Evren Yasar1,2, Jaspal R Singh2*, John Hill3 and Venu Akuthota2
1Gulhane Military Medical Academy, Rehabilitation Center, Interventional Pain Unit, Ankara / Turkey
2University of Colorado, Department of Physical Medicine and Rehabilitation, USA
3University of Colorado, Department of Family Medicine, Division of Sports Medicine, USA
Received: 02 July, 2014; Accepted: 13 September, 2014; Published: 15 September, 2014
Jaspal Singh, MD, Department of Physical Medicine and Rehabilitation, 525 E 68th Street, Baker 16 Floor, NYC, NY 10065, USA, Email:
Yasar E, Singh JR, Hill J, Akuthota V (2014) Image-Guided Injections of the Hip. J Nov Physiother Phys Rehabil 1(1): 039-048. DOI: 10.17352/2455-5487.0000008
© 2014 Yasar E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Hip Injections; Ultrasound; Fluoroscopy; Sports medicine
The authors present a technique paper on the utilization of both ultrasound and fluoroscopy guidance for injections about the hip joint. This review draws from specialists including physiatry, family medicine and orthopaedic surgery. We hope the editors and reviewers find this document beneficial to the readership, especially those practicing musculoskeletal medicine and may use this information when performing hip injections.
The primary purpose of this technique report is to outline ultrasound- and fluoroscopic-guided office based injections around the hip joint.In addition, this report could serve a reference to physician practicing interventional musculoskeletal medicine.
Traditional causes of hip pain may be divided into either intra-articular or extra-articular sources. The hip joint, pelvis and pelvic girdle muscles have a complex anatomical relationship with proximal and distal structures including the lumbosacral spine and the knee joint. Abnormalities in these regions may cause various referral patterns often mimicking primary hip pain . The character and location of pain is a key element in the differential diagnosis of hip pain. For instance, anterior hip or groin pain often suggests primary involvement of the hip joint itself. However, in a study conducted by Lesher and colleagues, hip joint intra-articular injections were shown to cause referred pain into the buttock (71%), thigh (57%) and groin (55%) . Lateral hip pain that is aggravated by direct pressure is the classic presentation of trochanteric bursitis. Referred pain from facet and sacroiliac joints as well as proximal lumbar radicular pain may also present with pain in the groin or hip. This pain typically originates at the waistline or posterior gluteal areas. The source of hip pain can be further defined by a detailed history and physical examination. However, a portion of hip pain patients may require additional diagnostic work up to further elucidate the etiology.
Radiographic examinations such as plain x-ray, radionuclide scans, magnetic resonance imaging (MRI), computerized tomography (CT) or ultrasonography are useful in the investigation of the possible causes of pain around hip. In addition, several injection techniques, often performed under fluoroscopy or ultrasound guidance, are also helpful to distinguish the conditions causing hip pain. These injection techniques may be used for therapeutic purposes, functional demonstrations, or even joint aspiration. Ultrasound provides real-time radiographic imaging of the musculoskeletal system and in particular has the ability to make dynamic assessments of deep-seated joints, muscles and tendons . Although it is highly operator-dependent, dynamic evaluation of hip girdle tendons and muscles is made possible with utilization of ultrasound.
Increasingly, differential injections of structures about the hip joint are used to guide clinical decision making.For instance, intra-articular injections with positive response to anesthetic are often mandated by surgeons considering operations of the hip labrum . Another common scenario is the patient with hip region pain folowing hip arthroplasty.Ultrasound guided injections can serve as a valuable tool in identifying the source of pain in these subjects .
Injection of local anesthetics provides a potential block of nociceptive structures, thus becoming a diagnostic tool with hip pain . These blocks can be performed to confirm the diagnosis of hip pain related to osteoarthritis, bursitis, meralgia paresthetica, lumbosacral roots, lumbar facet or sacroiliac dysfunctions [7,8]. If pain is significantly diminished within minutes after the local anesthetic injection, intra-articular sources vs. extra-articular sources of hip pain can be distinguished [9-11]. The duration of action, the maximum suggested dosage, and the contraindications regarding particular local anesthetics must be considered prior to their use. Local anesthetics act by reversibly inhibiting sodium-specific ion channels on neuronal cell membranes which thereby prevents the propagation of an action potential in the neuron, thus inhibiting pain signal conduction  (Table 1).
