Hip Pain

- Today I'm going to demonstrate the piriformis injection.
Piriformis injection under ultrasound guidance is useful
in diagnostic maneuvers,
specifically for patients
that may have sciatic-like symptoms
as the sciatic nerve passes close to the piriformis muscle.
In piriformis syndrome
the piriformis muscle is hypertrophied
and can mimic sciatic symptoms
caused by lumbar herniated disks.
If this has been excluded,
this particular procedure can be done
under ultrasonographic guidance.
The patient is placed in the prone position
with a pillow underneath to provide bolster.
The side in question is identified and prepped
in this particular fashion.
The gluteus is exposed.
For facilitation of visualization
I utilize the Sonosite M Turbo
with the musculoskeletal setting to help enhance
the muscular fibers of the piriformis muscle,
the gluteus minimus and maximus,
and the curvilinear shape facilitates entry of the needle
into the targeted site.
To perform this particular block
the following equipment is necessary.
Chlorhexidine for sterile technique,
local anesthetic syringe containing 1% buffered lidocaine,
and then a syringe containing five cc of bupivicaine 1/2%
mixed with five cc of 1% lidocaine,
and then 40 to 80 milligrams of triamcinolone kenalog,
which is a particulate steroid.
A 3-1/2-inch 25-gauge spinal needle
will also be utilized for the procedure.
There will be sterile four by fours
necessary to clean the area at the conclusion
and a simple BAND-AID will suffice to cover the wound.
Copious amounts of gel are required
for this particular procedure.
The middle portion of the gluteus is identified
and then in a transverse or left-to-right positioning
the probe is placed in contact with the skin.
The leg in question can be mobilized
in a abduction-adduction maneuver
demonstrating motion of the piriformis muscle
as it inserts out towards the greater trochanter
and towards the ischium centrally.
Clearly in the middle of the screen
you can also identify the sciatic nerve
as it passes very close
to the fibers of the piriformis muscle.
A central point is identified,
making sure to stay away from the investing fascia
around the sciatic nerve.
The skin is marked and then 1% local anesthetic is injected
directly in short axis view
and then a 25-gauge 3-1/2-inch needle
is passed through this anesthetized track
and approximately six cc of local anesthetic
containing bupivicaine and lidocaine in a one to one mixture
with a small amount of steroid if desired can be injected.
- [Voiceover] This is a short axis view
and the curvilinear probe is applied
in the transverse orientation.
The leg is being adducted and abducted
to show the muscle moving.
The sciatic nerve is clearly visible
in the substance of the muscle.
It is the band-like hyperechoic structure.
The injectate is the hypoechoic structure
that grows within the substance of the muscle.
- The probe is withdrawn,
the area wiped with a four by four,
and then a BAND-AID placed over the wound.
This is the successful completion
of a piriformis injection under ultrasonographic guidance.

Brightcove ID

5508136045001

https://youtube.com/watch?v=ZGcNFTHlFeQ

How To Perform An Ultrasound-Guided Hip Injection

Read more about How To Perform An Ultrasound-Guided Hip Injection

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Dr. Scott Pollock demonstrates how to perform an ultrasound guided hip injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

How To Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Hip

Hip Ultrasound

Trochanteric Bursitis

Subtitles

- I'm gonna do a simulated hip injection now,
and show you how this is approached.
I'm not using a sterile technique,
and I'm not actually going to insert the needle,
but I will show you how it's approached.
The needle that I've selected is
an echo block needle, is what it's called.
This is a hundred millimeter,
approximately four inch needle.
You can also use a spinal needle,
but in an individual who is large,
sometimes you need a special needle like this,
which has marks on it that reflect the ultrasound beam
and make it much more visible.
The orientation will be the same
as demonstrated previously.
The image on the screen the same as we've seen before,
with the femoral neck being the target area.
And what I would do is mark with an indelible pen
close to the transducer,
cleanse this area, anesthetize it,
and insert the needle at approximately this angle.
Parallel to the transducer,
so that the needle is as visible as possible.
You can check the angle of the needle quite quickly
once you see the needle coming in on the right top
of the screen, and adjust the angle depth accordingly.
The goal is to bring the tip of the needle
into the V of the neck,
and that will be the joint.
This injection could be performed
with a transducer in the longitudinal position,
coming in this way, or could be done transversely,
with the transducer in this position,
but I'm using an in-plane approach.
The needle and the syringe are parallel to the direction
of the transducer.
I would then insert the needle approximately a centimeter
away from the transducer.
The closer you get, the more steep the angle has to be
to get down to this depth,
and so sometimes it's better to be a little distance away
from the edge of the transducer.
By looking at the screen you can see that the depth
of the marker is nearly four centimeters,
and the surface where the tendons are
and the bursa,
is down about two and a half to three centimeters.
So I'm gonna have to get an angle that gets this
down to the depths,
and it's probably gonna be something like this.
The angle will be changed by me as I enter the skin
to direct the tip into the structure
that I'm aiming for.
This can also be injected
in a transverse plane, this way,
sometimes it's easier to have the alignment going
in the same direction as you're looking,
so I'm looking across the patient at the ultrasound screen,
and I now have my transducer pointing in that direction.

