10.1
Hip
The hip represents a challenging area to scan and inject effectively. The key elements in this region are the correct identification of anatomy, suitable positioning of the patient, bring structures as superficial as possible, and adapting techniques to suit the individual clinician. In this way, multiple areas can be effectively treated.
Joint injections
Two common joints that might require an injection this area include the hip joint (HJ) itself and the pubic symphysis (PS). Being deeper, the former tends to be more challenging while the latter, although more superficial can be associated with more pain during the procedure.
10.1.1
Anterior Hip joint
| Patient position: | For the anterior hip joint (AHJ), the patient should be positioned in a supine orientation and, if possible, the hip can be opened further, by lowering the end of the bed ( Fig. 10.1.1A ). This is particularly useful if there is extensive degenerative changes in the joint. |
| Identifying the anatomy: | In this position, the anterior joint is most readily visualised by placing the transducer in a LAX orientation, slightly oblique to the position of the leg. In the field of view, the femoral neck, femoral head and acetabulum should be visualised ( Fig. 10.1.1B and C ). The labrum may also be identified and in degenerative hips an effusion, bony irregularity or labral cysts might be seen. |
| Injections performed: | CSI for pain symptoms or synovitis. PRP or HA injections for degenerative disease. |
| Recommended transducer: | Curvilinear 3–5 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI or HA injections. Set 4 for PRP. Needle: 2.5-inch 21- or 23-gauge needle. Syringes: 3 mL for CSI. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (2 mL). Standard/available HA or PRP preparation. |
| Injection technique: | Using the femoral neck as the target and the transducer in a LAX orientation, the needle can be inserted using an IP approach at an approximately 50–60 degrees angle. With the bevel facing down, once the needle breaches the joint capsule, the tip can rest on the femoral neck and a small amount of fluid is injected to open the joint. At this point, the needle can be repositioned if needed and the remaining solution should be seen to flow proximally around the femoral head ( Fig. 10.1.1D and E ). Care must be taken to avoid vessels and nerves in the groin. |
Injections to the AHJ.
In the supine position, the AHJ can be opened further by lowering the end of the couch. The injection can be undertaken using an IP technique from a distal approach, with the transducer in a LAX orientation. The needle tip should be seen within distal joint capsule.
10.1.2
Pubic symphysis
| Patient position: | For the pubic symphysis (PS), position the patient in a supine position with the abdomen and suprapubic area exposed ( Fig. 10.1.2A ). |
| Identifying the anatomy: | The PS can be visualised by placing the transducer in a LAX orientation and following the superior pubic ramus until the symphysis is identified and the transducer lies across the joint ( Fig. 10.1.2.B and C ). The diarthrodal joint can be easily seen with the pubic rami either side. A SAX view is not usually required for the PS. |
| Injections performed: | CSI for synovitis, pain symptoms or degenerative disease. PRP injections for pain symptoms or degenerative disease. |
| Recommended transducer: | Hockey stick 8–18 mHz. Linear 6–15 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Set 4 for PRP injections. Needle: 1.5- to 2-inch 23- or 25-gauge needle. Syringes: 3 mL for CSI. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (1 mL). Standard/available PRP preparation. |
| Injection technique: | Maintaing the transducar in a LAX orientation, the needle can be inserted using an OOP technique, adjacent to the midline of the long edge transducer ( Fig. 10.1.2C–E ). With the bevel pointing downwards, the needle tip should be seen in the joint before the solution is injected. The solution should be seen to flowing into the PS and there might be tenting of the joint and a pressure sensation for the patient but this should improve with the LA. |
Injections to the PS.
In the supine position, the PS can be seen with the joint in the LAX. The injection can be undertaken using an OOP technique with the needle perpendicular to the skin. The needle tip should be seen within joint itself.
Tendon injections
Superficial tendons commonly injected around the hip area include the gluteus medius (GMT), the iliopsoas (ILT), hamstring origin (HSO) and adductor tendons (AdT).
