of Bigelow), and pubofemoral ligaments that extend over the femoral head and neck.
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The capsule extends from the acetabulum to the intertrochanteric line. It folds back from this point on itself and inserts on the femoral head-neck junction. Thus, from the acetabulum to the femoral head-neck junction, the capsule has one layer, and from the head-neck junction to the intertrochanteric line, the capsule is composed of two layers.
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The synovial folds are referred to as the retinaculum of Weitbrecht ( Fig. 20.1 ).
Fig. 20.1
Retinaculum of Weitbrecht Dissection.
Courtesy Christopher Centeno and John Schultz.
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The acetabulum is surrounded circumferentially by the labrum, which is composed of fibrocartilage. The hyaline cartilage on the femoral head articulates with the labrum. The labrum will appear hyperechoic and triangular on ultrasound.
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The femoral neurovascular bundle descends medially from the pelvis into the leg. It exits the pelvis through the femoral triangle, which is lined laterally by the sartorius, medially by the adductor longus, and superiorly by the inguinal ligament. The iliopsoas separates the bundle from the hip joint.
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The lateral and medial circumflex arteries surround and supply the femoral head. They arise from the deep femoral artery, a branch of the femoral artery. Hip joint innervation comes from branches of the femoral, obturator, and sciatic nerves ( Figs. 20.2 and 20.3 ).
Fig. 20.2
Posterior Pelvic Large Neurovascular and Bony Anatomy.
Fig. 20.3
Posterior View of Sacropelvic Ligaments.
Common Pathology
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Hip osteoarthritis, labral degeneration, labral tears, adhesive capsulitis, and can be a source for inflammatory arthropathies.
Equipment
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Needle size: 22- to 25-gauge, 2.5- to 5.0-inch spinal needle
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Low-frequency curvilinear ultrasound transducer
Common Injectates
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Local anesthetics for diagnostics, corticosteroids
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Prolotherapy, hyaluronic acid, orthobiologics (platelet-rich plasma [PRP], bone marrow concentrate, micronized adipose tissue, etc.)
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For capsular distention. local anesthetic and normal saline +/− corticosteroid, and/or orthobiologics, such as platelet-poor plasma, platelet lysate, etc.
Injectate Volume
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For weight-bearing intra-articular (IA) injection: 2 to 5 mL.
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For capsular distention 10 to 20 mL. Stop when getting back flow into the syringe to avoid capsular rupture. Most hip capsules max out close to 16 mL, but some may tolerate close to 20 mL.
Technique: Anterior Approach
Patient Position
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Supine with a pillow under the knees for comfort and to relax the superficial structures around the joint
Clinician Position
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Standing or sitting on affected side of patient
Transducer Position
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Anteriorly in the oblique sagittal plane, parallel with the femoral neck ( Fig. 20.4 )
Fig. 20.4
Anterior Sagittal Oblique Approach.
Transducer in position for in-plane approach to hip joint.
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Alternatively, anteriorly, slightly oblique with transducer in plane to the femoral neck ( Fig 20.5 )
Fig. 20.5
Anterior Transverse Approach.
Transducer position for alternate approach to hip joint.
Needle Position
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In plane
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Caudolateral to cephalomedial
Target
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Anterior synovial recess, located at or just proximal to the junction of the femoral head and neck ( Fig 20.6 ).
Fig. 20.6
Anterior Sagittal Oblique Approach.
Ultrasound image with target being the anterior recess of the joint capsule at or just proximal to the femoral head-neck junction. Arrow indicates desired path of needle into hip joint and head-neck junction. FH , Femoral head; FN , femoral neck.
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For IA biologics, optimal needle placement may be closer to the weight-bearing portion of the joint at the junction of the femoral head and the acetabulum ( Fig. 20.7B ).
Fig. 20.7
(A) Hip intra-articular injection setup with heel toe maneuver and gel standoff. (B) Hip intra-articular injection femoral acetabular junction for weight-bearing flow. AC , Acetabulum; arrows , needle; FH , femoral head.
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It is helpful to tilt the transducer so that the needle is parallel to the probe. Placing a gel standoff can eliminate ultrasound dead space (see Fig. 20.7A ). A slight bend to the needle tip can help for redirecting, with the goal being to keep the needle closer to the femoral neck and avoid potential harm to the acetabular labrum.
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Having an assistant apply distal traction on the leg can help open the joint more to allow for easier flow of injectate and open more space to avoid labral injection.
