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2019v1.0
 Atlas of Interventional
Orthopedics Procedures

i
This page intentionally left blank

     
Atlas of Interventional
Orthopedics Procedures
Essential Guide for Fluoroscopy and
Ultrasound-Guided Procedures

Chris J. Williams, MD
Adjunct Professor
Emory Rehabilitation Department
Emory University, Atlanta
Georgia
USA
CEO/Owner
Interventional Orthopedics of Atlanta, Atlanta
Georgia
USA

Walter I. Sussman, DO
Assistant Clinical Professor
Physical Medicine & Rehabilitation
Tufts University, Boston
Massachusetts
USA

John Pitts, MD
Fellowship Director
Interventional Orthopedics
Centeno- Schultz Clinic, Broomfield
Colorado
USA

London New York Oxford Philadelphia St Louis Sydney 2023

© 2023, Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or me-
chanical, including photocopying, recording, or any information storage and retrieval system, without permis-
sion in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions

This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contribu-
tors for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.

ISBN: 978-0-323-75514-6

Content Strategist: Humayra Khan

Content Development Specialist: Kim Benson/Grace Onderlinde
Project Manager: Andrew Riley
Design: Patrick Ferguson
Illustration Manager: Muthukumaran Thangaraj
Illustrator: Dr Patrick Nguyen
Marketing Manager: Kate Bresnahan

Printed in the USA

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contents

Foreword vii 9 Therapeutic Dextrose Injection: Prolotherapy,

Perineural Injection Therapy, and
Preface viii
Hydrodissection, 102
Editor Biographies x Kenneth D. Reeves, Stanley K.H. Lam and David Rabago

Contributors xii
10 Sclerosing Agents, 118
Acknowledgments xx Colton L. Wood, David J. Berkoff, and Justin R. Lockrem

Section I Introduction 11 Toxins for Orthopedics, 124

Zach Bohart, Walter I. Sussman, Jacob Sellon,
1 Introduction to Interventional Orthopedics and Natalie Sajkowicz
and Review of the Pathophysiology of
Orthopedic Conditions, 1 Section III Atlas
Walter I. Sussman, John Pitts, and Chris Williams
12 Cervical Injection Techniques, 134
2 Ultrasound Basics, 14 Marko Bodor, Stephen Derrington, John Pitts, Jason Markle,
Matthew Sherrier, Allison N. Schroeder, Kentaro Onishi, and Sairam Atluri, Navneet Boddu, and Vivek Manocha
Daniel Lueders
13 Thoracic Injection Techniques, 166
3 Principles of Fluoroscopy Imaging in Marko Bodor, Stephen Derrington, John Pitts, Jason Markle,
Spine and Musculoskeletal Interventional and Orlando Landrum
Orthopedics, 31
Katarzyna Iwan, Rahul Naren Desai, 14 Lumbar Injection Techniques, 186
and John J. Wolfson Di Cui, Lisa Foster, Brian Hart Keogh Jr., Jason Markle,
Hassan Monfared, Jaymin Patel, Shounuck I. Patel, John
Section II Injectates Pitts, and Diya Sandhu

4 Principles of Injection Therapy, 41 15 Sacrococcygeal Injection Techniques, 224

Lee Kneer, Robert Bowers, and Cleo D. Stafford II Joanne Borg-Stein, Catherine Mills, Carolyn Black, Oluseun
Olufade, and Giorgio A. Negron
5 Autologous Tissue Harvesting Techniques:
Bone Marrow Aspirate and Adipose Tissue, 16 Shoulder Injection Techniques, 242
50 Jason Markle and Cleo D. Stafford II
Gerard Malanga, Jay E. Bowen, and
Selorm L. Takyi 17 Elbow Injection Techniques, 272
Chris Williams, Walter I. Sussman, and John Pitts
6 Autologous Tissue Harvesting Techniques:
Platelet-Rich Plasma, 62 18 Wrist Injection Techniques, 290
Peter A. Everts Kevin Conley, Yoditi Tefera, Michael Erickson, Adam M.
Pourcho, Phillip Henning, and Oluseun Olufade
7 Autologous Orthobiologics, 70
Prathap Jayaram, Peter Chia Yeh, Max Epstein, and Shiv J. Patel 19 Hand Injection Techniques, 313
Yodit Tefera, Kevin Conley, Michael Erickson, Adam M.
8 Allograft Tissues, 89 Pourcho, Phillip Henning, and Oluseun Olufade
Alberto J. Panero, Alan M. Hirahara, Luga Podesta, Amir A.
Jamali, Wyatt Andersen, and Alyssa A. Smith

v
vi Contents

20 Hip Injection Techniques, 323 30 Ultrasound-Guided Anterior and Lateral

Ken Mautner, John Pitts, Oluseun Olufade, Heather Lynn Compartment Fasciotomies for Chronic
Saffel, and Adam Street Exertional Compartment Syndrome, 527
Jonathan T. Finnoff and Jacob Reisner
21 Knee Injection Techniques, 366
Josh Hackel, Todd Hayano, John Pitts, 31 Principles of Perineural Injections, 531
and Mairin A. Jerome Jeffrey A. Strakowski

22 Ankle Region Injection Techniques, 428 32 Ultrasound-Guided Release of the Transverse

Allison C. Bean, Allison N. Schroeder, Matthew Sherrier, Carpal Ligament (Carpal Tunnel), 535
Arthur Jason de Luigi, and Kentaro Onishi Adam M. Pourcho, Phillip Henning, and Jay Smith

23 Foot Injection Techniques, 465 33 Ultrasound-Guided Percutaneous Bone Spur

Douglas Hoffman, Jacob Jones, Pierre D’hemecourt, John Excision and Cheilectomy, 544
Pitts, and Arthur Jason De Luigi Brian J. Shiple

Section IV Advanced 34 Intraosseous Injections, 553

Steven Sampson, Hunter Vincent, and Sonali Lal
24 Calcific Tendonitis Barbotage/Lavage, 489
Jason Ian Blaichman and Kenneth S. Lee 35 Advanced and Emerging Interventional
Techniques, 573
25 High-Volume Ultrasound-Guided Capsular Nidal Elbaridi, Virlyn Bishop, Orlando Landrum, Marko
Distention for Adhesive Capsulitis, 496 Bodor, and John Pitts
Alyssa Neph Speciale and Brian Davis
36 Needle Arthroscopy of the Knee, Shoulder,
26 Ultrasound-Guided Needle Tenotomy and Hip, 594
and Ultrasound-Guided Tenotomy and Don Buford, Brice W. Blatz, and Nicola Hyde
Debridement With Tenex Health TX System,
502 Section V Postprocedure Considerations
Ryan C. Kruse and Mederic M. Hall
37 Rehabilitation Principles for Interventional
27 High-Volume Image-Guided Injections, 506 Orthopedics and Orthobiologics, 599
Maria-Cristina Zielinski, Nicola Maffulli, Otto Chan, and Walter I. Sussman, Ken Mautner, and Abby Perone
Romain Haym
38 Advanced Imaging in Interventional
28 Ultrasound-Guided Release of Trigger Finger Orthopedics, 612
and de Quervain Tenosynovitis, 514 Rahul Naren Desai and Katarzyna Iwan
Ricardo E. Colberg and Javier A. Jurado

29 Compartment Pressure Testing, 524

Jonathan T. Finnoff and Jacob Reisner
Foreword

In the early 2000s, I was frustrated with interventional spine a new medical specialty. Consequently, the concept of inter-
care. We were performing imaging-guided corticosteroid ventional orthopedics was born. Our clinic soon set up a fel-
injections in the spine as well as radiofrequency ablation lowship program to educate physicians as well as a non-profit
and could help many patients, but these were often “Band- organization, the Interventional Orthopedics Foundation
aid” procedures. The same held true for the corticosteroid or (IOF). The primary goal of the IOF was to train physicians in
hyaluronic acid injections we could offer in peripheral joints the United States and abroad with a background in muscu-
for osteoarthritis. Then a 2004 article was published show- loskeletal care how to precisely inject structures under image
ing that a rabbit disc could be regenerated with an injection guidance with hands-on didactic sessions.
of mesenchymal stem cells (MSCs) and my mind exploded. Looking back, I realize that this textbook is the culmi-
By 2005, we had begun an IRB-approved clinical trial using nation of both the problem of a limited set of treatment
cultured bone marrow MSCs in the intervertebral disc and options for musculoskeletal injuries and the dream of
in various peripheral joints. bridging non-operative and operative orthopedic care with
As we treated patients, we began to realize that what we precision-based interventional orthopedics. In other words,
had learned in interventional spine was only a small part of a new interventional specialty needs standard texts that
what was possible. For example, when tissue regeneration or describe the core procedures of that specialty. As radical as
healing is possible, placing stem cells or platelets using ultra- this concept may seem, there is nothing new under the sun,
sound or fluoroscopy into specific damaged structures of the as the phrase goes. Medicine witnessed a similar specialty
musculoskeletal system is the goal. However, it soon became emergence and transition in paradigm from a more surgical
clear that there were several limitations to the possibilities of model of cardiovascular care with the inception of interven-
treating musculoskeletal injuries. For example, there were tional cardiology in the late 1980s.
no interventional spine courses or texts that discussed how This textbook includes contributions from many of
to inject a damaged knee anterior cruciate ligament (ACL), the leaders in the field and several physicians that have
shoulder labrum, or ankle ligament. completed a fellowship in interventional orthopedics
Additionally, the diagnostic and therapeutic approach to and completed hundreds of didactic hours staying up to
these issues was entirely different than interventional spine date on emerging techniques and new research. This will-
or orthopedic surgery. For example, interventional spine had ingness to be an innovator and disrupter in the field is
nothing to say about how to diagnose an ACL tear or which necessary for laying the foundation of stones to the met-
tears would be appropriate for injection-based regenerative aphorical building, which will continue to cement the
medicine versus which ACL tears would be more appropri- legitimacy of this new medical specialty. I applaud and
ate for traditional surgical reconstruction. While orthope- 100% support their efforts and happily pass the torch to
dic surgery had a diagnostic approach, it was focused on a that next generation.
binary decision, which is whether the damaged ACL should
be surgically removed and replaced or not. Christopher J. Centeno, MD
Hence, it was clear based on the techniques required and
the different diagnostic and therapeutic approach that this was

vii
Preface

Evolution With the advent and growing evidence for the use of
orthobiologics in orthopedic medicine, we realized these
“The only constant in life is change” substances could be injected in far more tissue areas than
—HERACLITUS the traditional steroids and local anesthetics. Because these
substances can be used to treat joints, bursae, fibrocartilage
Musculoskeletal medicine is currently undergoing a para- structures, tendons, ligaments, muscles, bones, and peri-
digm shift as alternatives to the traditional approaches of neurally, they open up a whole new world of procedures
care are being investigated vigorously by clinicians, scien- that were previously not described. Thus, the pioneers of
tists, and patients. Conventional methods utilizing ana- these treatments had to discover or invent new ways to
tomic landmarks for injection-based therapy have slowly inject these substances safely and accurately into tissues one
been replaced by precision-guided injections at the point- would not typically treat with steroids only.
of-care with high-definition ultrasound and fluoroscopy.
Long-established surgical procedures are being substituted
for minimally invasive techniques without having a negative Blueprint
impact on patient outcomes. “Reading is the foundation of learning but an artist drew
All the procedure techniques described in this book are up the blueprints.”
image guided and we believe this to be the standard of care —GEORGE E. MILLER
at this time. Topics covered range from simple ultrasound-
guided joint injections, ligament and tendon injections, “Of what use is a dream if not a blueprint for courageous
perineural hydrodissection, fluoroscopically guided spine action.”
procedures, and advanced microinvasive surgical proce- —ADAM WEST
dures—such as minimally invasive carpal tunnel release, A1
pulley/trigger finger release, intraosseous subchondral injec- We have been fortunate to have the opportunity to learn,
tions, calcific tendinopathy debridement, and the TENEX advance, and create many of these techniques we learned
procedure, to name a few. from pioneers in this field, such as Chris Centeno, John
Schultz, and Kenneth Mautner to name a few.
Inception This atlas provides a systematic approach for injecting
“An Idea Is Like A Virus.” all the relevant structures that are commonly encountered
—CHRISTOPHER NOLAN by non-operative sports medicine and interventional spine
physicians. The primary goal was to provide a single text
The idea of this book came about as the authors were col- that an injectionist could utilize throughout the spectrum
lecting fluoroscopic and ultrasound-guided images of struc- of learning and practicing.
tures to perfect new injections techniques and for educating Section I of the book introduces the basics of image
doctors in training as well. We began collecting images guidance. Section II discusses the background and evidence
showing desired contrast flow patterns for structures such for the most commonly used injectates and orthobiologics
as the ACL, PCL, spine ligaments, shoulder labrum, and available at the time of writing this text. Section III is the
the hip ligamentum teres. During this process, we realized bulk of the text and describes ultrasound- and fluoroscopy-
that the majority of the techniques are not widely known guided procedures separated by body region. We provide
and only a handful of courses were offered to teach some of relevant anatomy and pathology and describe a step-by-step
the advanced techniques sporadically throughout the year. guide for the injectionist to utilize as a supplemental learn-
The idea was then born to create an inclusive “atlas” incor- ing tool for hands-on training. Section IV provides evidence
porating both ultrasound- and fluoroscopy-guided muscu- and descriptions for more advanced procedures that can
loskeletal procedures. Additionally, we wanted to include aide the more experienced interventional orthopedist and
an up-to-date resource on the current research and clinical should not be attempted until significant hands-on expe-
outcomes for orthobiologics given the overwhelming utili- rience has been completed. Finally, Section V starts with
zation by many clinicians. a chapter on postprocedure rehabilitation principles and

viii
 Preface ix

current evidence. It concludes with a chapter on imaging, of this book experience the same. Our hope is to further
with visual examples demonstrating various degrees of tissue advance the field of interventional orthopedics and regen-
healing and regeneration. erative medicine and inspire the next generation to take the
Ideally, this text will serve as a fluid reference point as field further.
procedural techniques and injectate options continue to
evolve. Chris J. Williams, MD
Making this book has expanded our thought process and Walter I. Sussman, DO
clinical knowledge, and we sincerely hope that the readers John Pitts, MD
Editor Biographies

Chris J. Williams, MD and treatment of musculoskeletal conditions in athletes,

Christopher J. Williams, MD, was born and raised in Jack- weekend warriors, adolescents, the underserved, and the
sonville, Florida. After high school, Dr. Williams entered the elderly. He strives to provide exceptional care to everyone
US Air Force and worked as a public health technician in he encounters.
England, Kuwait, and Mississippi. After serving 4 years in the Dr. Williams resides in Atlanta, Georgia with his wife
Air Force, he decided to get his undergraduate degree from Layla, who is an ObGyn physician; two children, Kemet
the University of North Florida, where he graduated summa and Egypt; and enjoys cooking, fitness activities, art, music,
cum laude. He then opted to attend medical school at Emory and traveling.
University where he also completed his residency training
in physical medicine and rehabilitation. During residency, Walter I. Sussman, DO
he was awarded the Resident of Year award for all 3 years of Dr. Walter I. Sussman is board certified in physical medi-
his residency training and was Chief Resident his last year cine and rehabilitation with fellowship training in sports
of training. During residency, Dr. Williams spearheaded the medicine. He completed his undergraduate studies at Col-
development of a musculoskeletal (MSK) ultrasound train- gate University and medical school at the University of New
ing curriculum and started a prosthetics and orthotics annual England College of Osteopathic Medicine in Biddeford,
symposium in collaboration with Georgia Tech. Maine. During medical school, he completed a 1-year fel-
Dr. Williams is board certified in physical medicine and lowship in anatomy and osteopathic manipulative medi-
rehabilitation and completed fellowship training in inter- cine. He completed his residency in physical medicine and
ventional orthopedics and regenerative medicine for 1 year rehabilitation at Emory University, where he served as chief
at the Centeno-Schultz Clinic in Broomfield, CO. After resident. He then pursued a fellowship in sports medicine
completing his training, he was an attending physician at at Emory University, where he provided coverage for the
the Centeno-Schultz Clinic prior to opening his practice Atlanta Dream WNBA team, Georgia Tech athletics, and
in Atlanta, GA: Interventional Orthopedics of Atlanta. In Emory University athletics.
collaboration with Ken Mautner at Emory, they started a Dr. Sussman currently works in private practice outside
joint non-accredited fellowship program in interventional of Boston and serves as the Head Team Physician for the
orthopedics and graduated their first fellow in July 2020. University of Massachusetts Dartmouth and provides care
Education is one of his passions, as he was raised by a for many of the local high schools. He is a clinical Assistant
very hardworking single parent who was also a teacher and Professor at Tufts University and is engaged in resident edu-
instilled in him the principles of humility, hard work, and cation. Dr. Sussman has published multiple book chapters
dedication. Currently, Dr. Williams is an adjunct faculty and peer-reviewed articles on regenerative medicine, chronic
member at Emory University in the Department of Reha- tendon injuries, diagnostic musculoskeletal ultrasound, and
bilitation Medicine, providing didactics annually and also concussion management.
allowing the residents to get hands-on training while rotat- Dr. Sussman takes pride in promoting the patient experi-
ing with him during their elective time. He is an instructor ence and individualizing the treatment to fit each patient.
and the educational committee co-chair for the Interven- Dr. Sussman has a clinical interest in the use of ultrasound
tional Orthobiologics Foundation, teaching several courses to diagnose musculoskeletal injuries, in post-concussion
annually. He also has lectured at the annual conference for syndrome, in orthobiologics, and in minimally invasive
The Orthobiologics Institute (TOBI). procedures. Dr. Sussman manages chronic musculoskel-
Dr. Williams has published over 10 peer-reviewed etal conditions, acute sports injuries, and sports-related
research articles and book chapters on the topics of orthobi- concussions.
ologics and rehabilitation medicine. He achieved best-sell-
ing author status on Amazon for his book Exercise 2.0 and John Pitts, MD
was recognized by Emory University Alumni Association 40 John Pitts, MD, was born and raised on the south side of
Under 40 in 2019. Chicago, IL. He received a BA in Mathematics/Economics
In his private practice at the Interventional Orthope- at Emory University in Atlanta, Georgia. Dr. Pitts received
dics of Atlanta, Dr. Williams specializes in the diagnosis his medical education at Vanderbilt School of Medicine

x
 Editor Biographies xi

in Nashville and then completed a physical medicine and nerves, joints, ligaments, tendons, bones, and muscle. He
rehabilitation residency back at Emory University. After res- regularly uses orthobiologics such as prolotherapy, neuroprolo-
idency he completed a 1-year fellowship (non-accredited) therapy, platelet-rich plasma (PRP), platelet lysate, bone mar-
in regenerative medicine and interventional orthopedics at row concentrate, micronized adipose tissue graft, and amniotic
the Centeno - Schultz Clinic, where he works currently and membrane. Additionally, he works in Grand Cayman Island
is part of the Regenexx network of physicians. He serves several times per year, where he is able to treat patients with cul-
as the fellowship director and helps to train new Regenexx tured expanded bone marrow mesenchymal stem cells (MSCs).
physicians. He also regularly teaches procedural courses for He utilizes other devices to be used in interventional orthope-
the Interventional Orthopedics foundations and has given dics and helps to pioneer and advance many of the procedures.
presentations at major conference for the American Acad- Dr. Pitts has co-authored several peer-reviewed articles
emy of Physical Medicine and Rehabilitation (AAPMR), relating to regenerative treatments. He also authored a book
The Orthobiologics Institute (TOBI), and the American named Nutrition 2.0, Guide to Eating and Living to Achieve
Association of Orthopedic Medicine (AAOM). a Higher Quality of Life Now and into Your Golden Years, and
Dr. Pitts has been practicing regenerative Medicine and gives this to all his patients.
interventional orthopedics exclusively since 2013. He diagno- Dr. Pitts resides in Denver, CO, with his wife, Ria, and
ses and treats patients with a variety of orthopedic and muscu- two young children, Malcolm and Camila. He enjoys work-
loskeletal problems, including spine (cervical, thoracic, lumbar, ing out, playing sports, snowboarding, scuba diving, being
sacroiliac joints), temporomandibular joint, upper extremity outdoors, traveling, watching movies, and spending time
(shoulder, elbow, wrist, hand, fingers), lower extremity (hip, with his family.
knee, ankle, foot, toes), and problems relating to peripheral
Contributors

Associate Editors Jason Markle, DO

Interventional Orthopedic Physician
Marko Bodor, MD Orthopedics
Founder The Centeno-Schultz Clinic
Interventional Spine and Sports Medicine Broomfield, Colorado
Bodor Clinic USA
Napa, California
USA Ken Mautner, MD
Assistant Professor Assistant Professor
Physical Medicine and Rehabilitation Physical Medicine & Rehabilitation
University of California Davis Emory University, Atlanta
Sacramento, California USA
USA
Assistant Professor
Neurological Surgery Contributors
University of California San Francisco Wyatt Andersen, BS, ATC
San Francisco, California Research Assistant
USA Physical Medicine & Rehabilitation
Sacramento, California
Don Buford, MD, RMSK USA
Orthopedic Surgeon
Sports Medicine Sairam Atluri, MD
Texas Orthobiologic Institute Medical Director
Dallas, Texas ReGen
USA StemCures
Cincinnati, Ohio
Rahul Naren Desai, MD USA
CEO
Musculoskeletal Radiology Allison C. Bean, MD, PhD
Restore Department of Physical Medicine and Rehabilitation
PDX Spine & Sports Medicine University of Pittsburgh Medical Center
Beaverton, Oregon Pittsburgh, Pennsylvania
USA USA
President
Interventional Orthopedic Foundation David J. Berkoff, MD
Broomfield, Colorado Professor
USA Orthopedics and Emergency Medicine
UNC Chapel Hill
Gerard Malanga, MD Chapel Hill, North Carolina
Partner USA
New Jersey Sports Medicine, LLC
Cedar Knolls, New Jersey Virlyn Bishop
USA Anesthesiology and Pain Medicine
Clinical Professor Center for Spine Interventions
PM&R Acworth, GA
Rutgers Medical School USA
Newark, New Jersey
USA
xii
 Contributors xiii

Carolyn Black, MD, PhD Joanne Borg-Stein, MD

Resident Physician Associate Professor
Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation
Harvard Medical School/Spaulding Rehabilitation Harvard Medical School
Hospital Boston, Massachusetts
Boston, Massachusetts USA
USA
Jay E. Bowen, DO
Jason Ian Blaichman, MDCM, FRCPC Medical Director
Adjunct Lecturer New Jersey Regenerative Institute, LLC
Department of Medical Imaging Cedar Knolls, New Jersey
University of Toronto USA Clinical Assistant Professor PM&R, Rutgers Medical
Toronto, Ontario School, New Jersey
Canada USA
Staff Radiologist
Department of Diagnostic Imaging Robert Bowers, DO, PhD
Scarborough Health Network Assistant Professor
Scarborough, Ontario Department of Orthopaedics
Canada Emory University School of Medicine
Atlanta, Georgia
Brice W. Blatz, MD, MS USA
Physician/Owner Assistant Professor
Sports and Regenerative Medicine Department of Rehabilitation Medicine
Pacific Regenerative and Interventional Sports Medicine Emory University School of Medicine
San Jose, California Atlanta, Georgia
USA USA

Navneet Boddu, MD Don Buford, MD, RMSK

Anesthesiologist Orthopedic Surgeon
Anesthesiology Sports Medicine
Anesthesia Service Medical Group Texas Orthobiologic Institute
San Diego, California Dallas, Texas
USA USA

Marko Bodor, MD Christopher J. Centeno, MD

Founder Research and Development
Interventional Spine and Sports Medicine Regenexx, LLC
Bodor Clinic Broomfield, Colorado
Napa, California USA
USA Centeno-Schultz Clinic
Assistant Professor Broomfield, Colorado
Physical Medicine and Rehabilitation USA
University of California Davis
Sacramento, California Otto Chan, MBBS, FRCS, FRCR
USA Doctor
Assistant Professor Radiology Department
Neurological Surgery Whittington Hospital
University of California San Francisco London
San Francisco, California United Kingdom
USA
Ricardo E. Colberg, MD, RMSK
Zach Bohart, MD, MS Sports Medicine Physician
Associate Professor Andrews Sports Medicine & Orthopaedic Center
Tufts University School of Medicine Birmingham, Alabama
Boston, Massachusetts USA
USA
xiv Contributors

Kevin Conley, MD Pierre D’Hemecourt, MD

Fellow Physician
Swedish Sports & Spine Sports Medicine
Providence-Swedish Health Alliance Boston Children’s Hospital
Seattle, Washington Boston, Massachusetts
USA USA

Di Cui, MD Nidal Elbaridi, MD, PT

Assistant Professor Medical Director
Department of Rehabilitation Interventional Pain
Emory University Loop Medical Center
Atlanta, Georgia Chicago, Illinois
USA USA

Brian Davis, MD, FACSM Max H. Epstein, MD

Volunteer Clinical Professor Resident
Department of Physical Medicine & Rehabilitation Physical Medicine & Rehabilitation
UC Davis Health System, Sacramento Baylor College of Medicine
California Houston, Texas
USA USA

Arthur Jason De Luigi, DO Michael Erickson, MD

Chair Swedish Sports Medicine Fellowship Director
Physical Medicine & Rehabilitation Swedish Family Medicine Residency
Mayo Clinic Arizona Swedish Medical Center
Scottsdale, Arizona Seattle, Washington
USA USA
Professor of Rehabilitation Medicine Clinical Instructor
Rehabilitation Medicine Family Medicine
Georgetown University School of Medicine University of Washington
Washington, District of Columbia Seattle, Washington
USA USA
Associate Professor of Physical Medicine &
Rehabilitation Peter A. Everts, PhD, FRSM
Physical Medicine & Rehabilitation Chief Scientific Officer EmCyte
Mayo Clinic Alix School of Medicine Program Director Gulf Coast Biologics
Scottsdale, Arizona Fort Myers. Florida
USA USA

Stephen Derrington, DO Jonathan T. Finnoff, DO, FAMSSM, FACSM

President and Medical Director Chief Medical Officer
Interventional Orthobiologics United States Olympic and Paralympic Committee,
Derrington Orthopedics – Interventional Sports and Spine Colorado Springs
Oceanside and Laguna Hills, California Colorado
USA USA
Professor
Rahul Naren Desai, MD Department of Physical Medicine and Rehabilitation
CEO Mayo Clinic College of Science and Medicine, Rochester
Musculoskeletal Radiology Minnesota
RestorePDX Spine & Sports Medicine USA
Beaverton, Oregon
USA Lisa Foster, MD
President Assistant Professor
Interventional Orthopedic Foundation Orthopedics
Broomfield, Colorado Emory University
USA Atlanta, Georgia
USA
 Contributors xv

Josh Hackel, MD, RMSK, CAQSM Katarzyna Iwan, MD

Fellowship Director USA/Andrews Research and Doctor
Education Foundation Pain Medicine
Primary Care Sports Medicine RestorePDX
Andrews Institute Beaverton, Oregon
Gulf Breeze, Florida USA
USA
Amir A. Jamali, MD
Mederic M. Hall, MD Medical Director
Associate Professor Orthopaedic Surgery
Orthopaedics and Rehabilitation Joint Preservation Institute
University of Iowa Walnut Creek, California
Iowa City, Iowa USA
USA
Prathap Jayaram, MD
Todd Hayano, DO Director of Regenerative Sports Medicine
Sports Medicine Fellow H. Ben Taub Physical Medicine & Rehabilitation
Orthopedics & Sports Medicine Department of Orthopedic Surgery
Andrews Research & Education Foundation Baylor College of Medicine
Pensacola, Florida Houston, Texas
USA USA

Romain Haym, MSc (MSK Ultrasound), MSc Mairin A. Jerome, MD

(Adv. Physiotherapy), MHCPC, MCSP, MMACPC Fellow
Tendon Clinic—Senior Physiotherapist Interventional Orthopedics
Physiotherapy Centeno-Schultz Clinic
BMI The London Independent Hospital, London Broomfield, Colorado
United Kingdom USA
MSK Sonographer
Imaging Jacob Jones, MD
NHS Whittington Trust, London Physician
United Kingdom Orthopedics and Sports Medicine
Boston Children’s Hospital
Phillip Henning, DO Boston, Massachusetts
Medical Director of Sports Medicine USA
Rehabilitation and Performance Medicine
Swedish Medical Center, Seattle, Javier A. Jurado
Washington Medical Student
USA The University of Alabama at Birmingham School of Medicine
Birmingham, Alabama
Alan M. Hirahara, MD, FRCSC USA
Owner
Private Practice Brian Hart Keogh Jr., MD
Sacramento, California East Carolina Pain Consultants
USA Interventional Pain Management
Vidant Medical Center
Douglas Hoffman, MD Greenville, North Carolina
Director of Musculoskeletal Ultrasound USA
Orthopedics and Radiology Affiliate Clinical Faculty
Essentia Health Department of Physical Medicine and Rehabilitation
Duluth, Minnesota East Carolina University School of Medicine
USA Greenville, North Carolina
USA
Nicola Hyde
Sports Medicine and Family Medicine Physician
Seattle, Washington
USE
xvi Contributors

Lee Kneer, MD FAAPMR Justin R. Lockrem, MD

Assistant Professor Sports Medicine Fellow
Department of Orthopaedics Sports Medicine
Emory University School of Medicine, Atlanta University of North Carolina
Georgia Chapel Hill, North Carolina
USA USA
Assistant Professor
Department of Rehabilitation Medicine Daniel Lueders, MD
Emory University School of Medicine, Atlanta Assistant Professor
Georgia Physical Medicine and Rehabilitation
USA University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Ryan C. Kruse, MD, CAQSM, RMSK USA
Assistant Professor
Orthopedics and Rehabilitation Nicola Maffulli, MD, MS, PhD, FRCP, FRCS(Orth)
University of Iowa Full Professor
Iowa City, Iowa Medicine, Surgery and Dentistry
USA University of Salerno
Salerno
Sonali Lal, MD Italy
Assistant Professor, Columbia University
Attending Physician, New York Gerard Malanga, MD
Presybyterian Hospital Partner
New Jersey Sports Medicine, LLC
Stanley K. H. Lam, MBBS, MScSEM, FHKIMM, RMSK, Cedar Knolls, New Jersey
CIPS, FIPP, POCUS USA
President Clinical Professor
Clinical Research PM&R
The Hong Kong Institute of Musculoskeletal Medicine Rutgers Medical School
Kowloon Bay Newark, New Jersey
Hong Kong USA
Clinical Associate Professor
Family Medicine Vivek Manocha, MD
The Chinese University of Hong Kong Medical Director
New Territory Pain Management
Hong Kong Midwest Spine Interventionalist
Clinical Assistant Professor Springboro, Ohio
Family Medicine USA
The University of Hong Kong Clinical Assistant Professor
Hong Kong Surgery
Wright State University
Orlando Landrum, MD, MBA Boonshoft School of Medicine
Physician CEO Dayton, Ohio
Pain & Regenerative Medicine USA
Cutting Edge Integrative Pain Centers
Elkhart, Indiana Jason Markle, DO
USA Interventional Orthopedic Physician
Orthopedics
Kenneth S. Lee, MD/MBA The Centeno-Schultz Clinic
Professor of Radiology Broomfield, Colorado
Section Chief of Musculoskeletal Imaging & Intervention USA
Fellowship Director
Musculoskeletal Imaging & Intervention Ken Mautner, MD
University of Wisconsin School of Medicine and Public Assistant Professor
Health Physical Medicine & Rehabilitation
Madison, Wisconsin Emory University, Atlanta
USA USA
 Contributors xvii

Catherine Mills, MD Shiv J. Patel, MD

Resident Physician Resident
Physical Medicine & Rehabilitation Orthopaedic Surgery
Harvard Medical School/Spaulding Rehabilitation Hospital University of Texas Medical Branch, Galveston
Boston, Massachusetts Texas
USA USA

Hassan Monfared, MD Shounuck I. Patel, DO

Assistant Professor Functional & Interventional Orthopedics
Physical Medicine and Rehabilitation Spine & Sports Physiatry
Emory University Regenexx Los Angeles
Atlanta, Georgia Los Angeles, California
USA USA
Residency Program Director Clinical Assistant Professor
Physical Medicine and Rehabilitation College of Osteopathic Medicine of the Pacific
Emory University Western University
Atlanta, Georgia Pomona, California
USA USA
Clinical Assistant Professor
Giorgio A. Negron, MD College of Osteopathic Medicine
Resident Physician Touro University
Department of Rehabilitation Medicine Harlem, New York
Emory University USA
Atlanta, Georgia
USA Abby Perone, DC
Love Health, Owner
Oluseun Olufade, MD Movement Therapy & Functional Medicine
Assistant Professor St. Petersburg, Florida
Department of Orthopedics USA
Emory School of Medicine
Atlanta, Georgia John Pitts, MD
USA Fellowship Director
Assistant Professor Interventional Orthopedics
Department of Physical Medicine & Rehabilitation Centeno-Schultz Clinic
Emory School of Medicine Broomfield, Colorado
Atlanta, Georgia USA
USA
Luga Podesta, MD
Kentaro Onishi Director
Assistant Professor Regenerative Sports Medicine
Physical Medicine and Rehabilitation Bluetail Medical Group-Naples
University of Pittsburgh Medical Center, Pittsburgh Naples, Florida
Pennsylvania USA
USA Team Physician
Florida Everglades
Alberto J. Panero, DO Estero, Florida
http://sacsportsmed.com USA
Sports Medicine
SAC Regenerative Orthopedics Adam M. Pourcho, DO
Sacramento, California Instructor of Sports Medicine
USA Physical Medicine and Rehabilitation
Swedish Medical Group
Jaymin Patel, MD Seattle, Washington
Assistant Professor USA
Orthopaedics
Emory University
Atlanta, Georgia
USA
xviii Contributors

David Rabago, MD Diya Sandhu, MD

Associate Professor Assistant Professor
Department of Family Medicine Orthopaedics
University of Wisconsin School of Medicine and Public Emory University
Health Atlanta, Georgia
Madison, Wisconsin USA
USA Assistant Professor
Physical Medicine and Rehabilitation
Kenneth D. Reeves, BS, MD Emory University
Private Practice Atlanta, Georgia
Physical Medicine and Rehabilitation and Pain USA
Management
Roeland Park, Kansas Allison N. Schroeder, MD
USA Resident Physician
Formerly Clinical Assistant/Associate Professor 1986–2015 Physical Medicine and Rehabilitation
Physical Medicine and Rehabilitation University of Pittsburgh Medical Center
University of Kansas Medical Center Pittsburgh, Pennsylvania
Kansas City, Kansas USA
USA
Jacob Sellon, MD
Jacob Reisner, DO Associate Professor
Primary Care Sports Medicine Fellow Physical Medicine and Rehabilitation/Sports Medicine Center
Physical Medicine and Rehabilitation Mayo Clinic
Mayo Clinic Rochester, Minnesota
Minneapolis, Minnesota USA
USA
Matthew Sherrier, MD
Heather Lynn Saffel, MD, MS Resident Physician
Primary Care Sports Medicine Fellow Physical Medicine and Rehabilitation
Department of Orthopedics University of Pittsburgh Medical Center
Emory Sports Medicine Center Pittsburgh, Pennsylvania
Atlanta, Georgia USA
USA
Brian J. Shiple, DO, CAQSM, RMSK
Natalie Sajkowicz, MD President AAOM
Physician Board Certified Sports Medicine
Physical Medicine and Rehabilitation The Center for Sports Medicine
Tufts Medical Center Philadelphia, Pennsylvania
Boston, Massachusetts USA
USA
Alyssa A. Smith, BSc
Steven Sampson, DO Medical Assistant
Founder Joint Preservation Institute, Sacramento,
PM&R California
The Orthohealing Center USA
Los Angeles, California
USA Jay Smith, MD
Founder Professor
The Orthobiologic Institute Physical Medicine & Rehabilitation
Los Angeles, California Mayo Clinic
USA Rochester, Minnesota
Clinical Instructor USA
Medicine
David Geffen School of Medicine UCLA Alyssa Neph Speciale, MD
Los Angeles, California Assistant Clinical Professor, PM&R Sports Medicine
USA UC Davis Health System
Sacramento, California
USA
 Contributors xix