10.1.3
Gluteus medius tendon
| Patient position: | For the gluteus medius tendon (GMT), position the patient in a side-lying position with the asymptomatic contralateral side down on the couch. The symptomatic hip should be exposed and facing up ( Fig. 10.1.3A ). |
| Identifying the anatomy: | With the transducer placed in a LAX orientation along the length of the leg, the GMT can be seen inserting on the middle facet of the greater trochanter. Overlying is the tensor fascia lata (TFL) muscle ( Fig. 10.1.3B and C ), which later becomes the Ilio-Tibial Band. It can also be seen in the SAX by turning the transducer 90 degrees ( Fig. 10.1.3D and E ). |
| Injections performed: | CSI for tendinopathy and pain. PRP injections for degenerative tendon disease with intra-substance tearing. |
| Recommended transducer: | Linear 6–15 mHz. Curvilinear 2–5 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Set 4 for PRP injections. Needle: 1.5- to 2-inch 23- or 25-gauge needle. Syringes: 5 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (5 mL). Standard/available PRP preparation. |
| Injection technique: | Viewing the GMT in the LAX orientation, needle can be introduced IP at approximately 45 degrees ( Fig. 10.1.3F and G ). Alternatively, the transducer can be turned 90 degrees into an SAX view and the needle can be brought in as horizontal as possible, also utilising an IP technique ( Fig. 10.1.3H and I ). For CSI, the needle should be aimed at the interface between the GMT and TFL to avoid direct injection into the tendon substance. If a PRP injection is being undertaken, the needle should be advanced into the tendon itself and a fenestration technique can be used to distribute the solution. |
Injections to the GMT.
In the side-lying position, the GMT can be seen in the LAX attaching to the greater trochanter with the TFL overlying. The injection can be undertaken using an IP technique in the SAX with the needle introduced as horizontal as possible to the transducer. The needle tip should be seen against the body of the tendon for CSI or within for PRP.
10.1.4
Iliopsoas tendon
| Patient position: | For the iliopsoas tendon (ILT), the patient should be positioned in a supine position with the hip slightly extended by lowering the end of the couch ( Fig. 10.1.4A ). This exposes the ILT and aims to make it more superficial. |
| Identifying the anatomy: | With the transducer placed in a LAX orientation over the hip joint, it can be moved medially to identify the ILT as it travels to its attachment at the lesser trochanter. In this position, the vascular bundle can be seen nearby. Once found, the ILT can be traced proximally before the transducer is turned 90 degrees to view the ILT in a SAX view ( Fig. 10.1.4B and C ). |
| Injections performed: | CSI for tendinopathy and pain symptoms. PRP injections for degenerative tendon disease with intrasubstance tearing. |
| Recommended transducer: | Linear 6–15 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Set 4 for PRP injections. Needle: 1.5- to 2-inch 23- or 25-gauge needle. Syringes: 3 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (2 mL). Standard/available PRP preparation. |
| Injection technique: | Viewing the ILT in the SAX, the needle should be introduced at approximately 45 degrees from a lateral approach ( Fig. 10.1.4D and E ). With the bevel down, it can be aimed at the tendon and once touching against the body of the tendon, a small amount of solution can be injected. Once the tissue planes separate, the needle can be repositioned in this space if required, and the remainder of the solution can be injected. An OOP can also be used with the needle introduced perpendicular to skin and adjacent to the long edge of the transducer ( Fig. 10.1.4F and G ). If a PRP injection is being undertaken, the needle should be advanced into the tendon itself before a fenestration technique is used to distribute the solution into the area of injury. |
Injections to the ILT.
In the supine position, the hip can be opened further by lowering the end of the couch. The injection can be undertaken using an IP technique from the lateral aspect with the transducer in the SAX or with an OOP approach. The needle tip should be seen against the body of the tendon for CSI or within for PRP.
