What is an ultrasound guided injection? 

Until recently in most cases injections for musculoskeletal conditions (joints, tendons, ligaments muscles) have been done without direct vision of the needle and instead have been carried out based on our knowledge of the anatomy of the structure that we are injecting. In injecting based on our knowledge rather than directly visualising the structures that we are injecting is called: landmark guided or unguided injections. 

Some GPs, sports physicians, rheumatologists, orthopaedic specialists, and Advanced Practice Physiotherapists have been carrying out landmark guided injections for many years. 

However accurately delivering an injection in for example, a tendon sheath or in a joint space without direct visualisation is quite difficult. This is why more clinicians have started using ultrasound guidance to target the injections accurately. 

 

What are the main benefits of ultrasound guided injections for patients? 

  • Studies have shown that ultrasound guidance reduce the risks  
  • Reduced overall side effects 
  • Better patient comfort 
  • Better patient satisfaction 
  • Significantly more accurate injection with all injection procedures 
  • Improved outcomes. 

 

How is an ultrasound guided injection done? 

Ultrasound-guided injections should be done in a clean environment with the use of sterile ultrasound gel which is placed on the skin. The ultrasound probe is placed on the gel allowing the operator to see the target structure. The tip of the needle is then carefully advanced whilst monitoring it. The tip of the needle is then placed exactly in the target structure. Once we are satisfied with the accuracy of the needle placement the substance in the syringe (steroid, local anaesthetic and or Hyaluronic acid) can be injected. 

 

 

Why do I need an ultrasound guided injection? 

Pain from joints, ligaments and tendons can affect your quality of life and prevent you from doing normal day to day activities. If symptoms do not respond to conservative treatments (rest, physiotherapy) then an injection of local anaesthetic and steroid can be used to provide pain relief. 

 

Who carries out the ultrasound and injection? 

The examination will be performed by a practitioner specialised in musculoskeletal problems (such as a specialist physiotherapist a specialist doctor or a radiologist). 

It can take many years to learn how to do an ultrasound injection. As ultrasound guided injections are a difficult skill to master it is important that you find a practitioner who has excellent skills. Those with high levels of skills often are the ones teaching other practitioners to become competent in ultrasound guided injections.  

It is important to be able to trust the degree of skill of your practitioner as the use of diagnostic ultrasound and ultrasound guided injections in the UK happens without clearly enforced regulation. This is why at Sonoscope injections are carried out by a practitioner who delivers 1000s of injections per year and who is an experienced lecturer and teacher of ultrasound guided injections both privately and through university (Brunel). 

How does it feel to have an injection of local anaesthetic/steroid medication? 

To perform the scan a small amount of gel is applied to the skin surface in the area being examined. The skin at the site of injection will be cleaned using an antiseptic solution. 

A needle will be put into the area to be treated and the local anaesthetic and/or steroid will be injected. You may feel some pushing as the needle goes in and it will feel heavy/tight as the medication is injected.  

You may be asked to wait fora short while after the injection to make sure that you do not have a reaction to the medication used. 

 

Is an ultrasound guided injection better than an unguided injection? 

A recent Systematic Review and Meta-analysis from Deng et. al (2022) Compared the effectiveness and safety of ultrasound-guided versus anatomic landmark–guided corticosteroid injection for the treatment of subacromial impingement syndrome. 

Another recent Systematic review and meta-analysis (ElMeligie, 2022) on the effectiveness of ultrasound-guided versus landmark corticosteroid injection in the treatment of shoulder pain US-guided CS injections showed significant improvement in pain and functional scores (VAS, shoulder functional scores, and shoulder abduction degree) but no difference in disability scores compared with landmark injections.  

A review of the existing evidence on ultrasound guided injections (Deng, 2018) summarises: “Given the improvements in accuracy, ultrasound-guided injections certainly have a role for deeper anatomic structures, for injecting targets that are close to large vascular structures, and for patients in whom nonguided injections have failed”. 

Conclusions:  

Ultrasound guided injections are more accurate than unguided injections. From a safety perspective alone, they should be done in areas with large neurovascular structures and in patients in whom landmark guided injections have failed. 

A recent systematic review found that ultrasound-guided injection of corticosteroids is potentially superior to anatomic landmark–guided injection in improving the clinical symptoms of subacromial impingement syndrome; however, these findings should be interpreted with some caution as the quality of evidence was rated as moderate to low. 

 

Daniels, E.W., Cole, D., Jacobs, B. and Phillips, S.F., 2018. Existing evidence on ultrasound-guided injections in sports medicine. Orthopaedic journal of sports medicine, 6(2), p.2325967118756576. 

Deng, X., Zhu, S., Li, D., Luo, Y., Zhang, X., Tan, Y., Li, J. and He, X., 2022. Effectiveness of Ultrasound-Guided Versus Anatomic Landmark–Guided Corticosteroid Injection on Pain, Physical Function, and Safety in Patients with Subacromial Impingement Syndrome: A Systematic Review and Meta-analysis. American Journal of Physical Medicine & Rehabilitation, 101(12), pp.1087-1098. 

ElMeligie, M.M., Allam, N.M., Yehia, R.M. and Ashour, A.A., 2022. Systematic review and meta-analysis on the effectiveness of ultrasound-guided versus landmark corticosteroid injection in the treatment of shoulder pain: an update. Journal of Ultrasound, pp.1-12.