Cleo D. Stafford II, MD, MS, CAQSM, RMSK, FAAPMR Hunter Vincent, DO
Assistant Professor Pain Fellow
Department of Orthopaedics Physical Medicine and Rehabilitation
Emory University School of Medicine, Atlanta University of California: Los Angeles
Georgia Los Angeles, California
USA USA
Assistant Professor
Department of Rehabilitation Medicine Chris J. Williams, MD
Emory University School of Medicine, Atlanta Adjunct Professor
Georgia Emory Rehabilitation Department
USA Emory University
Atlanta, Georgia
Jeffrey A. Strakowski, MD USA
Clinical Professor CEO/Owner
Physical Medicine and Rehabilitation Interventional Orthopedics of Atlanta
The Ohio State University Atlanta, Georgia
Columbus, Ohio USA
USA
Associate Director of Medical Education John J. Wolfson, RT (R), ASRT, (ARRT)
Physical Medicine and Rehabilitation Imaging and Interventional Coordinator
Riverside Methodist Hospital OR
Columbus, Ohio Injury Solutions
USA Greenwood Village, Colorado
Director of Musculoskeletal Research USA
The McConnell Spine, Sport and Joint Center Instructor
Columbus, Ohio Pain Imaging Education
USA Englewood, Colorado
USA
Adam Street, BS, DO
Fellow Colton L. Wood, MD
Emory Sports Medicine Center Primary Care Sports Medicine Fellow
Emory University Family Medicine
Atlanta, Georgia University of North Carolina at Chapel Hill
USA Chapel Hill, North Carolina
USA
Walter I. Sussman, DO
Assistant Clinical Professor Peter Chia Yeh, MD
Physical Medicine & Rehabilitation Chief Resident
Tufts University Physical Medicine and Rehabilitation
Boston, Massachusetts Baylor College of Medicine
USA Houston, Texas
USA
Selorm L. Takyi, MD
Regenerative Orthopedics and Musculoskeletal Maria-Cristina Zielinski, MD, PGDip, PGCert, AECC
Medicine Physician Centre for Sports and Exercise Medicine
Physical Medicine & Rehabilitation Barts and The London School of Medicine
Revive Spine and Pain Center, Marlton Queen Mary University of London
New Jersey London, UK
USA

Yodit Tefera, MD
Physician
Swedish Spine, Sports, & Musculoskeletal Medicine
Swedish Medical Center
Seattle, Washington
USA
Acknowledgments

A huge thank you is well deserved for my wife, who has I would like to thank my family, especially my wife and
been patient and very supportive during the completion three children, for their patience and understanding over
of this atlas. My siblings and the community I grew up in this past year, and my co-editors Dr. Chris Williams and Dr.
continue to serve as major inspiration for me. Additionally, John Pitts, whose clinical skill and time are reflected in the
my fellow associate editors John Pitts and Walter Sussman broad scope of this book. While at Emory, I had the benefit
have made an almost gargantuan task as seamless and toler- of training with so many talented musculoskeletal and spine
able as possible. The contributing authors have been great physicians, whose focus on individualized patient care,
to work with and their expertise is appreciated. A special minimally invasive image-guided treatments, and finding
thank you to all of the associate editors as well; I consider new and effective treatments influenced this text and con-
all of you as leaders in the field and most of you have served tinue to guide my practice. A special thank you to Dr. Ken
as a mentor for me at some point. Prior to starting PM&R Mautner. I wouldn’t be where I am today without his men-
residency at Emory University, I had no idea orthobiologics torship and introduction to this innovative field. I would
existed. I definitely owe an additional huge thank you to like to also recognize Drs. Hassan Monfared, Lee Kneer,
John Pitts, who is largely responsible for introducing me to and John Xerogeanes at Emory and Drs. John Lin and Eric
orthobiologics and providing excellent training during my Shaw at the Shepherd Center for their time and guidance.
Fellowship at the Centeno-Schultz Clinic, which served as Thank you to all whose work, expertise, and support helped
ground zero for the development and fine tuning of many of with this textbook, including all the contributing authors,
these procedural techniques. Last but not least, thank you to publishing team Elsevier, and all the readers. Finally, a big
Elsevier for seeing the vision for the atlas and definitely the thank you to my patients and colleagues who continue to
readers, who will ultimately lead to the continued evolution teach me daily.
of the field.
Walter Sussman, DO
Chris Williams, MD

I would first like to thank my wife for allowing me the

extra time required to edit this book. I surely could not
accomplish much without the love and support of my wife,
children, mother, and family. I would like to thank Dr.
Kenneth Mautner for first introducing me to PRP in resi-
dency. I would like to thank Drs. Christopher Centeno and
John Schultz for pioneering much of this field and serving
as great mentors and colleagues. Also, thank you to Dr.
Ron Hanson for teaching me many of these techniques as
a fellow. Many thanks to all the contributing authors for
their time and expertise. Thank you to my staff who helped
me acquire so many pictures for the book. Thanks to my
co-editors, colleagues, and friends, Dr. Christopher Wil-
liams and Dr. Walter Sussman. It has been an honor and
privilege to tackle this monumental task with you. Thank
you to my patients for humbling and teaching me daily.
Additionally, thanks to our publishing team at Elsevier for
all the hard work of bringing this to print. Lastly, thank
you to all the readers who will see this book as you are the
reason for this.
John Pitts, MD

xx
 S E C T I ON I Introduction

1
Introduction to
Interventional
Orthopedics and Review
of the Pathophysiology of
Orthopedic Conditions
WALTER I. SUSSMAN, JOHN PITTS, AND CHRIS WILLIAMS

Interventional orthopedics is a developing field that Therapeutic injections may include corticosteroids, but
attempts to bridge the gap between traditional non-opera- there is a focus on understanding the appropriate role of
tive orthopedics (e.g., sports medicine, interventional spine alternative injectates, which can be utilized to more accu-
or pain medicine) and surgical interventions. This field rately address the underlying pathophysiology. With the
expands the traditional approach to orthopedic problems, advent and expansion of regenerative treatments and ortho-
broadening the number of diagnoses and pathology that can biologics, there is an increasing emphasis on tissue preserva-
be targeted with minimally invasive injections and proce- tion, restoration of tissue function, and healing rather than
dures. For instance, instead of only evaluating orthopedic solely procedures that target “inflammation” and only pro-
pathology as severe enough versus not severe enough for vide temporary pain relief, or more invasive surgical proce-
surgery, we offer alternative interventions for patients that dures carrying increased cost and risk of complications.
have not responded to conservative therapy such as patients The traditional approach to the management of muscu-
with partial tendon or ligament tears, ligament laxity, and loskeletal pathology has largely been driven by locating and
nerve entrapment syndromes where surgical options are treating the primary pain generator. A good example is the
limited. The use of diagnostic ultrasound to complement treatment of low back pain. Typically, the interventionalist
the traditional orthopedic history and examination allows would try and identify a primary pain (i.e., the nerve root,
the clinician to more accurately diagnose and then target the facet joint, sacroiliac joint dysfunction, myofascial pain, or
underlying soft tissue and joint pathology. intradiscal pathology) and construct a treatment plan to spe-
Instead of traditional interventions being limited to cifically address the area of the spine most likely responsible
unguided injections and surgery, interventional orthope- for the patient symptoms. Conversely, an interventional
dics utilizes interventional musculoskeletal ultrasound and orthopedics approach would take an approach of addressing
fluoroscopy to guide injections to expand treatment options the entire spine as a “functional spinal unit” and consider
with the goal of precisely targeting and treating common the interplay of these structures and the biomechanical role
orthopedic problems. The use of image guidance for pro- of adjacent ligaments, tendons, and muscles. The overall
cedures has increased over the past decades, largely driven goal extends beyond general pain management and looks to
by decreased equipment costs, patient safety initiatives, and address the underlying etiology of musculoskeletal pathol-
higher-resolution imaging.1–3 In many cases, “blind” injec- ogy for long-term improvements in functional outcomes.
tions have been supplanted by image guidance, which gives With this in mind, the treatment plan for low back pain
the clinician the ability to directly visualize the target tissues may include treating the lumbar facets, corresponding level
and more accurately target specific pathology. epidurals if there is myoneural dysfunction on examination

1
2 SEC T I O N I Introduction

(e.g., weakness or gluteal enthesopathy at the posterior iliac cross-linked polypeptide chains, and their principal role is
crest), supraspinous and interspinous ligaments for stability, to resist tension, while proteoglycans are primarily respon-
and possibly the multifidus muscle if there is decreased acti- sible for the viscoelastic behavior of the tendon.23 The ten-
vation on examination and atrophy on magnetic resonance don is organized in a helical architecture, comparable to
imaging (MRI). man-made ropes.24 This helical organization of the tendon
The convergence of advances in imaging, an evolving components is present at various levels or organizations,
understanding of the pathophysiology of both acute and including when collagen fibers are bundled together to form
chronic degenerative pathology, and a growing interest in fascicles, and fascicles are bundled to form the tendon itself.
minimally invasive approaches to orthopedic pathology has The cellular component of the tendon is made up of
fueled this field and has expanded the type of injections and tenoblasts and tenocytes arranged in parallel rows among
procedures performed.1 Some of the procedures discussed the collagen fibers. Tenoblasts are immature tendon cells
in this text did not exist before the widespread adoption and transform into tenocytes as they mature. Tenocytes
of ultrasound. Many of these new procedures have become function to synthesize collagen and other components of
more common, including nerve hydrodissection, barbotage the extracellular matrix (ECM). Tenoblasts and tenocytes
of calcific tendinosis, and percutaneous needle tenotomy comprise 90% of the cellular component of the tendon,
procedures. Others are characterized by using specialized with the remaining 5% to 10% made up of chondrocytes,
surgical tools or devices to duplicate surgical procedures synovial cells, and vascular cells.22,25
using a percutaneous approach that will expand and con- A thin film of loose connective tissue (endotenon) is pres-
tinue to be adopted due to improved safety and morbidity. ent between the fascicles, allowing the fascicles to slide inde-
The growth of regenerative injections, including but not pendently against each other. The endotenon is continuous
limited to dextrose, platelet-rich plasma, and autologous with the connective tissue (epitenon) that surrounds the ten-
stem cells, has also driven the emergence of new techniques don as a whole (Fig. 1.1). Some tendons, such as the Achil-
and procedures. In some cases, the use of these treatments les tendon, have a paratenon that surrounds the tendon but
clinically has outpaced the scientific data. The scientific separate from the tendon itself.23 The paratenon is made up
literature will undoubtedly evolve, and the field of inter- of type I and III collagen fibers, and the inner surface is lined
ventional orthopedics will continue to mature and as we by synovial cells. In some cases, the tendon is surrounded by
explore alternatives to many of the more traditional injec- a true synovial sheath. There is often great confusion when
tates and many surgical techniques that have limited evi- describing the tissue that surrounds the tendon.
dence and efficacy.4,5 Several studies have been published The tendon inserts on bone in the form of a myo-enthesis
that question whether nonsurgical conservative measures, or cartilaginous entheses. Myo-enthesis have superior blood
sham surgeries, or placebo therapy is as effective as manage- supply and are less prone to degenerative pathology. Intrin-
ment. In some cases, it is unclear if the traditional injec- sic blood supply to the tendon is located at the myoten-
tions with corticosteroids or surgical interventions are better dinous and osteotendinous junction, with extrinsic blood
than non-operative management, placebo, or sham surgery, supply coming from the paratenon and synovial sheath.
including the intermediate and long-term benefit of corti- The musculotendinous junctions and entheses are vulner-
costeroids,6–9 arthroscopic meniscectomy, and debridement able sites, and increased age and mechanical loading can
in patients with arthritis,9–17 or subacromial decompression decrease vascular supply to these areas. Small afferent nerves
surgery for rotator cuff impingement.18–21 throughout the paratenon form plexuses with penetrating
This introductory chapter focuses on the composition branches innervating the tendon.
and organization of different tissue types and the current Areas of the tendon with poor blood supply are at
concepts in the pathophysiology of orthopedic conditions increased risk of injury. While tendon injuries can occur in
and how our understanding of common musculoskeletal the mid-tendon (i.e., Achilles), most pathology and pain arise
conditions has influenced current and future management at the enthesis. Poor blood supply predisposes damaged ten-
strategies. Conventional nonoperative therapies have tar- dons to tissue hypoxia. Tendinopathy is thought to develop
geted inflammation, but inflammation is important to the from excessive loading and tensile strain. Although load is
healing process. Treatment strategies must be tailored to a major component in the development pathology, the eti-
the underlying tissue involved (nerve, muscle, tendon, lig- ology of tendinopathy is likely multifactorial and includes
ament, bone, and cartilage) and the underlying pathology. genetics,26 age,27 body composition,28 comorbidities (e.g.,
dyslipidemias, rheumatoid disease, tumors, infections, heri-
Tendinopathy table connective tissue diseases, endocrinopathies including
thyroid disease, metabolic diseases including diabetes), and
Tendons come in various shapes and sizes and connect medication exposure (e.g., statin, fluoroquinolones).29
muscle to bone. The normal tendon structure is largely The interplay between structural change, dysfunction,
composed of collagen and proteoglycans. Type I collagen and pain is still not fully understood. Historically, ten-
comprises approximately 65% to 80% of the dry mass of don pain has been described as tendinitis, implying that
the tendon, with smaller amounts of type II, III, IV, V, inflammation was the central pathologic process. At the
IX, and X collagen also present.22 Collagen molecules are cellular level in early and chronic tendinopathy, there are
 CHAPTER 1 Introduction to Interventional Orthopedics and Review of the Pathophysiology of Orthopedic Conditions 3

Tendon
Tertiary fiber bundle

Primary fiber bundle

Secondary fiber bundle

Collagen fiber
Collagen fibril

Paratenon

Endotenon Epitenon

• Fig. 1.1 Hierarchy of a Tendon.

an increased number of leukocytes (primarily macrophages ligament composed of type III, VI,V, XI, and XIV colla-
and mast cells).30–32 However, compared to rheumatoid gen.37 Collagen bundles within ligaments have a crimped
arthritis and other immune-driven pathology, the number appearance, and with stress, the ligament elongates as col-
of leukocytes is small,29 and there has been widespread rec- lagen fibers uncrimp. This allows the ligament to elongate
ognition that the terminology of tendinitis, tendinosis, and without sustaining damage, contributing to the viscoelastic
paratenonitis should reflect the histopathologic feature of property of the ligament.37
the tendon.33 In both tendons and ligaments, the major cell type is
Histopathologic studies have shown the progression the fibroblast, or ligamentoblast and ligamentocytes.37
from normal ECM to reactive response and tendon disre- Epiligamentous plexus forms a net-like branching anasto-
pair, characterized by greater tissue matrix breakdown, col- motic pattern on the surface of the ligament with branches
lagen separation, neovascularization, and proliferation of that penetrate the ligament and become intraligamentous
abnormal tenocytes. The new model of tendon pathology vessels distributed into longitudinal channels within the
is of a continuum that has three stages: reactive tendinopa- ligament.39 The distribution of blood vessels varies among
thy, tendon disrepair (failed healing), and degenerative ten- ligaments, and compared to the synovial tissue or bone,
dinopathy.34–36 While these are described as three distinct ligaments appear to be relatively hypovascular.39
stages for convenience, the idea of a continuum recognizes Ligaments are most often injured in traumatic injuries
that the tendon can move forward or back along this con- and follow the three phases of healing (inflammation, pro-
tinuum. This model highlights the need to tailor treatments liferative, and remodeling).40 Although the ligament may
to the specific tendon pathology and that a single interven- heal, the scar tissue that forms has major differences in col-
tion is unlikely to be efficacious in every case. lagen types,41 failure of collagen crosslinking,42 altered cell
connections,43 small collagen fibril diameter,44 and increased
Ligament Injury vascularity.45 Even after fully healing, the ligament matrix
apparels grossly, histologically, and biomechanically differ-
Similar to tendon tissue, ligaments are constructed from ent from normal ligament tissue.46 The remodeled ligament
dense regular connective tissue and can vary in size, form, can contain material other than collagen, including blood
orientation, and location.37 Skeletal ligaments stabilize the vessels, adipose cells, and inflammatory cells, resulting in
joint and guide the joint through a normal range of motion weakness.37,46,47 In studies of injured medial collateral liga-
and provide proprioception to coordinate movements.37,38 ments (MCLs), the ligament typically remains weaker after
The orientation of collagen fibrils tends to be in the direc- healing and only regains 40% to 80% of the strength and
tion of applied force, and while tendon collagen fibrils stiffness compared to normal MCLs.46,48 The viscoelas-
tend to be in parallel, the ligament collagen fibrils are not tic property of an injured ligament has a somewhat better
uniformly oriented as forces are applied in more than one recovery, returning to within 10% to 20% of normal.46
direction.38 Type I collagen makes up 85% of the ligament, Ligaments have a poor regenerative capacity due to the
depending on the type of ligament, with the rest of the low cell density and lack of blood flow, and after an injury,
4 SEC T I O N I Introduction

the tissue is weaker, disorganized, and prone to reinjury.40 Injury to the articular cartilage can occur from a single
These persistent collagen abnormalities can present as symp- traumatic event or repetitive microtrauma. Progressive carti-
toms of instability, with 7% to 42% of subjects reporting lage injury can be accompanied by alteration in the underly-
symptoms even 1 year after injury.49 Early resumption of ing bone.
activity can stimulate repair and restoration of function, Articular cartilage has limited repair potential once dam-
while prolonged rest and immobilization delay or adversely aged. In mature articular cartilage, chondrocytes are quies-
affect recovery.50–53 In chronic instability, traditional treat- cent and no longer divide with very little turnover of the
ment strategies, including immobilization, rest, nonsteroi- cartilage matrix.57 The articular cartilage receives nutrition
dal antiinflammatory drugs (NSAIDs), and corticosteroid mainly through diffusion from the synovial membrane and
injections fail to address the underlying pathophysiology. cyclic loading.58 The lack of a direct blood supply in articular
In vitro studies have shown platelet-rich plasma (PRP) cartilage, paucity of cells, and high matrix to cell ratio cre-
induces proliferation of fibroblasts and the production on ates a challenging healing environment, and full-thickness
type I collagen,54 and there has been interest in the use of articular cartilage defects rarely heal spontaneously.56 Treat-
orthobiologics in the regeneration of ligaments.55 ment approaches for focal cartilage defects or osteochondral
lesions vary, and there is no uniform approach. Techniques
Cartilage Injury to treat focal cartilage defects are usually divided into mar-
row-stimulating (reparative) and reconstructive techniques.
There are two common types of cartilage: hyaline and fibro- Isolated lesions to the cartilage should be differentiated
cartilage. Hyaline cartilage is present at the connection from osteoarthritis (OA), where there is more diffuse dam-
between the ribs and the sternum, in the trachea, and on age to the articular surface. While impacting the same tis-
the articular surfaces of synovial joints. Hyaline cartilage sue, the pathophysiology differs. OA is characterized by the
is composed of a rich ground substance, glycosaminogly- involvement of the cartilage, synovial membrane, and sub-
cans (GAGs), and collagen fibers (mainly type II collagen). chondral bone, making OA a disease of the whole joint.57
Unlike most tissues, articular cartilage is devoid of blood The pathology is multifactorial but is driven by inflamma-
vessels, nerves, or lymphatics. Fibrocartilage is present in tory mediators within the joint, resulting in pain, deformity,
intervertebral discs and meniscal tissue. and loss of function.59
The earlier changes in the cartilage often appear at the
Hyaline Cartilage joint surface in areas where mechanical and shear stress are
Articular cartilage is hyaline cartilage within synovial joints the greatest.60 In OA, chondrocytes go from being quies-
and functions as a shock-absorbing tissue that provides low cent to becoming “activated,” characterized by cell prolifera-
friction movement during articulation. Chondrocytes are tion, matrix degradation and remodeling, and inappropriate
sparsely distributed throughout the dense ECM of the artic- hypertrophy-like maturation.61 Degradation of the articular
ular cartilage, and the ECM is primarily composed of col- cartilage, thickening of the subchondral bone, osteophyte
lagen, proteoglycans, and water (Fig. 1.2). The composition formation, and synovial inflammation. This proinflamma-
of the ECM varies within different zones of the articular tory environment can result in reduced chondrogenesis,
cartilage, and articular cartilage is typically divided into four as well as suppression of type II collagen synthesis.62,63
zones: superficial, middle, deep, and calcified (Table 1.1).56 These negative effects of inflammation on chondrogenic

Articular surface

Superficial zone

Middle zone

Deep zone

Calcified zone

A Cancellous bone B
• Fig. 1.2
Structure of articular cartilage with (A) schematic diagram of the cellular organization in the different
zones and (B) diagram of the collagen fiber architecture.
 CHAPTER 1 Introduction to Interventional Orthopedics and Review of the Pathophysiology of Orthopedic Conditions 5

TABLE
1.1   Articular Cartilage Structure: Zones of the Extra-Cellular Matrix

Zone Cell Thickness Function

Superficial (STZ) • H igh number of flattened chondrocytes 10%–20% Resists tensile forces and
• Tightly packed collagen (type II and IX) fibers, protects deeper layers from
aligned parallel to the articular surface
shear stresses
Middle • F ew chondrocytes 40%–60% Resists compressive forces
• Thicker collagen fibrils, organized obliquely
Deep • C hondrocytes arranged in a columnar 30% Resists compressive forces
orientation
• Largest collagen fibrils, aligned perpendicular
to the joint surface
• Highest proteoglycan content
Calcified • Cell population is scarce Anchors collagen fibrils to the
subchondral bone

differentiation may have negative effects on cell-based With age, the nucleus generally becomes more fibrotic
therapy. and less gel-like,72 and the collagen and elastin of the annu-
Treatment strategies for OA often involve behavioral lar lamellae become irregular and disorganized.69 It can
(e.g., exercise and weight loss), pharmacologic (e.g., oral be challenging to differentiate changes that occur due to
medications, injection therapy, and biologics), and in end aging and those that might be “pathologic.” The most sig-
stages, joint replacement surgery. Intra-articular injections nificant change that occurs in disc degeneration is the loss
are common in the management of OA; however, the dense of proteoglycan (aggrecan), which is responsible for main-
articular cartilage is less permeable to injected medications taining tissue hydration and impacts the disc load-bearing
penetrating the cartilage extracellular matrix, and the injec- behavior.73 The collagen population of the disc also changes
tate can be rapidly cleared by the lymphatic system.64,65 In with degeneration, but these changes are not as obvious as
recent years, there has been a growing interest in alternative those of the proteoglycans.74,75 The loss of proteoglycan
approaches to injection therapy and altering joint homeo- and matrix disorganization leads to an inability to maintain
stasis.57 There has been increased interest in the treatment of hydration, and when loaded, they lose height, bulge, and
the subchondral bone in patients with OA and focal lesions. subsequently lead to inappropriate stress along the endplate
The proposed mechanism is stimulating subchondral bone or the annulus.76,77 The loss of disc height can also affect
that influences the articular cartilage because of communi- adjacent structures, resulting in spinal stenosis, apophyseal
cation and cross-talk between both tissues.66,67 joint arthropathy, and ligamentum flavum hypertrophy.
The intervertebral disc is largely avascular and must rely
Fibrocartilage on passive diffusion from adjacent endplate vessels for nutri-
tion.78 The limited vascular supply and indirect access to
Fibrocartilage contains high levels of type I and II collagen nutrition limit the discs’ intrinsic capacity for remodeling
and is present between vertebral bodies, the pubic symphy- and repair. Traditional therapies may provide symptomatic
sis, menisci, labrum, and the tendon–bone interface.68 relief but do not target the underlying degenerative patho-
physiology. Newer cell-based therapies aim to achieve cel-
Intervertebral Disc lular repair.79

The intervertebral discs’ major role is mechanical, transmit- Meniscus

ting load and forces through the spinal column.69 Structur-
ally, the intervertebral disc is composed of the inner nucleus Vascularization of the meniscus is from the lateral, medial,
pulposus (NP) and an outer annulus fibrosus. The NP is and middle genicular arteries, forming a perimeniscal capil-
gelatinous and primarily formed from water, proteoglycans, lary plexus. There is significant discrepancy in the vascular-
and randomly organized type II collagen, and the intrinsic ity of the meniscus, and the meniscus is often described as
hydrostatic pressure of the NP resists compressive loads.70 having three distinct zones characterized by the degree of
The outer fibrocartilaginous annulus fibrosus is composed vascularization. The outer zones with the greatest vascularity
of 15 to 25 concentric rings (lamellae), with elastin fibers region are the red-red zone and the transitional red-white
and type I and II collagen fibers lying in parallel and pro- zone.80 The inner or central avascular zone is the white-
vides the tensile strength of the disc.71 white zone. The healing capacity is directly related to blood
6 SEC T I O N I Introduction

circulation, with the peripheral meniscus (red-red and red- bone by thick collagenous fibers (Sharpey’s fibers). Unlike
white zone) having the greatest potential for healing.80,81 bone, the periosteum has nociceptive nerve endings and
The morphology of the meniscus cells also can be char- contains a store of bone-remodeling cells (osteoblasts) that
acterized by the zone in which the cells are found. There are play a role in healing fractures.92
three cell populations within the meniscus. The outer zone The microstructure of bone is highly complex. In cortical
is mainly populated with fibroblast-like cells with an oval, bone, large vascular channels (Haversian canals and Volk-
fusiform shape and long cell extensions, which facilitate mann canals) are oriented along the longitudinal direction
communication among cells and the extracellular matrix. of the bone and contain the blood supply to compact bone.
These fibroblast-like cells are surrounded by dense connec- These channels are surrounded by compact highly mineral-
tive tissue consisting of type I collagen, with a small percent- ized cylindrical rings (lamellae). The lamellae and Haversian
age of glycoproteins and type III and V collagen present.82 canal form the osteon or Haversian systems, which is the
The main cell type in the inner zone is classified as fibro- chief structural unit of cortical bone.93 Cancellous bone is
chondrocytes or chondrocyte-like cells, and they have a spongy and fills the inside of many bones and has a rich
chondrocyte appearance (round or oval-shaped). These vascular supply.92,93
fibrochondrocytes are embedded in a fibrocartilage matrix Regarding the nanostructures, the mineral content of
consisting mainly of type I (60%) and II (40%) collagen bone is mostly tiny mineral crystals (calcium phosphate–
and aggrecan.83 based hydroxyapatite), which provide rigidity and load-
The superficial zone of the meniscus harbors progenitor bearing strength to bone. The organic matrix is primarily
cells.84 composed of collagenous proteins, which crosslink to add
Meniscal injuries are classified depending on location, stability to the bone matrix.94,95 Collagenous proteins
thickness, and resulting instability. The type of tear has a compose 85% to 90% of bone proteins, with bone matrix
significant impact on the ability of the tear to heal and the mainly composed of type I collagen.91,94–96
most appropriate and effective therapy. Partial or total men- The primary cellular component of bone cells are
iscectomy can lead to altered loading dynamics, leading to osteocytes, osteoblasts, and osteoclasts. Osteoclasts are
degeneration and OA on an average of 14 years following derived from a monocyte stem-cell lineage and carry
surgery.4,85 A detailed discussion of surgical management is out resorption of old bone, while osteoblasts are bone-
beyond the scope of this chapter, but in general, there is forming cells and synthesize a new bone matrix. Osteo-
an increased emphasis on meniscal preservation whenever blasts are found in large numbers in the periosteum and
possible to preserve loading dynamics in the knee. Tears in endosteum, while osteocytes are osteoblasts that have
the vascular region do have the potential to heal due to the become trapped in the calcified bone matrix. Together,
existing blood supply and the possibility of progenitor cells osteoblasts and osteoclasts influence the remodeling of
in this region.86–88 bone after trauma.92
Bone adapts to physical stimuli, dietary changes, or
Bone Pathology injury.97 Bone is constantly undergoing remodeling to pre-
serve bone strength. Remodeling occurs at sites that require
The skeleton serves a variety of functions, providing support, repair but also occurs in a random manner throughout
permitting movement, and protecting vital internal organs. life.98–100 Woven bone is put down rapidly during growth
The skeleton also serves as a reservoir of hematopoietic stem or repair, with fibers aligned at random. As a result, woven
cells, which give rise to blood cell lineages and mesenchy- bone has lower strength than lamellar bone, which has
mal stromal cells that are multipotent with the potential to its fibers oriented in parallel and in line with the axis of
differentiate into bone, cartilage, fat, or fibrous connective stress.101
tissue.89,90 In order to understand the mechanical properties Healing of cancellous bone with its rich vascular supply
of bone clinically, it is important to understand the compo- occurs more rapidly compared to the cortical bone that can
nent structure of bone. be complicated by delay or nonunion. In normal fracture
At the macrostructure level, bone can be characterized healing, osteoblasts form immature woven bone, result-
as cancellous (trabecular) or cortical (compact) bone, with ing in early callus formation at the fracture margins. With
cortical bone forming a dense outer shell around the hon- remodeling, callus is replaced by lamellar bone.92 Delayed
eycomb-like structure of cancellous bone. Different bones union is when healing is slower than anticipated, and a non-
have different ratios of cortical to cancellous bone. In long union of a fracture is defined as a fracture where healing has
bones, the diaphysis is primarily composed of dense corti- not occurred at 9 months.102 There is a growing interest in
cal bone, while the metaphysis and epiphysis are composed orthobiologics for nonunion fractures, but there have been
of cancellous bone surrounded by dense cortical bone. In conflicting results in the literature.103,104 Preclinical in vivo
general, cancellous bone is more metabolically active and studies have suggested PRP may enhance bone regenera-
remodeled more often than cortical bone.91 Bone is sur- tion with favorable results, but there are inherent limita-
rounded by an inner endosteal and an outer periosteal sur- tions to the clinical translation of basic science studies and
face. The periosteum is a fibrous connective tissue sheath in the majority of studies PRP was used to augment surgery
surrounding cortical bone and is tightly attached to the either at the time of surgery or a delayed injection.103,105
 CHAPTER 1 Introduction to Interventional Orthopedics and Review of the Pathophysiology of Orthopedic Conditions 7

Fewer studies have examined autologous stem cells in non- the axons with myelin. Myelin is a lipid-rich sheath that
unions,106 and the real benefit of biologics for bone healing surrounds and insulates the axon and facilitates the trans-
is unknown.103,104 mission of electrical signals.112,113
Unlike fractures that are generally classified by mecha- Surrounding the peripheral nerve fibers and supporting
nism of injury (i.e. traumatic, pathologic, stress), the events the Schwann cell is connective tissue. Individual nerve fibers
leading to avascular necrosis (AVN) are incompletely under- are embedded in the endoneurium, and each nerve fascicle
stood, have unclear causality, and have delayed diagno- is surrounded by the perineurium. The outermost connec-
ses.107,108 Ischemia or direct toxic effects on bone marrow tive tissue of the peripheral nerve is the epineurium.114 A
and cells may contribute to AVN, and necrosis predomi- variety of mechanisms can injure the nerve. Systemic con-
nantly develops at sites composed predominantly of adi- ditions include autoimmune inflammation or vasculitis,
pocytes (yellow marrow), such as the femoral head.107 The infectious, metabolic (i.e., diabetes mellitus), nutritional,
natural history of AVN is better understood than the early toxin or drug-induced injury, or hereditary, and usually
triggering factors, with necrosis, inadequate remodeling, involve multiple nerves in multiple compartments or bilat-
and eventually collapse of the necrotic segment and OA. eral distributions.115–122 Local pathology includes blunt or
Basic science and clinical trials of PRP may be more appro- penetrating trauma, traction or stretch injury, or freezing
priate as an adjunct therapy, while autologous stem cells injury.123 Injury to the nerve can be divided into demyelin-
have shown promising results.109,110 ating and axonal pathology, involving a loss of the myelin
sheath surrounding the axons or injury to the axon itself.
Nerve Injury Injury to the peripheral nerve can be classified according
to the severity of injury, and different classification systems
Nervous tissue consists of two types of cells, neurons and exist (Table 1.2).124–126
glial cells.111 Neurons are responsible for communication
and are composed of the cell body (soma), dendrites,
and axon. The dendrite receives information from other TABLE
neurons, allowing the cell to integrate multiple impulses. 1.2   Classification of Nerve Injury
Most cell bodies have multiple dendrites arising from Seddon Sunderland Nerve Injury
the cell body, and dendrite-branching patterns are char-
acteristic of each neuron. The axon arises from the cell Neurapraxia Grade I Focal segment
demyelination
body and propagates nerve impulses between cells, trans-
porting nerve impulses along the axon, and the axon can Axonotemesis Grade II Axon damaged with
branch repeatedly to communicate with many target intact endoneurium
cells. At the terminal end of the axon, synaptic junctions Axonotemesis Grade III Axon and endoneurium
facilitate the transmission of the nerve impulse from one damaged with intact
neuron to another or the target cell (muscle or gland perineurium
cells) (Fig. 1.3). Axonotemesis Grade IV Axon, endoneurium, and
Glial cells play a supporting role. The supporting glial perineurium damaged
cells differ in the central nervous system compared to the with intact epineurium
glial cells in the peripheral nervous system (PNS).111 In the Neurotmesis Grade V Complete nerve
PNS, there are two types of glial cells: (1) satellite cells sur- transection
rounding the cell bodies, and (2) Schwann cells ensheathing

Cell body

Dendrites

Schwann cells
Axon Endings

Synapse

Node of Ranvier

• Fig. 1.3
8 SEC T I O N I Introduction

Subperineural and endoneural edema

Corticosteroid injections have a long history in manag-
ing carpal tunnel syndrome, but the role remains con-
troversial with strong evidence only for short-term
Impairment of blood−nerve barrier
benefits.140,141 Studies of corticosteroid injection for
carpal tunnel syndrome have shown that the volume of
the injectate does influence outcomes independent of
the corticosteroid, with larger- volume injections signifi-
Chronic tissue changes causing perineural thickening
cantly improving outcomes.142 Hydrodissection of the
surrounding constrictive tissue and flushing of inflam-
matory mediators has become more common clinically,
Demyelination but the literature on the hydrodissection of entrapment
neuropathies is largely limited to case reports and retro-
spective studies.139,143 Limited high-quality clinical data
Wallerian degeneration
exist to determine the efficacy of these procedures. There
•Fig. 1.4 Nerve Compression Pathology Cascade. (Modified from
is an increasing interest in biologics for nerve pathol-
Barrett SL, Nickerson DS. Pain Practice Management; 2016.) ogy, and a recent meta-analysis published in May 2020
of randomized trials comparing PRP to control groups
(corticosteroid injection, saline injection, and splinting)
The type of trauma has a major influence on neuro- for carpal tunnel syndrome demonstrated significant and
logic recovery, and injuries can vary from a mild injury similar improvement in visual analog score for pain and
due to compression resulting in mild or no pathologic nerve conduction studies in the PRP group compared to
changes to a traumatic stretch or penetrating injury with controls.144 In recalcitrant cases, peripheral nerve decom-
severely damaged and complete disruption of the normal pression procedures vary widely, and there has been
nerve architecture. Compressive neuropathies can involve increased interest in limiting incision size and minimally
any peripheral nerve, are not always captured by the com- invasive approaches.145
monly used classification schemes, but generally fall under
the general class of neuropraxia or Grade 1 nerve injuries. Muscle Injury
These are defined by focal demyelination at the site of
compression and lack of axonal damage, although in later The basic cellular unit of skeletal muscle is myocytes, or
stages as the condition progresses, compression injuries muscle fibers. A network of connective tissue (endomysium)
can result in axonal damage.123 surrounds each muscle fiber. Adjacent fibers are bundled
Chronic nerve compression injuries, such as carpal together in a fasciculus and surrounded by the perimysium,
tunnel or cubital tunnel syndrome, are the most com- and fasciculi are grouped together to form the complete
mon peripheral nerve pathology.127 The underlying muscle and are surrounded by epimysium (Fig. 1.5).146
pathophysiology of these focal entrapment neuropathies Each muscle fiber is composed of thousands of myofibrils,
is primarily derived from animal models with bands or and the subunits are known as sarcomeres. The sarcomere
ligatures placed around the sciatic nerve.128–133 While is the basic contractile unit of a single muscle fiber and is
these models cannot reproduce in vivo nerve compres- composed of protein filaments that line up in parallel with
sion, the animal models have shown that physical com- overlapping sets of actin (thin filaments) and myosin (thick
pression with ligature or banding of the nerve can result filaments).147
in histologic changes and slowing of the nerve conduc- Myocytes are surrounded by a cell, or plasma membrane
tion velocity.129,130,134 Increased pressure can compress (plasmalemma), that along with various layers of the base-
the blood vessels that supply the nerve, impairing micro- ment membrane for the sarcolemma provide external sup-
circulation and leading to epineural ischemia, venous sta- port and help maintain the shape of the muscle fiber.146
sis, and extraneural edema (Fig. 1.4).135 This can result In some texts, the plasmalemma and sarcolemma are used
in fibroblast proliferation, connective tissue fibrosis and interchangeably. The sarcoplasmic reticulum and T system
scaring around the nerve,130 and late process focal demy- is a tubular system running parallel to the myofibrils and
elination and remyelination.133,136,137 This process is allows communication by relaying nerve impulses along the
distinct and different from traumatic crush injuries and fibers and delivering calcium to the cells, which is necessary
results in Schwann cell proliferation in areas and thin- for muscle contraction.146
ner myelin following injury.137,138 In many cases, com- Nerve axon terminals interdigitate with the motor end-
pression or entrapment occurs in fibro-osseous structures plate of the muscle membrane, forming a neuromuscular
formed by ligaments and bones but can also occur sec- junction (NMJ).146 When an action potential reaches the
ondary to trauma and/or scar tissue.139 axon terminal, acetylcholine (ACh) crosses the NMJ and
Treatment algorithms reflect the wide range of treat- binds to receptors on the plasmalemma, and this process
ment options from medical to surgical management is what is inhibited with botulinum toxin (for more, refer
depending on the severity and duration of compression. to Chapter 11). Having depolarized the muscle membrane,
 CHAPTER 1 Introduction to Interventional Orthopedics and Review of the Pathophysiology of Orthopedic Conditions 9

denervation of the muscle distal to the site of injury.151,153 A

cle loss of skeletal muscle mass (sarcopenia) occurs with aging,
us
M and aged muscles can also show an impaired response to
injury.149,154
Tearing in muscle tissue creates a gap between the
retracted fibers, and a hematoma will form at the site of
injury. The interaction growth factor in muscle regen-
eration is a complex process, but there has been an
es interest in controlling the regenerative microenviron-
icl
sc ment.150,151,155–158 The repair process has been described
Fa
cle in detail in a number of articles. In brief, resident myo-
us
M genic precursors (satellite cells) that are dormant in the
periphery of healthy skeletal myofibers respond to signals
coming from damaged myofibers and create new fibers.
Over time, these nascent muscle fibers will continue to
ril bridge the gap.149,159
f ib The local milieu of certain growth factors can have var-
yo
M
ied effects on skeletal muscle cells. High concentrations of
certain growth factors have been shown to promote myo-
blast proliferation and prevent differentiation, while low
concentrations may induce myoblast differentiation and
multinucleated cell formation.160–162 PRP has shown a
contradictory effect on myogenic differentiation and may
even result in a fibrotic response, possibly due to variations
in PRP preparation or dosing.150 Recently platelet-poor
plasma (PPP) preparations have shown a robust ability to
induce human myoblast differentiation in vivo, and while
PPP may hold promise, no consensus exists and additional
investigation is needed.155
• Fig. 1.5
The Hierarchical Structure of a Muscle. (2022). Used with per-
mission of Elsevier. All rights reserved.
How to Use this Book
The primary objective of this text is to provide a reference
the action potential spreads rapidly along the muscle fiber, to inject most areas of the musculoskeletal system safely
releasing calcium from the sarcoplasmic reticulum and and accurately. This text includes a comprehensive atlas
resulting in a muscle contraction as the actin and myosin section, which details techniques to safely approach ultra-
fibers bind and slide in a ratchet-like fashion, shortening sound and fluoroscopically guided musculoskeletal and
the muscle.146 axial injections. It discusses the different types of injec-
Muscle fibers are classified into two groups, type I (slow- tates the practitioner should consider when approaching
twitch) and type II (fast-twitch) fibers. Slow-twitch and these structures and introduces new procedures and future
fast-twitch fibers refer to the time taken for each type of trends. The text provides the most up-to-date literature
fiber to reach peak tension, 110 milliseconds (ms) and 50 on biologic injectates, techniques, indications, and sup-
ms, respectively.146 Fiber types differ in the form of myosin porting evidence for varying techniques. However, some
ATPase, structure of the sarcoplasmic reticulum, and neural of the newer techniques described may not be validated
innervation, with more fibers per motor neuron in type II in the current literature, and many do not have a clear
fast-twitch fibers.148 Type I fibers are used in low-intensity consensus on the appropriate injectates. Nevertheless, as
or endurance events, and type II fibers are used in short more research emerges and our understanding of the role
duration, high-intensity activities. of orthobiolgics or other injectates emerges, this book
Skeletal muscle has a robust capacity for regeneration will still be relevant as a comprehensive guided injection
after focal injuries but is dependent on the type of injury atlas. Additionally, we hope this text will also stimulate
and severity.149–151 Muscle injuries caused by eccentric con- new research and innovation that helps advance the field
traction typically damage the myofibrils, while other acute of interventional orthopedics.
injuries (laceration, contusions, toxins, or thermal injury) This text and atlas should serve as a reference tool and
largely damage the muscle cell membrane.152 Skeletal mus- an adjunct to formal training. It is not meant to replace
cle can compensate for up to a 20% loss in muscle mass, in-person instruction and hands-on training. This text does
but beyond this, muscle injuries with significant volumetric not seek to teach a comprehensive orthopedic history and
loss typically will not heal without scar tissue formation and physical examination, how to interpret imaging studies, or
10 SEC T I O N I Introduction

how to perform a diagnostic musculoskeletal ultrasound. 16. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic
Clinicians should also understand alternative treatments, surgery for degenerative knee: systematic review and meta-anal-
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orthotics and bracing, acupuncture, manual techniques and 17. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of
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physical/occupational therapy, and surgical indications to
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2
Ultrasound Basics
M ATTHEW SHERRIER, ALLISON N. SCHROEDER,
KENTARO ONISHI, AND DANIEL LUEDERS

Introduction tissues will permit greater penetration of ultrasound energy.