10.1.5
Adductor tendons
| Patient position: | For the adductor tendons (AdT), the patient should be positioned in a supine position with the hip abducted and slightly externally rotated ( Fig. 10.1.5A ). The knee can be laid to rest on a pillow or rolled towel. This should expose the adductor/groin region. If needed, the lower half of the treatment couch can be lowered to bring the tendons in to a more superficial position. |
| Identifying the anatomy: | With the transducer placed in a LAX orientation over the adductor muscle, it can be brought to the groin where the conjoint tendon can be seen to attach onto the pubic tubercle (PT). The three adductor muscles (longus, brevis and magnus) are seen ( Fig. 10.1.5B and C ). |
| Injections performed: | CSI for tendinopathy and pain. PRP injections for degenerative tendon disease with intrasubstance tearing. |
| Recommended transducer: | Linear 6–15 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Set 4 for PRP injections. Needle: 1.5- to 2-inch 23- or 25-gauge needle. Syringes: 3 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (2 mL). Standard/available PRP preparation. |
| Injection technique: | Viewing the AdT in a LAX oreintation, the needle can be introduced IP from a distal position at approximately 30 degrees depending on body habitus. With the bevel facing down, the needle can be brought to rest against the tendon and once a small amount of solution has been injected to separate the tissue planes, the needle can be repositioned within this space and the remainder of the solution can be injected ( Fig. 10.1.5D and E ). If a PRP injection is being undertaken, the needle should be advanced into the tendon itself and using a fenestration technique the solution can be distributed. |
Injections to the AdT.
In the supine position, the hip can be abducted and externally rotated to access the tendons. The injection can be undertaken using an IP technique from a distal approach, with the transducer in a LAX orientation. The needle tip should be seen over the tendons for CSI and within for PRP.
10.1.6
Hamstring origin
| Patient position: | For the hamstring origin (HSO), the patient should be positioned in a prone or side-lying position. In the former, the hip can be flexed by lowering the end of the examination couch ( Fig. 10.1.6A ), and in the latter, the hip and knee can be flexed ( Fig. 10.1.6B ). Doing so in both positions, brings the HSO to a more superficial position. |
| Identifying the anatomy: | The transducer can be placed in a LAX orientation over the ischial tuberosity and the HSO can be seen to attach to this ( Fig. 10.1.6C and D ). Following it in the LAX position, the musculotendinous junction can be seen as it is moved distally ( Fig. 10.1.6.E ). Over the attachment, the transducer can be rotated 90 degrees ( Fig. 10.1.6F and G ) to view the tendon in a SAX orientation ( Fig. 10.1.6H ). |
| Injections performed: | CSI for tendinopathy or bursitis. PRP injections for degenerative tendon disease with intrasubstance tearing. |
| Recommended transducer: | Linear 3–12 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Set 4 for PRP injections. Needle: 2- to 2.5-inch 21- or 23-gauge needle. Syringes: 3 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (2.5 mL). Standard/available PRP preparation. |
| Injection technique: | Identifying the HSO in a SAX orientation, with the bevel facing down, the needle can be introduced using an IP technique as horizontal as possible so that it rests upon the tendon ad beneath the gluteus maximus muscle ( Fig. 10.1.6I–K ). Here a small amount of solution can be injected to separate the tissue planes and open the space. Having done so, the needle can be repositioned if required, before the remaining solution is injected over the attachment. A LAX orientation can also be used to perform the injection but depending on the habitus of the individual it may be more challenging due to the thickness of the gluteal muscle ( Fig. 10.1.6L–N ). If a PRP injection is being performed, the needle can be inserted into the tendon and an OOP view can be used to confirm placement. A fenestration technique can be used to distribute the solution in the tendon. |
Injections to the HSO.
In the prone or side-lying position, the HSO can be made more superficial by flexing the hip. The injection can be undertaken using an IP technique with the transducer in a LAX or SAX orientation. The needle tip should be seen over the tendons for CSI and within for PRP.
Bursa injections
The trochanteric bursa (TB) is situated on the lateral aspect of the hip, between the tensor fascia lata (TFL) and GMT, is a common source of hip pain after minor trauma and can be injected under ultrasound guidance.