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Use lower-frequency probe for better visualization.
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Identify the location of the lateral circumflex femoral artery, as it will often be in the projected trajectory of the needle and the femoral neurovascular bundle medially.
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Needle visualization may be difficult in deeper structures, especially if significant subcutaneous tissue is present, reducing the conspicuity of the target.
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For injecting a collapsed joint recess, it is often helpful to first inject local anesthetic to ensure accurate IA needle placement before final injection.
Adhesive capsulitis can occur in the hip similar to the shoulder and can be associated with arthritis. It can be treated first conservatively with physical therapy. Other interventions include steroid injection, capsular dilation, manipulation under anesthesia, and open or arthroscopic synovectomy, lysis of adhesions, and capsular release.
Capsular distention can help for adhesive capsulitis. There are small reports in the literature.
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Pitts-Williams A through D criteria for capsular distention:
- A.
Utilize color flow to ensure that flow is confined to the capsule and not flowing into the surrounding soft tissue structures.
- B.
Inject 5 mL of 0.25% ropivacaine initially, followed by an additional 5–15 mL of injectate connected to the syringe with a T-connector.
- C.
Maximal distention volume is reached when there is significant anterior thigh pressure reported by the patient or observed backflow from the T-connector once the syringe is removed. We recommend checking for backflow while injecting in 2–3 mL increments.
- D.
Hip range-of-motion (ROM) techniques (i.e., proprioceptive neuromuscular facilitation, muscle energy, muscle activation technique [MAT], etc.) should be performed within 15 min of the distention while the joint is anesthetized. For optimal results, record a side-to-side comparison prior to the distention. Patients should be given a home stretching program to implement three times daily until they can start physical therapy.
- A.
Technique: Lateral Approach
Alternative approach for patients that have difficulty lying supine
Patient Position
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Lateral decubitus with pillow between the knees
Clinician Position
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Positioned behind the patient
Transducer Position
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Parallel with the femoral neck; often will need to angle and rock the probe to keep the bony cortex parallel or near parallel to the probe
Needle Position
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In-plane, lateral-to-medial approach
Target
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Synovial recess at or just proximal to the junction of the femoral head and neck
- •
Probe positioning and needle must be positioned to clear the greater trochanter on the initial approach. Often, the angle trajectory can be steep, making needle visualization challenging.
Technique: Posterior Approach
Patient Position
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Prone
- •
Will likely need the hip internal rotated to move the greater trochanter out of the needle trajectory. To achieve this, bend the patient’s leg at the knee and rotate from the lower leg outward ( Fig. 20.8A )
Fig. 20.8
(A) Posterior hip joint and capsule injection prone setup. (B) Posterior hip joint and capsule lateral decubitus setup. (C) Posterior hip joint injection ultrasound view. AC, Acetabulum; arrow , needle tip trajectory; FH , femoral head.
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Alternatively, patient can be in the lateral decubitus position (see Fig. 20.8B )
Clinician Position
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Standing ipsilateral to the symptomatic hip
Transducer Position
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Posteriorly in the oblique sagittal plane, parallel with the femoral neck
Needle Position
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In plane inferiolateral to superiomedial approach
Target
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Posterior synovial recess, located at or just proximal to the junction of the femoral head and neck (see Fig. 20.8C )
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There is more acetabular coverage posterior, so this approach is more difficult to obtain good weight-bearing flow. As such, this is not the preferred approach for IA biologics.
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This is the preferred approach when there is a desire to distend posterior hip capsule due to tightness and adhesions that limit hip internal rotation and hip flexion.
Pubic Symphysis
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Commonly underdiagnosed area of pain or instability, and often associated with sacroiliac joint dysfunction and instability. ,
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The pubic symphysis is widest anteriorly.
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There will be some resistance while injecting the fibrocartilage disc in the joint.
Pertinent Anatomy
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The pubic symphysis is a non-synovial amphiarthrodial joint connecting each pubis bone of the pelvis.
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It consists of a fibrocartilaginous disc between the articular surfaces of the pubic bones. It resists tensile, shearing, and compressive forces, and is capable of a small amount of movement under physiologic conditions in most adults (up to 2 mm shift and 1 degree rotation).
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Four ligaments reinforce the joint: superior and inferior pubic ligaments, along with the anterior and posterior pubic ligaments.
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The anterior portion of the joint is 3 to 5 mm wider than the posterior portion (see Fig. 20.3 ).