As the sound waves penetrate deeper, energy is lost to
Ultrasound guidance can be applied to assist in a multitude refracted and absorbed sound waves and the ultrasound
of interventional orthopedic procedures. This chapter pro- signal becomes attenuated or weaker in strength. Reflected
vides a review of ultrasound physics, image optimization, sound waves travel retrograde to return to the transducer
common artifacts, and fundamentals of ultrasound-guided where they interact with the piezoelectric crystal array of
interventions. the transducer head. Those reflected sound waves are con-
verted back to an electrical signal, by a reverse piezoelectric
Ultrasound Principles effect, and are transmitted to the central processor of the
ultrasound machine. The processor knows the pulse veloc-
Diagnostic ultrasound knowledge complements interven- ity of the anterograde ultrasound waves that were trans-
tional ultrasound skills. Understanding ultrasound phys- mitted and can calculate the depth of reflecting structures
ics, image optimization, and artifacts are key components from the measured echo time to create an ultrasound image.
of diagnostic ultrasound. Mastery of diagnostic ultrasound Bright, hyperechogenic-appearing structures result from
serves as the foundation for safe and effective ultrasound- the reflection of greater amounts of ultrasound energy by
guided interventions. Awareness of sonographic artifacts more dense tissues, which have higher impedance, such as
and why these occur is imperative to distinguish those arti- bone. Conversely, dark, hypoechogenic-appearing struc-
facts from pathology and to effectively prevent or mitigate tures result from the reflection of less amount of ultrasound
artifacts that could make an intervention unsafe or more energy by less dense tissues with lower impedance, such as
challenging. fibrocartilage.

Ultrasound Physics Image Optimization

A comprehensive description of the pertinent physics of Image optimization requires selection of the most appro-
ultrasound mechanics and the resulting imaging output is priate ultrasound transducer and skillful manipulation of
beyond the scope of this chapter. Briefly, electric current is ultrasound probe and ultrasound machine settings such as
transmitted from a wall-plug or an affixed battery through depth, focal zone number and location, gain, and dynamic
the ultrasound processor and, ultimately, to the ultrasound range. This is imperative to best visualize the targeted struc-
transducer. The head of an ultrasound transducer contains ture, to permit the most complete visualization of the needle
an array of piezoelectric crystals, which convert the electric or tool, and to ensure the safety and avoidance of neurovas-
current into pulses of ultrasonic waves. The piezoelectric cular structures.
crystal array within a transducer head can vary in the align-
ment, shape, thickness, and width, which influence quality Transducer Selection
of spatial resolution, the depth of ultrasound wave penetra- Ultrasound transducers vary by the range of ultrasound fre-
tion, and signal-to-noise ratio. The transducer is coupled quencies (labeled on the body of the transducer in megahertz
to the skin of the patient through a sonoconductive gel for [MHz]) that they transmit and the size of the transducer
sound waves to conduct through the target tissue. head footprint (Fig. 2.1). In general, a linear array trans-
Once the sound wave travels through patient’s skin, the ducer can transmit higher-frequency, lower-amplitude
energy of the waves can be reflected by a tissue, absorbed ultrasound waves. The higher-frequency transducer will
by a tissue, or penetrate through a tissue. More dense tis- transmit more ultrasound waves and thus receive more
sues will reflect more ultrasound energy, and less dense returning ultrasound waves, facilitating the production of

14
 CHAPTER 2 Ultrasound Basics 15

different models within a manufacturer’s range of platforms.

It is essential for each individual operator to familiarize him-
self or herself with the layout of the control panel of each
platform that might be used. The depth of the ultrasound
image should be adjusted, often by turning a dial or adjust-
ing a switch up or down, to ensure that the targeted struc-
ture and any “at-risk” structures are captured but also that
the image does not have unnecessary depth beyond those
structures (Fig. 2.2).
Focal zone depth can be adjusted and their number
increased or decreased on most platforms. Focal zones repre-
sent the narrowest segments of the ultrasound beam where
the ultrasound processor is directed to optimize the ultra-
A B C sound waves and processing power so as to produce the best
temporal and spatial resolution (Fig. 2.3). The number and
• Fig. 2.1 Common Transducers From left to right, (A) 8-1 MHz cur- positioning of focal zones should be modified according to
vilinear array transducer, (B) 24-8 MHz linear array transducer, and (C) the depth and size of the targeted structure. Minimization
22-8 MHz small-footprint linear array transducer (commonly referred to
as “hockey-stick” transducer).
of the number of focal zones reduces processing demands
by reducing the frame rate and improves image resolution.
Gain increases or decreases the overall brightness of
greater detail and spatial resolution in the image produced. the raw returned echoes and is most often adjusted and
However, the lower-amplitude waves have less energy and increased to account for beam attenuation resulting in
will become attenuated and lose strength more quickly, image hypoechogenicity. Increasing or decreasing gain with
so deeper objects are not as well visualized. In contrast, a the dial or switch does so uniformly and modifies the entire
curvilinear array transducer will transmit lower-frequency, image. Time gain compensation (TGC) involves the indi-
higher-amplitude waves. The lower-frequency transducer vidual manipulation of one of a vertically oriented stack of
will transmit fewer ultrasound waves, but those waves will sliding switches which correlate to different image depths.
have a higher amplitude and more energy; thus they are less Modification of the TGC permits focal manipulation of
susceptible to attenuation as they penetrate to deeper tis- gain at specific image depths (Fig. 2.4). Typically, the TGC
sues. As a result, more sound waves return from deeper tis- is used to focally increase gain in the far field to account for
sues and deeper objects are better visualized, but there is less beam attenuation and relatively hypoechogenic imaging at
detail and spatial resolution of superficial tissues. increasing depths.
In general, a lower-frequency curvilinear array transducer
is preferable for tissues targeted at 4 to 5 cm and deeper and Sonographic Appearance of Normal
a higher-frequency linear array transducer will be preferable Structures
for tissues more superficial than that. The convex transmis-
sion of ultrasound waves from a curvilinear array transducer An ultrasound image is produced by the return and process-
can improve visualization of a needle directed at a steep ing of ultrasound waves by the transducer, which is affected
angle. The curvilinear array directs more ultrasound waves by how the ultrasound waves penetrate, reflect, or are
perpendicular to that needle that are reflected at an angle of absorbed by different tissues. Different image echogenicities
incidence that facilitates return to the transducer, improv- represent the reflection of waves at the interface of struc-
ing needle visualization. This same benefit can be obtained tures of relatively different density and orientation within
in beam-steering mode on linear array transducers, which is a single tissue type or between different adjacent structures
described later in this chapter. (Fig. 2.5).1 The interface between structures with a wide dif-
Specialized small-footprint linear array transducers (com- ference in impedance (e.g., that seen between soft tissue and
monly referred to as “hockey-stick” transducers because of bone) results in more reflected sound waves and producing a
their shape) will have a smaller footprint of approximately relatively bright, or hyperechoic, structure on the ultrasound
15 to 20 mm (vs. 45+ mm for a standard linear transducer), image. Structures that are less dense or sit adjacent to a very
which can facilitate improved skin contact and beam cou- dense structure will reflect fewer sound waves or waves with
pling on the sharp contours of the hands and feet. The smaller amplitude, resulting in a less bright, or hypoecho-
smaller footprint also decreases the size of the field of view, genic-appearing, structure. Adjacent structures of similar
which must also be considered when performing interven- impedance are termed isoechoic to each other. Regions where
tional procedures. all ultrasound waves are absorbed and no echo returns to
the transducer appear black on an ultrasound image and are
Knobology termed anechoic.
The layout of knobs, switches, and touch screen interfaces Comprehensive knowledge of local and regional muscu-
will vary by ultrasound platform manufacturer and by loskeletal and neurovascular anatomy is essential. Tendon,
16 SEC T I O N I Introduction

A B

C
• Fig. 2.2 Poorly optimized ultrasound images of the lateral femoral cutaneous nerve (arrowheads) demon-
strating (A) excessive depth and (B) Suboptimal focal zone location (arrows) for such a superficial structure. (C)
Ultrasound image of the lateral femoral cutaneous nerve (arrowheads) with an optimized depth and focal zone.

A B
• Fig. 2.3 Ultrasound image of the anterior femoroacetabular joint in long axis with the femoral neck con-
trasting the effect of focal zone location (arrows). (A) Superficial focal zone, poorly optimized for the deep
hip joint. (B) Deep focal zone which is better optimized for visualization of deep target structure.

ligament, muscle, bone, cartilage, bursa, and peripheral appearance of pathologic tissues and anatomic variations is
nerve have distinct sonographic appearances (Table 2.1). A beyond the scope of this text.
thorough understanding of the normal sonographic appear-
ance and surrounding anatomy of pertinent structures in Sonographic Artifacts
both short-axis and long-axis imaging planes is critical to
identify potentially at-risk structures, recognize congenital Ultrasound imaging is inherently susceptible to image arti-
variation or absence of a structure, and diagnose pathol- facts because the sonographic character of normal tissue can
ogy.2,3 A comprehensive description of the sonographic change based on the angle of insonation of the ultrasound
 CHAPTER 2 Ultrasound Basics 17

A B
• Fig. 2.4Ultrasound image of the anterior femoroacetabular joint in long axis with the femoral neck dem-
onstrating image optimization through manipulation of time gain compensation (TGC) at depth. (A) dem-
onstrates neutral TGC settings, whereas (B) demonstrates increased gain at depth to better visualize the
femoral neck.

beam and the relative sonographic characteristics of adja- Anisotropy can be minimized or eliminated in short-
cent tissues. A thorough awareness of such artifacts and an axis visualization by angulating or “wagging the tail” of the
understanding of why they occur is essential to avoid erro- transducer to ensure that the ultrasound beam is perpen-
neous diagnosis of pathology and unnecessary and unpro- dicular to the structure (face of the probe is parallel to the
ductive procedures.5 Common artifacts include anisotropy, structure), approximating the angle of incidence as close to
shadowing, posterior acoustic enhancement, posterior 90 degrees as possible. When visualizing a structure in long
reverberation, and beam-width artifact. axis, anisotropy is addressed by heel-toeing or “rocking” one
end of the transducer to ensure that the ultrasound beam
Anisotropy is perpendicular to the structure, again, approximating the
Anisotropy is the artifactually hypoechoic or anechoic angle of incidence as close to 90 degrees as possible.
appearance of a structure that occurs when a structure is
imaged at an angle of incidence. The angle of incidence is Posterior Acoustic Shadowing
the angle at which the ultrasound waves encounter the sur- Posterior acoustic shadowing results when ultrasound waves
face of a structure. If the angle is perpendicular, or close to are reflected or attenuated by a structure resulting in little,
90 degrees, more waves will be reflected back to the trans- to no, waves penetrating through to deeper structures (Fig.
ducer. If the ultrasound waves are more parallel, waves will 2.8A).6 This results in a relatively hypoechoic appearance of
be reflected or “scattered,” resulting in a failure of the antici- all tissues deep to the structure. Dense structures, such as
pated ultrasound waves returning to the transducer head. bone, calcifications, and foreign bodies, are most likely to
Anisotropy will occur when imaging structures in both long cast a posterior acoustic shadow.
and short axes. Tendons and ligaments are most susceptible,
specifically when curving around a bony prominence or Posterior Acoustic Enhancement
quickly changing depth to become more deep or superficial Posterior acoustic enhancement, or increased through-
(Fig. 2.7). Anisotropy produces an artifactually hypoechoic transmission, occurs deep to structures that are hypoechoic
appearance that can mimic pathology. relative to adjacent tissues, resulting in less ultrasound beam
18 SEC T I O N I Introduction

R
U U
A B

F
F
C D
• Fig. 2.5 (A) Pronator quadratus muscle (arrowheads) in long axis shows demonstrating hypoechoic
myocytes and interspersed hyperechoic fibroadipose septae (arrows). More superficially, the wrist and
finger flexor musculature (open arrows) is demonstrated in anatomic short axis with the intramuscular
fibroadipose septae appearing as punctate hyperechogenicities. (B) Ulnar collateral ligament of the elbow
in long axis demonstrating compact fibrillar echotexture (arrowheads). (C) Patellar tendon in long axis
(arrowheads) demonstrating an even-appearing hyperechoic fibrillar echotexture. Deep to the tendon is
hypoechoic fluid within the deep infrapatellar bursa (arrows). (D) Transverse image of the femoral trochlea
demonstrating the homogeneous, hypoechoic hyaline cartilage (arrows) overlying hyperechoic cortical
bone (arrowheads). F, Femur; H, humerus; R, radius; U, ulna.

attenuation or reflection (see Fig. 2.8B). Tissues deep to the Beam-Width Artifact
less dense structure will appear relatively hyperechoic com- Beam-width artifact results when the ultrasound beam is too
pared with adjacent soft tissues because relatively more of wide relative to a small object being imaged and is similar
the ultrasound waves penetrate through the more superficial to volume averaging in magnetic resonance imaging (MRI).
and less absorptive structure to the deeper tissues.6 This arti- For example, shadowing from a small calcification may not
fact can be used to advantageously image structures deep to be visualized due to a wide beam width. This artifact can be
vasculature and cystic or fluid-filled structures. eliminated by adjusting the focal zone to the level of the object
of interest or changing to a probe with a smaller footprint.
Reverberation Artifacts
Reverberation appears as a series of hyperechoic, linear arti-
Visualization of Blood Flow
facts deep to dense structures and results from a series of
ultrasound wave reflections between two parallel, highly Color and power Doppler imaging detect motion toward
reflective surfaces. The single reflection will be displayed at or away from the transducer by detecting the delay between
the proper location but the artifactual late return of attenu- frequencies of the transmitted and received ultrasound
ated, reflected ultrasound waves are interpreted by the waves (Fig. 2.10).7,8 Color Doppler displays differences in
ultrasound processor as deeper, hypoechoic structures. This flow direction, red color representing flow toward the trans-
commonly occurs with bone and with metal surfaces, such ducer and blue color representing flow away from the trans-
as a needle or orthopedic implant (Fig. 2.9). Ring-down ducer. Power Doppler does not discriminate direction of
artifact appears as a solid streak or series of parallel bands flow but is more sensitive to low flow and provides superior
which result from the resonant vibration of air bubbles. detection of small vessels and slow flow rates. Power Dop-
Comet-tail artifact appears as a series of multiple closely pler is sensitive to transducer movement and susceptible to
spaced reverberation echoes deep to a more focal or punc- flash artifact. Increased blood flow on Doppler imaging may
tate structure which results from sequential echoes from two occur with greater perfusion, inflammation, and neovascu-
closely spaced, highly reflective interfaces. larization and can assist in differentiating complex fluid
 CHAPTER 2 Ultrasound Basics 19

TABLE
2.1   Distinct Sonographic Appearance of Neuromusculoskeletal Structures

Structure Appearance on Ultrasound

Tendon Linearly oriented between a muscle body and osseous insertion. Homogeneously and densely oriented
fibers produce a dense, linear hyperechoic structure in long-axis imaging with distinct superficial and
deep tenosynovial borders. In short axis, tendon appears as a regular-bordered ovoid structure with
homogeneously echogenic and sized internal tendon fibers, often referred to as a “broomstick” viewed on
end (Fig. 2.6)
Ligament Linearly oriented between two osseous structures. Ligament is composed of homogeneously and densely
oriented fibers and visualized as echogenic fibrillar fibers, which tend to be less echogenic than tendons
but echogenicity also depends on anisotropy and contrast with surrounding structures.4 Although the
echotexture of nonpathological ligaments has not been well described, they are often visualized as a
linear hyperechoic structure in long-axis imaging. In short axis, ligament will appear as a more irregularly
bordered, flattened structure
Muscle Composed of relatively hypoechoic muscle fibers and interspersed hyperechoic intramuscular stromal
connective tissue of the endomysium and perimysium. In short axis, its appearance is often referred to as a
“starry night”
Bone Densely hyperechoic relative to all surrounding tissues because of the inherent high acoustic impedance
mismatch. Cortical bone appears as a continuous, regular, brightly hyperechoic line with deep reverberation
artifact and posterior acoustic shadowing which precludes visualization of any deeper structures
Hyaline cartilage Densely and evenly hypoechoic secondary to its high water content and the high acoustic impedance
mismatch with the deep bone
Fibrocartilage Homogeneously hyperechoic relative to more superficial connective tissue or muscle. It has the same
appearance in both long- and short-axis orientations
Bursa When distended with fluid, anechoic-to-mixed-echogenic fluid and debris can fill the bursa. Firm transducer
pressure will compress and displace the fluid
Peripheral nerve Hyperechoic perineurium and endoneurium, which surrounds numerous small, round, and hypoechoic nerve
fascicles. All of this is contained within a hyperechoic epineurium, giving a “honeycomb” appearance when
visualized in short axis (see Fig. 2.6)4

R Distal

• Fig. 2.6 Transverse Ultrasound Image of Distal Volar Forearm. • Fig. 2.7 The distal biceps brachii tendon (arrowheads) demonstrates
Observe the “honeycomb” appearance of the median nerve in this anisotropy as it descends from superficial plane parallel to the trans-
short-axis view (open arrows) adjacent to the more hyperechoic and ducer (left of image) toward its distal radial insertion in a deep plane
more densely packed fibrillar-appearing flexor tendons (arrowheads). oblique relative to the transducer (right of image).
R, Radius; U, ulna.

Role for Ultrasound Guidance in

and synovitis because the former will often lack blood flow Interventional Orthopedic Procedures
whereas the latter demonstrates increased flow.9
Microvascular imaging mode, such as superb microvas- General indications for needle placement into or about a soft
cular imaging (SMI), has been demonstrated to have greater tissue or joints include, but are not limited to, the removal
sensitivity for the identification of microvessels at a high of fluid for diagnostic evaluation or symptom palliation
frame rate.10–12 This technology facilitates detailed visual- and the delivery of diagnostic or therapeutic agents. When
ization of microvessels and lower-velocity blood flow with- considering the use of image guidance for a procedure, one
out the use of contrast medium.13 should understand the indications and contraindications.
20 SEC T I O N I Introduction

A INFRASPINATUS TRANS B SEMIMEMBRANOSUS TRANS

• Fig. 2.8 (A) Posterior acoustic shadowing. A hyperechoic intratendinous calcification within infraspi-
natus (arrows) casts a posterior acoustic shadow, which results in an artifactually hypoechoic-appear-
ing humerus deep to the calcification (open arrows). (B) Posterior acoustic enhancement. A fluid-filled
hypoechoic parameniscal cyst (arrows) attenuates less ultrasound energy than the adjacent musculature,
which results in a relative hyperechogenic appearance of the joint capsule (open arrows) deep to the cyst.

• Fig. 2.9
Reverberation (open arrows) is seen as a series of linear reflective echoes extending deep as the
sound beam reflects back and forth between the smooth surface of the needle shaft and the transducer.

A B
• Fig. 2.10 Radial artery and veins without (A) and with (B) color Doppler.

Ultrasound affords many distinct advantages as an imaging Advantages of Ultrasound

modality for procedure guidance, but clinicians should be
able to discern when the inherent limitations of ultrasound The use of ultrasound as an imaging modality to assist in the
may make another imaging modality a safer or more effec- guidance of musculoskeletal interventions has the potential
tive tool for the procedure. to improve accuracy, efficacy, and safety when compared
 CHAPTER 2 Ultrasound Basics 21

TABLE   Advantages of Ultrasound Over Other of medications other than corticosteroids, such as visco-
2.2 Imaging Modalities supplementation injections and orthobiologic agents, may
be dependent upon their accurate placement into or about
Relative portability
a structure or joint. More research is needed to compare
Superior spatial resolution of superficial soft tissue and whether ultrasound guidance may improve the effectiveness
neurovascular structures
of such interventions as compared with palpation guidance.
Relative low cost
Continuous needle/device visualization
Safety
Ultrasound guidance of an intervention affords continuous
No exposure to ionizing radiation
visualization of the at-risk neurovascular structures, the tar-
No metallic artifact on imaging allows for prosthetic get structure, and the needle or device, which can decrease
imaging the incidence of adverse events such as hematomas/hemar-
throsis, postinjection pain, and neurovascular injuries.25,26

with palpation guidance.14,15 When used for procedural

Indications for Use of Ultrasound-Guided
guidance, ultrasound also affords multiple distinct advan- Intervention
tages over x-ray, MRI, and computed tomography (CT) Use of ultrasound for guidance of an injection or procedural
that make it an ideal diagnostic and interventional imaging intervention is indicated when a palpation-guided injection
tool (Table 2.2). Ultrasound can be used at the point of care has failed to have positive therapeutic effect or when the
to identify tendinosis/tendinopathy, ligamentous injury, diagnostic or therapeutic injection depends upon precise
muscular injury, bony pathology and joint pathology (i.e., visualization of the pathologic structure. In procedures with
effusion, hemarthrosis, loose body, meniscal injury). Clini- relatively high risk of injury to nearby neurovascular struc-
cal evaluation, diagnostic ultrasound evaluation, and pro- tures or unintended soft tissue structures, ultrasound guid-
gression to an ultrasound-guided intervention are possible ance can be used to avoid injury. Furthermore, ultrasound
to complete in a single outpatient clinic visit. is useful to monitor for postprocedure hematoma forma-
tion in anticoagulated patients.27,28 Another common indi-
Accuracy
cation for ultrasound guidance is when palpation of bony
Injection accuracy is defined as placement of the injec- anatomic landmarks and confident target identification are
tate or needle tip into or about the intended structure.14 compromised by body habitus or pannus, postsurgical or
There is strong evidence that image-guided injections are posttraumatic changes and deformities, or deep location of
more accurate than palpation-guided injections into joints the target.
of all sizes.15 Most soft tissue and intrabursal injections
are also more accurate when performed with ultrasound
guidance.16,17
Contraindications for Use of Ultrasound-
Guided Intervention
Efficacy
Once the indications have been identified, contraindications
Assessments of the effectiveness of a procedure, whether must be assessed. Similar to palpation-guided injections,
palpation or ultrasound guided, vary based on different ultrasound-guided procedures should not be performed in
outcome measures used. For the purposes of this dis- patients with known allergy to injectate or in the location
cussion, positive efficacy will be defined as studies that of an active infection, rash, or skin breakdown. Another
describe a positive change in an outcome measure such important contraindication is the skill limitations of the
as pain, range of motion, mobility, function, or patient proceduralist. Substantial training, practice, and time com-
satisfaction.14 mitment are necessary to obtain competency; one must not
One would logically anticipate improved efficacy with perform an intervention that one does not feel comfortable
more accurate injectate placement, but studies to date have performing.
demonstrated mixed outcomes with regards to improve- Relative contraindications include interventions on patients
ments in efficacy with ultrasound guidance.15 Multiple with coagulopathy or who are on anticoagulation/antiplatelet
studies have demonstrated that ultrasound guidance for therapy, given the increased risk of bleeding complications.
musculoskeletal conditions contributes to improved efficacy Additional relative contraindications include underlying medi-
and quality of life when compared with palpation-guided cal conditions that may be affected by the injectate, such as
injections.18–23 diabetics who receive corticosteroid injections.
One important consideration is that most studies com- Contraindications specific to ultrasound guidance relate
paring palpation versus ultrasound-guided corticoste- to an inability to sufficiently or clearly visualize a targeted
roid injections, except cortisone, will have some systemic pathologic structure because of inherent imaging limita-
effects of pain reduction no matter the specific location tions. Specifically, ultrasound does not penetrate through
of the injection.19,24 However, the mechanisms of action bones and other dense or metallic structures. This can
22 SEC T I O N I Introduction

preclude visualization of structures deep to bone and needle exposes the operator, staff, and patient to ionizing radiation,
visualization deep to bone or within an obliquely oriented requires contrast to confirm needle placement and injectate
joint, such as the sacroiliac (SI) joint or lumbar facet joint. flow, and is much less portable. Fluoroscopy provides no
detail of neurovascular structures, musculature, and ten-
Ultrasound Compared With Other Imaging dons. Relative to ultrasound, fluoroscopy does afford supe-
Modalities for Procedure Guidance rior visualization deep to and between bony prominences,
and allows confirmation of placement with flow of injected
Ultrasound, MRI, CT, and fluoroscopy can each be used radiopaque contrast into such joints.
to guide interventional orthopedic procedures. Relative to Axial injections are believed to be safer and more effective
other imaging modalities, ultrasound has the benefits of when performed with fluoroscopic guidance compared with
improved portability, lower cost, absence of exposure to ultrasound guidance. However, in recent years, this opinion
ionizing radiation or gadolinium contrast, and unparalleled has been challenged in the literature. Ultrasound-guided
spatial resolution of superficial soft tissue structures. Even cervical medial branch blocks take less time to perform
the largest platform-based ultrasound machine will have a and use fewer needle passes with no difference in preblock
smaller footprint and is more portable than other imaging and postblock pain scores or complication rate when com-
hardware. Ultrasound can be moved between different pro- pared with fluoroscopic guidance.31,32 In the lumbar spine,
cedure rooms, unlike other modalities which can require a a recent systematic review of nine randomized controlled
large, dedicated room and outfitting with extensive electri- trials comparing ultrasound to fluoroscopic guidance for
cal and computer wiring or leaded protection. Ultrasound the management of lower back pain, including transforam-
also affords continuous, real-time visualization of the needle inal and caudal steroid injections, found no difference in
or device as it is advanced or redirected, unlike other modal- pain reduction, procedure time, complications and adverse
ities which require repeating a cycle of advancing a needle or events, patient satisfaction, or postprocedure opioid con-
device, taking an image, and image analysis. sumption.33 These findings are similar to those reported in
a meta-analysis of randomized and nonrandomized lumbar
Magnetic Resonance Imaging facet joint injections, which did not find significant differ-
MRI is often the imaging reference standard for musculoskele- ences in pain or function in the ultrasound-guided cohorts
tal disorders because of its unparalleled global detail of osseous, when compared to fluoroscopy.34 Although the research for
articular, and musculotendinous structures. When compared ultrasound guidance is promising, the accuracy and safety
with MRI, ultrasound is more accessible at the point-of-care, of fluoroscopy-guided neuraxial injections is well estab-
less expensive, and more cost-effective, has superior superficial lished and currently remains the standard of care for axial
spatial resolution, and provides dynamic anatomic detail in injections.
real time.29–31 To the authors’ knowledge, there are no stud- In addition to spine procedures, fluoroscopy has tradi-
ies that directly compare MRI versus ultrasound guidance for tionally been the imaging modality of choice for SI joint
procedures performed on the musculoskeletal system. injections.35–37 Ultrasound has been demonstrated to have
similar accuracy and improvements in pain scores and dis-
Computed Tomography ability measures when compared with fluoroscopy for SI
CT provides cross-sectional imaging of bone, soft tissues, joint injections,38 although some studies show superior accu-
and blood vessels, making it a useful modality for proce- racy of fluoroscopy when compared with ultrasound.36,39
dural guidance. Limitations of CT relative to ultrasound Fluoroscopic guidance has historically been the imaging
are its requirement of a specialized and dedicated room for modality of choice for intra-articular hip joint injections
large machinery, exposure of the operator, staff, and patient and aspirations, but a growing body of evidence demon-
to ionizing radiation, and lack of real-time visualization of strates equivalent accuracy, efficacy, and decreased cost with
the needle or device. CT guidance is most commonly used ultrasound guidance.40–44 Ultrasound-guided intra-articular
for spinal injections and implements cycles of needle/device hip injections are less painful than fluoroscopically guided
advancement, image capture, and image analysis to confirm injections, which is likely attributable to its ability to visual-
accurate needle/device placement and medication delivery; ize and to avoid painful contact or injury to periarticular
it does not allow for continuous real-time visualization of structures.45
the needle or device that is possible with ultrasound. The
cycle of needle/device advancement and image gathering Cost
used with CT guidance increases the length of time for the
intervention and comparison studies have been mixed as to There is an 8% reduction in cost per patient per year and a
whether CT or ultrasound is more time efficient for image 33% reduction in cost per responder per year with the use
guidance for facet joint injections.29,30 of ultrasound guidance compared with palpation guidance
for intra-articular injections in patients with inflammatory
Fluoroscopy arthritis.23 In the knee joint specifically, ultrasound guid-
Fluoroscopy uses radiography to visualize detailed bony ance achieves a 13% reduction in cost per patient per year
anatomy. However, relative to ultrasound, fluoroscopy and a 58% reduction in cost per responder per year when
 CHAPTER 2 Ultrasound Basics 23

compared with palpation guidance in patients with osteo- transducer should be held with the nondominant hand,
arthritis.46 Ultrasound guidance has also been shown to be with the other hand performing the procedure. A supply
more cost-effective than palpation or fluoroscopic guidance tray should be within reach of the operator’s dominant hand.
for glenohumeral joint injections in patients with adhesive An assistant may be required to help with image modifica-
capsulitis.47 tion to ensure optimal visualization of the targeted structure
It is important to note that the cost-effectiveness of sono- and the needle/device, image storage, and modification of
graphic guidance for musculoskeletal interventions can be image labeling if orientation is changed. Lighting should
less impactful in the hands of a less-experienced operator be dimmed for optimal screen viewing and appreciation of
who may be less efficient or less accurate. Additional studies black/white contrast.
are also needed to determine whether the improved accu- The patient is positioned to facilitate reproducible and
racy from ultrasound guidance translates into improved effective access to the procedural site while optimizing the
outcomes and cost savings. orientation of the ultrasound platform for viewing and
image manipulation. Patient comfort must also be con-
Technical Considerations sidered. Ultimately, positioning is an interplay between
physician access to the procedure site and minimization
Prior to performing any procedure, the physician should: of patient discomfort and may require small compromises
review prior imaging, confirm an accurate diagnosis, obtain in both variables to effectively and efficiently complete the
the informed consent of the patient, use site marking and procedure.
local anesthetic as appropriate, and apply aseptic technique.
Specific to the ultrasound guidance of a procedure, the phy- Preprocedural Scan
sician should ensure optimization of patient comfort, the
ergonomics of the procedural setup, including arrangement The ultimate utility of the preprocedural scan is to make
of the procedure table, ultrasound platform, and screen. the procedure as efficient as possible after cleaning the pro-
cedural site and donning sterile equipment, so that no fur-
Patient Information and Labeling ther modification of the ultrasound imaging and labeling
is needed. The following should be completed in the pre-
Patient identifier information should be entered to allow procedural ultrasound scan: optimization of probe selection
for proper documentation. This will usually consist of based on target depth, contour and access or limitations of
the patient’s name, birth date, and an identifying medical the procedure site, optimization of the ultrasound image to
record number. Specific standards for labeling of target tis- visualize the target structure, location of any at-risk struc-
sue and orientation can vary but generally must include the tures, determination of the most appropriate orientation of
structure of interest and its orientation, when appropriate. approach, and needle gauge and length. The skin at the pro-
Labeling must also include an identifier of anatomic ori- cedural site can be marked with a surgical marking pen to
entation. Conventionally, the proximal or right side of the ensure that the optimal image can be quickly and accurately
patient corresponds with the right side of the ultrasound located during the procedure and to minimize the possibil-
screen. However, when performing musculoskeletal ultra- ity of skin contamination from rescanning from an area of
sound, the label should be appropriately placed on the ultra- uncleansed skin into the procedural site.
sound image, to accurately indicate medial/lateral, anterior/ Anatomic variations of musculotendinous structures,
posterior, cephalad/caudal, or proximal/distal and allow the anomalous neurovascular structures, and previously uniden-
sonographer and anyone reviewing images to easily deter- tified pathology can be encountered during the preproce-
mine image orientation. dural ultrasound scan.49,50 The physician must determine
whether such variations would make an injection or proce-
Ergonomics dure unsafe. However, with a comprehensive understanding
of the specific anatomic variation and how it introduces risk
Optimization of the physician, patient, and ultrasound plat- to the procedure, adequate visualization of at-risk structures
form ergonomics can minimize fatigue and work-related in the preprocedural scan and during the procedure, and
injuries.48 Optimal comfort of the sonographer and patient calculation of a modified or an alternate approach for the
are essential. To reduce fatigue, the height and placement procedure as needed, the injection/procedure can still be
of the examination table should allow the scanning hand to completed in most cases. All significant finding of pathol-
be lower than the ipsilateral shoulder. The elbow should be ogy and anatomic variation should be documented in detail
close to the sonographer’s body with ample contact between in the procedural report.
the scanning hand and the patient to provide secure trans-
ducer positioning. A chair with wheels and back support Direct Versus Indirect Guidance
can improve comfort and maximize maneuverability. Screen
location should be adjusted to enable full visualization of Ultrasound-guided procedures can be separated into indi-
the procedure site and the ultrasound image throughout rect and direct techniques. With the indirect approach,
the procedure to minimize head or neck movement. The ultrasound is used to identify the target and determine
24 SEC T I O N I Introduction