10.1.7
Trochanteric bursa
| Patient position: | For the trochanteric bursa (TB), position the patient in a side-lying position with the symptomatic hip exposed and facing up ( Fig. 10.1.7A ). If the contralateral hip is asymptomatic, then the patient can rest this upon the treatment couch, whereas if that is also symptomatic, cushioning should be provided. |
| Identifying the anatomy: | With the transducer placed in a LAX orientation along the length of the leg, the TB can be seen between the tenor fascia lata (TFL) and gluteus medius tendon (GMT) ( Fig. 10.1.7B and C ). The transducer can then be turned 90 degrees to view the bursa in a SAX view ( Fig. 10.1.7D and E ). |
| Injections performed: | CSI for pain and bursitis. |
| Recommended transducer: | Linear 6–15 mHz. Curvilinear 2–5 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Needle: 1.5- to 2-inch 23- or 25-gauge needle. Syringes: 5 mL for CSI. Medication: 40 mg triamcinolone (0.5 mL) and 1% lidocaine (4 mL). |
| Injection technique: | Viewing the bursa in a LAX orientation, the needle can be introduced with the bevel facing down with an IP technique at approximately 40 degrees, until the tip is seen between the TFL and GMT ( Fig. 10.1.7F and G ). In the SAX, the needle should be brought in as horizontal as possible to enable IP visualisation and again, the needle is aimed for the interface between the GMT and TFL ( Fig. 10.1.7H and I ). In both situations, once a small amount of fluid is injected to open the space, the needle can be repositioned as required and it is important to avoid direct injection into the tendon beneath or muscle above. |
Injections to the TB.
In the side-lying position, the TB can be seen in the LAX between the GMT and TFL. The injection can be undertaken using an IP technique in the SAX with the needle introduced as horizontal as possible to the transducer. The needle tip should be seen between the GMT and TFL.
Nerve injections
The lateral femoral cutaneous nerve (LFCN) is commonly compressed as it passes beneath the inguinal ligament, causing meralgia paraesthetica (pain, tingling and numbness in the anterolateral aspect of the thigh). This can be readily identified and injected under ultrasound guidance.
10.1.8
Lateral femoral cutaneous nerve
| Patient position: | For the lateral femoral cutaneous nerve (LFCN), the patient should be placed in a supine position with the hip slightly extended by moving the end of the treatment couch downwards ( Fig. 10.1.8A ). In this position, the patient can be asked to perform a straight leg raise and a hollow between the rectus femoris (RF) and sartorius (SRT) can be seen. This is where the LCFN is located. |
| Identifying the anatomy: | The transducer can be placed in a SAX oreintation over the anatomical position for the LFCN and it can be seen running in this channel ( Fig. 10.1.8B and C ). The nerve can be followed proximally to the inguinal ligament where compression normally occurs. |
| Injections performed: | CSI for meralgia paraesthetica. |
| Recommended transducer: | Linear 6–15 mHz. Hockey stick 8–18 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Needle: 1- to 1.5-inch 25- or 27-gauge needle. Syringes: 3 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (1 mL). |
| Injection technique: | Viewing the LFCN in the SAX oreintation, the needle can be introduced with the bevel facing down using an IP technique at 10–15 degrees from the lateral aspect so that it rests above the nerve ( Fig. 10.1.8D and E ). A small amount of solution can be injected to separate the layers and open the space and once the anatomy is more clearly defined, the remainder can be injected around the nerve. Care must be taken not to inject into the nerve directly. |
Injections to the LFCN.
In the supine position, the hip can be opened further by lowering the end of the couch. The injection can be undertaken using an IP technique from a lateral approach, with the transducer in a SAX orientation. The needle tip should be seen above the LFCN.
Muscle
Although not commonly undertaken, an intramuscular injection can be performed into the piriformis muscle (PM) for patients experiencing significant radicular pain from sciatic nerve compression as it passes near the PM.
