Sonographically guided injections

Last updated date: 07-Jul-2023

Originally Written in English

Sonographically Guided Injections

Sonographically Guided Injections


Many people wonder, "What is an ultrasound guided injection?" So, in this section, we will try to answer the questions "what it is" and "why it is required." 

Ultrasound refers to high-frequency sound waves that can pass through the skin. Ultrasound guided injections are widely employed in medicine because they are a safe technique of imaging deep into the tissues of the body. The imaging allows us to view all of the different tissues in the body extremely clearly. Ultrasound also helps to protect the patient from radiation and other potentially dangerous side effects.

Every year, around one million steroid injections are administered in the United Kingdom. Steroid injections have been used for almost fifty years.

Taking corticosteroids orally (by pill) for an extended length of time has been linked to negative effects. The idea behind injecting a steroid is to limit the body's total exposure to the steroid while also minimizing the amount necessary to alleviate the patient's symptoms.


What is Sonographically Guided Injections?

Sonographically Guided Injections

Ultrasound involves the use of high-frequency sound waves that are sent into the body's tissues using a portable probe. The returning waves are then computed in order to produce a picture of the anatomy within the body. Ultrasound is frequently utilized in diagnostics to help in proper evaluation prior to injection.

When conducting an injection, ultrasonic waves bounce off the needle as it moves through the body's tissues, giving clear sight of the needle tip and, as a result, accurate injection guidance to the target region.

An ultrasound-guided injection might be corticosteroid, hyaluronic acid, or platelet-rich plasma (PRP). Ultrasound guiding also enables a variety of highly specialized operations such as joint aspiration (the removal of swelling from a joint), barbotage (the removal of calcium deposits from within a tendon), and hydrodistension (stretching ligaments and joint capsule to improve movement).

Ultrasound imaging is noninvasive and improves with needle guide accuracy. It is convenient for patients and may be used as many times as needed. Because ultrasound does not use radiation, it is a fairly safe exam for patients.


Benefits of Sonographically Guided Injections

Benefits of Sonographically Guided Injections

There is a large body of data demonstrating that ultrasound guided injections provide greater pain relief, have longer lasting benefits, and increase functioning when compared to injections performed without ultrasound guidance (blind or surface marked injections). There is also evidence that it minimizes the likelihood of needle trauma or misplacement and thus improves injection safety while lowering the risks of adverse events associated with injection therapy.


Indications for Diagnostic & Therapeutic Sonographically Guided Injections

Therapeutic Sonographically Guided Injections

There are two types of indications for joint or soft tissue aspiration and injection: diagnostic and therapeutic. Aspiration of synovial fluid for examination is a typical diagnostic indication for inserting a needle into a joint. Synovial fluid analysis can distinguish between various joint disease etiologies such as infection, inflammation, and trauma. A second diagnostic indication is the injection of a local anesthetic to confirm the presumptive diagnosis by relieving the affected body part's symptoms.

Reduced mobility and pain, as well as the injection of medications as a therapeutic adjunct to other types of treatment, are therapeutic indications for joint or soft tissue aspiration and injection. When extracting fluid for pain relief, care must be taken to avoid introducing infection and causing continued or new bleeding into the joint. In addition, fluid reaccumulation can occur early in many situations.

Therapeutic injection with corticosteroids should always be viewed as adjuvant therapy. The improper or indiscriminate use of corticosteroids is likely to have a bad outcome. These injections should never be undertaken without diagnostic definition and a specific treatment plan in place. Physicians should resist external pressure for a quick return of athletes to playing sports by the use of joint or soft tissue injections.

  • Soft tissue conditions:
  • Bursitis.
  • Tendonitis or tendinosis.
  • Trigger points.
  • Ganglion cysts.
  • Neuromas.
  • Entrapment syndromes.
  • Fasciitis.


  • Joint conditions:
  • Effusion of unknown origin or suspected infection (only diagnostic).
  • Crystalloid arthropathies.
  • Synovitis.
  • Inflammatory arthritis.
  • Advanced osteoarthritis.


Contraindications of Sonographically Guided Injections

Contraindications of Sonographically Guided Injections

There are absolute and relative contraindications to any invasive diagnostic or therapeutic injection technique. Absolute contraindications to joint and soft tissue injection include drug allergies, infection, fracture, and tendinous areas with high risk of rupture.

Relative contraindications are less clearly defined and should be evaluated on an individual basis. Physicians should be aware that the contraindications stated apply only to therapeutic injections and not to diagnostic aspiration of joints or soft tissue regions. Suspected septic arthritis, for example, is a contraindication to therapeutic injection but an indication for joint aspiration.

Absolute contraindications:

  • Local cellulitis.
  • Septic arthritis.
  • Acute fracture.
  • Bacteremia.
  • Joint prosthesis.
  • Achilles or patella tendinopathies.
  • History of allergy or anaphylaxis to injectable pharmaceuticals or constituents.