its depth. The overlying skin is marked, the transducer is by specific practice or institution guidelines and may include
removed, and the procedure is performed without real- nonsterile sheaths, gel, and gloves. Clinicians who use the
time guidance. The needle is typically directed perpen- “no-touch” technique place the uncovered transducer over
dicular to the skin into the target. This technique has the the target region but remote from the prepared skin entry
obvious disadvantage of not being able to visualize the site. The needle is passed through the prepared skin region
needle in real time. Although the use of either technique and passes under the transducer within the body but does
may be appropriate in specific clinical circumstances, the not pass through unprepped skin, nor do the uncovered
preferred modality of ultrasound guidance for interven- transducer and nonsterile gel contact the procedure site or
tional orthopedic procedures is the direct approach. In needle. It is recommended that this technique be used only
this approach, the needle tip is continuously visualized by experienced clinicians due to the risk of procedure site
approaching and encountering the target throughout the contamination. Specific detail of the aseptic technique used
procedure. during the ultrasound-guided procedure should be docu-
mented in the procedure report.
Needle Selection
Local Anesthesia
Needle selection may vary per clinician preference and
patient factors. Selection of the smallest-gauge needle with The injection of local anesthetic can reduce procedural dis-
the appropriate length for the desired injection is recom- comfort. If used, it is best to start with a thinner, higher-
mended. Selection of needle type, gauge, and length will gauge needle (e.g., 30- or 27-gauge) to minimize pain from
depend on the procedure at hand, but, in general, the small- the needle. This may limit the length of needle available and
est-gauge needle possible, while permitting adequate length require a second skin entry with a longer, larger-gauge nee-
and needle visualization, is preferable for patient comfort. dle to get the therapeutic injectate to the target. If the opera-
Larger needles (e.g., 22 gauge or larger) are necessary for tor is able to reach the target structure with the same needle
aspiration and for injection of viscous medications. When used to administer local anesthetic, that needle can be left in
advancing the needle, it is important to keep in mind that place at the target structure, the anesthetic syringe removed,
smaller-gauge needles will be more prone to bending and and one containing the therapeutic injectate affixed to obvi-
more challenging to visualize. ate the need for a second needle entry. In addition, injection
of local anesthetic with a smaller-gauge and shorter needle
Aseptic Technique can provide the physician with an estimate of the appro-
priate needle trajectory to the target tissue and make the
After adequate sonographic visualization of the target tis- direction of the therapeutic injectate with a larger gauge and
sue, selection of the most appropriate transducer and needle longer needle more accurate and efficient.
gauge and length, and optimization of the ultrasound image
Needle Approach
settings, the skin overlying the location of transducer place-
ment and needle entry can be marked and sterilized. A ster- In-Plane and Out-of-Plane Techniques
ile field prepared by the operator or assistant should contain The targeted structure can be approached in two ways rela-
aseptic cleaning solution, sterile needles and syringes with tive to the ultrasound transducer. In an “in-plane” approach
medications prepared in a sterile manner, sterile probe cover the needle is parallel to the long axis of the ultrasound trans-
and gel, sterile gauze, and a sterile bandage. Physicians per- ducer, and the entire needle shaft is visualized during the
forming the procedure should wash their hands and don procedure. An “out-of-plane” approach involves the needle
sterile gloves before using an appropriate skin cleansing being placed perpendicular to the ultrasound transducer,
solution, such as iodine or chlorhexidine. These are available and the needle shaft and tip are visualized in short axis as
as a single-use swab or applicator. Sterile drapes or towels a single punctate, hyperechoic dot. In the hands of those
can be used to cover the surrounding areas, creating a sterile with greater technical ultrasounds skills, these approaches
field surrounding the procedure site that allows the opera- can both be used within the same single procedure by rotat-
tor to easily set the transducer while exchanging equip- ing the transducer to ensure accurate and safe direction of
ment and minimizing contamination during the procedure. the needle to the target structure. The optimal approach
Nonsterile gel is applied to the probe, which is next draped includes the safest approach to the target structure that
with a sterile cover and secured, usually with supplied rub- avoids injury to blood vessels, nerves, and surrounding
ber bands. Sterile ultrasound gel can then be applied to the structures. The operator should consider not only how to
now-sterile ultrasound probe or directly to the skin at the best orient the transducer to visualize the target and sur-
procedure site. rounding structures but also the needle trajectory relative to
The preprocedural technique detailed previously pro- the transducer.
vides the best means by which to mitigate the risk of con- In an in-plane approach, also known as long-axis or
tamination and infection during an injection/procedure, longitudinal approach, the needle is directed co-linear
but clinicians may prefer to use alternative or individualized to the long axis of the transducer, allowing for continu-
techniques. The choice of infection management is dictated ous visualization of the entire needle shaft throughout
 CHAPTER 2 Ultrasound Basics 25

the procedure, including the needle tip and target. This be more co-linear to an injectate needle advanced at a steep
method is preferable because it allows for real-time visu- angle with the skin.
alizations of needle angle and depth modifications during
needle advancement. Optimizing Needle Visualization
In an out-of-plane technique, also known as short-axis
or transverse approach, the needle is directed perpendicular When directing a needle in the long axis of the ultrasound
to the long axis of the transducer. The target structure is transducer (in-plane injection), the needle will be best visu-
centered on the ultrasound screen with the needle passed alized when it passes directly under the transducer without
under the middle of the transducer. In this view, the needle deviation. Leftward or rightward deviation of the needle
manifests as a single, punctate, hyperechoic “dot” rather from under the transducer will result in incomplete visu-
than a linear structure. The out-of-plane approach may alization of the needle and the loss of the needle tip as it
be used in procedures where the target is superficial with advances out-of-plane from the transducer. If needle visu-
minimal surrounding soft tissues, such as the acromiocla- alization is compromised, moving the transducer in small
vicular joint and small joints of the hand and foot. Many increments to the needle is preferred while maintaining
ultrasound machines can project a centerline on the display the needle in the same location. The needle should not
and will have indicator of the center point of the transducer be advanced until the tip is again visualized to ensure the
head. Placing the centerline marker directly over the tar- safety of any at-risk neurovascular structures. It can be help-
geted structure and directing the skin entry site at the center ful to look down at the procedure site from the ultrasound
point indicator on the transducer head can improve accu- screen to visually reconfirm that the needle is indeed directly
racy of needle direction to the target structure. beneath and parallel to the transducer. As the needle enters
Disadvantages of the out-of-plane approach are that only deeper tissues, maneuverability is limited and may result in
a short segment of the needle is visualized at a single time bending of the needle, which makes it difficult to visualize
as it passes through the sound beam plane. A common, and the tip and shaft in one image.
potentially dangerous, error is to pass the needle tip beyond
the plane of the transducer because it can be challenging to Transducer Manipulation
distinguish the needle shaft from the needle tip in this view. Manipulation of the ultrasound transducer will modify
When using the out-of-plane approach, one can consider how the ultrasound waves are transmitted and return to the
the walk-down maneuver. In this technique, the needle transducer, which will result in changes to the image that is
enters superficially, the tip is identified, and then the needle produced. It is essential to understand how, and when, to
is drawn back slightly, angled more steeply and advanced use specific maneuvers to eliminate unwanted artifacts and
toward the target depth. This is repeated until the target is to optimize visualization of the target tissue and the needle
reached and ensures that the tip of the needle or structures during a procedure. Nomenclature for these maneuvers can
in the needle trajectory are continuously visualized. vary slightly. Frequently used transducer movements are
Alternation between in-plane and out-of-plane views described in Table 2.3 and Fig. 2.12, with their most com-
facilitates identification of the entire needle shaft and tip mon names listed.
location relative to the targeted structure and at-risk struc-
tures to ensure safety and accuracy. Continuous Visualization of Needle Tip
The capacity for continuous visualization of a needle during
Needle Trajectory a procedure and its relation to the target tissue and at-risk
It is important to triangulate the depth of the target struc- structures is a unique benefit of ultrasound. It is impera-
ture and to determine a needle entry point and trajectory tive that the operator is proficient in the skills of needle
that will allow for visualization of the needle tip during the guidance during the procedure to ensure that these ben-
entire procedure. A needle trajectory that is parallel to the efits are indeed realized. A general principle of ultrasound-
face of the transducer will allow for improved needle visu- guided procedures is that the operator must not continue to
alization. This can be accomplished by choosing a needle advance a needle or device if the tip is not visualized during
entry point below the transducer when convex anatomy an in-plane approach. Needle visualization can be improved
permits (Fig. 2.11). This is not always possible with very by maintaining a steady hand on the transducer, specifically
deep structures and when the overlying superficial anatomy by firmly holding the transducer with three to four fingers
is flat or concave. In those instances, an approach must be and anchoring the hypothenar eminence of the hand on the
selected that best accounts for the depth of a structure, the skin. A thicker, larger-gauge needle will be more easily visu-
anticipated subcutaneous distance needed to be traversed alized because of the increased diameter. A needle trajectory
by the needle, superficial anatomy, and how it may limit parallel to the long axis of a linear ultrasound transducer
or affect the trajectory (e.g., at-risk structures, abdominal head or convexity of a curvilinear probe will increase the
pannus, large musculature). A curvilinear array transducer return of ultrasound waves to the transducer and improve
will usually be optimal for these instances as it affords bet- visualization of the needle. This can be modified by either
ter resolution of structures deeper than 4 to 5 cm and the withdrawing and redirecting a needle, by performing a heel-
curvilinear array of the transmitted ultrasound waves will toe transducer maneuver, or by using a gel stand-off.
26 SEC T I O N I Introduction

A B
• Fig. 2.11Demonstration of a suprapatellar recess injection taking advantage of the convexity of the distal
thigh to insert the needle at the depth of the targeted tissue at a trajectory parallel to the transducer, to
best optimize needle visualization in figures (A) and (B).

TABLE
2.3   Frequently Used Transducer Movements

Use for Image Optimization During

Transducer Movement Description Procedures
Translate, slide Movement of the entire transducer in the Used to locate the needle or target structure
direction of the long axis of the probe
Sweep Movement of the entire transducer in the Used to locate the needle or target structure
direction of the short axis of the probe
Rotate Rotation of the transducer around a center This can facilitate alternation between the short-
point/axis axis and long-axis views of a structure or a
needle
Rock, heel-toe Angling the transducer along the long Modification of the angle of incidence when
axis of the probe to change the angle attempting to optimize tissue or needle
of insonation by applying more or less visualization or eliminate anisotropy
pressure on one side of the probe while
maintaining the same skin location
Angulate, fan, toggle, tilt, wag Angling the transducer along its short axis Modification of the angle of incidence when
by moving the transducer its convex attempting to optimize tissue or needle
short-axis plane while maintaining the visualization or eliminate anisotropy
same skin location
Compression Increasing or decreasing the manual Used to displace fluid, compress blood vessels,
pressure of the transducer at the skin or aid in dynamic visualization of fascial planes

Gel Stand-off skin contact by the probe or sonocoupling through a con-

A gel stand-off involves using a thick layer of gel under the tinuous gel medium results in loss of all ultrasound waves
transducer so that part of, or all of, the transducer does not and a completely anechoic image at that location. When
directly contact the skin (Fig. 2.13). This facilitates sono- performing an in-plane procedure, a gel stand-off under
coupling from the transducer, through gel, to the underly- one side of the transducer can be combined with a heel-toe
ing skin on convex anatomic surfaces. That sonocoupling maneuver to facilitate entry of the needle at a steeper trajec-
maintains a continuous image. Conversely, lack of direct tory under the transducer, better capacity to maintain the
 CHAPTER 2 Ultrasound Basics 27

needle at a perpendicular to the angle of insonation to the

ultrasound beam, and for continuous gel contact and visu-
alization of the needle prior to puncture through the skin.

Needle Tracking Techniques

Identification of the needle and visualization throughout
the procedure can be improved by different maneuvers and
image modifications (Table 2.4).

Postprocedure Protocol
After completion of the procedure, the needle is withdrawn.
The area should be scanned after the procedure to confirm
that the injectate was placed in the intended location, indi-
cated by sonographic visualization of injectate about the tar-
geted tendon or soft tissue structure and within the targeted
joint space. This postprocedure scan also allows for evalu-
ation of hematoma formation. Injectate flow can also be
A confirmed in real time during the injection procedure with
the use of Doppler imaging ahead of the needle tip. Fol-
lowing the procedure, a dressing is applied, and procedure-
specific instructions are reviewed with the patient. Probes
and ultrasound equipment should be disinfected between
each procedure.

Conclusion
There is strong evidence to support improved accuracy,
efficacy, and safety of musculoskeletal injection procedures
with the utilization of ultrasound guidance when compared
with palpation guidance. In addition, ultrasound provides
many advantages over CT and fluoroscopy for procedural
guidance, including lower cost, absence of ionizing radia-
tion, greater portability and flexibility in setting up a proce-
dure room, and real-time visualization of neurovasculature.
The skills required to effectively and efficiently use
B
ultrasound for the guidance of musculoskeletal interven-
• Fig. 2.12 (A) Transducer fan/wag. (B) Rock/heel-toe. tions requires extensive practice and training to develop

A B
• Fig. 2.13
Gel Stand-off Technique Overlying the Prepatellar Bursa. Diamond (♢) designates anechoic
ultrasound gel in figures (A) and (B).
28 SEC T I O N I Introduction

TABLE
2.4   Common Techniques to Improve Needle Tracking

Needle Tracking Technique Action Benefit

Needle perturbation Needle is moved back and forth in a Small degree of needle motion can make it more
low-amplitude, high-velocity motion conspicuous and make the needle tip easier to
visualize
Bevel rotation Rotation of the needle bevel to The angled bevel at the needle tip can be easier
alternately face up or down to visualize when facing upward toward the
transducer
Stylet movement Advancing and withdrawing the stylet Motion of the stylet can be visualized
Low volume injection Injection of hypoechoic fluid can be Contrast between the hyperechoic needle tip and
visualized the hypoechoic surrounding fluid
Needle size and echogenicity51 Use of larger-gauge needle Larger-gauge needle is easier to visualize
Compound imaging52 Uses beam steering to rapidly acquire Needle is easier to visualize due to improved
overlapping views of a target from contrast resolution and tissue differentiation
different angles
Beam steering Ultrasound beams are emitted at a Even if the transducer cannot be parallel to the
45-degree angle to the transducer, needle, needle can be perpendicular to the angle
rather than perpendicular of insonation of the ultrasound beam allowing for
better visualization of the needle

sufficient understanding of normal sonographic anatomy 7. Boote EJ. AAPM/RSNA physics tutorial for residents: topics in
and the technical skills of needle visualization and guidance US: Doppler US techniques: concepts of blood flow detection
under ultrasound. Training and education may be acquired and flow dynamics. Radiographics. 2003;23(5):1315‒1327.
through a structured residency or fellowship with a mus- 8. Bude RO, Rubin JM. Power Doppler sonography. Radiology.
1996;200(1):21‒23.
culoskeletal ultrasound didactic curriculum. Didactic con-
9. Breidahl WH, Stafford Johnson DB, Newman JS, Adler RS. Power
ferences, courses, books, online learning, and mentoring Doppler sonography in tenosynovitis: significance of the periten-
programs can also facilitate such learning. When diagnostic dinous hypoechoic rim. J Ultrasound Med. 1998;17(2):103‒107.
ultrasound knowledge and procedural skills are mastered 10. Chen J, Chen L, Wu L, et al. Value of superb microvascular imag-
by the skilled clinician, ultrasound-guided procedures are ing ultrasonography in the diagnosis of carpal tunnel syndrome:
a valuable tool in the treatment of various musculoskele- compared with color Doppler and power Doppler. Medicine (Bal-
tal pathologies. As ultrasound technology and techniques timore). 2017;96(21):e6862.
advance, ultrasound will continue to play an increasingly 11. Ishikawa M, Ota Y, Nagai M, Kusaka G, Tanaka Y, Naritaka H.
important role in the clinical management of musculoskel- Ultrasonography monitoring with superb microvascular imag-
etal conditions. ing technique in brain tumor surgery. World Neurosurg. 2017;97:
749.e711–749.e720.
12. Ohno Y, Fujimoto T, Shibata Y. A New era in diagnostic ultra-
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23. Sibbitt Jr WL, Band PA, Chavez-Chiang NR, Delea SL, Nor- Comparison of fluoroscopy and ultrasound guidance for sacro-
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inflammatory arthritis. J Rheumatol. 2011;38(2):252‒263. 39. Stelzer W, Stelzer D, Stelzer E, et al. Success rate of intra-articular
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of subacromial and gluteal single injections with placebo. J Int 40. Levi DS. Intra-articular hip injections using ultrasound
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25. Bhatia A, Gofeld M, Ganapathy S, Hanlon J, Johnson M. Com- 2013;5(2):129‒134.
parison of anatomic landmarks and ultrasound guidance for 41. Martinez-Martinez A, Garcia-Espinosa J, Ruiz-Santiago F,
intercostal nerve injections in cadavers. Reg Anesth Pain Med. Guzman-Alvarez L, Castellano-Garcia MM. Comparison of
2013;38(6):503‒507. ultrasound and fluoroscopic guidance for injection in CT
26. Leopold SS, Battista V, Oliverio JA. Safety and efficacy of intraar- arthrography and MR arthrography of the hip. Radiologia.
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Res. 2001;391:192‒197. 42. Micu MC, Bogdan GD, Fodor D. Steroid injection for hip
27. Malloy PC, Grassi CJ, Kundu S, et al. Consensus guidelines for osteoarthritis: efficacy under ultrasound guidance. Rheumatology
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Radiol. 2009;20(suppl 7):S240‒249. come of sonographically guided intra-articular sodium hyal-
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antiplatelet drugs: a case report. J Anesth. 2011;25(2):318‒320. 44. Smith J, Hurdle MF, Weingarten TN. Accuracy of sonographi-
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AJNR Am J Neuroradiol. 2013;34(2):466‒470. hip injections: a comparative study with fluoroscopy-guided
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versus Computed Tomography-controlled facet joint injections 46. Sibbitt Jr WL, Band PA, Kettwich LG, Chavez-Chiang NR,
in the middle and lower cervical spine: a prospective randomized Delea SL, Bankhurst AD. A randomized controlled trial evalu-
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ultrasound: can you reduce risk? Ultrasound. 2015;23(4):224‒230. gation of a new echogenic needle for use with ultrasound periph-
49. Sites BD, Macfarlane AJ, Sites VR, et al. Clinical sonopathol- eral nerve blocks. Anaesth Intensive Care. 2007;35(4):582‒586.
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subcutaneous tissue, and foreign bodies. Reg Anesth Pain Med. feldt T. Compound imaging technology and echogenic needle
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3
Principles of Fluoroscopy
Imaging in Spine
and Musculoskeletal
Interventional Orthopedics
KATARZYNA IWAN, RAHUL NAREN DESAI, AND JOHN J.
WOLFSON

Introduction postdoctoral training. Many injections, including joint

injections, require experience, spatial awareness, and ana-
Fluoroscopy has played a central role for injection therapies of tomic understanding so as not to puncture nerves, vessels,
the spine and peripheral joints, for both interventional pain or critical structures that may be in the needle path. In the
management and orthopedics. In this chapter, we focus on setting of fluoroscopic guidance, the superficial anatomy,
the principles and the use of fluoroscopy regarding both spi- manual palpation, and bony landmarks on the images serve
nal and peripheral interventions as it applies to the emerging as guides for the needle’s pathway. The developing field of
field of regenerative medicine. Fields such as interventional regenerative orthopedics relies on the knowledge and tech-
radiology, sports medicine, physiatry, and orthopedics rely niques of traditional diagnostic and therapeutic injections
on fluoroscopy to enhance the accuracy and effectiveness of of the spine, joints, nerves, and soft tissues. In this chapter,
procedures.1–5 As these fields have incorporated regenerative we discuss the principles of fluoroscopy as it applies to diag-
injectates, it is a natural progression to use fluoroscopic guid- nosis and treatment of musculoskeletal conditions.
ance for more precise delivery of the biologic treatment to
the injured tissue. Fluoroscopy allows providers to precisely, Radiation Terminology and Measurement
efficiently, and safely direct the needle and literally “pinpoint”
the target location while minimizing damage to unintended There are numerous terms and units of measurement used
structures. By using bony landmarks and confirmation with in radiology, and one must be familiar with their value and
contrast, there is a very high degree of certainty that injectates relationship to each other. Radiation can be described in
reach the target tissues and give the best possible chance of terms of radioactivity, exposure, absorbed dose, and dose
therapeutic success. In addition, fluoroscopy allows for pre- equivalent (Table 3.1). In general:
cision injection of materials, be it cement or orthobiologics • 1 R (exposure) = 1 rad (absorbed dose) = 1 rem or 1000
into bone. Simply placing a needle into bone does not ensure mrem (dose equivalent)
placement and retention of the material into bone, and one
can frequently see venous vascular flow of contrast out of the
Fluoroscopy History and Background
bone and away from the intended targets. Small adjustments
of the needle tip can make a substantial difference in the Fluoroscopy is an imaging technique that uses real-time
deposition of the treatment injectate. x-rays to create images of a patient. The history of fluoros-
A keen sense of anatomy, trajectory, and understanding copy dates back over a century.1–3 In 1895, physicist Wil-
of vital structures is a crucial and required skill set for any helm Conrad Roentgen (1845–1923) discovered and coined
interventionalist performing these therapies. Although it the term “x-ray.” His discovery was accidental; he noticed a
may be inferred, these procedures should only be performed glow when attempting to pass cathode rays through glass.
by well-qualified physicians who have completed adequate Later, he discovered that x-rays penetrate soft tissue but not

31
32 SEC T I O N I Introduction

TABLE
3.1   Measuring Radiation

Definition Unit Measurements Relationships

Radioactivity Amount of radiation released by a Curie (Ci) 1 Ci = 3.7 × 1010 Bq
material Becquerel (Bq)
Exposure Amount of radiation exiting the x-ray Roentgen (R) 1 R = 2.58 × 10−4 C/kg
tube, traveling through the air Coulomb/kilogram (C/kg)
Absorbed dose Amount of radiation absorbed by an Rad (r) I Gy = 100 r
object/person Gray (Gy)
Dose equivalent Amount of radiation absorbed as it Roentgen-equivalent-man (rem) 1/1000th rem is known as millirem
relates to the radiation type and Sievert (Sv) (mrem); commonly used for
subsequent biologic impact biologic dose equivalent
1 Sv = 100 rem

Created with information from the United States Nuclear Regulatory Commission. https://www.nrc.gov/about-nrc/radiation/health-effects/measuring-
radiation.html

metal or bone, and he captured the first x-ray image of his • I nput phosphor—cesium iodide: converts x-ray pho-
wife’s hand. In 1897, x-rays were used to identify broken tons to light photons
bones during the Balkan War. In 1901, Roentgen won the • Photocathode—antimony and alkali metals: converts
Nobel Prize in Physics for his discovery. Following Roent- light photons to electrons
gen’s work on x-rays in 1895, Thomas Edison’s assistant, • Electrostatic focusing lens (electrode focusing plates):
glassblower Clarence Dally, worked on development of the guides electrons to the anode
Edison x-ray focus tube, resulting in a fluoroscope that pro- • Accelerating anode: accelerates electrons and gives
duced sharper images than the Roentgen fluoroscope. them electronic gain
Unfortunately, the potential harmful effects of x-rays • Output phosphor—zinc cadmium sulfide: converts
were identified more slowly. In 1904, Dally died from skin electrons back to light photons, creating magnifica-
cancer. He is considered the first documented radiation tion and a thousand times increase in brightness or
fatality, but it was not until the 1950s that x-rays were deter- intensity
mined to carry significant risk. In the subsequent decades, • Lens/aperture: focuses the light
engineering and computing advances made fluoroscopy • Video camera (new technology) or television camera
capable of high-resolution imaging using minimal radia- (older technology): displays the image
tion. Currently, the technique of fluoroscopy is practiced in More recently, flat-panel detector systems have been
most hospitals, surgery centers, and outpatient clinics and available and have many advantages, most importantly
is readily available. reduction in radiation dose. Flat-panel digital fluoroscopy,
In general, fluoroscopes are considered fixed (perma- derived from thin film transistor technology, emerged in
nent) or mobile (portable). Fixed fluoroscopes are either the 1990s and is replacing the image intensifier and video
a vertical fluoroscope or fixed C-arm fluoroscope. Mobile camera. Thin film transistor technology, best known for its
fluoroscopes use a C-arm system on wheels and are com- use in modern television, avoids motion or image distor-
monly implemented in outpatient interventional pain prac- tion and improves dynamic range, allowing for improved
tices. The C-arm system moves the x-ray tube and image image quality.6,7,8–10 However, some concerns remain about
intensifier in any axis, thereby allowing image acquisition its potentially poor image quality at low exposure levels,
from nearly any angle.1–5 technology replacement costs, and equipment durability.4,5
Two categories of fluoroscopic units are currently avail- There are significant benefits with flat-panel display
able for mainstream medical use, traditional image-intensi- (FPD) systems when compared with the image intensifier–
fier, and flat-panel detector systems. The more traditional based units. Solid-state FPD image receptors generally have
image-intensifier television camera-based systems have been better stability, lower radiation dose rates, and improved
in use since the 1950s. The traditional image-intensifier dynamic range, and they eliminate glare and geometric dis-
based C-arm fluoroscopy system (Fig. 3.1) consists of the tortions such as vignetting and defocusing effects.6 Costs
following components (from bottom to top): for units appropriate for interventional pain procedures
• X-ray generator and tube: generates x-rays have dramatically reduced, which had been a major lim-
• Collimator: restricts the x-ray field and focuses the beam iting factor for prior generations of the technology. Based
• Image intensifier: allows visualization of the image in a upon the reduced exposure to radiation for both the patient
brightly lit room and reduces the radiation dose when and physician, this technology should be seriously consid-
compared with standard screen-film cassette ered by anyone purchasing new units for implementation.
 CHAPTER 3 Principles of Fluoroscopy Imaging in Spine and Musculoskeletal Interventional Orthopedics 33

Monitor

Video camera

Optical coupling

Image intensifier
Electron lenses
Input window
Grid

Patient
Output window
Table
Substrate Output phosphor
Filtration Input phosphor Anode

Collimator Photocathode

X-ray tube
B. Image intensifier with electron paths from
input window to output phosphor.
X-ray generator

A. Fluoroscopic imaging chain.

• Fig. 3.1 The traditional image intensifier–based C-arm fluoroscopy system.

Disadvantages include a different appearance than the tra- 0.6% to 6.8% of x-rays are transmitted through protec-
ditional image intensified units, and lower spatial resolution tive aprons.12 Finally, the x-ray generator should be as far
with very large or very small field of view (FOV). and the image intensifier as close to the patient as possible.
Three-dimensional (3D) fluoroscopy, the newest inno- The scatter of x-rays is greatest between the patient and the
vation to modern fluoroscopy systems, is rotational 3D x-ray generator, and positioning the x-ray generator below
imaging in which the gantry of a fluoroscopy system rapidly the patient will concentrate scatter to the operator’s feet
rotates through 180 degrees while continuously acquiring rather than head. Placing the x-ray generator twice the dis-
images.10 The resultant cine display resembles a volume- tance from the patient reduces the scatter of x-rays by one-
rendered computed tomographic image and may be used by fourth.13 As the demonstrated efficacy and ease of access
physicians to better understand the geometric location of of fluoroscopy increases, and thus the frequency of fluoro-
various structures, and precision delivery of biologics into scopic use increases, it is imperative that practitioners pri-
bone, disc, and tissue.9 oritize radiation safety. Pain management interventionalists
and regenerative specialists must appreciate the unwelcome
fallout of improperly managed radiography, develop safety
Precautions: As Low As Reasonably protocols to limit both patient and provider exposure, and
Achievable follow the principle of ALARA.14

Fluoroscopic guidance involves channeling beams of high- Radiation Dose

energy, ionized particles (x-rays) through the human body.
The x-rays that do not follow this path are scattered into Most interventional pain medicine procedures performed
the surrounding environment and create occupational haz- under fluoroscopic guidance result in total radiation expo-
ard concerns.1–5,11 The resultant patient and staff exposure sure time in seconds, not minutes. Regenerative medicine
to radiation necessitates safety equipment and guidelines to procedures should follow the benchmark guidelines of stan-
minimize the risk of skin injury or cancer. ALARA (as low as dard procedures and the average radiation dose delivered
reasonably achievable) is a radiation reduction concept that (Table 3.3). Studies show that doses less than 2 Gy should
should be used and enforced in all fluoroscopic settings. It not result in any observable effects over the span of 400
aims to minimize radiation exposure to patients and staff by days.13 Assuming a 0.02 to 0.05 Gy/min skin absorption
implementing guidelines around exposure time, shielding, rate, this would take nearly an hour of constant fluoroscopic
and distance (Table 3.2). guidance to reach. There is contemporary discourse revolv-
The annual individual radiation dose limits were set in ing around the wisdom of using peak skin dose or concen-
1990 and reconfirmed in 2007 by the International Com- tration in place of fluoroscopy time as a safety measure. This
mission on Radiological Protection and are currently as fol- should be considered, particularly when a patient undergoes
lows: 20 mSv (5000 mrem/year) for whole body, 150 mSv multiple consecutive injections, such as is commonly done
for thyroid, and 500 mSv for hands.11 However, protective with prolotherapy or platelet-rich plasma.14 Furthermore,
equipment is imperfect. It is estimated that approximately due to the necessary increase in dose and exposure, obese
34 SEC T I O N I Introduction

TABLE when a threshold dose has occurred, usually as a large, sin-

3.2   Reducing Risk from Fluoroscopic X-rays gle radiation dose. This is a consideration most notably in
radiation oncology and radioactive spills. In this case, a clear
Important actions for reducing exposure time and risk to
patient and provider when using fluoroscopy cause and effect relationship is identified, and the degree of
effect is dependent on the magnitude of exposure.
1. Obtain adequate and appropriate training
Although the relative simplicity of interventional pro-
2. Wear a dosimeter and know your own dose cedures protects patients against the longer exposure times
3. Use personal protective equipment including found with other fluoroscopic procedures, patient dose and
aprons, thyroid collar, eyewear, and shielding exposure should not be taken lightly.16 Of equal concern is
when appropriate practitioner exposure. It is significantly difficult to negate
4. Use good imaging-chain geometry; do not scatter radiation in interventional pain management and
overuse geometric or electronic magnification regenerative medicine procedure setting due to the prox-
5. Use collimation, and always collimate to the area
imity the interventionist must maintain with the injection
of interest (and the imaging) site; accordingly, this suggests reduc-
ing patient exposure would reduce occupational exposure.
6. Position yourself in a low-scatter area
Cumulative dose and the risk of cancer becomes concerning
7. Plan the intervention in advance to minimize when interventionalists regularly perform high volumes of
number of acquired images interventional procedures, as is often done in a regenerative
8. Obese patients will require and receive higher medicine practice.
doses, and you will too Radiation Protection Services oversees the public’s health
9. Keep beam-on time to a minimum and safety as it pertains to radiation exposure. The orga-
nization governs appropriate use and maintenance of fluo-
10. Keep the image intensifier as close to the patient
as possible and keep the patient as far from the
roscopes. Although national and statewide regulations vary
x-ray tube as possible widely, the following is an approximate list of the required
documentation, taken from Oregon Radiation Protection
11. Use last-imaged-stored viewing
Services (author’s state of licensure and practice). Please see
12. Incorporate variable frame rate pulsed practices state-specific documents for a complete list.
rather than continuous or “live” fluoroscopy Fluoroscope Inspection Required Documentation:
when possible
1. Dosimetry Records
13. If image quality is not compromised, remove the 2. Licenses for all qualified operators
grid during procedures on small patients or 3. Annual Physics Survey for each fluoroscope
when the image intensifier cannot be placed
4. Written procedures regarding the setup and operation
close to the patient
of each fluoroscopic machine registered to the facility
14. A single step away from the patient will decrease 5. Written radiation safety procedures pertaining to the
provider exposure by a factor of four
use and operation of fluoroscopy
Adapted and modified from Miller DL, Van˜o´ E, Bartal G, et al. Occu- 6. Benchmarks defining procedural exposure times
pational radiation protection in interventional radiology: a joint guideline 7. Fluoroscopy logs—documentation of procedure per-
of the Cardiovascular and Interventional Radiology Society of Europe
and the Society of Interventional Radiology. Cardiovasc Intervent Radiol.
formed
2010;33:230–239; and Wagner LK, Archer BR. Minimizing Risks from 8. Annual Program Review—benchmark review, quality
Fluoroscopic X-rays. 3rd ed. The Woodlands, TX: RM Partnership; 2000. assurance, and corrective actions
9. Patient ESE (entrance skin exposure)
10. Gonadal Shielding Policy
11. Annual lead apron check
patients—and those present for their procedure—are at sig-
nificantly greater risk of skin injury and possibly cancer due Contrast Media
to fluoroscopy.15
Regarding radiation exposure, it is imperative to con- Contrast media are used to enhance or outline anatomic
sider both stochastic and nonstochastic effects. Stochastic boundaries of a target area to help ensure proper needle
effects, such as cancer or genetic changes, are effects that placement prior to injection of a diagnostic or therapeutic
take place by chance. The likelihood of a stochastic effect agent and avoid inadvertent intravascular placement. When
increases with the individual’s radiation dose (e.g., occupa- performed intentionally, this is referred to as an angiogram
tional exposure or repeated fluoroscopic exams); however, (arteriogram or venogram). Fluoroscopy may be superior
there is not a single threshold dose that guarantees the effect for targeting soft tissue structures that are routinely difficult
to occur. The effects usually present years after exposure, to visualize with ultrasound such as anterior cruciate liga-
and the severity does not correlate to the degree of exposure. ment, posterior cruciate ligament, and iliolumbar ligament
In contrast, nonstochastic (or deterministic) effects, such as injections. Contrast can be injected into these ligaments,
radiation burns or hair loss, are those that take place only tendons, and other soft tissues to illustrate the lesion and
TABLE
3.3   Dose (mGy) Per Injection and Time (s) Per Injection by Procedure

Radiation Dose (mGy)

Number of Standard 10th Percentile 25th Percentile 50th Percentile 75th Percentile 95th Percentile
Procedure Studies Mean Dose Deviation With 95% CI With 95% CI With 95% CI With 95% CI With 95% CI
Transforaminal lumbar 3590 10.4 11.9 2.0 (1.9–2.2) 3.5 (3.3–3.6) 6.7 (6.5–7.0) 12.5 (11.9–13.1) 32.4 (30.6–34.2)

CHAPTER 3
Transforaminal cervical 157 5.6 6.5 1.0 (0.8–1.1) 1.8 (1.4–2.2) 3.3 (3.0–3.7) 5.7 (3.3–6.5) 21.8 (18.0–27.6)
Caudal epidural 658 10.0 12.4 1.6 (1.3–1.7) 3.1 (2.8–3.6) 6.0 (5.5–6.4) 11.0 (9.6–12.4) 32.8 (27.3–36.3)
Facet joint cervical 62 2.6 2.8 0.5 (0.4–0.8) 0.7 (0.3–0.9) 1.5 (0.9–1.7) 3 (1.3–4) 8.4 (6.8–12.1)
Facet joint lumbar 410 6.45 6.41 1.1 (0.7–1.2) 2.2 (2.1–2.5) 4.1 (3.3–4.5) 8.7 (7.9–10) 19 (15.2–22.1)

Principles of Fluoroscopy Imaging in Spine and Musculoskeletal Interventional Orthopedics

Interlaminar 446 11.2 14.7 1.4 (1.2–1.6) 2.7 (2.2–3.0) 6.4 (5.8–7.4) 12.4 (9.3–13.6) 42.2 (26.7–52.5)
(translaminar)
Radiofrequency 318 4.7 6.6 0.5 (0.4–0.6) 1.3 (1.1–1.5) 2.7 (2.3–3.1) 6.3 (5.7–7.5) 15.8 (13.0–20.1)
denervation (lumbar)
Lumbar sympathetic 296 15.4 16.2 2.5 (2.0–2.8) 4.5 (3.1–5.3) 9.9 (7.9–10.9) 19.2 (15.3–21.9) 49.9 (40.1–62.8)
block
Medial branch block 41 2.2 2.1 0.4 (0.2–0.5) 0.7 (0.3–1) 1.7 (0.8–2.4) 2.8 (1.4–3.4) 6.4 (2.7–8.9)
cervical
Medial branch block 169 3.4 4.4 3.9 (3–4.1) 5.2 (4.6–5.5) 7.9 (6.8–8.5) 12.1 (10.6–13.8) 21.8 (14.8–25.7)
lumbar
Sacroiliac joint 87 9.9 8.2 2.0 (1.4–2.5) 3.7 (1.9–4.9) 7.0 (5.9–7.7) 15.0 (11.8–21.3) 27.4 (22.6–33.9)
Procedure Time (s)
Number of Standard 10th Percentile 25th Percentile 50th Percentile 75th Percentile 95th Percentile
Procedure Studies Mean Time Deviation With 95% CI With 95% CI With 95% CI With 95% CI With 95% CI
Transforaminal lumbar 3590 24.3 15.4 10.4 (10.1–10.6) 14.3 (14.0–14.6) 20.3 (19.7–20.8) 29.9 (29.2–30.9) 52.7 (50.9–55.2)

Transforaminal cervical 157 40.4 28.6 18.2 (17.3–20.5) 21.1 (18.6–22.6) 31.2 (27.0–35.7) 46.3 (37.7–52.0) 105.0 (84.5–
122.6)
Caudal epidural 658 18.9 13.9 7.3 (6.7–7.9) 10.1 (9.6–10.5) 14.8 (13.8–15.6) 22.6 (20.7–23.8) 44.8 (34.9–49.4)

Facet joint cervical 62 27.0 18.5 11.2 (9.7–13.5) 13.6 (10.3–15) 22.1 (17.8–26.7) 35.2 (28.3–43.6) 52.3 (19.8–61.2)

Continued

35
 36 SEC T I O N I
Introduction
TABLE
3.3   Dose (mGy) Per Injection and Time (s) Per Injection by Procedure—Cont’d

Procedure Time (s)

Number of Standard 10th Percentile 25th Percentile 50th Percentile 75th Percentile 95th Percentile
Procedure Studies Mean Time Deviation With 95% CI With 95% CI With 95% CI With 95% CI With 95% CI
Facet joint lumbar 410 16.5 9.1 7.3 (6.7–7.7) 10.3 (9.3–11.1) 14.4 (13.5–14.9) 20.5 (18.9–21.8) 33.5 (31.2–37.2)
Interlaminar (translaminar) 446 29.5 20.7 11.6 (10.8–12.1) 15.4 (14.3–16.5) 23.5 (20.9–25.4) 37.3 (34.9–40.1) 64.2 (54.7–70.3)
Radiofrequency 318 13.5 10.4 4.8 (3.7–5.5) 7.3 (6.6–8.0) 11.5 (10.9–12.4) 16.2 (14.8–17.8) 28.2 (21.4–30.6)
denervation (lumbar)
Lumbar sympathetic 296 32.3 14.0 19.1 (17.8–20.6) 23.9 (22.9–24.7) 29.1 (27.2–30.5) 37.5 (35.8–39.7) 59.1 (48.9–67.8)
block
Medial branch block 41 19.1 10.0 6.9(1.8–8.4) 12.3 (9.4–16.6) 16.9 (11.3–19.6) 25.4 (21.1–29.6) 35 (18.4–41.4)
cervical
Medial branch block 169 9.8 7.3 3.9 (3–4.1) 5.2 (4.6–5.5) 7.9 (6.8–8.5) 12.1 (10.6–13.8) 21.8 (14.8–25.7)
lumbar
Sacroiliac joint 87 28.6 14.5 13.3 (12.4–15.1) 16.6 (13.5–19.4) 27.8 (23.7–33.8) 36.1 (30.1–38.6) 54.7 (46.7–63.8)

CI, Confidence interval.