10.1.9
Piriformis muscle
| Patient position: | For the piriformis muscle (PM), the patient can be placed in a prone position ( Fig. 10.1.9A ). To put the area on stretch, the hip can be slightly flexed by lowering the end of the examination couch, thereby taking the PM into a more superficial position. |
| Identifying the anatomy: | The transducer can be placed in a SAX orientation over the ischial tuberosity and moved proximally and laterally. The PM should then be seen in a LAX view, moving towards the greater trochanter (GT) of the femur beneath the gluteus maximus (GMax) ( Fig. 10.1.9B and C ). The sciatic nerve can be seen running in close proximity to the PM. |
| Injections performed: | CSI for pain symptoms. |
| Recommended transducer: | Linear 6–15 mHz. Curvilinear 2–5mhz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Needle: 2- to 2.5-inch 23- or 25-gauge needle. Syringes: 5 mL for CSI. Medication: 40 mg triamcinolone (0.5 mL) and 1% lidocaine (3 mL). |
| Injection technique: | Viewing the PM in the LAX orientation, the needle can be introduced using an IP technique at an angle of approximately 45 degrees ( Fig. 10.1.9D and E ). This may need to be altered according to patient habitus or muscle bulk. With the bevel facing down, the needle tip can be inserted into the muscle and provided there is no blood flow on aspiration, the CSI can be distributed using a fenestration technique. Care should be taken to avoid the sciatic nerve. |
Injections to the PM.
In the prone position, the PM can be made more superficial by flexing the hip. The injection can be undertaken using an IP technique with the transducer in a LAX orientation over the PM. The needle tip should be taken into the PM before the injection is undertaken.
Notes
(Please use this area to reflect on your procedure and how you can build on these experiences).
10.2
Knee
With many superficial structures around the knee that can be injured, several can be treated with ultrasound guided interventions. The key with knee injections is stability, sufficient exposure and ease of access to the structure of interest. As such the prone, supine or side-lying position is most suited for knee injections and an appropriate support can help with stability.
Joint injections
The common joint injections around the knee include the main knee joint (KJ) itself, proximal tibio-fibular joint (PTJF) and posteriorly into a Baker’s cyst (BC).
10.2.1
Knee joint
| Patient position: | For the knee joint (KJ), the patient can be positioned in a supine position with the knee flexed to approximately 45 degrees. Using a stable support limits movement and eases the guidance of injections ( Fig. 10.2.1A and B ). |
| Identifying the anatomy: | The KJ can be accessed via the suprapatellar bursa (SPB) or patello-femoral joint (PFJ). For the former, the transducer is best placed in a SAX orientation over the quadriceps tendon and SPB can be seen beneath it ( Fig. 10.2.1C and D ). For the PFJ, the transducer can be placed over the medial or lateral border of the patella and medial or lateral femoral condyle (MFC or LFC); the joint space should be seen between the two bony prominences ( Fig. 10.2.1E and F ). |
| Injections performed: | CSI for pain or degenerative disease. HA or PRP injections for degenerative disease. |
| Recommended transducer: | Linear 6–15 mHz (SPB). Hockey stick 8–18 mHz (PFJ). |
| Equipment suggested: | Equipment preparation: Set 1 for CSI and HA injections. Set 4 for PRP injections. Needle: 2- to 2.5-inch 21- or 23-gauge needle. Syringes: 5 mL for CSI. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (4 mL). Standard/available HA or PRP preparation. |
| Injection technique: | Viewing the SPB in a SAX orientation, the needle can be introduced with the bevel down, using an IP technique from the lateral aspect ( Fig. 10.2.1G and H ). It is often good to start a few centimetres below the transducer so that the needle can be brought in parallel to the field of view. Accessing from the PFJ, the transducer can be placed in a SAX orientation over it and the needle can be introduced using either an IP ( Fig. 10.2.1I and J ) or OOP technique ( Fig. 10.2.1K and L ). In the former, the needle may be less visible once in the joint, while with the latter, only the needle tip will be seen in the joint space. |
Injections to the KJ.
In the supine position the knee can be flexed to 45 degrees. The injection can be undertaken with the transducer in a SAX orientation over the SPB (IP approach) or PFJ (OOP approach). The needle tip should be seen in the bursa or joint before the injection is undertaken.
