Ultrasound Guided Pain Relieving Injections - Joint & Tendon Pain Treatments

Shoulder injections can be broadly defined as three types of injections.  Firstly, a shoulder intra-articular injection alternatively known as a glenohumeral intra-articular injection which is performed under ultrasound guidance to ensure the needle is placed within the shoulder joint capsule. A shoulder ultrasound guided injection is normally performed from the back of the shoulder (known as the posterior aspect of the shoulder) which means it is a very safe and relatively pain-free way of delivering high volumes of steroid within the the shoulder joint cavity. Conditions which benefit from an intra-articular shoulder joint injection include a frozen shoulder but also stiff and painful shoulders due to shoulder joint (glenohumeral joint) osteoarthritis. If you would like further detailed information regarding evidence-based treatments for a frozen shoulder please visit frozenshoulderexpert.co.uk before considering your options.

Patient's that have read up on a shoulder injection procedure known as a shoulder hydrodilatation injection should be aware that this type of injection is very similar to a standard shoulder joint intra-articular injection and again should visit the dedicated page at frozen shoulder expert which discusses this is in detail... https://www.frozenshoulderexpert.co.uk/treatment

The second type of shoulder injection performed is known as a sub-acromial shoulder injection which essentially means an injection to the tissues at the top of the shoulder joint (the sub-acromial region of the shoulder). The needle is guided either within the sub-acromial bursa or into an area of rotator cuff tendon defect. The exact location of the injection will depend on a patient's symptoms as well as ultrasound imaging findings. Again these injections should always be conducted under ultrasound guidance as there is very little chance of hitting the target accurately without image guidance.

Lastly, patients with shoulder pain focally on top of the bony part of the shoulder known as the acromioclavicular joint (AC joint) should be considered for a shoulder acromioclavicular joint injection delivered by ultrasound guidance. When patients have an accurate diagnosis of acromioclavicular joint pain whether it is osteoarthritis of the AC joint or other causes an acromioclavicular joint injection is normally extremely helpful at alleviating pain.

Elbow injections are normally used to target the areas known as the lateral epicondyle and common extensor tendon (tennis elbow) or medial epicondyle and common flexor tendon (golfers elbow). These elbow tendon injections can be a useful tool to treat tennis and golfers elbow in cases where rehabilitation and ergonomic adjustments have not relieved pain. 

Elbow tendon injections should be performed under an ultrasound scan to guide the path of the needle to the tendon defect or perform a injection to the bone/ tendon interface referred to as a enthesitis of the tendons. 

Although the elbow is not an area that is commonly affected with significant degenerative change (osteoarthritis) it is sometimes necessary to perform an elbow intra-articular joint injection (within the elbow joint capsule). These injections can be performed in several different locations depending on the part of the elbow that appears most affected by the condition. 

The wrist and hand Anatomy is complex and is composed of several bones, many joints as well as tendons and nerves which lie on both sides of the wrist and hand. Due to this complex anatomy, a wrist joint injection or a hand joint injection must be targeted at the specific area of  pain or pathology which the clinician will decide on the basis of a physical examination and ultrasound scan. Wrist and hand joint injections may target the following joint complexes:

• Radiocarpal wrist joint injection

• Ulnocarpal wrist joint injection

• Distal radioulnar joint injection

• Scapholunate joint injection

• Scaphotrapeziotrapezoidal joint (STT) injection

Due to the small joint cavity of these wrist and hand joints an intra-articular corticosteroid injection is normally very effective at relieving pain and inflammation from degenerative osteoarthritis or following wrist or hand trauma. 

Many cases of wrist and hand pain are also related to a problem with the tendon or tendon sheath known as tenosynovitis. Often a tenosynovitis of the wrist or hands may develop due to repetitive movements or overuse of this area in poor economic positions but can also develop following trauma. To reduce the swelling and pain in the tendon sheath appropriately the needle must be guided under ultrasound into the small area between the tendon and tendon sheath itself. A steroid wrist injection is normally a very effective solution for these conditions.

Lastly, wrist and hand pain, especially when associated with  sensory symptoms such as numbness pins and needles or tingling may relate to an irritation or compression of one of the nerves which lie through this area. The most common neuropathy in the wrist and hand which can be targeted successfully with an ultrasound guided wrist injection is known as carpal tunnel syndrome.