Adapted from Cohen SL, Schneider R, Carrino JA, et al. Radiation dose practice audit of 6,234 fluoroscopically-guided spinal injections. Pain Physician. 2019;22:E119–E125.
 CHAPTER 3 Principles of Fluoroscopy Imaging in Spine and Musculoskeletal Interventional Orthopedics 37

ensure intralesional placement and accurate delivery of the nontoxic while allowing for renal excretion. Adverse reac-
biologic. Meniscal or labral lesions are often visualized and tions to ICAs range from mild to severe and life threaten-
accessible via ultrasound; however, in cases such as meniscal ing. If interventionalists are going to administer an ICA,
root tears or glenoid labral tears in larger patients, fluoros- they should be sure that they are trained and equipped to
copy may be a superior modality. handle anaphylaxis and anaphylactoid reactions. Because
When the needle is placed in a joint and direct contrast the interventionalist will be administering the ICA by
media is injected, this is referred to as an arthrogram. Simi- direct injection, the risk of contrast-induced nephropathy
larly, if the contrast media is injected into an intervertebral is negated. The most common adverse reactions reported
disc, the fluoroscopic image is referred to as a discogram. in relation to direct ICA administration are swelling of the
When confirming epidural needle placement, injection of associated joint and injection site hematoma.
contrast media into the epidural space is referred to as an
epidurogram. Differing imaging modalities may require Contrast Media and Orthobiologics
one of many possible contrast media classes, yet the class of
contrast media indicated for x-ray (and thus fluoroscopic) To our knowledge, there are very little data on the effects of
imaging is iodinated contrast agents (ICAs). fluoroscopy and contrast media on biologics such as plasma-
ICAs are broadly classified as either ionic or nonionic. rich protein (PRP). A study using human intervertebral disc
Ionic ICAs such as diatrizoate (Hypaque) and ioxaglate cells in vitro found contrast media to be cytotoxic to the
(Hexabrix) are hyperosmolar relative to blood. These ionic cells. The cytotoxic effects were greater with ionic contrast
agents are associated with a risk of neurotoxicity; therefore media when compared with nonionic, dimeric contrast
they should not be injected into the spinal cord or bronchial media and was dose dependent.25 A more recent study from
tree.17,18,19 Nonionic ICAs, such as iohexol (Omnipaque) Wu et al. evaluated potential cytotoxic effects of iohexol
and iodixanol (Visipaque), are generally low osmolar or iso- (Omnipaque 300) on human adipose-derived mesenchymal
osmolar, respectively. There are three general administra- stem cells (MSCs). Wu et al. demonstrated that there was
tion routes of a given contrast agent: intravascular, enteric, toxicity to MSCs in a time- and concentration-dependent
or direct injection. For the interventionalist performing manner; however, a brief 30-minute exposure did not affect
fluoroscopic-guided procedures, direct injection is the indi- MSC function or viability.26 Another study by McKee et al.
cated administration route. When considering risks associ- studied the effects of contrast on human umbilical stem
ated with either contrast agent or route of administration, cells in vitro. It showed that contrast had cytotoxic effects
ionic ICAs delivered intravascularly pose the highest risk in a concentration- and time-dependent manner, with
of adverse reaction. The incidence of adverse reaction to a iopamidol (Isovue-300) being significantly more toxic than
high-osmolarity ionic agent is approximately 15% and only iohexol.27 One must consider the risks and benefits of plac-
approximately 3% for low-osmolarity nonionic agents.20 ing the biologics in the incorrect location versus the pos-
This is one of several reasons why low-osmolarity nonionic sible effect of contrast media on the biologic injectate itself.
agents such as Omnipaque or Visipaque are the contrast As a general recommendation, as little contrast as needed
agents of choice. for accurate and safe injection of cells should be used and
An ICA administered by direct injection is not metabo- one can consider diluting the contrast where appropriate to
lized locally or systemically.21 Instead it is postulated that reduce the concentration. Avoid ionic agents and iopamidol
the ICA is slowly absorbed into the body via the lymphatic (Isovue-300) for use with cellular therapies.
system and then cleared by the kidneys. Adverse reactions
to a low-osmolar ICA delivered by direct injection is very
rare, yet it is best practice to try to prevent possible acute Practical Fluoroscopy Bullets
adverse reactions by screening patients for the most com-
Protective Equipment, Shielding, Monitoring
mon risk factors for an acute reaction to an ICA. These
three risk factors are a history of asthma, a prior reaction Key Points
to an ICA, and atopy.22 For patients who have one of these • R
 adiation safety can be accomplished with the use of
risk factors, be sure to avoid ionic high-osmolar ICAs and widely available protective equipment, shielding, dis-
consider whether an ultrasound-guided injection may be tances from the x-ray source to the pertinent anatomy,
adequate. Recent literature review has shown that the rela- and awareness of personnel distances from the x-ray
tionship between shellfish allergies and iodine allergies source.
does not increase the likelihood to contrast allergic reac-
tions.23,24 Moreover, common interventional procedures Pertinent Information
using ICAs expose the patient to very small volumes of • D
 uring fluoroscopic interventional spine procedures,
contrast, unlike intravascular administration; therefore the use of lead aprons with a lead equivalency of at least
the risk is further diminished. Patients can be premedi- 0.25 mm should be worn by all staff members within the
cated with diphenhydramine if there is any concern by the room and any personnel who may enter the room during
physician. All gadolinium-based contrast agents are che- procedures. Lead protective aprons with a 0.50-mm lead
lated with the intention of making the agents less toxic or equivalent are preferred. This is especially true for the
38 SEC T I O N I Introduction

interventionalist and any staff members who would be at • F or real-time dosimeters, it is common to wear the
the patient’s head during procedures. devices inside of the lead apron.
• Lead aprons attenuate between 90% and 95% of scat- • Each facility should have a dedicated radiation or medi-
tered radiation.28 cal physicist who oversees the radiation safety program.
• During fluoroscopic orthopedic extremity procedures, it The physicist will determine whether radiation dosim-
is recommended that lead aprons with at least 0.25-mm eters should be worn outside or inside of the lead protec-
lead equivalent be worn by the interventionalist. tive aprons. If your facility does not have a physicist, then
• This is a recommendation only when using smaller, consult with your radiation dosimetry entity.
lower-output exposure fluoroscopic units that may Dose Reduction During Interventional
commonly be termed as “mini C-arms.”
• The use of additional lead transparent shielding is Orthopedic Procedures
encouraged where available. Key Points
• Thyroid shields that meet a 0.50-mm lead equivalency • Th
 ere are many controllable techniques and machine fea-
should be worn in conjunction with lead aprons. tures that can be used to decrease the x-ray radiation dose
• Lead protective eye wear should also be used by the inter- that the patient, interventionalist, and staff are exposed to.
ventionalist and anesthesia provider whenever possible. • Use of good exposure practices can serve to decrease radi-
• The use of protective lead gloves is dependent upon the ation exposure to the patient and staff.
practices of the interventionalist. Interventionalists who
practice techniques that keep their hands within the Pertinent Information
area of the imaging field should not wear protective lead • M ost modern fluoroscopic C-arm units have dose-lim-
gloves. The reasons for this are as follows: iting and x-ray beam–limiting capabilities. The most
• The automatic exposure control used by most newer- common dose-limiting capabilities are the “low-dose”
generation C-arm fluoroscopy units will detect an mode and pulsed fluoroscopy modes. Use of either of
increase in the density of the required imaging field. these capabilities will degrade image quality in exchange
This density is created by now adding two layers of a for lower radiation exposures. The interventionalist must
lead protective glove into the imaging field. weigh the risks of radiation exposure versus the need for
• The fluoroscopy unit will respond to any increase image quality when using these dose-limiting modes.
in detected density by increasing the overall output • Fluoroscopic C-arms have beam limiting capabilities in
exposure to sufficiently penetrate the added density. the form of collimating the size and shape of the x-ray
The x-ray machine will try to penetrate two layers of beam. Using proper collimation that allows visualization
lead protective gloves if the interventionalist’s hands of the pertinent anatomy and the reference anatomy will
are in the imaging field. decrease the overall output x-ray exposure of the machine.
• The increased output exposure will cause the interven- • Distance from the x-ray source allows for the use of the
tionalist’s hands to become overradiated in addition inverse square law to reduce the radiation exposure to
to increasing the absorbed patient dose and the scatter staff. When the distance from an x-ray source is doubled,
dose that exposes other staff in the room. the amount of exposure is decreased by a factor of 4.
• Interventionalists who regularly remove their hands to • The use of high-level fluoroscopy or boosted fluoroscopy
just beyond the area of the imaging field are encouraged mode should be minimized (normally indicated by an
to wear lead protective gloves. The x-ray beam attenua- icon that looks like an “eye” with a plus sign next to it).
tion properties of most commonly available lead protec- Although the amount of increased radiation exposure
tive gloves will decrease the scatter radiation exposure to from using this mode will vary depending upon the fluo-
the hands. roscopy machine manufacturer, it is recommended that
• Active radiation dosimetry monitoring should be used in the use of this mode should be limited to intermittent
every interventional procedure environment. The use of spot visualization. The use of high-level fluoroscopy may
cumulative dosimetry badges that are analyzed, at least also be needed due to patient body habitus or anatomic
on a quarterly basis by an accredited dosimetry entity, is part thickness. Nonetheless, it is recommended that such
highly encouraged. use remains limited. Final documentation of needle or
• Care should be taken to remove the dosimeters from device positioning can be accomplished in normal or
the procedure suite at the end of each procedure day. low-dose mode, depending upon patient body habitus.
• Storing dosimeters within the lead protective aprons Care should be taken to limit constant exposure of the
on a regular basis is discouraged because these may x-ray beam while in the high-level or boosted fluoros-
end up being left in the procedure suite, thereby pro- copy mode.
ducing falsely increased dose readings.
• A secondary type of active radiation dosimetry moni- Technique and Use of Good Exposure Practices
toring is the use of real-time dosimeters. This type of • Th
 e fluoroscopic C-arm consists of an image intensifier
dosimeter can be turned off or reset at the end of each (“the receptor”), which is the larger rounded end, and
day, and each dose reading can be logged daily. on some newer models the flat-panel end. This receives
 CHAPTER 3 Principles of Fluoroscopy Imaging in Spine and Musculoskeletal Interventional Orthopedics 39

• U sing the pulsed mode on fluoroscopy systems that are

equipped with this feature significantly decreases radia-
tion exposure during procedures. Systems that can pulse
the x-ray beam at less than 10 pulses per second can
result in up to 90% less exposure compared with non-
pulsed systems.31,32
• Most modern day fluoroscopy units will have a “low-
dose” feature that decreases the radiation output by as
much as 50% when used.
• Proper collimation is the standard of care for technicians
who operate fluoroscopic units, regardless of whether the
technician is initiating each exposure or the intervention-
alist is using a foot pedal for exposure.
• The use of both iris (sometimes referred to as “circle-
• Fig. 3.2 Demonstration of correct C-arm orientation with the emitter cone”) and shutter collimators is recommended. This
underneath the procedure table and the receptor above the patient. will significantly reduce the amount of scatter radia-
(From Wagner LK. Radiation management for patients and protection tion exposure to the patient and personnel.
of staff. In: Manchikanti L, Singh V, eds. Interventional Techniques in
• Note: for older model fluoroscopic machines typically
Chronic Spinal Pain. Paducah, KY: ASIPP Publishing; 2007:113–124.)
manufactured before 1999, some manufacturers used
shutter collimators made primarily of copper. The use
the x-ray beam and processes it into a video image that of shutter collimation on the older model machines is
is seen on the displays. The opposite end of the C-arm is not advised, because the copper collimators will cause
the emitter (“the tube”), where x-ray radiation is emitted the machine to “average-in” the incorrect amount of
from. contrasting. This may degrade the ability of visualize
• The typical configuration when performing interven- necessary detail. Therefore only iris collimation is rec-
tional orthopedic or pain management procedures is ommended when using the older model machines.
to keep the emitter below the surface of the procedure • In addition to collimation, centering of pertinent
table (Fig. 3.2). anatomy within the fluoroscopic display is important.
• Scatter radiation production is primarily generated Centering anatomy will allow for a better overall aver-
from the area of the patient that is within the closest aging of the contrast and density by the fluoroscopic
proximity to the x-ray radiation source.29 machine. Proper centering also serves to preserve the
• Interventionalist and staff exposure rates will increase ability of “spatial acuity” (the visual reference points of
as they get closer to the side of the patient where the the image) for the interventionalist each time that the
x-ray beam enters first.29 interventionalist views the fluoroscopic display. These
• Using a “best practice habit” of keeping the emitter practices can serve to decrease the amount of repeat fluo-
below the table and patient will decrease the overall roscopic exposure needed to visualize the same anatomic
radiation exposure to the patient and staff. detail, which in turn, will lead to a decrease in overall
• The interventionalist should direct the C-arm operator exposed radiation to the patient and staff.
to adjust the C-arm to the angles needed, based upon
how the target anatomy is positioned within the patient, Conclusion
before taking any exposures.30
• This will facilitate a closer alignment of the x-ray beam Fluoroscopic imaging will continue to play a very signifi-
to the target anatomy, thereby decreasing the usage of cant role in the precision delivery of biologics and regenera-
what is termed as “scout-fluoro.” tive materials for treatment of joint and spine pathology. In
• Less “scout-fluoro” (continuous or rapidly intermit- fact, as regenerative therapies become more prevalent, more
tent exposure of the fluoroscopy beam to localize the sophisticated, and more comprehensive, there likely will be
target anatomy) utilization, will facilitate a decrease an increase in utilization of fluoroscopic guidance. It pro-
in the amount of overall x-ray exposure for each vides a level of precision and safety that, for many structures
procedure. of the spine, cannot be replicated with ultrasound guid-
• The interventionalist should support the use of x-ray ance. This is especially relevant to spine and neural axis-
beam collimation whenever anatomic reference imag- based therapies. There will also be increased use of mixed
ing is not required. modality imaging in which both fluoroscopic and ultra-
• The receptor should be as close to the patient as the sound guidance will be used to safely and comprehensively
procedure will allow. This will create increased distance treat our patients. Real-time 3D fluoroscopy is an intrigu-
between the emitter and the patient. As a result, the ing new technology that could greatly aid precision deliv-
patient dose will decrease along with the amount of scat- ery of biologic materials into deep and complex structures,
ter radiation. such as regions of avascular necrosis of bone, bone marrow
40 SEC T I O N I Introduction

lesions, disc herniations, annular tears, and other deep tissue 15. Giordano BD1, Baumhauer JF, Morgan TL, et al. Cervical
structures. Radiation exposure will continue to be an area spine imaging using standard C-arm fluoroscopy: patient and
of concern, and proper education about exposure-limiting surgeon exposure to ionizing radiation. Spine (Phila Pa 1976).
technique, increased availability, and decreased cost of flat- 2008;33:1970–1976.
16. Makhesh M. Fluoroscopy: patient radiation exposure issues.
panel detector technology will provide for improved safety
RadioGraphics. 2001;21:1033–1045.
and less risk of stochastic and nonstochastic effects of radia- 17. Cohen SL, et al. Radiation dose practice audit of 6,234 fluoro-
tion exposure. scopically guided spinal injections. Pain Phys. 2019;22:E119–
E125.
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Non-Spinal Pain. Paducah, KY: ASIPP Publishing; 2009:27–34. e1‒e4.
6. Edward LN. Physics tutorial for residents: physics of flat-panel 25. Kim K, Park J, Park H, et al. Which iodinated contrast media is
fluoroscopy systems, survey of modern fluoroscopy imaging: flat- the least cytotoxic to human disc cells? Spine J. 2015;15:1021–
panel detectors. RadioGraphics. 2011;31:591–692. 1027.
7. Monfett M, Harrison J, Boachie-Adjei K, et al. Intradiscal plate- 26. Wu, Tao et al. Cytotoxic effects of nonionic iodinated con-
let-rich plasma (PRP) injections for discogenic low back pain: an trast agent on human adipose-derived mesenchymal stem cells.
update. Int Orthop. 2016;40:1321–1328. PM&R: the Journal of Injury, Function, and Rehabilitation. 2018;
8. Bushberg J, Seibert J, Leidholdt E, et al. The Essential Physics of S1934-1482(18):30294‒30296.
Medical Imaging. 2nd ed. Philadelphia: Lippincott, Williams & 27. McKee C, et al. Cytotoxicity of radiocontrast dyes in human
Wilkins; 2002:231–254. umbilical cord mesenchymal stem cells. Toxicol Appl Pharmacol.
9. ICRP, 2007. The 2007 Recommendations of the International Com- 2018;349:72–82.
mission on Radiological Protection. ICRP Publication 103. Ann. 28. Manchikanti L, et al. Radiation exposure to the physician
ICRP 37. in interventional pain management. Pain Physician. 2002;
10. Christodoulou EG, Goodsitt MM, Larson SC, et al. Evaluation 5(4):385–393.
of the transmitted exposure through lead equivalent aprons used 29. Young, C. Fluoroscopy: Mobile Unit Operation and Safety.
in a radiology department, including the contribution from back- American Society of Radiologic Technologists web article. www.a
scatter. Med Phys. 2003;30:1033–1038. srt.org/SelfDirectedLearning/10203.
11. Kaplan DJ, Patel JN, Liporace FA, et al. Intraoperative radiation 30. McKay-Best T. Fluoroscopy Manual for Pain Management.
safety in orthopaedics: a review of the ALARA (as low as reason- American Society of Radiologic Technologists; 2000: ISBM-10:
ably achievable) principle. Patient Saf Surg. 2016;10:27. 0967817609.
12. Giordano BD, Grauer JN, Miller CP, et al. Radiation exposure 31. Johnson M. Fluoroscopy: Regulation and Radiation Protection.
issues in orthopaedics. J Bone Joint Surg Am. 2011;93:e69. American Society of Radiologic Technologists; 2017. Self-
13. Gibson TR, Bevill B, Foster M, Spohrer MA. Technical White directed Learning article www.asrt.org.
Paper: Monitoring and Tracking of Fluoroscopic Dose. Conference 32. Seeram E, Travis EL. Radiation Protection. Philadelphia, PA: Lip-
of Radiation Control Directors; 2010. pincott, Williams & Wilkins; 1997:171–176.
14. Nicol AL, Benzon HT, Liu BP. Radiation exposure in interven-
tional pain management: we still have much to learn. Pain Pract.
2015;15:389–392.
 S E C T I ON II Injectates

4
Principles of Injection
Therapy
LEE KNEER, ROBERT BOWERS, AND CLEO D.
STAFFORD II

Musculoskeletal injections are common procedures across before being translocated into the nucleus and binding to
various medical specialties. The evidence for musculoskel- the glucocorticoid response element (a short sequence of
etal injections is varied and is complicated by differing DNA that binds transcription factors and regulates gene
injection techniques, injectates, and landmark versus image transcription).6 Corticosteroids affect cellular transcription
guidance. When performed for the proper indication and in two ways: (1) inflammation is suppressed through the
with correct technique, musculoskeletal injections can be inhibition of tumor necrosis factor α and other proinflam-
beneficial and rewarding for both patients and physicians. matory mediators; and (2) antiinflammatory gene transcrip-
Before proceeding with an injection, it is critical to obtain tion is enhanced while inflammatory gene transcription is
a proper diagnosis and rule out relevant contraindications. suppressed.6,7
Absolute contraindications include injectate hypersensitiv- When administered orally, these hydrophobic com-
ity, infection, uncontrolled bleeding disorder, and fracture. pounds are small enough to be transported via diffusion
Relative contraindications include corrected bleeding disor- across the capillary wall; however, diffusion leads to low
der, anticoagulant use, hemarthrosis, diabetes, immunosup- overall bioavailability in the synovial fluid. Thus the need
pression, prosthetic joint, high risk of tendon rupture, and to provide high doses to achieve an adequate therapeutic
psychogenic pain.1,2 effect, and while the effects of oral steroids are theoretically
This chapter addresses the most common nonbiologic beneficial to the targeted structure they are nonspecific and
injectates used in clinical practice including corticosteroids, can have systemic side effects. Short-term systemic corti-
local anesthetics, ketorolac, and hyaluronic acid (HA), as costeroid use is generally associated with mild side effects,
well as the evidence for and against their use. including cutaneous effects, electrolyte abnormalities,
hypertension, hyperglycemia, pancreatitis, hematologic,
Corticosteroids immunologic, and neuropsychologic effects. Long-term
systemic corticosteroid use may be associated with more
Corticosteroid injections (CSIs) first gained popularity in serious sequalae, including osteoporosis, avascular necrosis,
the 1950s and were used to treat patients with joint pain adrenal insufficiency, gastrointestinal, hepatic, and ophthal-
associated with rheumatoid arthritis. Benefits included mologic effects, hyperlipidemia, growth suppression, and
delivery of a lower dose of steroid compared with oral possible congenital malformations.8,9 Thus practitioners
options, resulting in a lower systemic risk profile.3 Risks sought a more directed means of delivering corticosteroids
associated with CSIs include infection, flushing, a transient into the joint space.
increase in pain, skin hypopigmentation in superficial injec-
tions, allergic reaction, and transient hyperglycemia, among Intra-articular Injections
other less common complications.4,5
Corticosteroids are small hydrocarbon molecules. At the Intra-articular injection of corticosteroids not only improves
cellular level, once the amphipathic corticosteroid arrives the concentration within the joint and minimizes systemic
in the synovial fluid it crosses the lipid bilayer of the cel- effects but also allows for delivery of polymers or salts mole-
lular membrane and binds to the glucocorticoid receptor cules complexed with the corticosteroid in aqueous solution

41
42 SEC T I O N I I Injectates

to improve drug stability and extend the therapeutic win- addition, the authors prefer the use of ultrasonographic
dow. Despite this, and due to their very low molecular guidance because it is associated with improved accuracy
weight (<700 Da), corticosteroids routinely exhibit a half- of intra-articular injections.27 Wyles and colleagues also
life of 12 hours or less.10,11 demonstrated that corticosteroids are cytotoxic to human
Corticosteroids have a long track record of use in intra- mesenchymal stem cells in a dose-dependent fashion, with
articular inflammatory processes. Matzkin and colleagues betamethasone being most toxic and dexamethasone being
showed improvements in pain and function at all time the least toxic.28 Again, current data suggest that use of the
points (3 weeks, 6 weeks, 3 months, and 6 months) after lowest efficacious dose of corticosteroid should be favored.
one CSI, with obesity and severity of disease associated with Management of pain associated with intra-articular
less improvement and duration of response.12 Several orga- inflammatory processes requires an individualized approach,
nizations have deemed CSIs safe and temporarily efficacious, taking into account the patient’s personal goals, medi-
including the Osteoarthritis Research Society International, cal history, tolerance of risk, and extent of disability. Any
the US National Institute of Health, the American College intra-articular injection for such an inflammatory process,
of Rheumatology, the Arthroscopy Association of Canada, corticosteroid or otherwise, should only be pursued as part
and the American Academy of Orthopaedic Surgeons.13–16 of a multimodal approach that includes mitigating other
An initial Cochrane review of the efficacy of intra-articular risk factors for recurrent pain and dysfunction.
CSIs concluded temporary benefit.17 However, an updated
review of the literature suggested the heterogeneity in trial Axial Spine Injections
design and variability of studies limit the ability to assess the
benefit of these injections and that there is a low likelihood Fluoroscopy-guided CSIs have been used for radicular pain,
of meaningful benefit 6 months post injection.17,18 Despite both diagnostically and therapeutically.29,30 There are sev-
the poor data quality, the Cochrane review did find that eral options of corticosteroids for epidural steroid injec-
injected corticosteroids improved pain scores by 1 cm on a tions, and corticosteroids are divided between particulate
standard 10-cm visual analog scale compared with control, (triamcinolone, methylprednisolone, betamethasone) and
with a number needed to treat of 8. nonparticulate (dexamethasone) preparations. There is lim-
More recently, the potential negative long-term effects ited evidence to support the superiority of particulate or
of intra-articular CSIs have been highlighted. Cartilage nonparticulate steroids for epidural CSIs, but there is a con-
exposure to corticosteroids has been associated with such cern that particulate formulations pose an increased risk of
deleterious outcomes as decreased extracellular matrix pro- embolism after inadvertent intravascular injection. The US
duction, decreased type 1 collagen synthesis, and induction Food and Drug Administration (FDA) has produced a risk
of chondrocyte apoptosis.19,20 In a study by McAlindon and assessment of serious neurologic events after epidural gluco-
colleagues, repeated exposure to CSIs over 2 years for symp- corticoid injections and stated that “although many experts
tomatic knee osteoarthritis was associated with increased believe the risk is greatest with suspensions [or particulate
cartilage loss compared with control subjects injected with steroids], the available data do not support comparative
saline.21 safety labeling implying that solutions are safer.”31 Given
Klocke and colleagues subsequently showed a decrease the lack of strong data favoring the efficacy of particulate
in the concentration of serum biomarkers for cartilage and steroids and the risk of catastrophic adverse events, the
bone metabolism at 3 weeks post injection, and Lu and col- authors prefer nonparticulate corticosteroids for epidural
leagues demonstrated protective effects of steroids on glycos- CSIs.32,33
aminoglycan loss after a mechanical injury to the cartilage Irrespective of the choice of injectate, the cost-effective-
and proinflammatory cytokine exposure.22,23 A systematic ness and clinical benefit of epidural CSIs are debated.34,35
review from Wernecke and colleagues in 2015 determined Many reviews and meta-analyses have been written on the
that corticosteroids have a time- and dose-dependent effect topic of epidural CSIs. A 2015 meta-analysis in Annals of
on articular cartilage, with beneficial effects occurring at low Internal Medicine from Chou and colleagues determined
doses and durations and detrimental effects at high doses that epidural CSIs provided immediate improvements in
and durations.24 Therefore it seems prudent to use the low- pain and function. However, the improvements were small
est efficacious dose and to limit repeat injections based on and not sustained. Epidural CSIs also did not affect long-
current data. More research into the longer-term effects of term surgery risk.36 Furthermore, in a retrospective follow-
these changes and clinical implications is warranted. up performed by Jang and colleagues, a small minority
There is no consensus regarding the volume of injectate of those who underwent a remote lumbar transforaminal
or choice of injected corticosteroid. A comparison study epidural CSI achieved complete relief with one injection,
showed similar efficacy between injected triamcinolone while nearly half had relied on repeat epidural CSIs and oral
hexacetonide (40 mg) and methylprednisolone acetate (40 pain medications, and approximately 25% of patients had
mg).25 There are data to suggest improved benefit from progressed to surgery.37 Of note, outcomes from surgery
triamcinolone hexacetonide over triamcinolone acetonide, in the cohort were relatively poor, leading the authors to
and the authors prefer the combined effectiveness with recommend consideration of epidural CSIs as a viable pre-
mitigation of risk in using 40 mg rather than 80 mg.26 In surgical intervention despite the lack of definitive relief in
 CHAPTER 4 Principles of Injection Therapy 43

the majority of cases. In addition to the lack of expected to relieve pain.64,65 All local anesthetics are membrane-sta-
permanent relief, repeat epidural CSIs expose the patient bilizing drugs that decrease the rate of depolarization and
to the risk of significant adverse events including epidural repolarization of the cellular membranes of neurons by
hematoma, infection, and strokes, among others, and repeat inhibiting sodium influx through ion channels in the cell
epidural CSIs have been associated with adrenal suppression membrane, thus inhibiting action potentials and blocking
due to systemic uptake.38,39 signal conduction.66 All nerve fibers are sensitive to local
anesthetics; however, type C pain fibers are some of the
Soft Tissue Corticosteroid Injections most sensitive.67
Beyond membrane-stabilizing effects, local anesthetics
CSIs have been used for decades to treat the pain and dis- are known to have antiinflammatory actions due to their
comfort associated with soft tissue pathology, including structural similarity to steroid agents.68 Lidocaine is the
injections into the bursae and tendon sheaths. In the upper most well-studied local anesthetic and is thought to have
extremity, CSIs directed at the common extensor tendon antiinflammatory effects by inhibiting sympathetic postgan-
for the treatment of lateral epicondylalgia have been shown glionic neuron–mediated inflammation. Specifically, lido-
to lead to short-term pain relief but have been associated caine inhibits the release of inflammatory mediators such as
with worse outcomes at 1 year compared with placebo.40–43 leukotriene B4, interleukin (IL)-1α, and histamine and has
Other potential targets for ultrasound-guided CSIs have direct inhibitory effects on proinflammatory SPGN-medi-
better data to support their use and include the first dorsal ated plasma extravasations through inhibiting synovial EP1
compartment of the wrist, trigger finger, median nerve in receptors.69 Thus mechanisms of local anesthetics, such as
the carpal tunnel in the distal upper extremity, subacromial lidocaine, include stabilizing nerve cell membranes, inhibit-
bursitis, and shoulder impingement when used in conjunc- ing nociceptive signaling, and decreasing the inflammatory
tion with an active home exercise program focusing on scap- response.67 Treatment with local anesthetics may also pro-
ular stabilization.44–48 vide longer-term benefit beyond the immediate pain relief.
In the lower extremity, CSIs for patellar and insertional Eker and colleagues showed that treatment of knee osteoar-
Achilles tendinopathy have not reliably shown benefit.49,50 thritis with intra-articular injection of 0.5% lidocaine pro-
There are more data for the treatment of iliopsoas bursi- vided improvements in pain and function that continued at
tis at the hip, trochanteric bursitis in the lateral hip, and the 3-month follow-up.67 They postulated that this may be
pes anserine bursitis.51–54 The use of CSIs in the setting of due to decreasing neural cell metabolism and stabilizing the
plantar fasciitis has shown mixed results in comparison with neural membrane.
autologous blood-derived products and inferiority to dry However, it is important to note that local anesthetics
needling.55–57 are known to have chondrotoxic effects on human carti-
Despite widespread use, the rationale for use of CSIs is lage. Jayaram and colleagues published an elegant review on
contentious. Chronic systemic steroid use in the etiology this topic, noting variable chondrotoxic potential of differ-
of tendon rupture is well established.58,59 These negative ent local anesthetics and that a single injection can result
effects have been shown to extend to injected corticosteroids in chondrocyte death.70 Local anesthetics reviewed were
as well.60 In animal models, intratendinous injections have lidocaine, bupivacaine, ropivacaine, levobupivacaine, and
been shown to cause tendon necrosis at the site of injection mepivacaine. The chondrotoxic effects are dose and dura-
and a delayed healing response compared with a saline injec- tion dependent and are influenced by the type of local anes-
tion.61 Collagen degeneration and an increase in matrix thetic used. Chondrotoxicity also seems to be exacerbated
metalloproteinase-3 (MMP3) have been identified in his- by co-administration with corticosteroid.71 Of the local
tologic analysis of tendons exposed to steroid injections. In anesthetics studied, ropivacaine was the least chondrotoxic
contrast, other studies have shown a decrease in inflamma- and bupivacaine the most chondrotoxic. The mechanisms
tory mediators such as MMP2 and substance P.62,63 leading to chondrotoxicity appear to be increased apopto-
Potential complications of CSIs include infection, subcu- sis, caspase inhibition, necrosis, mitochondrial dysfunction,
taneous atrophy, skin depigmentation, and tendon rupture. extracellular matrix damage, and decreased DNA-normal-
The use of ultrasound guidance for these procedures has ized glycosaminoglycan expression. Local anesthetics have
resulted in improved accuracy compared with palpation- or also been demonstrated to be toxic to human mesenchy-
landmark-guided injections.27 The authors encourage image mal stem cells, which are crucial for healing.72–74 Here too,
guidance given the increased risk of tendon damage and ropivacaine is the least cytotoxic.73,74 Furthermore, Zink
risk of rupture with intratendinous CSIs. Further studies and colleagues have shown local anesthetics to be toxic to
are certainly warranted to continue to evaluate the effects of muscle tissue, with bupivacaine causing significantly more
corticosteroids on soft tissues and the efficacy of CSIs. tissue damage than ropivicaine.75,76
In summary, amide local anesthetics have general dose-
Local Anesthetics and duration-dependent cytotoxic effects, with ropivacaine
having the least toxicity, bupivacaine the most toxicity to
Amide local anesthetics (lidocaine, bupivacaine, ropiva- chondrocytes and muscle tissue, and lidocaine the most tox-
caine, etc.) are commonly used in musculoskeletal injections icity to mesenchymal stem cells.70,72–74
44 SEC T I O N I I Injectates

Ketorolac decrease of inflammatory mediators, improvement in the

viscosity of the microenvironment, immunomodulation of
Ketorolac is a nonsteroidal antiinflammatory drug (NSAID) catabolic enzymes, and downregulation of nociceptors.93,94
that inhibits the inflammatory cyclooxygenase and lipoxy- Exogenous HA has been shown to decrease inflamma-
genase enzyme systems, and the synthesis of prostaglan- tion through the suppression of proinflammatory media-
dins and leukotrienes.77 Ketorolac provides a reasonable tors; specifically, IL-β and tumor necrosis factor α.94,95 HA
alternative to corticosteroids and HA because it has fewer has displayed the ability to immunomodulate catabolic
side effects than corticosteroid, has a faster onset of action processes by downregulating matrix MMP3 expression
than HA, and is more economical than both HA and and inhibiting MMP synthesis, potentially reducing carti-
corticosteroid.78 lage destruction.5,7 Exogenous HA also has the capability
In patients with knee and first carpometacarpal joint of improving viscosity by stimulating the production of
osteoarthritis, the addition of ketorolac to HA injection endogenous HA in the synovial fluid and restoring homeo-
provided more rapid onset of pain relief without any added stasis.96,97 Lastly, exogenous HA is able to decrease pain by
complications when compared with HA alone.79,80 In addi- binding neuropeptides, creating a boundary layer around
tion, when compared head-to-head with corticosteroid in nociceptors and not allowing the receptors to transmit pain
patients with knee and hip osteoarthritis, ketorolac pro- signals.98
vided similar improvements in pain and function for up There are several exogenous HA products currently on
to 6 months.78,81 Ketorolac has also been shown to be safe the market that differ in their molecular properties, single-
and more effective than corticosteroids in the treatment of or multi-injection therapies, and whether they are derived
shoulder impingement and adhesive capsulitis.82,83 from animal products or using a genetically modified bacte-
In a 2018 review, Sardana and colleagues concluded rial source (Table 4.1). These differences have been shown
that NSAID injections had a less severe side-effect profile to affect clinical outcomes, and thus all exogenous HA
compared with corticosteroids and provided equivalent, products should not be evaluated as a group.99 Molecularly,
if not better, pain relief for musculoskeletal pathology.84 the most significant difference between products is their
Ketorolac has demonstrated no detrimental effects on chon- molecular weight, with products either being low molecu-
drocytes and tenocytes in animal models.85,86 Beitzel and lar weight (<1500 kilodaltons [kDa]), moderate molecular
colleagues reported no toxic effects on human chondrocytes weight (>1500 kDa and <3000 kDa), or high molecular
and tenocytes; however, other studies have indicated a dose- weight (>3000 kDa). A meta-analysis performed by Altman
dependent cytotoxic effect of ketorolac on human articular and colleagues has suggested that high-molecular-weight
chondrocytes.87,88 In Abrams and colleagues, the methods HA is more efficacious than moderate- or low-molecular-
more closely reflect the exposure duration of a single-dose weight products.99
injection, but the authors note their methods potentially In addition to differences in molecular weight, exog-
overestimated the chondrotoxicity of ketorolac.88 Nonethe- enous HA products can also differ in the number of injec-
less, there is no consensus on the cytotoxicity of ketorolac tions from single- to multi-injection formulations. A
and the risk of ketorolac intra-articular injections. There is systematic review proposed that single-injection therapy has
a theoretical association between ketorolac injections and similar efficacy to multi-injection formulations, with less
bleeding risk; however, there have been no studies docu- patient inconvenience.100 The last major difference between
menting a bleeding complication after a ketorolac injection exogenous HA products is if they are derived from bacte-
in contact or collision sport athletes.89 rial processes of biologic fermentation or through extrac-
tion of avian-derived molecules. Based on the available data
Hyaluronic Acid compiled by Vincent and colleagues, biologically fermented
formulations tend to be more efficacious and have a better
HA is a polysaccharide consisting of repeating units of the safety profile than avian-derived formulations.100
disaccharide N-acetylglucosamine and sodium glucuro- HA has been shown to be effective and safe in the
nate.90 This glycosaminoglycan structure is found within treatment of knee osteoarthritis based on the most recent
the extracellular matrix of a variety of soft tissue structures Cochrane review of the subject.101 However, caution should
and is synthesized by type B synoviocytes, fibroblasts, and be taken when attempting to apply this recommendation
chondrocytes.90,91 Namiki and colleagues were one of the to all HA products, given the variability in formulations
first groups to evaluate its use of HA for knee osteoarthritis and molecular properties as stated earlier. Overall, given the
more than 30 years ago.92 The injection was later approved available data, exogenous HA is a viable alternative in early
by the FDA in 1997 for the treatment of knee osteoarthritis. to moderate osteoarthritis with the potential to delay the
The term ‘viscosupplementation’ was coined for this time until knee arthroplasty.102,103
injection based on the initial work of Namiki and colleagues, Exogenous HA has been used for symptomatic ankle
where the proposed mechanism of action was thought to osteoarthritis with promising results.104 Multiple system-
be improving the viscosity of the arthritic joint.92 How- atic reviews have elucidated that HA is safe, decreases pain
ever, since that time there have been several studies that scores, and improves functional outcome measures for
have uncovered several possible mechanisms, including the ankle osteoarthritis.105,106 There have also been a number
 CHAPTER 4 Principles of Injection Therapy 45

TABLE
4.1   Hyaluronic Acid Products Currently on the Market.