Cardiac as well as central nervous system toxicites are the most well-known adverse events following inadvertent intravascular or intrathecal injection of local anesthetics [13,14]. Furthermore, local anesthetics can cause a dose-dependent and clinically relevant toxicity to skeletal muscle. Clinical features including muscle weakness and decreased function have been reported after repetitive muscle infiltration of bupivacaine [15-17]. Chondrotoxicity induced by local anesthetics has come into light recently and care must be taken to avoid this complication. Chu and colleagues have performed multiple studies demonstrating that both bupivacaine and lidocaine cause both dose and time dependent cytotoxic effect on bovine as well as human articular cartilage [18-20]. These dose dependencies are most noted with 0.5% bupivacaine and 2% lidocaine while the less potent doses have minimal effect on chondrolysis .
Additives to injectate
A range of additives can be used as adjuncts to commonly performed nerve blocks. Sodium bicarbonate can speed up the onset of local anesthesia while epinephrine has been shown to prolong nerve blockade. While tramadol, magnesium, dexmedetomidine, ketamine and other agents have been used, these are not routinely implemented due to the paucity of safety and efficacy data. A discussion of these additives is beyond the scope of this technique paper .
Intra-articular Hip Injection
Hip osteoarthritis (OA) is a common cause of disability and impaired quality of life in older individuals  and has a mean prevalence of 8% in the general adult population . Although the primary change is loss of hyaline articular cartilage, secondary changes include osteophyte formation, bony remodelling and changes of the synovium, capsule, ligaments and muscles.Intraarticular hip injections of local anesthetic with or without steroids can determine if the hip pathology is the primary pain generator causing hip pain . Complications from these intraarticular hip injections include joint infection and hemarthrosis, however stict adherence to asceptic technique and the use of image guidance can minimize these . Rarely, air embolism or mild pain and swelling at the injection site can occur. Accordingly, we suggest that single dose vials of sterile medications and contrast be used. Sterile technique is paramount in all interventional procedures. The hip joint has a volume capacity ranging from 8-20 cc  and therefore in an effort not to increase intra-articular pressures which could limit functional range of motion, authors suggest injecting a total volume of 8cc (6cc of local anesthetic and 2cc of corticosteroid) [28,29].
As with most injections described in this manuscript, contraindications to injections, esepcially with steroid include, bleeding/clotting disorrders, systemic infection, uncontrolled diabetes and other uncontrolled cardiovascular disease. When using fluoroscopy for image guidance, pregnancy is also a contraindication.
Supine anterior intra-articular hip fluoroscopic procedure
The patient is placed in supine position with the involved hip slightly externally rotated. This allows the patient’s anterior musculature to relax and facilitates ease of the procedure. Prep and drape in typical sterile fashion and palpate to identify the femoral neurovascular bundle. Using antero-posterior fluoroscopic imaging, mark the skin at a spot over the center of the femoral neck. Make a skin wheal and deeper infiltration with local anesthetic with a 27- or 25-gauge needle. Once anesthetized, using a 22 gauge, 3.5 inch spinal needle, penetrate the skin and direct towards the junction of the femoral head and neck. The target may be at the center of the femoral head or lateral to the center under AP imaging (Figure 1 and 3a). Once osseous contact is attained and the needle is purchased in a firm subcapsular position, aspirate and then inject contrast to confirm intraarticular flow. The authors recommend the use of tubing when injecting both contrast and the steroid/anesthetic mixture in order to prevent inadvertent manipulation of the needle once position has been confirmed. The authors of this paper recommend injected a total volume of 8cc (3cc 1% lidocaine, 3cc 0.25% bupivacaine and 2 cc of steroid, either betamethasone (6mg/ml) or triamcinolone (40mg/ml). Occasionally, the hip capsule does not extend as distally on the femoral neck, thus the needle will need to be repositioned more proximally to obtain proper intraarticular flow patterns. Of note, using this lateral to medial approach maintains a safe distance from the femoral neurovascular bundle.