10.2.2
Proximal tibio-fibular joint
| Patient position: | To view the proximal tibio-fibular joint (PTFJ), the patient can be positioned in a supine position with the knee flexed to approximately 45 degrees ( Fig. 10.2.2A and B ). Using a stable support limits movement and eases injections. |
| Identifying the anatomy: | The PTFJ can be identified by tracing the tibia laterally in a SAX orientation and the fibula should be seen within the same view. The joint space should be seen between the two bony prominences ( Fig. 10.2.1C and D ). |
| Injections performed: | CSI or LA for pain or degenerative disease. PRP injections for degenerative changes. |
| Recommended transducer: | Linear 6–15 mHz. Hockey stick 8–18 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI. Set 4 for PRP injections. Needle: 2- to 2.5-inch 21- or 23-gauge needle. Syringes: 3 mL for CSI. Medication: 20 mg triamcinolone (0.5 mL) and 1% lidocaine (1 mL). Standard/available PRP preparation. |
| Injection technique: | Maintaining the PTFJ in a SAX oreintation, the needle can be introduced perpendicular to the skin, using an OOP technique adjacent to the distal border of the transducer. With the bevel facing down, the needle tip should seen within the joint line ( Fig. 10.2.2E and F ). Alternatively, an IP technique can be used, approaching from the lateral aspect ( Fig. 10.2.1G and H ). If this method is used then it is important to avoid injury to the common peroneal nerve or its branches. In either situation once the needle is within the joint, provided there is no blood flow on aspiration, the solution can be injected. |
Injections to the PTFJ.
In the supine position the knee can be flexed to 45 degrees. The injection can be undertaken with the transducer in a SAX orientation across the proximal tibia and fibula using an IP or OOP approach. Care should be taken to avoid nearby neurovascular structures.
10.2.3
Baker’s cyst
| Patient position: | To access a Baker’s cyst (BC), the patient can be positioned in a prone position with the knee fully extended to bring the posterior joint line into a superficial position ( Fig. 10.2.3A ). A rolled towel around the ankle can help stabilise the lower leg and limit movement. |
| Identifying the anatomy: | The BC can be identified by tracing the medial gastrocnemius proximally or the semi-membranosus (SMT)/semi-tendinosus (STT) tendons distally. As the two structures cross at the posterior-medial border of the knee, the BC should be seen as a hypoechogenic swelling with the neck extending from the joint ( Fig. 10.2.3B and C ). |
| Injections performed: | CSI for pain or degenerative disease. HA or PRP injections for degenerative disease. |
| Recommended transducer: | Linear 6–15 mHz. Curvilinear 2–5 mHz. |
| Equipment suggested: | Equipment preparation: Set 1 for CSI or HA injections. Set 4 for PRP injections. Needle: 1.5- to 2-inch 23- or 25-gauge needle. Syringes: 5 mL for CSI. 10 mL(s) for drainage. Medication: 40 mg triamcinolone (1 mL) and 1% lidocaine (4 mL). Standard/available HA or PRP preparation. |
| Injection technique: | Maintaining the transducer in a SAX oreintation, the needle can be introduced from the medial aspect of the knee, using an IP technique. With the bevel facing down, the needle can be angled at approximately 30 degrees, but this might need adjustments depending on body habitus. The needle is advanced until the tip is seen within the BC itself ( Fig. 10.2.3D and E ). It is important to ensure that the neurovascular bundle is visualised and avoided. Provided there is no blood flow on aspiration, the solution can be injected. |
Injections to the BC.
In the prone position, the knee is fully extended, and the injection can be undertaken with the transducer in a SAX orientation across the popliteal fossa. The needle is introduced using an IP technique. Care should be taken to avoid nearby neurovascular structures.
Tendon injections
With multiple tendons around the knee joint, those commonly requiring an injection include the quadriceps (QT), the patella (PT), biceps femoris (BFT) or popliteus tendon (PopT). While it is not recommended to put steroid around weight-bearing tendons such as the QT or PT, clinical judgement may be required depending on the patient’s presentation and clinical need.