High, Moderate,
or Low Molecular
Product Name Weight (kDa) Source Dosing (mg/mL) Number of Injections
Synvisc-one High Avian derived 48 mg/6 mL Single
Gel-one Unknown Avian derived 30 mg/3 mL Single
Monovisc Moderate Bacterial derived 88 mg/4 mL Single
Durolane High Bacterial derived 60 mg/3 mL Single
Hymovis Unknown Bacterial derived 24 mg/3 mL Two
Synvisc High Avian derived 48 mg/2 mL Three
Orthovisc Moderate Bacterial derived 30 mg/2 mL Three
Euflexxa High Bacterial derived 20 mg/2 mL Three
Gelsyn-3 Low Bacterial derived 16.8 mg/2 mL Three
Hyalgan Low Avian derived 20 mg/2 mL Three or five
Supartz FX Low Avian derived 25 mg/2.5 mL Three or five

of studies showing favorable results for the use of HA in the synovial sheath rather than the tendon itself. More rigorous
glenohumeral osteoarthritis.107–110 HA has been shown to study is needed to make robust conclusions on the efficacy of
be superior to physical therapy with treating glenohumeral HA for tendinopathies, but early studies show promise.
osteoarthritis and has a numeric but not statistically signifi-
cant advantage when compared with other injectables.108,109 Summary
A meta-analysis and systematic review by Zhang and col-
leagues concluded that HA has the capability of improv- In summary, a consensus does not exist regarding the use of
ing pain scores and functional outcomes in glenohumeral traditional injectates corticosteroid, local anesthetic, ketoro-
osteoarthritis; however, more randomized controlled trials lac, or HA in musculoskeletal pathology. Emerging evidence
are needed to evaluate the optimal dosing and efficacy.111 suggests that there is dose- and time-dependent cytotoxicity
With the lack of high-quality and comparative studies with associated with corticosteroid and local anesthetic. There-
other commonly used intra-articular therapies for glenohu- fore it seems prudent to use the lowest possible dose to exert
meral osteoarthritis, a definitive recommendation cannot be clinical benefit. There are some data that ketorolac may be
reached at this time. More high-level studies are warranted less toxic than corticosteroids yet provides similar improve-
and needed to further uncover the potential of HA in this ments in pain and function. Thus ketorolac may be a safer
scenario. alternative for use in musculoskeletal injections. HA is safe,
HA is currently indicated (on-label) only for knee osteo- has chondroprotective properties, and may have a positive
arthritis by the FDA; however, it has been approved for effect on tendons; however, the onset of action is slow. To
ankle and shoulder osteoarthritis by the European Medi- this point, the decision of when to use any of these injectates
cines Agency.70 Given the unpredictability of coverage for in clinical practice is based on specific pathology as well as
this product by insurance companies in the United States, patient and physician goals.
combined with the favorable evidence mentioned earlier, an
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 CHAPTER 4 Principles of Injection Therapy 47

39. Shin WS, Ahn DK, Kim MJ, Cho KJ, Go YR. Influence of 56. Rastegar S, Baradaran Mahdavi S, Hoseinzadeh B, Badiei S.
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2019;47(2):77–82. type local anesthetics and human mesenchymal stem cells: clini-
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48 SEC T I O N I I Injectates

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75. Zink W, Seif C, Bohl JR, et al. The acute myotoxic effects of arthritis or 3 weekly injections of other hyaluronan products:
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76. Zink W, Bohl JR, Hacke N, Sinner B, Martin E, Graf BM. tive effectiveness of alternative dosing regimens of hyaluronic
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 CHAPTER 4 Principles of Injection Therapy 49

106. Vannabouathong C, Del Fabbro G, Sales B, et al. Intra-articular 110. McKee MD, Litchfield R, Hall JA, Wester T, Jones J, Harri-
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5
Autologous Tissue
Harvesting Techniques:
Bone Marrow Aspirate and
Adipose Tissue
GERARD MALANGA, JAY E. BOWEN, AND SELORM L.
TAKYI

Introduction potential risks of the procedure, anticipated benefits, and

alternatives. The risks include but are not limited to infec-
Regenerative medicine has become an increasingly popular tion, skin necrosis, hematoma, seroma, skin deformity, sore-
field of interest over the last several decades. Its potential ness at the graft site and donor site, or pulmonary embolism.
application for treating various disease pathologies is prom-
ising and much research is currently being conducted across Contraindications
the globe.1 Its application for orthopedic conditions has a
place in the treatment paradigm for many conditions. There Contraindications to performing a bone marrow procedure
is a growing interest in the proper use of biologic treatments are severe anemia, active systemic or local infection at the site
by clinicians and a desire for these services by patients. With of harvest or injection, and active cancer, including but not
this heightened level of interest comes the need to under- limited to myelodysplastic syndromes. Contraindications
stand when and how best to apply biologics to musculoskel- for an adipose procedure would be active cancer and infec-
etal conditions. tion at harvest or injection site. Relative contraindications
We will focus this chapter on how to perform tissue include pregnancy. Low body mass index (BMI) individuals
harvesting for autologous use of bone marrow and adipose require additional investigation for adipose procedures.
tissue. The techniques, materials, and pearls required to suc-
cessfully perform these procedures are paramount. While Medications
obtaining these cells and tissues, it is important to recall that
while practicing in the United States one must comply with After obtaining consent for an orthobiologic procedure, review-
Food and Drug Administration (FDA) regulations concern- ing any medications, supplements, or habits that may interfere
ing minimal manipulation and intention for homologous with good cell acquisition or potential therapeutic effect is
use of the HCT/P (human cells, tissues, and cellular and crucial. Medicines can have deleterious effects on adipose and
tissue-based products). In addition, these tissues cannot be bone marrow procedures. Most have not been studied for their
expanded.2 The reader should be familiar with their regional effects on healing. Therefore, it is important for patients to take
regulations, which is beyond the scope of this chapter. It is only medications that are necessary, which helps reduce poly-
also necessary to consider the potential adverse effects from pharmacy. It is in the best interest of the patient to avoid certain
performing these procedures: infection, hematoma, and medications in order to optimize the harvest. Such medications
anemia.3 include: systemic steroids, inhaled steroids or steroid injections,
fluoroquinolone antibiotics, HMG-CoA (3-hydroxy-3-meth-
Risks ylglutaryl-CoenzymeA) reductase inhibitors or statins, and
nonsteroidal antiinflammatory drugs (NSAIDs).
Before performing bone marrow aspirate or adipose tis- Corticosteroids can have deleterious effects on stem cells
sue harvesting it is imperative to obtain informed verbal and healing4 and should be avoided for at least 6 weeks prior
and written consent. A patient must fully understand the to the procedure. Fluoroquinolones can increase the risk

50
 CHAPTER 5 Autologous Tissue Harvesting Techniques: Bone Marrow Aspirate and Adipose Tissue 51

of Achilles tendinitis and Achilles tendon rupture.5 Statins extreme anxiety, minors, or patients with central sensitiza-
have a negative effect on stem cells and muscle cells. They tion may require the assistance of an anesthesiologist or cer-
have been found to impair the chondrogenic and osteogenic tified registered nurse anesthetist (CRNA).
potential of Medicinal Signaling Cells (MSC, formerly Mes-
enchymal Stem Cells) and they increase cell senescence and
apoptosis.6 If the patient is on a statin, they should supple- Bone Marrow Aspiration Techniques
ment with coenzyme Q10, which can help prevent some of Site and Positioning
the deleterious effects of statins on muscle cells.7 NSAIDs
can inhibit bone healing, increase the risk of bone fractures,8 Extracting red bone marrow is usually best performed at the
and increase bleeding. They should be held for at least 5 days iliac crest. This region has been shown to have a higher yield
prior to the procedure, and aspirin for at least 7 days prior. of osteogenic progenitor cells compared to the tibia and cal-
Holding of other antiplatelet medications and statin medi- caneus.11 Knowledge of the pertinent anatomy is important
cations depends on the pharmacokinetics of the particular and the goal is to stay within the inner and outer tables of
drug. If patients are on any anticoagulant medications, phy- the iliac crest throughout the aspiration.12 The two typical
sicians should discuss with their prescribing doctors the pro- approaches when aspirating from the iliac crest are the par-
cedure they will perform and determine if they can safely allel and perpendicular approaches (Fig. 5.1A and B).13 For
hold these medications. the perpendicular approach, you can access the posterior
superior iliac spine (PSIS) with the patient in a prone or
Preparation lateral decubitus position. For the parallel approach through
the iliac crest, the patient may be supine for an anterior
Patients should be instructed to hydrate in the days leading approach or prone for a posterior approach.
up to the procedure, especially for bone marrow aspiration. Bain and colleagues surveyed hematologists from 1995
The patient should avoid eating solid food 4 to 6 hours prior to 2001. A total of 26 out of 54,890 reported adverse events
to the procedure as a precaution against nausea but may from the perpendicular bone marrow biopsy approach for a
continue to drink clear liquids. A review of the patient’s past rate of 0.05%. Of the 26 adverse events, 14 were reported
medical history should be performed to determine if there are as hemorrhage complications, with 6 requiring blood trans-
risk factors for anemia, and obtaining a hemoglobin/hema- fusions and 1 leading to death. Risk factors most often
tocrit on patients prior to a bone marrow aspiration should associated with these hemorrhaging events were aspirin
be considered. Results may impact the clinician’s decision to use, myeloproliferative disorders, or both. Additional risk
perform the procedure or how much bone marrow to extract. factors seen included warfarin use, disseminated intravascu-
The procedures to be discussed should be performed in lar coagulation, and obesity.14 This population likely has a
a clean manner, using a sterile technique with the provider greater risk of complications than a typical patient who will
wearing sterile gloves, a facemask, and hair covering; consider have a cellular treatment.
using sterile sleeves or a gown. Baseline and post-procedure Our preferred approach is harvesting in a perpendicular
vital signs (blood pressure, heart rate, respiratory rate, oxygen approach from the PSIS with the patient prone. The pos-
saturation, and temperature) should be obtained; based on terior region of the iliac crest has been shown to have one
the vital signs, decisions can be made to proceed with the of the thickest regions of bone. The average distance of the
procedure. Patient monitoring with a pulse oximeter that iliac crest is 24 cm. When determining which area to best
includes heart rate monitoring is generally sufficient. Supple- access along the iliac crest, the concept of dividing the iliac
mental oxygen, blood pressure, automated external defibrilla- crest into six different sectors (Fig. 5.2A and B)15 has been
tor (AED), and Crash Cart AED supplies should be available. established to bring awareness of the anatomic differences in
sector thickness and to help prevent violating neurovascular
Anesthesia structures (Fig. 5.3A–C).12

Nonexperienced providers and patients may think that Anesthetic

bone marrow procedures are very painful; however, in our
experience, the procedure is well tolerated when adequate A local anesthetic is required to control pain from the
pre-procedure local anesthesia is provided. These proce- larger needle/trocar used in bone marrow aspiration. The
dures are routinely performed in the office setting outside typical anesthetic used is 1% lidocaine without epineph-
of the hospital or surgical center and usually cause more rine and up to 10 mL total per side. Alternatively, 0.25%
anxiety than pain. Anxiety can lead to the patient having to 0.5% ropivacaine can be used as well. This may be
more muscular tension, which can increase discomfort, so guided by the same imaging modality used for harvesting.
relaxation is paramount. Less is more, and preferably music A 22- to 27-gauge, 2 inch to 3.5 inch needle is typically
therapy is all that is necessary to control for anxiety.9,10 In used, depending on the chosen approach. Local anesthetic
cases where patients have elevated levels of anxiety or other should be applied to skin at the needle entry site, soft tissue
psychiatric diagnoses, the physician may recommend an trajectory of the needle, and the surface of the bone/peri-
oral anxiolytic of choice. The use of controlled substances osteum. The needle used to anesthetize the bone should
may require more diligent monitoring. Patients with more never be longer than the needle used to harvest the bone
52 SEC T I O N I I Injectates

Anticoagulation
35-40° Anticoagulant is necessary to prevent clotting of the mar-
row when performing an aspiration. If a proper anticoagu-
lant protocol is not used, clots will form, preventing the
acquisition, adequate isolation, and concentration of the
4-5 cm desired buffy coat of the aspirate. Heparin is the desired
anticoagulant. To calculate the proper dose, identify the
amount of marrow desired and the syringes to be used for
aspiration. Draw a ratio of 500 to 1000 IU of heparin per
1 mL of desired marrow amount. For example, if planning
on aspirating 20 mL in a 30 mL syringe, draw 10,000 IU
A
of heparin in the smallest-available volume. If planning on
drawing 10 mL in a 10 mL syringe, draw 0.5 mL of hepa-
rin (10,000 IU/mL). An additional heparin mixture will be
required for anticoagulation prior to bone marrow aspira-
tion at each site. This will consist of a 5 mL syringe with 1
mL of heparin (5000 IU/mL) and 4 mL of normal saline
or a 10 mL syringe with 1 mL of heparin (10,000 IU/mL)
and 9 mL of normal saline. After each marrow aspiration,
gently rock the syringe back and forth to ensure adequate
anticoagulation.

Needles
Bone marrow aspiration can be obtained by manually plac-
ing a cannula (Fig. 5.4) into the iliac crest, which requires a
larger gauge due to the axial load needed. This is usually 11
gauge and can be placed by hand with a clockwise/counter-
clockwise maneuver while applying axial force or placement
of the cannula/trocar against the bone and use of a mal-
let to force the cannula through the cortex. If performing
a manual needle aspiration, typically an 11-gauge 4 inch
trocar is used. Rarely, in some larger patients a larger tro-
car may be needed. We prefer a diamond-tipped needle as
opposed to a slanted tip, which may have a greater tendency
to slip off of the periosteum. Alternatively, when using a
rotary-powered device to guide the aspiration, a smaller
gauge needle, such as a 15-gauge 2.7 inch to 3.5 inch, may
B be used. Additionally, a needle assisted with a rotary drill has
• Fig. 5.1 (A) Bone marrow aspiration in parallel to the ilium. (B) Bone
been shown to decrease procedure time and residual pain
marrow aspiration in perpendicular. Black box represents the ultra- for the patient.16–18 Rotary devices decrease the stress on the
sound probe footprint and blue arrow represents the needle for aspira- wrist of the physician, especially when harvesting from mul-
tion. (A, From Hernigou J, Alves A, Homma Y, et al. Anatomy of the tiple sites. Please refer to rotary device instructions on how
ilium for bone marrow aspiration: map of sectors and implication for to properly engage and disengage the needle for harvesting.
safe trocar placement. Int Orthop. 2014;38[12]:2585–2590. https://
doi.org/10.1007/s00264-014-2353-7. B, From Bowen JE. Technical
It is important to have a good kinesthetic sense of how it
issues in harvesting and concentrating stem cells (bone marrow and feels to enter the marrow space. Adequate training including
adipose). PM&R. 2015;7:S8–S18. https://doi.org/10.1016/j.pmrj.201 mentoring should occur prior to attempting bone marrow
5.01.025) aspirations in live patients.

Syringe
marrow. This helps to avoid needle length mismatch in
reaching the bone for harvesting. Never inject anesthetic Harvesting bone marrow from one site will likely result in a
through the trocar or needle used to aspirate marrow, as lower MSC count due to dilution with peripheral blood.19
this can have a deleterious effect on cell viability. After the Therefore, multiple samples from different areas should be
anesthetic is administered, the physician should wait at acquired while harvesting. MSCs adhere to the trabeculae of
least 3 to 5 minutes until adequate anesthesia is achieved. bone at low volume pressures, resulting in minimal nucle-
Doing so greatly improves patient comfort. ated cells. Therefore, it is important to obtain the best-quality
 CHAPTER 5 Autologous Tissue Harvesting Techniques: Bone Marrow Aspirate and Adipose Tissue 53

3 2
4 4 1
3 5
5

2 6
6

A B
• Fig. 5.2 Iliac Sectors for Bone Marrow Aspiration. (A) The iliac crest divided into six sectors has vari-
ability in sector thickness that must be understood when performing bone marrow aspiration. The iliac
wing (three-dimensional reconstruction) was divided by drawing lines from equidistant points spaced along
the rim of the iliac crest to the center of the hip. These lines were approximately perpendicular to the curve
of the iliac crest. Six sectors were defined by these lines. Sectors 1 and 2, anterior part of the iliac bone;
sectors 3 and 4, center part of the iliac bone; sectors 5 and 6, posterior part of the iliac bone. (B) The cor-
responding sectors can be found and marked on the patient by using the same technique and correspond
in clinical practice to different zones of bone marrow aspiration according to the position of the patient.
Three different approaches can be used to harvest bone marrow from the iliac crest: patient supine and
anterior crest approach (sectors 1, 2, and 3), patient prone and posterior iliac crest approach (sectors 4, 5,
and 6) and patient in the left or right lateral position allowing easier middle iliac crest approach (sectors 3
and 4). (From Hernigou J, Picard L, Alves A, et al. Understanding bone safety zones during bone marrow
aspiration from the iliac crest: the sector rule. Int Orthop. 2014;38[11]:2377–2384. https://doi.org/10.10
07/s00264-014-2343-9)

draws by not completely filling the syringes as you aspirate • I dentify the skin entry site by placing a radiopaque
bone marrow. Hernigou and colleagues found that filling 18-gauge needle marker on the skin.
the syringe to 10% to 20% of its total volume resulted in an • Move the marker until you view your target entry image.
improved yield of MSCs and a better-quality harvest, and • The marker identifies your single entry point. Utilize a
smaller-volume syringes resulted in a higher concentration small-gauge needle to create a skin wheal of anesthetic at
of progenitor cells. Using 10 mL syringes yielded on average the skin entry site about 1 cm lateral to the PSIS.
a 300% higher concentration of progenitor cells compared • Next, anesthetize the soft tissue down to the periosteum,
to a 50 mL syringe.20 as detailed in the aforementioned anesthetic section.
Redirect and aim for 3 to 5 different sites along the tar-
Techniques geted area, depending on the total desired marrow.
• Allow sufficient time for the anesthetic to work (3 to 5
For these procedures, other medical staff members should minutes). Confirm the heparin syringes and other equip-
prepare the procedure tray prior to the patient entering the ment are ready per the above protocol with the procedure
room. Please refer to the previous sections for consideration tray.
of needle choice, syringe size, anesthetic, and manual or • Next, under intermittent fluoroscopy, guide the trocar
rotary-powered needle advancement. Our preferred tech- from the skin entry site to the desired region on the ilium
nique consists of 20 mL aspirations at each site using 30 about 1 cm lateral to the PSIS that has been anesthetized
mL syringes. and obtain a hub view (Fig. 5.5).
• Rotate the trocar back and forth while applying axial
Fluoroscopy Perpendicular pressure until a loss of resistance is appreciated or the
• Th
 e patient is placed prone on a firm surface such as the needle has advanced less than a 1 cm, which likely rep-
fluoroscopy table. resents entrance into the marrow cavity. Alternatively, a
• The C-arm is then positioned to obtain an A-P scout view rotary-powered device may be used to advance the nee-
of the harvest site, followed by 20 to 30 degree ipsilateral dle, as detailed in the needle section, for less than 1 cm
oblique and caudal tilt to view the iliac crest, ilium, and PSIS. or until a loss of resistance is appreciated.
54 SEC T I O N I I Injectates

Superior cluneal nerves

(cutaneous branches
of dorsal rami)
L1 L2 L3

Middle cluneal nerve S1 * * Sciatic notch

(cutaneous branches S2
of dorsal rami) S3

Sciatic nerve

A C

Spinal midline

*
Superior gluteal vessels

B
• Fig. 5.3 (A) Diagrammatic representation of the sensory distribution for right posterior iliac crest.
Procurement including the superior (L1 to L3) and middle (S1 to S3) cluneal nerves. Asterisk marks the
posterior superior iliac spine. (B) Diagrammatic representation of the superior gluteal vessels. Asterisk
marks the posterior superior iliac spine. (C) Diagrammatic representation of the course of the sciatic
nerve. Asterisk marks the posterior superior iliac spine. (From Sittitavornwong S, Falconer DS, Shah
R, et al. Anatomic considerations for posterior iliac crest bone procurement. J Oral Maxillofac Surg.
2013;71[10]:1777–1788. https://doi.org/10.1016/j.joms.2013.03.008)

• R emove the stylet and inject 0.5 mL of the heparin • R epeat this procedure for three to five sites depending on
flush (1000 IU per mL of heparin solution with 9 mL of the desired volume of bone marrow aspirate.
saline). • If necessary, repeat the procedure on the contralateral
• Then attach a heparinized syringe and pull with a side to obtain the desired bone marrow volume.
constant quick force to aspirate the desired volume of
marrow. Fluoroscopy Parallel
• Replace the stylet and rotate the needle to barely with- • Th
 e patient is positioned prone on a firm fluoroscopy
draw from the bone. Redirect the trocar to the next aspi- table.
ration site. • The physician should be positioned on the patient’s side.
 CHAPTER 5 Autologous Tissue Harvesting Techniques: Bone Marrow Aspirate and Adipose Tissue 55

• Th
 e C-arm is then positioned to obtain an A-P scout • M anually advance the needle to the periosteum and con-
view of the harvest site, followed by 20- to 30-degree firm placement between the medial and lateral borders of
contralateral oblique to view the iliac crest and PSIS until the iliac crest with image guidance.
the medial and lateral borders of the iliac crest are clearly • Advance your needle until you just access the bone mar-
defined. row cavity, as described above, pointing anterolateral
• Identify the skin entry site by placing a radiopaque (18- along the plane of the ilium in your hub view.
gauge needle) marker on the skin. • Remove the stylet and inject 0.5 mL of the heparin
• Move the marker and intermittently take pictures until flush (1000 IU per mL of heparin solution with 9 mL of
you view your target entry image. saline).
• Utilize a small-gauge needle to create a skin wheal of • Attach a heparinized syringe and pull with a constant
anesthetic at the skin entry site. quick force to aspirate the desired volume of marrow.
• Next anesthetize the skin and soft tissue down to the • Replace the stylet and rotate the needle to barely with-
periosteum using a similar-size needle as the one you will draw from the bone. Redirect the trocar to the next aspi-
aspirate with. ration site.
• Allow sufficient time for the anesthetic to work (3 to 5 • Redirect and aim for 2 to 4 different sites along the tar-
minutes). Confirm the heparin syringes and other equip- geted area until obtaining the total desired marrow.
ment are ready per the above protocol with the proce-
dural tray. Ultrasound-guided Perpendicular (Author
Preferred)
• Th
 e patient is positioned prone on a firm table.
• A 1 ultrasound probe is used to scan for the PSIS.
The probe is perpendicular to the sagittal plane of the
patient and to the posterior ilium. Identify the rounded
PSIS.
• Keep the probe in the same orientation and scan cepha-
lad 2 cm until the ilium has the appearance of a moun-
tain peak. The bone should be in the middle of your
screen or slightly further away from the needle entry site,
which will be lateral. Rotate probe to be perpendicular to
the face of the ilium.
• Make a skin wheal with local anesthetic 1 cm lateral to
the PSIS adjacent to the footprint of the probe.
• Then in-plane anesthetize the soft tissue down to the
periosteum. The needle should touch bone at a depth of
• Fig. 5.4 J-style bone marrow manual aspiration needle (11 gauge × 1 cm below (lateral to the PSIS) the peak or most super-
4 inches). ficial aspect of the bone (Fig. 5.6A and B).

N.J. SPORTS MEDICIE

PSIS

3.79 mA
88 kv

• Fig. 5.5
Hub view of needle for bone marrow aspiration under fluoroscopic guidance. The arrow identifies
the bone marrow aspiration needle which is in parallel to the x-ray.
56 SEC T I O N I I Injectates

• F rom the same needle entry on the skin redirect the is deeper and usually requires a steeper angle. Do not
probe inferiorly around the PSIS for 1 to 2 more loca- pivot more than 90 degrees to avoid bringing the probe
tions and superior for 1 to 2 more locations. Pivot the closer to the cluneal nerves.
proximal portion of the probe lateral along the iliac crest. • No matter the angle of the probe or the depth of the
• Be sure you pivot the probe from the single needle entry bone, the target should be 1 cm inferior to the most
site. superficial aspect of the bone. This ensures you are stay-
• When scanning inferiorly, avoid going too inferior where ing in a thick area of bone and not so close to the surface
you lose the round superficial PSIS and see a drop in the that the needle risks sliding off. Do not go deeper than
bone as this is the sacrum and SI joint. When scanning 1 to 2 cm, especially inferiorly, as this risks injury to the
inferior, the probe should only pivot 5 to 15 degrees to gluteal neurovascular structures.
obtain a new area. • Allow sufficient time for the anesthetic to work (3 to 5 min-
• When scanning superior, the probe should pivot 30 to utes). Confirm the heparin syringes and other equipment
40 degrees for a new area and 70 to 80 degrees for a sec- are ready per the above protocol with the procedure tray.
ond new area. Note that the superior aspect of the ilium • Under ultrasound guidance guide the trocar to the sites that
were anesthetized in the same technique described above.
• The needle should be as close to perpendicular to the
bone angle as possible. This ensures a shorter distance
to travel to the marrow space and less likelihood for the
needle to slide off of the bone (Fig. 5.7).
• Advance the trocar until a loss of resistance is appreciated
or the needle has advanced less than 1 cm, which likely
represents entrance into the marrow cavity.
• Alternatively, a rotary-powered device may be used to
advance the needle, as detailed in the needle section, for
less than 1 cm or until a loss of resistance is appreciated.
• Remove the stylet and inject 0.5 mL of the heparin
flush (1000 IU per mL of heparin solution with 9 mL of
saline) (Fig. 5.8).
• Then attach a heparinized syringe and pull with a con-
stant quick force to aspirate the desired volume of mar-
row (Fig. 5.9A and B).
• Replace the stylet and rotate the needle to barely with-
draw from the bone. Redirect the trocar to the next aspi-
ration site.
• Repeat this procedure for 3 to 5 sites depending on the
A desired volume of bone marrow aspirate.

B
• Fig. 5.6(A) Bone marrow aspiration anesthetic setup. (B) Ultrasound-
guided in-plane anesthetic injection of the soft tissue trajectory of the • Fig. 5.7
Ultrasound image of a trocar in-plane for perpendicular bone
needle and the surface of the bone/periosteum. marrow aspiration.
 CHAPTER 5 Autologous Tissue Harvesting Techniques: Bone Marrow Aspirate and Adipose Tissue 57

• Fig. 5.8 Injection of 0.5 mL of heparin mixture prior to bone marrow

aspiration.
A
• I f necessary, repeat the procedure on the contralateral
side to obtain the desired bone marrow volume.

Ultrasound-assisted Parallel
• Th
 e patient is positioned prone on a firm table.
• Using an ultrasound transducer identify the PSIS.
• Using ultrasound, identify the inferior (Fig. 5.10),
medial, and lateral portion of the PSIS on the skin.
• Mark the medial border of the iliac crest, moving the
ultrasound from a midline to lateral direction (Fig. 5.11).
• Mark the lateral border of the iliac crest, moving in a
lateral to medial direction (Fig. 5.12).
• The needle entry site will be within the borders within
the US marked regions.
• Mark the desired skin entry site with a surgical marker.
• Utilize a small-gauge needle to create a skin wheal of B
anesthetic at the skin entry site.
• Next, anesthetize the skin and soft tissue down to the • Fig. 5.9
(A) Bone marrow aspiration with a quick constant force. (B)
Bone marrow aspiration under ultrasound guidance.
periosteum using a needle similar in size to the one you
will aspirate with.
• Allow sufficient time for the anesthetic to work (3 to 5 min-
utes). Confirm the heparin syringes and other equipment
are ready per the above protocol with the procedure tray.
• Angle the needle 30 degrees directed anterolaterally
along the plane of the iliac crest between the medial and
lateral borders and advance to the bone (Fig. 5.13).
• Advance the trocar until you just access the bone marrow
cavity, as described above, pointing anterolateral along
the plane of the ilium.
• Remove the stylet and inject 0.5 mL of the heparin flush
(1000 IU per mL of heparin solution with 9 mL of saline).
• Attach a heparinized syringe and pull with a constant
quick force to aspirate the desired volume of marrow.
• Replace the stylet and rotate the needle to barely with-
draw from the bone. Redirect the trocar to the next aspi- • Fig. 5.10 Ultrasound scanning from inferior to superior to demarcate
ration site. the PSIS.
58 SEC T I O N I I Injectates

• R
 edirect and aim for 2 to 4 different sites along the
targeted area until you have obtained the total desired
marrow.

Processing
This varies depending upon the bone marrow aspiration kit
and is beyond the scope of this chapter.

Adipose Harvesting Techniques

Positioning
Prior to a lipoaspiration, one must consider where the adi-
pose tissue will be harvested. This is usually the area that
• Fig. 5.11 Ultrasound scanning midline to lateral to demarcate the iliac contains the most adipose tissue on the individual and is
crest. dependent on body habitus. These areas include but are not
limited to the lower abdomen, lateral thigh, flank, or but-
tock region. When harvesting from the lower abdomen the
patient is supine. The lateral thigh is best accessed in the lat-
eral decubitus position. While the patient is prone, adipose
tissue can be harvested from the flank or buttock region.
Pearl: Choose a position that permits the patient to be
most comfortable and stationary in order to tolerate the
length of the procedure. Additionally, this position should
easily allow the physician to acquire the tissue with minimal
to no repositioning of the patient during the harvest.

Anesthetic
For adipose harvesting, it is important to consider the
type of anesthetic used. Anesthetics can be toxic to the
viability of the cells, particularly adipocytes, and a list of
anesthetics and their maximum recommended doses can
be seen in Table 5.1.21 Generally, ropivacaine is the least
• Fig. 5.12 Ultrasound scanning lateral to medial to demarcate the iliac toxic anesthetic available.22–24 For adipose procedures, use
crest. a mixture of tumescent anesthetic which contains lido-
caine with epinephrine to help control bleeding and pro-
vide pain relief. A typical tumescent anesthetic mixture
would consist of 500 mL of normal saline, 25 mL of 2%
lidocaine, two ampules of epinephrine 1:1000, and 10 mL
of 8.4% sodium bicarbonate. If the patient has a lidocaine
allergy you may consider ropivacaine as a tumescent; it has
been used in both animal and human studies25,26; how-
ever, further studies are necessary to determine optimal
concentrations.

Imaging
In patients with a very low body fat percentage, scanning
with an ultrasound may be useful to identify sufficient
quantities of adipose tissue for harvest. However, in our
experience, the mid-buttock a few inches superior to the
gluteal cleft is an adequate entry point even in some of
the leanest or most fit individuals. With experience, the
• Fig. 5.13 Ultrasound-assisted parallel bone marrow aspiration along harvesting of adipose tissue will not require the use of an
the iliac crest. ultrasound.
 CHAPTER 5 Autologous Tissue Harvesting Techniques: Bone Marrow Aspirate and Adipose Tissue 59

TABLE
5.1   Dose Recommendations for Commonly Used Local Anesthetics.

Maximum Dose
Local Concentration Maximum Dose With Epinephrine
Anesthetic (%) (mg/kg) (mg/kg) Onset Time (min) Duration (h)
Lidocaine 0.5–2 4–6 6–8 10–20 0.75–2
Bupivacaine 0.125–0.5 2 3 15–30 2.5–8
Ropivacaine 0.2–1 2–3 – 10–20 2.5–8
Mepivacaine 0.5–1.5 6–8 10 5–10 1–1.5
2-Chloroprocaine 2–3 10 15 5 1

Used with permission from Dillane D. Local Anesthetic Toxicity: Prevention and Management. Complications of Regional Anesthesia: Principles of Safe Practice in
Local and Regional Anesthesia. 3rd ed. In Finucane BT, Tsui BCH, eds. Springer International Publishing;2017.