Finger and thumb injections fall into two categories. The first finger and thumb injection is a targeted injection to to a painful or swollen finger or thumb joint. The most common cause of this is degenerative change also known as finger or thumb osteoarthritis. Due to the small nature of finger and thumb joints, to accurately place a needle within the joint cavity and within the joint capsule, ultrasound guidance is necessary. Occasionally, a finger or thumb joint injection may be required after a sprain or other trauma to the joint which results in a swollen and stiff finger or thumb joint. A corticosteroid intra-articular finger or thumb injection is a very helpful procedure for degenerative osteoarthritis or following trauma. Finger and thumb joints which can be targeted by an ultrasound-guided intra-articular injection include:

• Carpometacarpal joint (CMCJ) finger or thumb injection

• Metacarpophalangeal joint (MCPJ) finger or thumb injection

• Interphalangeal joint (IPJ) finger or thumb injection

The second category of conditions which a finger or thumb injection is beneficial for, includes an injection to inflamed tendons or more commonly inflamed tendon sheaths or tendon pulleys. The most common condition which falls into this category is known as trigger finger or trigger thumb. A trigger finger or trigger thumb injection is an extremely effective solution to this problem as well as other finger or thumb injections targeted at tendon sheaths -  known as a tenosynovitis finger or thumb injection. 

A hip injection is most often a term used to describe an intra-articular (within the hip joint cavity) hip  injection. In recent years, hip injections have become far more common as we can now accurately guide a hip injection with ultrasound diagnostic imaging in real-time rather than having to rely on x-ray and CT scan guidance within an operating room. Generally, patients will have a degree of hip osteoarthritis, hip labral pathology or hip impingement underlying the cause for a hip intra-articular injection.

Another form of hip injection is to the outer aspect of the hip (lateral hip) known as the trochanteric region. Two problems can occur in this region that may respond well to a trochanteric hip injection. Firstly, there can be inflammation of the fluid-filled protective sac known as the hip trochanteric bursa. Secondly, similar to an Achilles tendon issue at the back of the heel, there can be pain and what is termed a gluteal tendinopathy in this region to the tendons of the hip gluteal muscles. Both of these anatomical structures can benefit from a trochanteric hip injection. 

A substantial number of knee injections exist due to the complex anatomy of the knee and the significant number of different  conditions that can give problems in this area. An intra-articular (within the knee joint itself) injection is a common injection aimed at alleviating pain from knee osteoarthritis and sometimes knee meniscus tears.

The most common needle entry point is on the inside of the knee (medial aspect of the knee). The ultrasound transducer is placed across the knee cap (patella) and the inside of femoral condyle (leg bone) which gives clear visibility to the knee joint capsule. The needle can then be clearly visualized passing through the joint capsule into the medial knee cavity between the patella and the medial femoral condyle. 

Another way of entering the knee joint cavity for an ultrasound guided intra-articular knee injection (which is often favoured in a very swollen knee as it enables easy aspiration of excess fluid before injection) is termed a suprapatellar recess knee injection. The knee joint capsule extends to the upper outer part of the knee cap area and and remains very near to the skin (superficial) in this part of the knee which is another advantage to this technique. 

Other extra-articular (outside the joint capsule) knee injections can be a useful adjunct in the treatment of a range of knee conditions which persist in spite of good quality rehabilitation or which have substantial inflammation to the tissues. Depending on the knee joint condition we are treating further types of knee aspirations and injections can include:

• Knee bursitis aspiration and injection

• Patellar tendon injection

• Medial collateral ligament injection

• Pes anserine tendon injection

Ankle and foot injections can be performed for a wide variety of musculoskeletal conditions. Intra-articular ankle and foot joint injections are often performed due to degenerative changes at the respective joint (osteoarthritis). joints which are commonly injected under ultrasound guidance include:

• Talocrural ankle joint injection

• Subtalar ankle joint injection

• Talonavicular foot injection

• Calcaneocuboid foot injection

• Intercuneiform foot injection

The ankle joint is technically known as the talo-crural joint and has a coupled joint known as the subtalar joint which together produce the movements at the rear foot. In many cases of an ankle sprain either one of these joints may not settle adequately and may remain painful and swollen. An intra-articular ankle talocrural or intra-articular ankle subtalar joint may be considered in these circumstances.

Tendon issues around the outer aspect of the ankle (closed) may occur due to trauma following repetitive use injuries. Similarly,  the medial ankle tendons and in particular the tibialis posterior tendon may also suffer from traumatic injury or overuse injuries. Many times an ankle or foot injection (under ultrasound guidance) will target the interface between the tendon and tendon sheath to reduce ongoing inflammation. Ankle and foot tendon injections commonly performed include:

• Peroneal tendon ankle injection

• Tibialis posterior ankle injection

• Tibialis anterior ankle injection

Lastly, heel pain also known as plantar fasciitis which has not responded to adequate rehabilitation and customised orthosis management may also be treated with an ultrasound guided corticosteroid or platelet-rich plasma heel injection. 

A toe injection is normally used to target degenerative osteoarthritis of the toe joints.  However, on occasion toe joints may remain painful and swollen after a trauma such as stubbing the toe. In this circumstance a toe joint intra articular injection can also provide excellent pain relief and help to restore range of movement in the long-term.

Another type of toe injection is used to relieve the symptoms of Morton's neuroma which is a swelling of the interdigital nerves between the toes. When combined with appropriate footwear modification and orthoses management in the long-term, an ultrasound guided steroid injection to the affected toes is extremely effective.