Common Pathology
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Degenerative of the pubic symphysis syndesmosis,
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Chronic anterior pelvic instability
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Rare but underdiagnosed. Most common causes of instability include pregnancy and parturition, which often resolves but can persist. External causes of instability include direct trauma, insufficiency fractures, athletics, prior surgery, and osteitis pubis.
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Osteitis pubis
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Stress injury most commonly seen in athletes that participate in sports involving quick changes of direction, such as football, soccer, ice hockey, etc.
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Secondary pubic symphysis disorder due to sacroiliac joint dysfunction.
Equipment
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Needle size: 22- to 25-gauge, 1.5- to 2.5 inch needle
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High-frequency linear ultrasound transducer
Common Injectates
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Anesthetics for diagnostics.
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Orthobiologics: (PRP, bone marrow concentrate, etc.) and prolotherapy
Injectate Volume
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For IA injection: 0.5 to 1 mL
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For ligamentous injection: 1 to 3 mL
Technique
Patient Position
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Supine with a pillow under knees for comfort (if needed) and to relax the superficial structures around the joint
Clinician Position
- •
Standing to side of patient
Transducer Position
- •
Out-of-plane approach ( Fig. 20.9 ), anatomic transverse plane over the anterior aspect of the pubic symphysis, with the joint space midline on the monitor
Fig. 20.9
Patient supine, with transducer in the transverse plane over the anterior aspect of the pubic symphysis for an out-of-plane approach.
- •
In-plane approach ( Fig. 20.10 ), anatomic sagittal or transverse plane over the anterior aspect of the pubic symphysis
Fig. 20.10
Patient supine, with transducer in the sagittal plane over the anterior aspect of the pubic symphysis for an in-plane approach.
Needle Position
- •
Out of plane, needle starting midline over the joint space
- •
In-plane, from lateral to medial (preferred approach to target the anterior ligaments) ( Fig. 20.11 )
Fig. 20.11
Pubic Symphysis Anterior Ligament Injection In-Plane Setup.
Target ( Fig. 20.12 )
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Pubic symphysis fibrocartilaginous disc ( Fig. 20.13 )
Fig. 20.12
Short-Axis View of Pubic Symphysis Joint.
Arrow indicates needle entry into the joint space. Note the absence of cortical bone in the picture, as this indicates the best view of the pubic symphysis joint for this technique. Stars indicate joint space.
Fig. 20.13
Long Axis View of Pubic Symphysis Joint.
Dots represent walk-down technique into the joint space for out-of-plane injection. PR , Pubic ramus.
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Anterior ligaments
- •
Can inject along the ligament lateral to medial and fan out superiorly and inferiorly ( Fig. 20.14 )
Fig. 20.14
Pubic Symphysis Anterior Ligaments In-Plane Injection.
AL , Anterior ligament; arrows , needle; PR , pubic rami.
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- •
Because this joint is a non-synovial joint, it is important to inject the fibrocartilage disc within the joint. There will be some resistance while injecting the fibrocartilage disc. A 25-gauge needle may be used to anesthetize the soft tissue down to the joint; however, a 22-guage needle is often needed to enter the joint.
- •
An anterosuperior to posteroinferior approach or lateral in-plane approach is recommended to avoid vascular structures of the genitalia that are inferior to the joint.
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Be sure not to puncture posterior to the joint as this may cause injury to the bladder. A distended bladder can be positioned above the superior margin of the joint and is susceptible to puncture there, as well.
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Hip Capsular Ligaments
Hip Capsular Ligaments
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Injection technique is very similar to IA injections except just superficial to the joint, and the goal is to inject multiple sites along the ligaments/capsule.
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Prolotherapy and biologics can be used to stabilize a loose hip, especially in the presence of labral tears, traumatic injuries, connective tissue disorders, and joint arthritis.
Pertinent Anatomy
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Anterior ligaments include:
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Pubofemoral: originates on iliopectineal eminence of the pubic rami and attaches triangularly to the femoral head, capsule, and ischiofemoral ligament, and orients more transverse. Limits excess external rotation. Weakest hip ligament.
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Iliofemoral ligament (Y ligament of Bigelow): the strongest ligament in the body. Inverted Y shape originates vastly along the anterior femur and inserts around the base of the anterior inferior iliac spine (AIIS). Supports standing posture, which limits excessive hip extension
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- •
Lateral ligaments include:
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Iliofemoral ligament and ischiofemoral ligament
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Posterior ligaments include:
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Ischiofemoral runs mostly transverse from the ischial acetabular margin to broadly at the base of the greater trochanter. It prevents excessive extension and internal rotation (see Fig. 20.3 )
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Common Pathology
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Hip instability.