Technique Adipose Processing

• O nce the patient is sterilely draped and the harvest site Processing adipose tissue to micro-fragmented adipose tis-
cleansed in the normal aseptic fashion, a skin wheal of sue (MFAT) depends on the specific device that is used. All
tumescent anesthesia is administered at the entry site of devices must comply with FDA regulations so that less than
harvest. minimal manipulation is achieved. One should not solely
• A superficial skin nick is required with an 18-gauge nee- rely on a commercial representative of a company to deter-
dle or scalpel to allow penetration through the skin with mine whether a device is FDA-compliant prior to using it.
a blunt tip cannula that will ultimately deliver the rest of Most processing for consists of washing the fat tissue to
the tumescent anesthetic. remove red blood cells, tumescent anesthesia, and oil from
• A volume of 200 to 300 mL of the anesthetic is broken adipocytes. The remaining product is resized in dif-
delivered to each harvest region. It is delivered in a ferent manners to leave intact tissue in small clusters that
fan-like distribution and the region should become can be delivered through a small needle. FDA-compliant
tense and exhibit a tumescence toward the end of devices and methods such as Lipogems, PureGraft, or Intel-
completion. liFat work within a closed system and allow for the final
• After its delivery, at least 15 minutes is required for the product to be delivered percutaneously. These systems do
anesthesia to take effect. not extract cells from the adipose tissue (i.e., stromal vascu-
• P earl: Adequate volume of tumescent anesthetic and lar fraction [SVF]) and are compliant with the FDA’s regu-
time should allow for an easy harvest. lation of minimum manipulation.
• When this time has passed, a blunt tip cannula can be At the time of publication, processing of adipose tissue
introduced at the harvest entry site. and bone marrow must use minimal manipulation and be
• Initially, this blunt tip cannula may be used to penetrate intended for homologous use for compliance with FDA
and break up the adipose tissue. regulations. Following processing, the adipose tissue may be
• Next, the lipoaspiration cannula with a vacuum lock transferred to additional syringes via Luer lock connectors
syringe is attached. for therapeutic use (Fig. 5.14).
• A vacuum locking syringe (20 to 60 mL) is typically sup-
plied in the lipoaspirate kits.
Post Procedure
• Aspirate by using back and forth movements in the areas
that were anesthetized. Once the tissue harvest is complete, the entry site can be
• Perform this technique until sufficient volume is obtained cleansed and covered. A clear occlusive dressing, such as
for the injectate. Tegaderm, with sterile gauze with or without antibiotic
• During the procedure, remember to talk to your patient ointment may be used. Ice packs may be used temporar-
as needed and encourage them to provide feedback if ily, and a compressive garment may be applied to the har-
there are any sensitive areas throughout the harvest. vest site. The compressive garment may be worn for a week,
• In our experience, there is usually a 3:1 to 4:1 ratio of which can help to prevent post-procedural complications
what is harvested to the final product after decanting and of a seroma and/or hematoma. NSAIDs should be avoided
processing. post-injection. The application of topical arnica to the har-
• Aspiration to final product ratio may vary depending on vesting site can help prevent bruising as well.
the chosen method of processing.
60 SEC T I O N I I Injectates

Generally, ultrasound is preferred for most soft tissue struc-

tures and has the advantage over fluoroscopy of avoiding
radiation exposure and providing the ability to visualize
neurovascular structures.27 Therefore, training and familiar-
ity with these techniques are of utmost importance.

Rehabilitation
Rehabilitation after these procedures will be discussed in
another chapter within this text. Generally, it is best to
adhere to relative rest for the first 1 to 2 days, with a clear
and comprehensive rehabilitation plan discussed with the
treating provider.

References
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88X14666190411121528.
2. Center for Biologics Evaluation and Research and Center for
• Fig. 5.14 Micro-fragmented Adipose Tissue. Micro-fragmented Devices and Radiological Health. Regulatory Considerations for
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of the ilium for bone marrow aspiration: map of sectors and impli- effects of ropivacaine, bupivacaine, and lidocaine on rabbit inter-
cation for safe trocar placement. Int Orthop. 2014;38(12):2585– vertebral disc cells in vitro. Spine J. 2014;14(3):483–490. https://
2590. https://doi.org/10.1007/s00264-014-2353-7. doi.org/10.1016/j.spinee.2013.06.041.
14. Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Hae- 23. Sung C-M, Hah Y-S, Kim J-S, et al. Cytotoxic effects of ropi-
matol. 2003;121(6):949–951. https://doi.org/10.1046/j.1365- vacaine, bupivacaine, and lidocaine on rotator cuff tenofibro-
2141.2003.04329.x. blasts. Am J Sports Med. 2014;42(12):2888–2896. https://doi.
15. Hernigou J, Picard L, Alves A, Silvera J, Homma Y, Hernigou P. org/10.1177/0363546514550991.
Understanding bone safety zones during bone marrow aspiration 24. Rahnama R, Wang M, Dang A, Kim H, Kuo A. Cytotoxic-
from the iliac crest: the sector rule. Int Orthop. 2014;38(11):2377– ity of local anesthetics on human mesenchymal stem cells. J
2384. https://doi.org/10.1007/s00264-014-2343-9. Bone Jt Surg. 2013;95(2):132–137. https://doi.org/10.2106/
16. Swords RT, Anguita J, Higgins RA, et al. A prospective ran- JBJS.K.01291.
domised study of a rotary powered device (OnControl) for bone 25. Breuninger H, Hobbach PS, Schimek F. Ropivacaine: an impor-
marrow aspiration and biopsy. J Clin Pathol. 2011;64(9):809– tant anesthetic agent for slow infusion and other forms of tumes-
813. https://doi.org/10.1136/jclinpath-2011-200047. cent anesthesia. Dermatol Surg. 1999;25(10):799–802. https://
17. Reed LJ, Raghupathy R, Strakhan M, et al. The OnControl bone doi.org/10.1046/j.1524-4725.1999.99087.x.
marrow biopsy technique is superior to the standard manual tech- 26. Abimussi CJX, Menegheti TM, Wagatsuma JT, et al. Tumescent
nique for hematologists-in-training: a prospective, randomized local anesthesia with ropivacaine in different concentrations in
comparison. Hematol Rep. 2011;3(3). https://doi.org/10.4081/ bitches undergoing mastectomy: plasma concentration and post-
hr.2011.e21. operative analgesia. Vet Anaesth Analg. 2014;41(5):516–525.
18. Berenson JR, Yellin O, Blumenstein B, et al. Using a powered bone https://doi.org/10.1111/vaa.12178.
marrow biopsy system results in shorter procedures, causes less 27. Smith J, Hurdle M-F, Locketz AJ, Wisniewski SJ. Ultrasound-
residual pain to adult patients, and yields larger specimens. Diagn guided piriformis injection: technique description and verifica-
Pathol. 2011;6(1):23. https://doi.org/10.1186/1746-1596-6-23. tion. Arch Phys Med Rehabil. 2006;87(12):1664–1667. https://
19. Li J, Wong WH-S, Chan S, et al. Factors affecting mesenchymal doi.org/10.1016/j.apmr.2006.08.337.
stromal cells yield from bone marrow aspiration. Chin J Cancer
Res. 2011;23(1):43–48. https://doi.org/10.1007/s11670-011-
0043-1.
6
Autologous Tissue
Harvesting Techniques:
Platelet-Rich Plasma
PETER A. EVERTS

Introduction a comfortable seated or recumbent position. Sterile and

Whole Blood and Platelets single-use needles and syringes are used, and blood is gener-
ally drawn by phlebotomy with a venous catheter ranging
Platelet-rich plasma (PRP) was first used in cardiac surgery from 18 to 21 gauge in adults. The practitioner responsible
by Ferrari and colleagues in 1987 as an autologous blood for harvesting blood should maintain proper local guide-
transfusion after open heart procedures to avoid homolo- lines and use personal protective equipment (PPE). Several
gous blood product transfusions.1 The use of PRP to treat PRP manufacturers produce complete PRP kits that include
musculoskeletal disorders (MSK-D) was noted in the mid- processing devices, syringes (Fig. 6.1) and in most kits an
1990s for tendinosis and tendinitis. Currently PRP is being anticoagulant and a phlebotomy kit (including tourniquet,
utilized by providers in multiple specialties, including max- butterfly assembly, gauzes, alcohol pad, labels) (Fig. 6.2).
illofacial surgery, spinal disorders, orthopedics, chronic The whole blood collection syringe should contain an
wounds, and more.2 During the physiologic cascades of anticoagulant to avoid blood clotting during blood harvest-
soft tissue regeneration, a variety of cellular, hormonal, and ing and PRP preparation, thus preventing platelet activation
growth factors play pivotal roles and are stored in the alpha prior to its use. Manufacturer instructions provide guide-
and dense granules of platelets. lines on loading sufficient anticoagulant in the harvesting
Platelets are formed from megakaryocytes in the bone mar- syringe.
row by pinching off from their progenitor cells before being
released into the peripheral circulation. Platelets are small,
Vein Assessment
anucleate, discoid blood cells (1 to 3 μm), with an in vivo
half-life of 7 days, and the average platelet count in adults Assessment of the patient prior to phlebotomy to locate an
ranges from 150 to 350 × 106/mL of circulating blood.3 adequate vein is advised. In most instances the median ante-
Since platelets are an integrated part of whole blood, cubital vein is preferred by practitioners, but care should be
mimicking and accelerating physiologic tissue healing and taken in this area due to the close proximity of the median
regeneration, harvesting a calculated amount of fresh blood nerve. For the blood draw, it is important to select a large
is mandatory to acquire platelets and eventually other whole and stable vein in the antecubital fossa, with the cephalic
blood constituents. and basilic vein connected by the median antecubital vein
Medical and US Food and Drug Administration (FDA)- (Fig. 6.3). Another common option is the base of the
approved point-of-care devices can fractionate a unit of cephalic vein, located over the wrist joint proximal to the
autologous whole blood into various components and for- thumb (note that the superficial radial nerve is close to this
mulations, consisting of platelet-poor plasma, platelets, leu- area). In muscular patients, the cephalic vein is more super-
kocytes, and red blood cells (RBCs). ficial near the elbow in the antecubital fossa, presenting as
the median antebrachial vein. Veins at the back of the hand
Phlebotomy Procedure (Fig. 6.4) are more peripheral veins and are more suitable
for intravenous access to inject medication than for blood
Administrative duties, proper patient identification, and harvest. Supportive technology such as ultrasound devices
informed consent precede a blood harvesting procedure, or vein visualization systems can be used to map and access
with proper labeling of syringes. Patients can be placed in veins when not clearly visible/palpable on visual inspection.

62
 CHAPTER 6 Autologous Tissue Harvesting Techniques: Platelet-Rich Plasma 63

5 1
1

4 2
• Fig. 6.1Platelet-Rich Plasma Preparation Kit. Multiple platelet-rich
plasma manufacturers produce complete preparation kits, including
anticoagulant, drapes, concentrating system, syringes, phlebotomy
set, and so on. (Shown is the Pure PRP II kit, EmCyte Corporation,
Fort Myers, FL, USA.)
• Fig. 6.3Anterior view of the cubital fossa: 1, cephalic vein; 2, basilic
vein; 3, median cubital vein; 4, median antebrachial vein; 5, accessory
cephalic vein.

• Fig. 6.2 Phlebotomy Kit. A complete phlebotomy set is included in

the platelet-rich plasma preparation kit as shown in Fig. 6.1.

Tourniquet and Aseptic Technique • Fig. 6.4 Butterfly needle system injected in one of the dorsal meta-
carpal veins.
A tourniquet is placed to fill the patient’s venous vascular
system. Prior to venipuncture, aseptic techniques are used
for skin preparation. Single stick draws are preferred to clotting. Pull the skin taut to anchor the vein, and insert
decrease chances of activation and patient discomfort. PRP the needle bevel up, entering the skin at a shallow angle of
systems that minimize exposure of blood and cellular com- 5 to 15 degrees. Direct the needle into the vein from its
ponents to open air, allowing for minimal manipulation of top or side surface (Fig. 6.5). A slight resistance is felt as
tissue, are mandatory as per FDA guidance. the needle passes through the dense skin tissue and vein
wall. A slight ease in resistance is noted when the needle
Venipuncture enters the lumen of the vein. If the blood does not flow,
reposition the needle; if the blood is flowing slowly, adjust
Before performing the venipuncture, flush the butterfly the angle of the needle, as it may be sitting against the wall
assembly with the anticoagulant in the syringe to avoid of the vein.
64 SEC T I O N I I Injectates

• Fig. 6.5 Inserting the butterfly needle, directing the needle bevel up.

• Fig. 6.7 After collecting the whole blood and removal of the butterfly
(needle), agitate the blood in the collection syringe clockwise-to-coun-
terclockwise to prevent the blood from clotting and enable proper and
effective platelet-rich plasma processing.

• Fig. 6.6 Agitate the blood in the collection syringe during the blood Adverse Events and Complications
draw period sufficiently to avoid central clotting in the syringe by invert-
ing the syringe in order to move the air bubble as indicated in the red
Following Phlebotomy
circle.
Pain and Ecchymosis
Adverse events and complications following a phlebotomy
Blood Aspiration are rare. However, a poorly executed phlebotomy can cause
Pull slowly back on the plunger of the collection syringe in adverse effects for patients, ranging from pain or ecchymosis
a controlled fashion at a rate of approximately 1 mL/s to at the site of puncture, nerve damage, and hematoma.4 Tran-
prevent the vein from collapsing and inducing too much sient localized pain and localized ecchymosis are common
negative pressure, which can cause cell damage. During aspi- and improve with time. Occasionally, patients may experi-
ration, agitate the blood in the syringe with the anticoagu- ence a vaso-vagal reaction with associated light-headedness,
lant twice (by moving an air bubble backward and forward) hypotension, nausea, and sweating. This is treated with lay-
to assure proper mixing, as the whole blood is more dense ing the patient back, oral fluids, and the passage of time with
than the anticoagulant and will not be properly anticoagu- reassurance of the patient. Pulse and blood pressure should
lated otherwise during the blood draw, potentially initiating be checked until they normalize and then the patient should
clotting within the central part of the syringe (Fig. 6.6). be slowly brought to a seated, and then upright, position.
When the required amount of blood is obtained the tourni- The more severe adverse events that have been documented
quet can be released, the syringe is disconnected, and a sterile in blood transfusion services usually involve poor venipunc-
cap is placed. Remove the butterfly, or other needle assembly, ture practice or the presence of anatomic variants resulting
and apply a folded gauze to the site as a pressure bandage. in hematoma and injury to anatomic structures in the vicin-
Invert the syringe clockwise-to-counterclockwise five times to ity of the needle entry.
mix the anticoagulant and blood more completely (Fig. 6.7).
Infection
Contaminated Materials Poor infection-control practices can lead to bacterial infec-
Dispose of sharps and contaminated materials in designated tion at the site where the needle was inserted into the skin.5
medical waste containers. This is an extremely rare event. Such an infection could
 CHAPTER 6 Autologous Tissue Harvesting Techniques: Platelet-Rich Plasma 65

1.1 µm

A B
• Fig. 6.8 Electron Microscopic Scanning of Platelet-Rich Plasma Platelets. (A) Electron microscopic
image of single platelets in the circles. The platelet cell membranes are intact, and platelets contain platelet
alpha granules and dense granules (black and grey structures, respectively) and lysosomes. (B) The platelet
membranes are ruptured from the blood drawn from hand vein, and the granular content is no longer visible.

ascend more proximally in the venous vascular system and whole blood intended for PRP preparation.7 The authors
develop into a septic thrombophlebitis, which needs to be concluded that the duration of the blood draw and manner in
managed according to local protocols, potentially with cul- which the blood was drawn shows a relationship between the
ture-directed antibiotics. Furthermore, healthcare workers platelet count in the PRP prepared. Furthermore, the PRP
can be exposed to bloodborne pathogens from needlestick platelet concentrations were also influenced by the whole
injuries.6 blood harvesting site. Optimal platelet counts were obtained
when blood was drawn from a peripheral vein as compared to
Paresthesia an arterial collection site or a central venous line.

In rare cases post-venipuncture paresthesias are observed, Shear Stress

mainly due to edema at the site of the needlestick rather
than a nerve injury. This should resolve within 3 weeks. The use of small-gauge harvesting needles, excessive pull
Patients with longer-lasting paresthesia can be referred to force, and venipuncture of small blood vessels increase shear
a neurologist or electromyographer for further assessment. forces applied to blood components and will result in plate-
let activation and RBC lysis, resulting in plasma-free hemo-
Arterial Puncture globin. Under normal operational procedures and avoiding
high shear forces, PRP-platelet function is preserved (Fig.
Another potential complication is an arterial puncture. This 6.8A). Intact platelets maintain the alpha granules integ-
would be apparent by the spontaneous appearance, or with- rity, containing a variety of platelet-derived growth fac-
drawal, of bright red blood in the syringe. This is managed tors. Blood draw from small hand veins that have tendency
by quick and direct pressure on the area and monitoring for to collapse during aspiration and the use of small needles
any local expansion and/or change in pulse distally. lead to high shear forces at the point of the needle, result-
ing in premature platelet activation (Fig. 6.8B). The release
Possible Factors Influencing the Quality of of platelet contents, including the alpha granules platelet
growth factors, result in the platelets losing functionality.
Platelet-Rich Plasma
Blood Draw Anatomic Site and Time Hemolysis
Waters and Roberts discussed several possible factors that have Shear stress can cause RBC cell membranes to rupture
an effect on the quantity and quality of platelets in aspirated (hemolysis) with the subsequent release of heme and iron
66 SEC T I O N I I Injectates

• Fig. 6.10 A forceful blood draw from the hand is shown to extract
blood from the vein.

A B

• Fig. 6.9 (A) After the first spin of a concentration device, the plasma-
poor fraction is showing a clear yellow aspect. (B) The same container
has been used to process blood drawn from a metatarsal vein with a
forceful extraction of the blood. After the first spin, the upper plasma
part is clearly red colored, indicating ruptured red blood cell mem-
branes. (Devices used are PurePRP II concentration system, EmCyte
Corporation, Fort Myers, FL, USA.)

from hemoglobin. In a PRP syringe containing hemolyzed

RBCs, free heme and iron cannot be cleared by natural scav-
enger mechanisms and will therefore be injected in tissues.
This will lead to a significant inflammatory tissue response
and might induce cellular dysfunction.8 In Fig. 6.9A, a non-
hemolytic and clear yellow platelet-poor plasma fraction on
top of the RBC layer is visible after the first spin. In Fig. 6.9B,
whole blood aspirated from a hand vein utilizing excessive
force to fill the collection syringe (Fig. 6.10) was processed.
After the first spin, the platelet-poor plasma fraction is col-
ored red, indicating severe RBC hemolysis. RBC damage
may signify platelet damage as well, as the platelet cell mem-
• Fig. 6.11
Transferring the Collected Whole Blood to a Concentration
branes are more fragile than the cell membrane from RBCs. Device. The transfer of the collected blood to the concentration device
Transferring the whole blood from the collection syringe to should be performed meticulously, avoiding squirting air and blood in
the concentration container for processing should be done the device.
in an unrushed fashion, to avoid causing damage to the cel-
lular contents and allowing air in the device, possibly induc- • s odium citrate (SC)
ing hemolysis in this final step (Fig. 6.11). • ethylenediaminetetraacetic acid (EDTA).
In clinical cases, heparin has also been used as an anti-
coagulant. Currently, ACD-A is present in the majority of
Chemical Composition of Blood commercially available PRP kits; EDTA is more frequently
Anticoagulants used in hematologic studies. The use of an anticoagulant
to collect blood for PRP applications in MSK-D is a major
Manufactures of PRP systems may provide an anticoagu- issue and has impacts on the healing of tissues, platelet
lant in the kits. The most commonly used anticoagulants yields, and preservation following centrifugation, as well as
for blood draws are: platelet morphology. Different anticoagulants have different
• citrate dextrose solution–formula A (ACD-A) chemical compositions and pH. Several groups investigated
 CHAPTER 6 Autologous Tissue Harvesting Techniques: Platelet-Rich Plasma 67

whether the chemical composition of anticoagulants dramatically in the quality of PRP they produce. PRP sys-
modulates PRP characteristics with regard to pH, platelet tems operate on a relatively small volume of drawn blood
recovery, glucose concentration, growth factor release, and (10 to 60 mL) and on the principle of density whole blood
mesenchymal stem cell differentiation.9,10 separation, by using a variety of centrifugation protocols
and proprietary design. Based on specific design characteris-
Glucose Concentration tics of the PRP collection device, methods of centrifugation,
and processing time, the PRP composition and concentra-
Fitzpatrick and colleagues concluded that the glucose concen- tion of platelets and leukocytic cells differs widely. Ulti-
tration in PRP prepared with ACD-A was four to six times mately, this influences the concentration of growth factors
the baseline value when compared to the glucose levels of the and other cytokines. Without addressing PRP classification
donors. This PRP concentration was found to be a signifi- strategies, PRP devices can be coarsely divided into:
cant higher glucose concentration than used in prolotherapy.9 • plasma type PRP (P-PRP) (0.5 to 1.25 times baseline
Although the significance of these high glucose levels is yet concentration),
unclear, it might be of clinical importance, as animal studies • low platelet content PRP (Lo-PRP) (1.5 to 3 times base-
indicate that high glucose levels affect tendon homeostasis.11 line concentration), and
• high platelet content PRP (Hi-PRP) (5 to 9 times base-
Mesenchymal Stem Cell (MSC) Proliferation line concentration) systems.16
The P-PRP systems require only 8 to 10 mL of whole
From another study it was concluded that PRP obtained blood. Several test-tube containers are used to perform a
using SC presented the smallest variation in mesenchymal single-spin centrifugation of 8 to 10 mL of whole blood
stem cell gene expression, with a larger amount of platelets to acquire “some” acellular PRP, excluding RBCs and leu-
and potential for better mesenchymal stem cell prolifera- kocytes, while collecting as many platelets as possible from
tion, without phenotype changes.10 the plasma layer.9 It is noteworthy that some of these test-
tube containers that are being used to process whole blood
Platelet Dosing and Blood Volume for PRP therapies (for example, BD Vacutainer CPT) are
not intended for clinical human use, and according to their
PRP can be characterized as a complex composition of instructions for use these systems contain chemical additives
autologous multicellular components in a small volume of and endotoxins that are not controlled.
plasma with a substantial clinical dose of concentrated plate- The Lo-PRP producing devices need approximately 10 to
lets, compared to baseline values. Marx12 and Giusti and 20 mL of whole blood. Both the P-PRP and Lo-PRP devices
colleagues13 concluded that 1 to 1.5 × 109 platelets/mL are can be labeled as single-spin devices, as the harvested whole
needed to induce a functional angiogenic response in tissue blood is spun only once in a centrifuge in order to accom-
repair mechanisms to stimulate (neo)angiogenesis and stim- plish whole blood separation. The platelet fraction after a
ulate in the healing of MSK-D. Interestingly, Lopez-Vidriero single spin is collected as PRP. The Hi-PRP devices require a
and associates indicated that specific tissue structures and blood draw varying between 25 and 55 mL of whole blood
MSK pathologies with a poor healing tendency should be and are dual-spin devices. These dual-spin devices are more
ideally treated with PRP preparations capable of increasing effective in whole blood density separation and cellular and
angiogenesis.14 A PRP platelet count of at least 1 to 1.5 × platelet concentration to create a so-called buffy-coat cel-
109/mL has become the working definition for therapeutic lular stratum. It is important to understand that the platelet
PRP, and subtherapeutic doses may explain negative clinical concentrate is located on top of the RBC layer (Fig. 6.12).
results, which may simply be due to platelet concentration.15 Therefore, in order to collect as many platelets as possible,
In order to use a PRP product with therapeutic platelet it is essential to make contact with the RBC layer during
numbers, practitioners have to acquire a sufficient amount PRP collection. Unfortunately, there is no consensus on
of whole blood from their patients to yield high platelet con- standardizing PRP techniques,17 which has contributed to
centrations after a dual spin processing. It is important to the large variation in PRP devices and produces variability
understand that not all PRP products are the same and that in platelet concentrations and cellular compositions.18,19
the therapeutic platelet concentrations cannot be achieved Some offices prepare PRP using homemade protocols,
by many devices currently available on the market. with multiple modifications of plasma-based and buffy-
coat-based preparation protocols.20 Knowledge of proper
Blood Draw Volume and Platelet-Rich laboratory techniques, the availability of proper and vali-
dated equipment, including a fume hood, are prerequisites
Plasma Protocols in order to produce a reproducible PRP vial. Homemade
Platelet-Rich Plasma Device Grouping PRP products should at a minimum meet the currently
accepted clinical PRP formulations to treat patients accord-
Many PRP systems are commercially available, with the ing to the current standards of care.
intention to produce a “ready to go” PRP suspension. Of substantial importance is that in the United States
However, point-of-care PRP devices and centrifuges differ the collection, transport, preparation, and storage of blood
68 SEC T I O N I I Injectates

be versatile and compliant to enable the production of

different PRP formulations. In addition, consideration
should be made for cell counting following the produc-
tion of a PRP product provided to patients to best quan-
tify the amount of platelets and the presence of RBCs and
white blood cells, which have been previously noted to
affect outcomes.

References
1. Ferrari M, Zia S, Valbonesi M, et al. A new technique for hemo-
dilution, preparation of autologous platelet-rich plasma and
intraoperative blood salvage in cardiac surgery. Int J Artif Organs.
1987;10(1):47–50.
2. Everts PAM, Knape JTA, Weibrich G, Hoffmann J, Overde-
vest EP, Box HAM, et al. Platelet-rich plasma and platelet gel: a
review. J Extra Corpor Technol. 2006 Jun;38(2):174–87.
3. Everts PA. Autologous platelet-rich plasma and mesenchy-
mal stem cells for the treatment of chronic wounds. In: Hakan
Dogan K, ed. Wound Healing—Current Perspectives [Internet].
2019. IntechOpen; [cited 2019 Oct 4]. Available from: htt
ps://www.intechopen.com/books/wound-healing-current-
• Fig. 6.12 Cellular Density Separation of Whole Blood by
perspectives/autologous-platelet-rich-plasma-and-mesenchymal-
Centrifugation. After the first-spin centrifugation procedure, blood stem-cells-for-the-treatment-of-chronic-wounds.
is separated in two layers. The first layer is the platelet-poor plasma 4. Daugherty K. Best practices in phlebotomy... in an ACO envi-
fraction with a multicomponent buffy coat layer, containing platelets, ronment. MLO Med Lab Obs. 2012;44(4):20–22.
monocytes, lymphocytes, and neutrophils. The second layer consists 5. Bae M, In Kim H, Park JH, et al. Improvement of blood culture
of the red blood cell pack. The range of the specific cell densities varies contamination rate, blood volume, and true positive rate after
among individual cells as a result of the different cellular densities. (The introducing a dedicated phlebotomy team. Eur J Clin Microbiol
device shown is the PurePRP. SP, EmCyte Corporation, Fort Myers, Infect Dis. 2019;38(2):325–330.
FL, USA.) 6. Wagner SJ, Leiby DA, Roback JD. Existing and emerging blood-borne
pathogens: impact on the safety of blood transfusion for the hema-
tology/oncology patient. Hematol Clin. 2019;33(5):739–748.
and blood components is governed by FDA regulations and 7. Waters JH, Roberts KC. Database review of possible factors
specific guidance documents (http://www.aabb.org/advoca influencing point-of-care platelet gel manufacture. J Extra Corpor
cy/regulatorygovernment/bloodcomponents/Pages/default. ­Technol. 2004 Sep;36(3):250–4.
aspx). 8. Everts PA, Malanga GA, Paul RV, Rothenberg JB, Stephens N,
The basic characteristics for a minimal PRP product for Mautner KR. Assessing clinical implications and perspectives
efficacy in orthopedic conditions has been described, and of the pathophysiological effects of erythrocytes and plasma
free hemoglobin in autologous biologics for use in musculo-
this should be the goal for any practitioner providing PRP
skeletal regenerative medicine therapies. A review. Regen Ther.
to patients. 2019;11:56–64.
9. Fitzpatrick J, Bulsara MK, McCrory PR, Richardson MD, Zheng
Factors Determining the Need for Blood MH. Analysis of platelet-rich plasma extraction: variations in
platelet and blood components between 4 common commercial
In general, before harvesting a particular volume of blood to kits. Orthop J Sports Med. 2017;5(1):232596711667527.
prepare PRP, the physician should ideally consider in each 10. do Amaral RJFC, da Silva NP, Haddad NF, et al. Platelet-rich
individual patient: plasma obtained with different anticoagulants and their effect
• the number of treatment sites on platelet numbers and mesenchymal stromal cells behavior
• the PRP volume per treatment site in vitro. Stem Cells Int. 2016;2016:1–11.
• the need for a specific platelet dosing (formulation) 11. Snedeker JG. How High glucose levels affect tendon homeostasis.
Adv Exp Med Biol. 2016;920:191—198.
• the need, or absence, of specific leukocytic cells (neutro-
12. Marx R. Platelet-rich plasma (PRP): what is PRP and what is not
phil-monocyte poor/rich). PRP? Implant Dent. 2001;10(4):225—228.
This detailed information will assist in deciding how 13. Giusti I, D’Ascenzo S, Mancò A, et al. Platelet concentration in
much blood is required during the blood draw for that indi- platelet-rich plasma affects tenocyte behavior in vitro. BioMed Res
vidual patient. Int. 2014;2014:1–12.
Remarkably, Marques and co-workers found that infe- 14. Lopez-Vidriero E, Goulding KA, Simon DA, Sanchez M, John-
rior PRP treatment outcomes correlated directly with son DH. The use of platelet-rich plasma in arthroscopy and
poor quality and inconsistent PRP products.21 There- sports medicine: optimizing the healing environment. Arthrosc J
fore, it is the authors’ opinion that PRP devices should Arthrosc Relat Surg. 2010;26(2):269–278.
 CHAPTER 6 Autologous Tissue Harvesting Techniques: Platelet-Rich Plasma 69

15. Dhurat R, Sukesh M. Principles and methods of preparation of availability for tissues through four PRP-gel preparations: fibri-
platelet-rich plasma: a review and author′s perspective. J Cutan net®, RegenPRP-Kit®, Plateltex® and one manual procedure. Vox
Aesthetic Surg. 2014;7(4):189. Sang. 2009;97(2):110–118.
16. Dhurat R, Sukesh M. Principles and methods of preparation of 19. Everts PAM, Hoffmann J, Weibrich G, et al. Differences in plate-
platelet-rich plasma: a review and author’s perspective. J Cutan let growth factor release and leucocyte kinetics during autologous
Aesthetic Surg. 2014;7(4):189–197. platelet gel formation. Transfus Med. 2006;16(5):363–368.
17. Chahla J, Cinque ME, Piuzzi NS, et al. A call for standardization 20. Mariani E, Pulsatelli L. Platelet concentrates in musculoskeletal
in platelet-rich plasma preparation protocols and composition medicine. Int J Mol Sci. 2020;21(4):1328.
reporting: a systematic review of the clinical orthopaedic litera- 21. Marques FP, Ingham SJM, Forgas A, Franciozi CE da S, Sasaki
ture. J Bone Jt Surg. 2017;99(20):1769–1779. PH, Abdalla RJ. A manual method to obtain platelet rich plasma.
18. Mazzucco L, Balbo V, Cattana E, Guaschino R, Borzini P. Acta Ortopédica Bras. 2014;22(2):75–77.
Not every PRP-gel is born equal evaluation of growth factor
7
Autologous Orthobiologics
PRATHAP JAYARAM, PETER CHIA YEH, MAX EPSTEIN, AND
SHIV J. PATEL

Introduction count, pH, and glucose in four commercially available PRP

kits. The study revealed variation in platelet and other blood
The delivery of cell- and non-cell-based therapies can gener- component concentrations, and lack of standardization of
ally be classified as either autologous or allogenic. Autologous PRP preparation between kits.6 Proponents of these systems
treatments involve a procedure in which the patient’s own cite internal consistency in platelet concentration and ease of
tissues are collected and subsequently reintroduced into the use as reasons to use them; however, laboratory protocol can
patient’s own body. Some benefits of using autologous prod- also produce precise PRP formulations without specialized
ucts over allografts include the innate decrease in immuno- commercial equipment.7
logic side effects and tissue rejection, transfusion reaction, Another variable in PRP preparation is the use of an
and reduced possibility of disease transmission. Autologous exogenous activator. While used more commonly in surgi-
products include platelet-rich plasma (PRP), platelet lysate cal applications, these activators promote platelet clotting
(PL), alpha-2 macroglobulin, interleukin-1 (IL-1) receptor for surgical scaffold applications, degranulation, and sub-
antagonist, bone marrow aspirate (BMA) and concentrate, sequent growth factor release.8 Exogenous activators are
adipose tissue, and cultured cellular injectates. commonly calcium (i.e., calcium chloride and calcium glu-
conate) or thrombin based. The majority of reported studies
Platelet-Rich Plasma in the literature use 10% calcium chloride. Thrombin and
arachidonic acid are other activators that have been used.
PRP is an autologous preparation of concentrated platelets There has been increasing interest in activator selection as
isolated from whole blood by centrifugation, defined as hav- some in vivo studies have found that they may variably
ing a plasma product with total platelet count greater than release growth factors.7 Exogenous activator may extend the
normal physiologic levels. PRP therapy is currently being growth factor release period to 7 to 10 days beyond the ini-
used in musculoskeletal medicine as an injectable therapy tial injection, in addition to the platelet clot providing a sur-
for bone, joint, and connective tissue pathology. Platelets are gical scaffold.3,9–12 A more detailed discussion of scaffolding
an abundant source of growth factors that when released are applications is beyond the scope of this chapter.
available to aid in tissue repair.1 While the science behind Given the diversity in PRP preparation systems and for-
PRP continues to evolve, there is a need for optimizing and mulations, characterizing PRP is important to optimizing
characterizing PRP formulations. formulations and interpreting the literature. There have
PRP is formulated using various amounts of whole blood, been more than 10 proposed classifications for PRP since
with the final volume being around 10% of the original 1999.13,14 Most call for characterization of platelet count,
whole blood volume. The general process is outlined below, presence of cell lines besides platelets, and nuances of prepa-
though it should be noted that each commercial kit will ration such as the use of an exogenous activator. For exam-
have differing protocols, including starting volume, varying ple, the PAW system is based on absolute Platelet count,
speeds of centrifugation, and duration of the spin protocol, method of platelet Activation, and presence or absence of
among others.2 There are at least 33 commercial PRP sys- White blood cells (WBCs).15 The PLRA classification by
tems available on the market at the time of publication of Mautner and colleagues. was one of the first classification
this textbook.3,4 Each system varies in collecting tubes uti- systems to expand its characterization by including red
lized, centrifugation speed, single versus double spin, use (or blood cell and white blood cell counts.16 Newer classifica-
lack) of activating agents, leukocyte and red blood cell inclu- tion systems such as MARSPILL aim to address parameters
sion, and final platelet volume and total number.3–5 There is such as concentration folds over baseline, amount of spins,
significant variability across commercial kits. A 2017 study and spin speed, but classification systems have not caught on
assessed platelet count, red blood cell count (RBC), leukocyte widely due to the fragmented nature of PRP research.13,14

70
 CHAPTER 7 Autologous Orthobiologics 71

There are ongoing efforts to optimize PRP formulations, TABLE   Key Regenerative Growth Factors Stored in
with a focus on platelet concentration. Current commer- 7.1 Platelet Alpha Granules and Their Functions.
cial systems vary widely in their platelet concentrations,
Growth
ranging from 0.52 to 9× the baseline in some studies.3 It
Factor Function
is important to note that the positive effects of PRP can be
dose dependent, and proliferation of tendon stem/progeni- PDGF Stimulates cell proliferation, chemotaxis, and
tor cells cultured in various concentration of PRP has been differentiation
Stimulates angiogenesis
shown to increase in a dose-dependent manner in up to a
10% PRP dose.17 At high concentrations, PRP may begin TGF-β Stimulates production of collagen type I and
to exhibit anti-chondrogenic activity and impair healing.9,18 type III, angiogenesis, re-epithelialization,
and synthesis of protease inhibitors to inhibit
However this is largely dependent on which growth factors
collagen breakdown
are being degranulated, i.e., chondrotoxic or chondropro-
tective mediators and may not be platelet concentration VEGF Stimulates angiogenesis by regulating
endothelial cell proliferation and migration
dependent. Conversely, a 2019 study suggests a dose-depen-
dent response to higher PL concentrations in promoting EGF Influences cell proliferation and cytoprotection
tenocyte proliferation in vitro in the aged population (>50 Accelerates re-epithelialization
Increases tensile strength in wounds
years old) but not young donors.19
Facilitates organization of granulation tissue
The presence and absence of leukocytes in PRP is another
common area of discussion. Leukocyte infiltration of tis- bFGF Stimulates angiogenesis
sues has been linked to both muscle injury and repair and, Promotes stem cell differentiation and cell
proliferation
as such, the argument can be made for or against included Promotes collagen production and tissue
leukocytes in PRP formulations.20–22 Leukocyte-poor (LP) repair
PRP is generally defined as any PRP formulation contain-
IGF-1 Regulates cell proliferation and differentiation
ing fewer WBCs than baseline and leukocyte-rich (LR) PRP Influences matrix secretion from osteoblasts
conversely contains more WBCs than baseline.13 and production of proteoglycan, collagen,
and other noncollagen proteins