Relative contraindications

  • Minimal relief after two previous corticosteroid injections.
  • Underlying coagulopathy.
  • Anticoagulation therapy.
  • Evidence of surrounding joint osteoporosis.
  • Anatomically inaccessible joints.
  • Uncontrolled diabetes mellitus.


Timing of Sonographically Guided Injections

Timing of Sonographically Guided Injections

Appropriate timing can reduce difficulties while also allowing for a clear diagnosis or treatment response. Diagnostic injections should be conducted when acute or chronic symptoms are present, the diagnosis is unclear or needs to be confirmed, other diagnostic modalities have been considered, and septic arthritis has been ruled out (by aspiration and fluid analysis).

Therapeutic injections should be administered when acute or persistent symptoms are evident, after a diagnosis and treatment plan has been established, and after radiographs have been considered. Treatment injection should only be used in conjunction with or after other therapeutic methods have been initiated (e.g., physical therapy). Any joint with an effusion should be radiographed to rule out a fracture or other intra-articular pathologic event in the absence of an underlying chronic inflammatory arthritis.


Effectiveness of Sonographically Guided Injections

Effectiveness of Sonographically Guided Injections

Ultrasound guided injections can help to relieve localized discomfort. They will not heal the underlying reason, but they may help you feel better for several months.

With reduced discomfort, you may be able to conduct more physical activity, which may make the joint feel more comfortable. This can help you sleep better and manage your daily tasks better. Following a visit with their Clinician, some persons discover that they may reduce or discontinue the use of pain medications.

Injections, in combination with physiotherapy, can occasionally assist to obviate the need for surgery.

Some people gain immediate pain relief; others may not notice anything for a couple of weeks after the injection. And the results vary from person to person – it does not work for everyone.


Is an Ultrasound Guided Injection Better?  

joint and soft tissue issues

According to research, ultrasound injections are more accurate for the majority of joint and soft tissue issues. For example, we perform ultrasound guided knee joint injections with 100% accuracy vs traditional injections with 75% accuracy. There is also evidence that utilizing ultrasound helps pain alleviation. Ultrasound, for example, provides more significant pain relief in carpal tunnel syndrome, rotator cuff tendinitis, and knee joint arthritis. Finally, there is evidence that ultrasonic injections for knee and hip joint injections are less costly. This makes logical since patients will see their doctor less frequently if their pain is significantly reduced.

Moreover, as using ultrasound is more accurate, there are other advantages, such as reduced side effects and more reliable information on the correct source of pain.

  • Fluoroscopy vs. ultrasound: which is better?

Most studies indicate that fluoroscopy and ultrasound injection are equally accurate and effective. However, we know that ultrasonography is far less expensive. Furthermore, the majority of people prefer ultrasonography to fluoroscopy. The key reason for this choice is that we do ultrasounds in a clean office environment, which saves time. Doctors, on the other hand, do fluoroscopy in an operating room, which takes many hours. Furthermore, fluoroscopy uses radiation, whereas ultrasonography does not.


Can anyone Perform an Ultrasound Guided Injection?

Perform an Ultrasound Guided Injection

Like any ability, learning how to administer an ultrasonic injection takes years

Musculoskeletal ultrasound-guided injections are performed by doctors, physiotherapists, and podiatrists. Overall skill level might vary, influencing injection success. You must get an injection administered by a skilled practitioner. Doctors have better training in ultrasonography and ultrasound-guided injections than other practitioners. You should inquire about your practitioner's experience and training.

While cost is an important factor, always be wary of non-doctor practitioners who charge less for injections. Some non-doctor practitioners in the UK perform ultrasound guided injections in an unregulated environment. Conversely, doctors are tightly regulated by the government body called the CQC or Care Quality Commission and General Medical Council. Both of these bodies strive for safe and effective health delivery services.


Before Your Ultrasound Guided Injection

Blood clotting disorder

 Please contact us as soon as possible if: 

  • You have a known blood clotting disorder.
  • You are on medication that suppresses your immune system eg methotrexate or beta interferon, or steroids. 
  • You have an infection or any other medical condition which may mean we need to reschedule this appointment.
  • You are pregnant
  • Continue to take any regular medication as normal, unless asked otherwise. 
  • Your insurance provider may choose not to cover you if you have a road accident. 
  • Please wear comfortable clothing that allows easy access to the area of the body to be injected. We may ask you to change into a hospital gown, if needed.


How Ultrasound-Guided Injections are Performed?

Ultrasound procedure

The ultrasound is one of the most commonly used instruments for image-guided injections. Until recently, they were rarely utilized in an orthopedist's practice, either because they were cumbersome or costly (or both). Newer portable devices now provide the convenience, precision, and resolution required for a wider range of orthopedic operations.

Ultrasound-guided injections are administered in the same manner as conventional injections. An ultrasonic gel will be put directly to the skin to ensure that the pictures are clear. The gel serves as a conductive medium, forming a strong contact between the skin and the ultrasonic probe. This guarantees that the reflected sound waves have as little interference as possible.