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Causes include traumatic (post subluxation); iatrogenic, i.e., anterior dislocation after arthroscopy from traction or capsulotomy; developmental dysplasia of the hip; connective tissue/hypermobility disorders; and repetitive microtrauma
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Equipment
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Low-frequency curvilinear ultrasound transducer
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Typically, 25- or 22-gauge, 3.5-inch spinal needle is sufficient.
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In larger or taller patient, a 25-gauge, 4.69-inch needle or 22-gauge, 5-inch needle is required
Common Injectates
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
- •
Steroids should not be used as they can potentially injure ligaments when injected directly.
Injectate Volume
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2 to 4 mL
Technique: Anterior Approach
Patient Position
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Supine, leg extended, same as IA approach
Clinician Position
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Standing on side of the affected hip
Transducer Position
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Anteriorly in the oblique sagittal plane, parallel with the femoral neck
Needle Position
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In plane, caudolateral to cephalomedial
Target
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Multiple areas along the capsule/iliofemoral and pubofemoral ligaments ( Fig. 20.15 )
Fig. 20.15
Hip Anterior Capsule Injection.
AC, Acetabulum; FH, femoral head; HC, hip capsule. Arrows , needle trajectory.
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Adjust transducer to inject multiple points along the joint capsule
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Observe injectate flow to ensure injectate is within the ligaments and not IA.
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Should have slightly more resistance than with IA injection, with resistance similar to tendons and other ligaments.
Technique: Posterior Approach
Patient Position
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Prone
- •
Internally rotate the hip to move the greater trochanter out of the needle trajectory. To achieve this, bend the patient’s leg at the knee and rotate from the lower leg outwards (see Fig. 20.8A )
Clinician Position
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Standing ipsilateral to the affected hip
Transducer Position
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Posteriorly in the oblique sagittal plane, parallel with the femoral neck
Needle Position
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In plane, inferolateral to superomedial approach
Target
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Multiple areas along the capsule/ischial femoral ligaments ( Fig. 20.16 ).
Fig. 20.16
Posterior Hip Joint Capsular Ligament Injection.
AC , Acetabulum; arrows , needle trajectories; FH, femoral head; PC , posterior capsule.
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Adjust transducer to inject multiple points along the joint capsule.
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Similar approach to intra-articular posterior approach, but injection is into the ligaments. Should have slightly more resistance than intra-articular injection.
Tendons and Bursae
Rectus Femoris/Sartorius Tendons
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Potential site of anterior hip pain.
Pertinent Anatomy
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The quadriceps muscle group is made up of the rectus femoris, and three vastus muscles (medialis, lateralis, and intermedius).
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The rectus crosses two joints and, thus, allows for hip flexion and knee extension.
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The rectus femoris has two origins: a direct head, which originates from the AIIS; and an indirect, which originates inferior and posterior to the AIIS from the superior acetabular ridge.
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The sartorius originates from the anterior superior iliac spine (ASIS) of the pelvis.
Common Pathology
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The quadriceps can be injured by a muscle strain pattern during knee flexion and hip extension. The rectus femoris is the most commonly injured, , as it is the most superficial and crosses two joints.
Equipment
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Needle size: 22- to 25-gauge, 1.5- to 3.5-inch (depends on body habitus)
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High-frequency linear ultrasound transducer or low-frequency curvilinear transducer
Common Injectates
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Anesthetics for diagnostics
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.)
Injectate Volume
- •
2 to 4 mL in total
Technique
See Fig. 20.17 .
Patient Position
- •
Supine with a pillow under knees for comfort (if needed) and to relax the superficial structures
Clinician Position
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Standing or sitting on affected side of patient
Transducer Position
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Long axis to the tendon
Needle Position
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In plane, distal to proximal approach
Target
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Pathologic tendon, usually at or just distal to attachment ( Figs. 20.18 and 20.19 )
Fig. 20.18
Ultrasound image in sagittal plane shows the direct head of the rectus femoris in long axis for an in-plane injection with path of needle directly to tendon pathology. I , Anterior inferior iliac spine; R , rectus femoris; arrow, path of needle.