Brightcove ID

5734024006001

https://youtube.com/watch?v=9CxPnc2-sH4

Body

Dr. Scott Pollock demonstrates how to perform an ultrasound guided hip injection.

How To: Hip Exam

Read more about How To: Hip Exam

/sites/default/files/Coach_pollock_hip_exam_thumb.jpg

Dr. Scott Pollock demonstrates how to perform a hip exam.

Clinical Specialties

Physical Med & Rehab

Media Library Type

How To Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Hip

Hip Ultrasound

Trochanteric Bursitis

Subtitles

- We're gonna examine the hip today,
this is her right hip and we'll look anteriorly
at the femoral acetabular joint,
and then we'll also look laterally
at the greater trochanter.
Positioning is important,
she is lying on her back with her leg extended
and slightly externally rotated.
This is the best position to see this joint.
I've chosen a C60 transducer.
There is a line here which corresponds
to the turquoise dot on the screen,
and this we usually, by tradition,
keep proximally or medially,
and that's the way I'll orient this image.
I'm trying to align the transducer
approximately parallel with the femoral neck,
and the left side of the screen,
the hyperechoic line is the acetabulum.
The curved structure, or circular structure,
is the femoral head.
It then drops down to the femoral neck,
and we can see the femur itself extending
parallel to the top part of the image,
out toward the right.
You can even see the joint capsule
and the cartilage on the femoral head,
and in the corner where the neck joins the ball
of the femur you can see the femoral joint space.
And that area right there at the base
is where you aim when you want to do an injection.
Before you do anything,
you want to identify the great vessels,
and I will turn the transducer transversely,
and look medially,
and we can see the anechoic structures that are pulsating.
I'll turn on the color.
Should be able to confirm that those are the vessels.
We want to, obviously, avoid those.
When I turn back longitudinally,
I see that those vessels are medial
to where I was looking before,
and now that area that I have examined
does not have blood vessels.
Sometimes it's a good idea to look
in this area,
because that's the direction the needle
is gonna be coming,
to make sure there are no branches
of the femoral artery or vein going in that direction.
If an effusion is present,
you'll usually see it right at that junction point
between the femoral head and the neck.
You'll see a bulge in the joint capsule,
it will be coming up and to the right,
and we'll usually move the iliopsoas muscle
and tendon dorsally, or superficially.
I'm gonna examine the lateral aspect of her hip,
the greater trochanter especially.
This would be an area that you can examine
with ultrasound in a symptomatic patient.
She's lying on her left side
with her hip extended.
Just slight flexion position.
I'm using a linear transducer now.
Sometimes in a person who has a
much deeper area to traverse,
I might use a C60.
This transducer has a linear mark here,
which corresponds to the turquoise dot on the screen,
and we keep that proximal,
or we keep that medial.
The hyperechoic curved line
is the superior edge of the greater trochanter.
There are muscles and tendons, then,
just beneath the skin.
Going distally, we see the rest of the greater trochanter
with tendinous insertions
of the gluteus muscles.
If we turn this transversely,
we can again see the bony outline
deep as a hyperechoic structure,
and above it,
a series of tendinous structures,
the gluteus muscles come in and attach
to the greater trochanter.
Anteriorly
and posteriorly
we can see these images around the greater trochanter,
and there are a series of bursae present there,
with fluid-filled sacs
visible in a person who would have bursitis.

Brightcove ID

5734020657001

https://youtube.com/watch?v=0Fu4R9mEoz4

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How to: Piriformis Injection

How to: Piriformis Injection

How To Perform An Ultrasound-Guided Hip Injection

How To Perform An Ultrasound-Guided Hip Injection

How To: Hip Exam

How To: Hip Exam

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