After that, the probe, also known as a transducer, is positioned near or close to the targeted tendon or joint. The injection will be administered using a regular needle and syringe after the healthcare professional has recognized the anatomic landmarks on the monitor.

The ultrasound also allows you to see fluids, allowing you to check if the drug is being distributed correctly.


What Happens After?

after steroid injection

You may notice that your discomfort has gone or has been greatly decreased immediately following a steroid injection. This is because of the local anaesthetic, and the impact will last a few hours. The steroid normally begins to act in three to four days, although this might vary. The steroid injection's impact varies from person to person, and some people may not benefit at all. Symptoms can be alleviated for several weeks to months.

After the procedure, you must stay in the department for 10 minutes. We highly encourage you to be escorted to the department by a responsible adult and to refrain from driving for the rest of the day. If you are in an accident, your insurance may be void and worthless. For the next 1-2 days, you should relax the injected region.


Will Injections Affect Vaccination?

COVID-19 vaccination

  • You are advised to delay a local steroid injection for a minimum of 2 weeks following a COVID vaccination.
  • You are advised to delay a COVID-19 vaccination for a minimum of 2 weeks following a local steroid injection.
  • Other vaccinations may be administered as usual after local steroid injections.


The Debate Over Ultrasound-Guided Injections

Debate Over Ultrasound-Guided Injections

The question of whether ultrasound-guided injections are beneficial has been debated for some time. The majority of the arguments come from insurers and private payors who question the use of a tool that may add $100 or more to a bill. Others, on the other hand, question whether a lot of emphasis should be made on appropriate injection training rather than providing technology shortcuts to healthcare practitioners.

Regardless of whether the justifications are accurate or not, the reality remains that there are various anatomically problematic portions of the body that even experienced healthcare practitioners may cringe about. Consider the use of an ultrasonography during a lumbar puncture (spinal tap) on an older patient with severe osteoarthritis.

The same thing applies to people with joint disorders. If there is the long-term or acute damage, an otherwise "simple" injection can turn challenging for not only for the healthcare provider but the person undergoing the procedure.


Alternative Procedures

Ultrasounds are not necessarily the best tool to guide injections for every particular situation. In some situations, other imaging modalities can be used to assist with injection guidance. For example, X-ray machines and CAT scanners are routinely used for injection guidance in some situations.

Also, there are certain types of injections which may not benefit from imaging guidance at all. This is a subjective great debate among healthcare providers. Some healthcare providers will argue that the only reason why imaging guidance is used is that it is yet another means to bill insurance companies for a service. I think that most clinicians agree that imaging guidance certainly has a role, but it is unclear exactly which injections are worth the added cost of imaging guidance


What are the Risks?

risk of Ultrasound-Guided Injections

There are small risks associated with this injection, which you should be aware of before you proceed. The radiologist doing your procedure will talk you through this when you arrive.

  • Discomfort: You may experience some discomfort immediately after the procedure. This is usually mild and can be helped with over-the-counter painkillers if required. 
  • Bleeding: This is unlikely to cause you a problem. If you have a medical condition that affects your blood clotting, please let us know in advance. If you are on anticoagulant or antiplatelet medication, you are more likely to experience bruising and bleeding, please let us know about this when you come in for your injection. 
  • Infection: If you experience redness, swelling, or tenderness around the injection site, please see your GP or a walk-in clinic within 24 hours as this may require treatment. Additional risks of steroid injections 
  • Change in glucose control: If you are diabetic, particularly if you are on insulin, you may experience low or high blood glucose levels after a steroid injection. Please monitor this closely after the procedure until it returns to your normal pattern. 
  • Steroid flare: Occasionally steroid injections can temporarily worsen your symptoms temporarily. This is not common. If you are concerned about this, then please see your GP or contact the doctor who referred you. 
  • Facial flushing: This is not common. If this does happen, it is temporary and typically goes away within a couple of days. 
  • Skin depigmentation: Occasionally steroid injections can cause the skin around where the needle has been inserted to become slightly paler in color.



orthopedic surgeon

Injections are often used by orthopedic surgeons to treat a wide range of problems. Cortisone, local anesthetics, and joint lubricants such as hyaluronic acid are also often injected medicines. In certain circumstances, administering an injection is more difficult than it appears. Some require you to hit the mark exactly, frequently with the smallest margin of error.

Joint injections, for example, must be given within the joint area rather than the surrounding soft tissue. Similarly, tendon injections should be given into the tendon sheath, the tissue that covers the tendon, rather than the tendon itself.

Traditionally, injections were given "blind," requiring a healthcare provider to have a certain degree of experience, delicacy, and anatomical know-how. Even then, there was no guarantee of success. These days, orthopedists largely avoid the hit-or-miss approach by using guided technologies such as ultrasound.