Fig. 20.19
Ultrasound image shows long axis of the sartorius for an in-plane injection with path of needle directly to tendon pathology. I , Iliopsoas complex; IL , anterior superior iliac spine of ilium; S , sartorius; arrow , path of needle.
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Since there is no tendon sheath in this area, avoid corticosteroids, as they could have harmful effects on the tendon.
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If performing fenestration, with or without biologic, be sure to visualize and treat all damaged areas of the tendon.
Adductor Tendons
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The adductor longus is the most commonly injured adductor tendon.
Pertinent Anatomy
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The hip adductors are a powerful group of muscles that consist of the adductor magnus/minimus, adductor longus, adductor brevis, and the gracilis and pectineus muscle groups.
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The adductor longus, brevis, and magnus originate from the ischium and pubis of the pelvis.
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The adductor longus shares a common aponeurosis with the rectus abdominus muscle on the pubis.
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- •
Superficial and medial to the adductors, the gracilis originates from the inferior pubic ramus ( Fig. 20.20 ).
Fig. 20.20
Hip Anterior Musculature Anatomy and Large Neuroanatomy.
Common Pathology
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Rectus abdominus-adductor longus aponeurotic plate injury
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Adductor tendon injury (acute or chronic)
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Acute injuries—change of direction, push-off, or stop-and-go movements (i.e., as in soccer, football, hockey, lacrosse, basketball, tennis, etc.), and report a “pop” or “pull” at the time of injury
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Chronic overuse or repetitive movements, and athletes often complain of a dull ache with these injuries but are often able to continue to play
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- •
Athletic pubalgia—spectrum of related pathology conditions causing groin pain
Equipment
- •
Needle size: 22-to 25-gauge, 1.5 to 3-inch needle
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High-frequency linear ultrasound transducer
Common Injectates
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Anesthetics for diagnostics
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.)
Injectate Volume
- •
2 to 4 mL
Technique
Patient Position
See Fig. 20.21 .
- •
Supine, with the hip externally rotated and abducted with the knee flexed.
- •
Patient’s arms folded across the abdomen.
Clinician Position
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Standing on affected side.
Transducer Position
See Fig 20.22 .
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Long axis to the adductor longus tendon.
Needle Position
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In plane.
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Distal-to-proximal approach.
Target
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Adductor tendon where pathology is noted, most often at insertion to pubic symphysis at the insertion of the common aponeurosis of the rectus abdominus-adductor longus ( Fig. 20.23 )
Fig. 20.23
Ultrasound image of adductor longus (AL) tendinosis with cortical irregularities (small arrows) seen at insertion to the pubic ramus. Long arrow indicates needle angle and position for tenotomy procedure with long-axis, in-plane approach. AB , Adductor brevis muscle; P , pubic ramus.
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Must rotate the transducer to short axis during the procedure to ensure that the entire width of diseased tendon is treated.
- •
Identify the adductor longus tendon by palpation and place the transducer over it in order to properly identify the entire group of tendons.
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A distal-to-proximal approach for this injection decreases the risk of intravascular injection, as the needle is moving away from the major neurovascular bundle.
Iliopsoas Tendon and Bursa
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Dynamic ultrasound evaluation for iliopsoas snapping should be considered.
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Injury to the iliopsoas in this location can occur with total hip arthroplasty or hip arthroscopy.
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Iliopsoas impingement has been associated with anterior labral tears and should be targeted with the same procedure.
Pertinent Anatomy
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The iliopsoas musculotendinous unit is composed of the psoas major, iliacus, and psoas minor, and inserts on the lesser trochanter, with some fibers inserting on the proximal femur.
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The psoas major originates from T12 to L5 transverse processes, vertebral bodies, and intervertebral discs.
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The iliacus originates from the iliac crest and the thoracolumbar spine, and joins the psoas muscles, forming the iliopsoas tendon.
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The psoas minor (which is absent in approximately 40% of the population) attaches at T12 and L1 for its origin, courses anterior to psoas major, and merges to form the iliopsoas tendon.
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The myotendinous junction occurs at the level of the superior pubic ramus.
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The iliopsoas bursa is located between the anterior capsule of the hip joint and the iliopsoas tendon.