10.2.4
Quadriceps tendon
| Patient position: | For the quadriceps tendon (QT), the patient can be positioned in a supine position with the knee flexed to approximately 45 degrees ( Fig. 10.2.4A and B ). Using a stable support places the tendon under a slight tension and limits movement to ease injections. |
| Identifying the anatomy: | The QT can be visualised by placing the transducer in a LAX orientation to identify the longitudinal structure of the tendon ( Fig. 10.2.4C and D ). It can be traced proximally to confirm that it is intact. Turning the transducer perpendicular to this position, the tendon can be viewed in a SAX view ( Fig. 10.2.4E and F ). In both planes, if a joint effusion is present, a prominent bursa may be noted beneath it. |
| Injections performed: | PRP injections for degenerative tendon disease with intrasubstance tearing. |
| Recommended transducer: | Linear 6–15 mHz. |
| Equipment suggested: | Equipment preparation: Set 4 for PRP injections. Needle: 1.5- to 2-inch 25- or 27-gauge needle. Standard/available HA or PRP preparation. |
| Injection technique: | Viewing the QT in a SAX orientation, the needle can be introduced with the bevel facing down, using an IP technique from the lateral aspect. The aim is to keep the needle parallel to the transducer ( Fig. 10.2.4G and H ). Aiming for the area of interest in the tendon, the solution can be injected using a fenestration technique. The position of the needle in the tendon be assessed using an OOP view by rotating the transducer into a LAX orientation. An LAX approach can also be used, with the needle also introduced using an IP technique at an angle of approximately 30 degrees ( Fig. 10.2.4I and J ). A similar fenestration technique should be used to inject the PRP. |
Injections to the QT.
In the supine position the knee can be flexed to 45 degrees. The injection can be undertaken with the transducer in a SAX or LAX orientation over the QT, and the needle is introduced using an IP technique into the tendon. A fenestration technique can be used to inject the PRP.
10.2.5
Patella tendon
| Patient position: | For the patella tendon (PT), the patient can be positioned in a supine position with the knee flexed to approximately 45 degrees ( Fig. 10.2.5A and B ). Using a stable support places the tendon under a slight tension and limits movement during the procedure. |
| Identifying the anatomy: | The PT can be visualised by placing the transducer in a LAX orientation to identify the longitudinal structure of the tendon and confirming that its proximal (to the distal pole of the patella) and distal (to the tibial tuberosity) attachments are intact. Turning the transducer perpendicular to this position, the PT can be viewed in a SAX view ( Fig. 10.2.5C and D ). The fat pad should be visualised beneath the tendon. |
| Injections performed: | HVI tendon stripping for tendinopathy. PRP injections for degenerative tendon disease with intrasubstance tearing. |
| Recommended transducer: | Linear 6–15 mHz. |
| Equipment suggested: | Equipment preparation: Set 4 for PRP injections. Syringe: 10 mL(s) for tendon stripping from the fat pad. Medication: 1% lidocaine (5 mL) and normal saline (15–20 mL). Needle: 1.5- to 2-inch 25- or 27-gauge needle. Standard/available PRP preparation. |
| Injection technique: | Viewing the PT in a SAX orientation, the needle can be introduced using an IP technique from the lateral aspect ( Fig. 10.2.5E ). For tendon stripping, keep the needle parallel to the transducer, and aimed at the posterior border of the tendon. With the bevel facing upward, it is angled upwards to the interface between the PT and fat pad ( Fig. 10.2.5F ). Local anaesthetic and saline can be injected to separate the two layers and the needle can be repositioned if needed. For PRP injections into the PT, the needle entry can be higher, parallel to the transducer and directly into the body of the tendon ( Fig. 10.2.5G ). Once the tip is in position, the procedure can be undertaken using a fenestration technique to distribute the PRP. The position of the needle can also be assessed using an OOP view by turning the transducer into a LAX oreintation and observing the position in terms of depth within the tendon. |
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