Common Pathology
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Iliopsoas tendinosis or, less commonly, tendon tear
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Iliopsoas tendon impingement in the setting of a hip replacement and the anterior aspect of the acetabular cup or femoral collar, causing impingement
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Lesser trochanter avulsion fracture
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Lesser trochanter avulsion in the adult should raise concern for pathologic fracture
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Snapping iliopsoas tendon
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Seen with dynamic ultrasound when moving the hip from flexion-external rotation or frog leg position to a straightened position
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Iliopsoas bursitis
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Distention may coincide with iliopsoas tendinosis but is more likely related to an IA hip pathologic process due to continuous synovium between the joint and iliopsoas bursa
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Equipment
- •
Needle size: 22-gauge, 2.5- to 3.5-inch needle
- •
Medium- to low-frequency linear ultrasound transducer, depending on patient body habitus
Common Injectates
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Anesthetics for diagnostics
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Corticosteroids for bursa only; should not be injected intratendinous
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.)
Injectate Volume
- •
2 to 4 mL
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Technique iliopsoas bursa or tendon at the femoral head
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Patient Position
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Supine
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Hip in neutral position
Clinician Position
- •
Standing on affected side
Transducer Position
See Fig. 20.24 .
- •
Oblique axial plane parallel to inguinal ligament and iliopectineal eminence (just superior to femoral head)
- •
Alternatively, sagittal plane in line with the iliopsoas tendon as it crosses the femoral head ( Fig. 20.25A )
Fig. 20.25
(A). Iliopsoas tendon at the femoral head in-plane injection setup. (B) Iliopsoas at femoral head long-axis, in-plane injection. IP, Iliopsos at the femoral head long-axis, in-plane ultrasound injection. Hypoechoic interstitial tendon tear ( asterisk ); LT, lesser trochanter. Needle (arrowheads).
Needle Position
- •
In-plane, lateral-to-medial approach
Target
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Intratendinous pathology of the iliopsoas tendon, targeting areas of hypoechogenicity or occult tears
- •
Target: Iliopsoas bursa if it is distended ( Fig 20.26 ). Otherwise, injection should be deep to the iliopsoas tendon and superficial to the ilium at the iliopectineal eminence
Fig. 20.26
Short-axis ultrasound image to iliopsoas tendon (I) shows hypoechoic iliopsoas bursal distention (short arrow). Long arrow indicates path of needle to iliopsoas bursa injection. The left side of image is lateral. a , Femoral artery.
Fig. 20.27
Short-axis ultrasound image to iliopsoas tendon ( I ) shows hypoechoic iliopsoas bursal distension ( short arrow ). Long arrow indicates path of needle to iliopsoas tendon injection. The right side of image is medial. a , Femoral artery.
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- •
Due to the curvilinear course of the iliopsoas tendon, it is susceptible to anisotropy. Adjust the ultrasound probe to eliminate anisotropy and improve visualization of the tendon.
- •
Limited ultrasound evaluation of the hip prior to the procedure is essential to screen for snapping hip syndrome and other causes for anterior hip pain, such as paralabral cyst.
- •
Visualize the femoral neurovascular bundle in relation to the iliopsoas tendon before proceeding with the injection to avoid injury.
- •
The tendon can require several repositionings of the needle to target all pathologic areas.
- •
Anesthetic can be used to anesthetize the tendon sheath and small aliquots can be used within the tendon to assess for occult tears and plan where to place the orthobiologic.
Technique
- •
Alternative approach distally and insertional iliopsoas tendon
Patient Position
- •
Supine
- •
Knee flexed and hip externally rotated
Clinician Position
- •
Standing on affected side
Transducer Position
- •
Long axis to the tendon
- •
Scan distal along the tendon to visualize the insertion on the lesser trochanter
Needle Position
- •
Out-of-plane, lateral-to-medial approach ( Fig 20.28A )
- •
Alternative: in-plane, proximal-to-distal approach (see Fig. 20.28B )
Fig. 20.28
(A) Distal iliopsoas tendon out-of-plane injection setup. (B) Distal iliopsoas injection in-plane setup. (C) Distal iliopsoas long-axis, out-of-plane injection. (D) Distal iliopsoas injection long-axis, in-plane injection. Arrows , needle; IP , Iliopsoas; LT , lesser trochanter.
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Target
- •
Distal iliopsoas tendon, at or just proximal to the lesser trochanter (see Fig. 20.28C and D )
- •
Have to do pre-procedural scan to identify the femoral artery and avoid neurovascular injury.
- •
Proceduralist has to have good experience with out-of-plane approach as the target can be deep at close to the femoral artery that needs to be avoided.
- •
The iliopsoas tendon is a long tendon. Anesthetic injections into the tendon can help localize symptomatic pathology tendon at the iliopectineal eminence, superficial to the femoral or at the insertion, and guide future biologic injections.
Iliopsoas Bursa-Technique: Lateral Approach
Patient Position
- •
Supine, hip in neutral position
Clinician Position
- •
Seated or standing adjacent to the affected hip.
Transducer Position
See Fig. 20.29 .
- •
Short axis to the iliopsoas tendon, oblique axial plane, parallel to inguinal ligament and cephalad to femoral head
Needle Position
- •
In-plane, lateral-to-medial approach
Target
- •
Iliopsoas bursa (see Fig. 20.26 )
- •
If the bursa is not clearly distended, the injection should be deep to the iliopsoas tendon and superficial to the ilium at the iliopectineal eminence.
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In post-arthroplasty patients, if the bursa is not clearly distended, the target should be directly over the hip joint.
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When injecting deep to the iliopsoas tendon, the femoral head should not be in view. This will ensure that the injectate is located within the iliopsoas bursa and not accidently injected into the hip joint
Tensor Fascia Lata Tendon and Proximal Iliotibial Band Injections
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The proximal tensor fascia lata (TFL) tendon and iliotibial band are common sites of overuse injuries in runners with pain at the ASIS attachment.
Pertinent Anatomy
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The Tensor fascia lata (TFL) originates from the ASIS and anterior aspect of the iliac crest, and assists with hip flexion, internal rotation, abduction, and stabilization of both the hip and knee.
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The iliotibial band (ITB) is a dense fibrous band of connective tissue that runs laterally from the iliac crest to the lateral knee.
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The ITB is a three-layer structure that originates, as the fascia lata, from the iliac tubercle and superficial to the TFL. As it traverses distally, at the site of the greater trochanter, the fascia lata gains thickness (∼1.9 mm total) from a fibrous expansion of the gluteus maximus (gluteal aponeurosis) and the TFL to form the ITB.
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The ITB continues to run distally in the lateral portion of the thigh, superficial to the vastus lateralis. The distal insertion point is Gerdy’s tubercle, where it merges with biceps femoris and vastus lateralis (see Fig. 20.20 ).
Common Pathology
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The TFL can become clinically significant in cases of tightening and overuse at its origin, or through its attachment to the ITB
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The TFL is a secondary hip abductor, and pathology may be secondary to underlying gluteal medius weakness.
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Strain injuries of the ITB (or, more specifically, the fascia lata) at the iliac tubercle have been documented and referred to as proximal iliotibial band syndrome. It is described as a strain injury to the ITB enthesis, where it attaches to the iliac tubercle.
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Abnormalities of the ITB at the level of the greater trochanter are typically not considered part of proximal iliotibial band syndrome.
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Equipment
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High-frequency linear transducer
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Needle size: 22-gauge, 1.5- to 2.5-inch needle
Common Injectates
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Anesthetics for diagnostics and needle fenestration/tenotomy
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.)
Injectate Volume
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2 to 4 mL in total
Technique
Patient Position
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Side-lying with affected side upwards, and hip/knee flexed
Clinician Position
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Seated or standing behind the patient
Transducer Position ( Fig. 20.30 )
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Long axis to the origin of the TFL at the ASIS
Fig. 20.30
(A) Anterolateral sagittal approach. Patient is side-lying and the transducer is in the in-plane sagittal approach, long axis to the tensor fascia lata, on the posterior aspect of the anterior superior iliac spine. (B) Lateral coronal approach. Patient is side-lying and the transducer is long axis to the iliotibial band in the lateral plane at the superior portion of the iliac crest with in-plane needle approach.
Needle Position
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In plane, distal to proximal
Target
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Site of pathology, often at origin of TFL on the anterior iliac crest to the ASIS ( Fig. 20.31 )
Fig. 20.31
Ultrasound image in long axis to the proximal tensor fascia lata shows 20-gauge needle and needle tip (arrows) within tendon segment. I , Ilium.
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Superior portion of the anterolateral iliac crest at the attachment of the proximal ITB (fascia lata), or at the site of defect or fascial injury
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Pathology of the TFL is probably underdiagnosed, especially in running athletes.
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Would consider needle fenestration with or without PRP injection into the tendon with ultrasound guidance. The number of passes through the tendon during fenestration should be enough until there is a change in tissue resistance.
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