Mechanism of Action and Clinical Applications bFGF, Basic fibroblast growth factor; EGF, epidermal growth factor;
IGF-1, insulin-like growth factor-1; PDGF, platelet-derived growth factor;
Currently, there are no guidelines on PRP dosing and the TGF-β, transforming growth factor-β; VEGF, vascular endothelial growth
use of specific formulations for different pathologies. How- factor.
Reproduced with permission from Regenerative Medicine, An Issue of
ever, some studies have reported LP-PRP may be beneficial Physical Medicine and Rehabilitation Clinics of North America (Volume
for cartilaginous injuries and LR-PRP for tendinous inju- 27-4) (The Clinics: Orthopedics (Volume 27-4)). 1st Edition. Santos F.
ries. However, other studies report that LR-PRP should be Martinez: Elsevier 2016
Data from Refs.
avoided in osteoarthritis and tendinopathies because WBCs Malanga GA, Goldin M. PRP: review of the current evidence for muscu-
release proteases and reactive oxygen species that may harm loskeletal conditions. Curr Phys Med Rehabil Rep. 2014;2:1–5.
remaining cartilage or tendinous tissue, respectively.10 One Davis VL, Abukabda AB, Radio NM, et al. Platelet-rich preparations to
improve healing. Part I: workable options for every size practice. J Oral
study noted that compared to treatment with LP-PRP and Implantol. 2014;40(4):500–510.
phosphate-buffered saline (PBS), synovial cells treated with Boswell SG, Cole BJ, Sundman EA, et al. Platelet-rich plasma: a milieu
LR-PRP resulted in significantly greater cell death and of bioactive factors. Arthroscopy. 2012;28(3):429–439.
Blair P, Flaumenhaft R. Platelet alpha-granules: basic biology and clinical
some proinflammatory mediator production.23 While the correlates. Blood Rev. 2009:23(4):177–189.
exact dosing and preparation are unknown, some studies
have recommended that the platelet concentration for knee
osteoarthritis and tendinopathies should target close to 3 to
4× and be leukocyte free.10,24 growth factor (PDGF), vascular endothelial growth factor
There is no clear in vivo mechanism for the therapeutic (VEGF), epidermal growth factor (EGF), and fibroblast
effects of PRP and its subtypes; however, PRP’s therapeu- growth factor-2 (FGF-2) (Table 7.1). They also produce tis-
tic effects are often attributed to bioactive factors and high sue growth factor-β1 (TGF-β1)—one of the most impor-
concentration of growth factors. The true biologic response tant mediators in connective tissue regeneration and potent
to PRP is poorly understood and likely pleiotropic, and can inhibitors of matrix metalloproteinases (MMP-1, -3, -9),
have positive benefits on one tissue and deleterious effects which inhibit collagen synthesis.25
on other. In vitro, platelets play important roles in wound It is proposed that growth factors from PRP induce
healing including re-epithelialization, granulation tissue processes of inflammation and cell recruitment, angiogen-
formation, cartilage and bone matrix formation/remodel- esis, and matrix formation by delivering a large quantity
ing, chemotaxis, and angiogenesis.2,25 Platelets accomplish of platelets to the site of injury; however, this is still the
this through their alpha granules that contain the necessary subject of ongoing research. It is important to note that
growth factors for these processes, such as platelet-derived PRP’s effects through a complex sequence of growth factor
72 SEC T I O N I I Injectates

communication within the tissue microenvironment facili- tendinopathy more than dry needling alone at 12 weeks
tates healing of the remaining tissue and does not regenerate (P = .02) as evaluated by the Victorian Institute of Sports
absent tissue. Assessment (VISA), the benefits of PRP was not long last-
Common clinical applications for PRP use include, ing ≥26 weeks (P = .66).35 An RCT of a single injection
but are not limited to: tendinopathies (patellar, rota- of LR-PRP or LP-PRP was not found to be more effec-
tor cuff, gluteal, lateral epicondylitis, plantar fasciitis), tive than saline for the improvement of patellar tendi-
ligamentous tears (ulnar collateral ligament, anterior nopathy symptoms in a study by Scott and colleagues.36
cruciate ligament [ACL]), muscular strains (hamstring, There was no significant difference in the VISA score, pain
gastrocnemius, lumbar multifidus), peripheral mono- during activity, or global rating of change at 12 weeks,
neuropathies (carpal tunnel syndrome), spine pathology 6 months, and 12 months.36 A systematic review and meta-
(sacroiliitis, facet arthropathy, degenerative disc disease, analysis of nonsurgical treatments of patellar tendinopa-
and radiculopathy), and peripheral joints (knee osteoar- thy by Andriolo and colleagues noted that while eccentric
thritis, carpometacarpal joint pain, and temporomandib- exercises seem to be the most beneficial with short-term
ular joint syndrome).26–30 follow-ups less than 6 months (P < .05), multiple PRP
injections may offer more satisfactory results at long-term
Data on Efficacy follow-up (≥6 months, P < .05).37
Wu and colleagues conducted a single-blind RCT to
The main limitation for clinical use of PRP is not a lack of assess the 6-month effect of PRP in patients with mild to
data but rather heterogeneous data. There is a large varia- moderate carpal tunnel syndrome (CTS). Sixty patients
tion in standardization in its preparation and delivery, mak- with unilateral CTS were randomized into two groups of
ing it difficult to discern potential beneficial effects of PRP. 30, with one group receiving one dose of 3 mL of PRP
For instance, while PRP has demonstrated overall favorable using ultrasound guidance and the control group receiving
outcomes in some systematic reviews, the studies had vary- a night splint.38 The patients who received PRP exhibited
ing methods of PRP preparation, patient populations, and a significant reduction in the visual analog scale (VAS),
stages of disease. Boston Carpal Tunnel Syndrome Questionnaire score, and
Shen and colleagues conducted a systematic review that cross-sectional area of the median compared to those of the
found that most patients had significantly improved pain control group 6 months post-treatment (P < .05).38
relief and self-reported function after PRP injection for A systematic review and meta-analysis by Sheth and col-
knee osteoarthritis compared to saline placebos, hyaluronic leagues comparing PRP to control therapies (such as phys-
acid (HA), ozone, and corticosteroid injections. It was also iotherapy or placebo injections) in acute muscle injuries (≤7
reported that 10 of the 14 included studies had high risk days) found that while the use of PRP did not significantly
of bias associated with them, mostly due to lack of inves- decrease the rate of injury at 6 months follow-up, there was
tigator blinding.27 Laver and colleagues published a recent significant decrease in return to play times except with a
systematic review of PRP in knee and hip osteoarthritis subgroup with grade 1 or 2 hamstring muscle strain.39 A
encompassing 29 studies, including 1 hip and 8 knee ran- literature review by Setayesh and colleagues on the treat-
domized controlled trials (RCTs) and 11 total studies con- ment of muscle injuries with PRP found that while there
trolled with HA. For the studies controlled with HA, 9 were numerous clinical case series demonstrating faster
of 11 studies found that PRP was significantly superior to healing, less swelling, and quicker return to play times for
HA in terms of symptom improvement.9 In general, ben- patients with muscles strains who received PRP, most stud-
eficial effects of PRP therapy in osteoarthritis have been ies were retrospective and few RCTs demonstrate a clear
more effective in cohorts with milder disease and younger clinical benefit.40 They also observed variability in the injec-
populations.9,25 tant preparation, the platelet concentration, the presence of
A 2017 systematic review and meta-analysis comprised leukocytes, the volume of PRP injected, and the timing of
exclusively from Level 1 RCTs in rotator cuff injuries and treatments.40
lateral epicondylitis reports significantly less pain in PRP- Figueroa and colleagues conducted a systematic review
treated groups compared to control in the long term.31 This of prospective cohort studies or RCTs on PRP compared
differs from prior meta-analysis, largely including low-pow- to control in the treatment of ACL tears, assessing graft-to-
ered studies and heterogenicity in comparator outcomes, bone healing, graft maturation, and/or clinical outcomes.41
which have published contrasting results.32–34 While they found that more studies had evidence of faster
A double-blinded RCT by Dragoo and colleagues com- graft maturation, it appears there were mixed results, with
pared the clinical outcomes in patients with patellar ten- overall findings leaning to no significant improvement in
dinopathy after a single ultrasound-guided, leukocyte-rich graft-to-bone healing or clinical outcomes.41
PRP injection with dry needling compared to dry nee- Overall, there is currently a need for systematic charac-
dling in 23 patients.35 They reported that while the regi- terization of PRP therapy, which along with appropriately
men of standardized eccentric exercise and PRP injection conducted prospective trials, could better understand PRP’s
with dry needling appeared to help patients with patellar efficacy and formulations.
 CHAPTER 7 Autologous Orthobiologics 73

Caveats/Side Effects Platelet Lysate

PRP has demonstrated an excellent safety profile with no PL is a cell- and platelet-free supernatant rich in growth fac-
reported major adverse events or reactions.42 The side effects tors and cytokines, created when the platelet membranes
are similar to those for any intra- or extraarticular injection, have been lysed, releasing intracellular proteins.46 Anec-
such as infection, pain, bleeding, and injury to nearby blood dotally, this is thought to have inherent antiinflammatory
vessels or nerves. properties.47
Drug interactions with PRP have not been well studied PL became of increasing interest in the 1980s as the
and documented in literature. Nonsteroidal antiinflamma- growth-promoting effects of PL became studied in multiple
tory drugs (NSAIDs), such as aspirin and naproxen, have clinical applications including wound and soft tissue injury,
been shown to interfere with growth factor release given the ocular disorders, and equine musculoskeletal injuries, and
direct inhibition of cyclooxygenase pathway.7,43 Although more recently in human musculoskeletal conditions.48,49 Its
there is no research correlating growth factor release and main advantages include that it can be stored in a freezer
efficacy of PRP treatment in vivo, these studies suggest and used for future or consecutive applications.46 Studies
NSAIDs and aspirin should be held prior to PRP, and other with in vitro and animal models demonstrate PL promote
analgesics, such as acetaminophen, should be prescribed for the proliferation of various cell types, including equine mes-
post-injection pain control. enchymal stem cells (MSCs) and tenocytes, chondrocytes,
keratinocytes, osteoblasts, and bone marrow mesenchymal
cells.50,51
US Food and Drug Administration (FDA)
PL is derived from a platelet concentrate by mechanical
Regulations disruption of PRP by freezing and thawing followed by cen-
PRP is regulated under the FDA Center for Biologics Eval- trifugation to separate platelet debris. There is no consen-
uation and Research (CBER), which exempts it from the sus protocol for preparation of PL. One reported protocol
traditional regulatory pathway. The 510(k) application for included freezing a PRP sample to −80°C for 30 minutes to
“substantially equivalent” devices is used to bring PRP prod- lyse the platelets and release the growth factors. After thaw-
ucts to market. There are a myriad of FDA-approved devices ing to 37°C in the water bath, the lysate is centrifuged at
ranging from traditional, injectable PRP to PRP-based bio- 1600× g for 10 minutes to separate the cell debris.52 Other
materials intended for enhancing bone graft healing. Most protocols call for repeating of the freeze-thaw cycle for
of the 33 systems on the market have FDA 510(k) clearance higher yields.53
to enhance bone graft preparations with PRP. Although
PRP injections are considered off-label use, physicians are Mechanism of Action and Clinical Applications
allowed to administer them under CBER as long as they
are “well informed about the product…base its use on firm The mechanism of action of PL is poorly understood; how-
scientific rationale and on sound medical evidence, and… ever, theoretically, the mechanism of action and clinical
maintain records of the product’s use and effects.”44 effectiveness should be similar to PRP.54 There are no clear
The World Anti-Doping Agency (WADA), an interna- indications for the use of PL, but case reports and case series
tional independent agency that regulates doping-free sport, have reported the use of PL for knee osteoarthritis, lum-
had prohibited PRP in 2010, but removed it from the list in bar radiculopathy, and lateral elbow tendinopathy.47,55,56 It
2011. The initial concern from the experts was that growth has been theorized that PL may be of more benefit around
factors in PRP may stimulate muscle growth beyond the nerves as it is thought to be more antiinflammatory than
normal physiologic state and give individuals an unfair PRP. However, this has not been studied in detail and there
advantage; however, the prohibition was lifted as there was is no published literature on the effect of PL on nerve inju-
limited evidence for a systemic ergogenic effect of PRP.42 ries outside of the Centeno and colleagues’ lumbar radicu-
PRP appears to trigger an increase in circulating growth lopathy study mentioned above.
factors systemically, including elevated serum insulin-like
growth factor-1 (IGF-1), VEGF, and basic fibroblast growth Data on Efficacy
factor (bFGF), which may be banned by governing agen-
cies, and should be used with caution in athletes as this may There are limited data regarding clinical efficacy of PL. In a
cause false negatives in doping tests.45 prospective open-label study of 48 patients, Al-Ajlouni and
colleagues suggests intra-articular (IA) injection of autolo-
gous PL in patients with osteoarthritis of the knee is effective
Conclusion in reducing pain and restoring function without provoking
PRP continues to be a promising therapy, especially in early local or systemic adverse events.55 This is consistent with
osteoarthritis- and tendinopathy-related injuries. However, the in vitro study in 2017 that suggested PL induces qui-
its use is currently limited by mechanistic understanding, escent cartilage cell activation and proliferation leading to
cost burden, a lack of standardization in its formulation new cartilage formation.51 In 2017 Centeno and colleagues
protocols, and calls for more robust blinded studies. suggested in a retrospective review of 470 patients that PL
74 SEC T I O N I I Injectates

decreases pain in lumbar radiculopathy with a significantly cascade, and create a favorable healing environment in the
improvement in pain scores up to 2 years post-injection.47 joint or other area of tissue pathology.
Tan and colleagues observed in a prospective study of 56
patients significant improvement in VAS score and Mayo Data on Efficacy
score for function following PL in chronic lateral epicon-
dylitis who failed conservative therapy.56 There are limited Although used clinically, A2M has not been extensively
data regarding clinical efficacy of PL, or in vivo study of PL studied and to date there is minimal in vivo human studies.
on human cells. Of the available studies, most have involved assessing osteo-
arthritis of the knee in preclinical models. Elevated levels of
Caveats/Side Effects catabolic proteases and cytokines in synovial fluid have been
shown to induce chondrocyte death and cartilage matrix
Studies on clinical efficacy of PL are limited to small case degeneration. In a rat model of osteoarthritis induced by
series or case reports, and the study results have not been ACL transection, IA A2M provided chondral protection
repeated. PL as an autologous therapy has similar complica- and treated knees demonstrated less cartilage damage com-
tions and side effects to PRP. A more comprehensive review pared to controls.59,60 There is also suggestion in a rabbit
of drugs and their effects of PL remains to be conducted, model that it may help in healing of a ruptured ACL.61
but it is possible aspirin and NSAIDs can cause an inhibi- Theoretically, since A2M is thought to be antiinflamma-
tory effect on growth factor release, and therefore should be tory, it is thought to potentially have utility in patients with
withheld in the days prior and after injection.7 increased joint inflammation or inflammatory arthropa-
thies. An in vivo study by Cuellar suggests there may be effi-
FDA Regulations cacious use of A2M in discogenic pain in patients positive
for the fibronectin-aggrecan complex (a protein biomarker
The use of PL is not FDA approved, however, its off-label of disc disease), as measured by VAS and Oswestry Disabil-
use may be allowed by regulatory exemption per Title 21 ity Index (ODI) scores at 6 months following an intradiscal
United States Code of Federal Regulations Part 1271 (21 injection.62
CFR 1271) and the 361-product exemption.57 In the
author’s opinion, PL is exempt as it is derived from an Caveats/Side Effects
autologous source, has a homologous use of tissue, and is
processed with minimal manipulation. There are limited data on clinical efficacy and there are no
known specific risks of A2M other than general adverse pro-
Alpha-2 Macroglobulin cedural risks.

Alpha-2 macroglobulin protein (A2M) is a protease inhibi- FDA Regulations

tor, produced by the liver, and to a lesser extent by chon-
drocytes and synoviocytes. A2M can be found throughout A2M is not FDA approved; however, its off-label use may be
the body but is greatest in the blood where it binds to and allowed by regulatory exemption per 21 CFR 1271 and the
inactivates a wide variety of proteins and cytokines through- 361-product exemption.57 In the author’s opinion, current
out the body. Its orthobiologic activity involves binding to products to concentrate A2M from whole blood undergo
proinflammatory and catabolic proteins to make a more “minimal manipulation” and therefore would be exempt.
favorable healing environment.
A2M can also be derived from autologous whole blood. Interleukin-1 Receptor Antagonist Protein
Utilizing a centrifuge process similar to PRP, the platelet-
poor concentrate is then used to create a concentrated vol- IL-1 is a proinflammatory cytokine, produced in response
ume of A2M. There are various commercial systems that can to injury. IL-1 causes tissue degeneration and upregulates
be used to purify A2M concentrate. inflammatory mediators that can result in pain.63 Elevated
levels of IL-1 has long been associated with inflammation
Mechanism of Action and Clinical Applications in rheumatologic disease and osteoarthritis, and IA levels
of IL-1 correlates with osteoarthritis (OA) severity.64 IL-1
In the IA environment, A2M inhibits endoproteases, par- action is mediated by the interleukin-1 receptor antagonist
ticularly matrix metalloproteinases, responsible for cata- (IL-1Ra) protein, or IRAP, making IRAP an attractive ther-
bolic activity.58 Although A2M is found in the serum, apy for mediating pain and potentially modifying disease.65
A2M is a large molecule and does not cross into synovial IL-1Ra can be obtained in two ways: (1) derived from
fluid and joint spaces at large concentrations for signifi- autologous whole blood using commercial systems (Ortho-
cant IA effect. Injection of autologous A2M concentrate, kine, Regenokine or Arthrex IRAP II System) or specific lab
such as Cytonics APIC System, into the joint allows for processing protocol; or (2) commercially available recom-
the in vivo delivery of high-volume A2M, which can bind binant proteins. Recombinant forms of IL-1Ra have been
and inhibit catabolic enzymes, inhibit the inflammatory FDA approved for the treatment of rheumatoid arthritis
 CHAPTER 7 Autologous Orthobiologics 75

and are marketed as the drug anakinra (Kineret) and admin- Bone Marrow Aspirate Concentrate
istered as daily subcutaneous injections. Autologous pro-
cessing uses specialized equipment to process autologous Bone marrow aspirate concentrate (BMAC), also known
whole blood. Glass beads bind monocytes, which then as bone marrow concentrate (BMC), is a preparation of
produce antiinflammatory cytokines, particularly IL-1Ra, harvested autologous bone marrow. After harvesting, cen-
and a milieu of regenerative growth factors as the solution trifugation is used to concentrate MSCs, hematopoietic
is incubated typically for 6 to 24 hours. The process creates cells (HCSs), platelets, and bioactive molecules such as
a cell-free solution, autologous conditioned serum (ACS), cytokines.74 Similar to PRP, BMAC utilizes cytokines to
which is then recovered by centrifugation.66 harness the body’s ability for tissue healing. Unlike PRP,
BMAC utilizes multipotent stem cells that can theoretically
differentiate into damaged cell types, and also indirectly
Mechanism of Action and Clinical Applications
assist with healing by stimulating angiogenesis and recruit-
The proposed mechanism of action of IRAP is by com- ing local tissue-specific progenitor cells through paracrine
petitive inhibition at the IL-1 receptor, blocking the pro- effects.75 It is important to note that there has been efforts
inflammatory IL-1 effect. There are no clear indications to rename what is currently known as mesenchymal stem
for the use of autologous IL-1Ra at this time. Some pos- cells to medicinal signaling cells.76 Dr. Caplan, one of the
sible indications are in osteoarthritis of major joints. In pioneers to first coin the term “mesenchymal stem cells” in
osteoarthritis specifically, IL-1 directly contributes to car- the 1970s–80s, has suggested now using the new terminol-
tilage loss through upregulation of extracellular proteolytic ogy to more accurately reflect that the cells migrate to the
enzymes while simultaneously suppressing cartilage anabo- sites of injury or disease and then secrete bioactive factors.76
lism through downregulation of collagen and proteoglycan It appears that the MSCs do not necessarily function in the
synthesis.67,68 body as progenitor cells for new tissues, and instead the bio-
active factors secreted by the exogenously supplied MSC
stimulate the patient’s own site‐specific and tissue‐specific
Data on Efficacy
resident stem cells to construct the new tissue.76 Currently,
A 2019 systematic review of IL-1Ra products for knee there is no clear consensus on the mechanism of action of
osteoarthritis concluded that autologous IL-1Ra may these cells and how they ultimately influence the observed
improve pain and functionality for mild to moderate OA, effects on the tissue microenvironment.
and may be an effective adjunct for those unresponsive to The International Society for Cellular Therapy (ISCT)
traditional IA therapies.69 In a randomized, double-blind, proposed that MSCs must be plastic-adherent (such as to
placebo-controlled clinical trial in knee OA patients a one- a tissue culture flask); must express the surface markers
time injection of IL-1Ra significantly improved pain scores CD73, CD90, and CD105 and not express the hemato-
compared to placebo; however, there was no significant dif- poietic markers CD14, CD34, CD45, CD11b, CD79a,
ference 4 weeks after the injection.70 ACS with high-con- CD19, or HLA class II; and should be able to undergo
centration IL-1Ra has also been studied for the treatment multilineage differentiation (osteogenic, adipogenic, and
of lumbar and cervical radiculopathy with improvement in chondrogenic) in vitro.77–79 MSC’s low immunoreactivity
pain, function, and quality of life similar to that of cortico- and high immunosuppressive properties make it a promis-
steroids with epidural injections, but with possibly a longer ing stem cell source for therapy.
efficacy.71 There is early preclinical work in a rat model of The two currently available bone marrow stem cell prep-
tendon disease, where IL1-Ra improved structural end- arations are cultured bone marrow stem cell (referred to in
points with histologic analysis.72 the text as BMSCs) and noncultured BMAC that contains
Current research is exploring long-term IL-1Ra delivery MSCs but also a variety of other cells (referred to in the text
by gene therapy, or injecting the gene encoding the protein as BMACs). Cultured BMSCs require a two-step procedure
using a virus vector. This has been proposed to be a superior for expansion of BMSCs in vitro to increase cell counts to
method of increasing IA IL-1Ra expression. Gene therapy 100- to 10,000-fold during several weeks in culture.75,80 In
IL-1Ra has been studied in animal models and found to this section, we will be focusing on non-cultured BMACs,
be safe, symptomatically effective, and disease modifying; with a subsequent section elaborating on cultured BMSCs.
however, to date, there are no human trials.73 BMAC is harvested from the patient’s bone marrow,
most commonly from the posterior iliac crest, due to higher
yield, though other sites include tibia, femur, sternum, and
FDA Regulations
humerus.74,81 The physician inserts a needle percutaneously
There is no FDA-approved system to produce autologous into the posterior iliac crest, past the cortical bone and into
whole-blood–derived IL-1Ra proteins at this time. It is the the medullary cavity to obtain bone marrow.74 Detailed
opinion of the author that the Orthokine system (or Rege- techniques, yield, and additional information on bone mar-
nokine in the United States) to produce ACS is more than row harvest are described in Chapter 6 of this text.
minimally manipulating the whole blood product, and thus BMAC is a concentrated milieu of MSCs, HCSs, peri-
would not categorize under regulatory exemption per 21 cytes, endothelial progenitor cells (EPCs), osteochondro-
CFR 1271 and the 361-product exemption.57 reticular (OCRs) skeletal progenitor cells, stromal cells,
76 SEC T I O N I I Injectates

multilineage-differentiating stress-enduring (Muse) cells, Data on Efficacy

platelets, and various cytokines such as but not limited
to IL-1RA, PDGF, and VEGF. Cell components include Few studies have compared the use of noncultured (non-
erythroblasts, neutrophils, eosinophils, basophils, mono- expanded) BMSCs with cultured (expanded) stem cell
cytes, lymphocytes, macrophages, plasma cells, and mega- therapy, and it is unclear which method may be superior.75
karykocytes.75,82 The end composition is reduced in RBCs While there are no RCTs on the efficacy of noncultured
and blood plasma. It is important to note that while there BMAC for patients with cartilage disease, there have been
are multiple commercial BMAC devices available to the many publications illustrating its safety profile and thera-
practitioner, the composition and consistency of the prepa- peutic potential.75 Furthermore, the harvested stem cell
rations vary.83,84 Cassano and colleagues noted a significant quantity and quality can vary by patient, which makes
difference in the IL-1B, TGF-β, and PDGF concentration research comparisons difficult.74 Baseline pain and func-
between two commercial BMC systems.83,84 Dragoo and tional limitations, BMAC dose, PRP dose (if given at the
Guzman compared three commercially available BMAC same time), and individual biologic factors can all influence
preparation systems in a controlled laboratory study with 10 treatment efficacy.
patients.84 While the authors noted a variation in the WBC Some of the current indications and uses for BMAC
concentration consistency between two systems, there was under evaluation include chondral defects of the knee,93
not a significant difference in consistently among the plate- full-thickness and moderate-to-large cartilage defects of the
let, CD34+ cells concentration, and colony-forming unit knee, osteoarthritis of the knee,90 meniscal tears,94 spine-
(CFU) fibroblasts.84 However, the composition of the con- mediated pain,95 partial tear of the rotator cuff tendon,96,97
centrate products did differ across the systems.84 shoulder arthritis,98 osteochondral lesions of the talus,81
ACL repair,99 hip arthritis,100 and hip osteonecrosis.101
Autologous BMAC has also been used intraoperatively as
Mechanism of Action and Clinical Applications an adjunct to debridement or microfracture surgery for
While the exact mechanism of how BMAC functions is cartilage defect102 and has been shown to improve heal-
not known, the various components of BMAC have been ing and reduce rotator cuff retears when augmenting RTC
shown to induce differentiation and proliferation of resident surgery.103
stem cells, and have chondrogenic and osteogenic potential, Studies of autologous BMC for the treatment of IA knee
as well as antiinflammatory effects in vitro.75 HCSs, also pathology are among the most numerous. Shapiro and
found in BMAC, can differentiate into red blood cells and colleagues performed a prospective, single-blind, placebo-
muscle, are involved in muscle repair, and stimulate osteo- controlled trial that compared BMAC and saline placebo
genesis with direct contact with MSCs.75,85 In addition to injection for patients with bilateral knee osteoarthritis and
the platelet’s ability to release growth factors to initiate stem found no serious adverse events from the BMAC procedures
cell migration to the injury site and provide adhesion sites as well as a significant decrease in VAS pain scores at 1 week,
for migrating stem cells, platelets can also decrease pain via 3 months, and 6 months.104
a peripheral endocannabinoid related pathway.75,86 With respect to the spine, there is an increasing num-
There is evidence that the dose of progenitor cells can ber of studies. Pettine and colleagues examined outcomes
affect clinical outcomes. Hernigou reported that for the in 26 patients following intradiscal percutaneous injection
treatment of nonunion tibia fractures with BMC, the of BMC for discogenic low back pain.105 At 3-year follow-
total number and concentration of bone marrow progeni- up, six patients went on to surgery. Of the remaining 20
tor cells had a significant effect on fracture healing.87 Pet- patients, average ODI improved from baseline of 56.7
tine reported that in the treatment of discogenic pain with to 17.5 and average VAS improved from 82 to 22 at 36
BMC, higher MSC concentration was linked to pain reduc- months. At 1 year, 40% of patients had an improvement
tion post procedure.88 Centeno reported that in the treat- of one modified Pfirrmann grade on magnetic resonance
ment of knee arthritis with BMC, in patients with a total imaging (MRI) and no patients had worsening of their
nucleated cell (TNC) count above 400 million there was imaging.
significant improvement in all studied pain and functional
metrics compared to the lower cell count group.89 Both Caveats/Side Effects
groups did report significant improvement from baseline.89
The addition of a supplementary PRP injection to the Adverse reactions include general procedural risks, including
BMAC treatment protocol can potentially influence the but not limited to pain, swelling, bleeding, infection, dam-
results of an isolated BMAC injection for OA. A single, age to nearby structures, and potential detrimental effects
image-guided IA injection of BMAC followed by a supple- of erythrocytes when used for IA joints.74 Contraindica-
mentary IA injection with PRP at 8 weeks follow-up was tions include bone marrow–derived cancer (lymphoma),
well-tolerated and significantly improved pain at short-term active systemic infection, blood thinners, and non-bone
follow-up among patients with moderate-to-severe OA.90 An marrow–derived cancers which is a relative contraindica-
ongoing clinical trial called the CASCADE trial is examining tion.75 However, a study by Hernigou and colleagues found
the use of BMAC with and without HA for discogenic low no increased cancer risk in patients after application of
back pain.91,92 autologous cell-based therapy using bone marrow–derived
 CHAPTER 7 Autologous Orthobiologics 77

stromal progenitor cells either at the treatment site or else- The culturing method is currently prohibited in the
where in the patients after an average follow-up period of United States as current regulatory guidelines consider
12.5 years.101 in vitro expansion of the BMA more than “minimally
Centeno and colleagues performed a large prospective manipulated.” In contrast, noncultured BMACs do not
study on 339 patients who were treated for various ortho- require laboratory cell expansion and culturing, and are
pedic conditions with culture-expanded autologous, bone available after centrifugation for same-day treatment.75
marrow–derived MSCs that were harvested from the pos- Given that this is a single-step process with “minimal
terior superior iliac crest between 2006 and 2010.106 The manipulation” of cells, this meets the criteria established
mean patient age was 53 ± 13.85 years (214 males and 125 by the US FDA for homologous use.74,75 As defined in
females) and follow up varied from 3 to 36 months.106 Using 21 CFR 1271.3(c), “homologous use means the repair,
high-field MRI tracking and complications surveillance, reconstruction, replacement, or supplementation of a
they noted that while there were two patients who reported recipient’s cells or tissues with an HCT/P that performs
the development of cancer, the cancers were not at the injec- the same basic function or functions in the recipient as
tion sites and the percentage of patients that developed can- in the donor.”57 Bone marrow meets this criterion for
cer was not far from the annual rate of cancer in the general orthopedic uses as its constituents are involved in bone,
population.106 The most common complaints were pain cartilage, tendon, and muscle repair. Care should be taken
and swelling (2% of patients), with no reports of infections when processing BMAC to not combine the BMAC with
and procedure-related complications were self-limited or other agents, except for water, crystalloids, or a steriliz-
remediated with simple therapeutic measures.106 Centeno ing, preserving, or storage agent to satisfy the minimally
and colleagues subsequently performed a larger prospec- manipulated guidelines.
tive multicenter study investigating the safety of same day Minimally manipulated BMAC used for cartilage resur-
autologous BMC aspiration isolation, and injection (n = facing therapies is not regulated by 21 CFR 1271 and
1590 patients, 1949 injections), same day autologous BMC therefore does not require premarket approval, preclinical
aspiration, isolation and injection with an addition of mini- research, or clinical trials to be marketed for treatment in
mally processed lipoaspirate (n = 247 patients, 364 injec- the United States.57,108 The FDA released a guidance docu-
tions), and cultured expanded BMSCs re-implanted weeks ment in November 2017 to explain the regulatory demands
or months after bone marrow aspiration (n = 535 patients, of manufacturers of human cells, tissue, and cellular and
699 injections), orthopedics procedures across 18 sites. The tissue-based products by specifically delineating the defini-
discrepancy in the number of procedures and patients can tion of “minimal manipulation.”57,108 BMAC preparation
be explained by multiple joint procedures that occurred kits and concentration systems require only a 510(k) Pre-
during the same session, and/or serial injections occurring market Notification to the FDA 90 days before marketing
at different treatment sessions for the same patient. 3012 the product.108 Thus, it highlights the importance of the
procedures were performed over 9 years with 2372 patients clinician to counsel the patients effectively on the risks, ben-
reporting on adverse advents (AEs) with a mean follow up efits, and potential outcomes.108
time of 2.2 years.107 Follow-up ranged from 1 month to 8.8
years with an average of 2.2 years.107A total of 325 (12.1%) Adipose Tissue
AEs were reported, with 38 adjudicated to be definitely
related to the procedure (1.6% of the population).107 The Since the first isolation and classification of adipose tissue
majority of the AEs were post-procedure pain or pain due to stem cells (ASCs), human studies related to ASCs have
degenerative joint disease.107 Thirty-six (1.5% of the popu- increased, reaching up to 187 clinical trials in 2015 and
lation) reported a serious side effect, with 19 of those adju- more registered trials in 2019.109 Subcutaneous adipose tis-
dicated to be not related to the procedure and 4 definitely sue is a common reservoir of progenitor cells, such as MSCs,
related.107 There were 7 neoplasms reported with none at and the clinical application of fat has been used in cosmetic,
the site of injections. The BMC only group was less likely reconstructive, and corrective indications. MSCs have vast
to report AEs compared to the BMC with addition of mini- potential in regenerative medicine due to their ability to pro-
mally processed lipoaspirate and culture BMSC groups.107 liferate and differentiate into multiple lineages, including
Blood-thinning medications such as coumadin and aspi- adipocytes, chondrocytes, myocytes, and osteoblasts.77,110
rin may be discontinued and managed appropriately by MSCs can be obtained from different sources, including
the cardiologist or primary doctor prior to the procedure. bone marrow, adipose tissue, dental pulp, synovium, mus-
Lastly, the financial costs associated with BMAC procedures cle, and other tissues.111 The evidence and proliferation of
may be prohibitive for some patients as they are often not human use have vastly expanded since the first isolation and
covered by insurance for elective orthopedic procedures. description of the progenitor cells in rodents in 1964 by
Rodbell.112–114
FDA Regulations Current applications have included knee osteoarthri-
tis,115–121 osteonecrosis of the femoral head,116 hip osteo-
There are two currently available BMSC preparations: cul- arthritis,122 and shoulder osteoarthritis and rotator cuff
tured BMSCs and noncultured (nonexpanded) BMACs. pathologies.123 Some studies have assessed ASCs in varying
78 SEC T I O N I I Injectates

conditions in human and animal models,109 such as multiple technique, but UAL contained fewer stem cells, and viable
system atrophy,124 Crohn disease,110 cardiac disease,125 isch- stem cells had a longer population doubling time.140 Keck
emic heart disease,126 amyotrophic lateral sclerosis,127–129 and colleagues compared power-assisted liposuction with
Parkinson’s disease,130,131 spinal cord injury,132 rheumatoid manual aspiration in nine subjects undergoing abdomino-
arthritis,133–135 type 1 diabetes mellitus,136 type 2 diabetes plasty.149 Both conditions had a comparable number of
mellitus,137 and Alzheimer disease.138,139 viable ASCs per mL of aspirated fat, similar proliferation
Methods for harvesting adipose tissue include resec- rates, and ability to differentiate into mature adipocytes,
tion, tumescent, conventional liposuction, and ultrasound- though the cells harvested using power-assisted liposuc-
assisted liposuction (UAL; these are covered in more details tion had significantly higher expression levels of differ-
in Chapter 5: Autologous Tissue Harvesting Techniques: entiation markers adiponectin, GLUT4, and PPARg.149
Bone Marrow Aspirate and Adipose Tissue).140,141 After Duscher and colleagues compared an UAL device versus
harvesting, the raw lipoaspirate can be processed using vari- standard suction-assisted lipoaspiration in three patients
ous methods and protocols to produce an injectable MFAT, with paired collection.150 They reported that both meth-
enzyme digested stromal vascular fraction (SVF), or cultured ods had comparable ASC yield, viability, osteogenic and
ASC product.78,141 When the adipose tissues are further adipogenic differentiation capacity, and certain cytokine
processed into the SVF or cultured ASC, they are consid- expressions such as VEGF, hepatocyte growth factor, stro-
ered more than minimally manipulated and do not meet mal cell–derived factor 1, and bFGF, though the UAL
the current regulations and criteria established by the FDA. method had more expression of the monocyte chemotactic
Information regarding SVF and ASCs will be described in protein 1.150
further detail in the subsequent section under cultured cel- The effectiveness of AT-MSCs when obtained from and
lular injectates. There are FDA-compliant devices that can utilized in elderly patients must be considered. Choud-
make MFAT with intact stromal vascular niche and MSCs hery and colleagues noted that aged AT-MSCs displayed
that can then be injected back into the patients, such as senescent features when compared with cells isolated from
Lipogems, PureGraft, and IntelliFat.142–145 young donors, and also exhibited reduced viability and
MFAT preserves the stromal vascular architecture and proliferation.151 The authors noticed a significant drop in
stem cell niche; however, robust studies that have assessed its the osteogenic potential of AT-MSCs with increased donor
molecular profile are lacking. SVF has been better character- age; however, the adipogenic and the neurogenic potential
ized, and is composed of a heterogeneous mixture of cells of the AT-MSCs seemed to be maintained during aging.151
including pre-adipocytes, pericytes, mast cells, fibroblasts, Schipper and colleagues assessed the composition of cells
smooth muscle cells, endothelial cells, hematopoietic stem harvested from 12 female patients within 3 age ranges (25
cells, and adipose tissue–derived mesenchymal stem cells to 30, 40 to 45, and 55 to 60 years old) and from 5 differ-
(AT-MSCs).78,146 Adipose tissue can yield up to 500,000 to ent subcutaneous adipose depots.152 They observed sensitiv-
2,000,000 cells per gram of tissue.116 ity to apoptosis was linked to the anatomic depot, with the
The AT-MSC yield, proliferation, and differentiation superficial abdominal depot (above Scarpa layer) more resis-
capacity can be influenced by the location of adipose tissue tant to apoptosis compared to the other sites (deep abdomi-
harvested, the method of harvesting, the age of the patient, nal layer, arm, thigh, and trochanteric).152 They also noted
and other factors such as donor’s body mass index.114,147 faster cell proliferation rates in younger patients than the
Adipose has a high heterogeneity among individuals and older age groups, and that younger patients had increased
within the same individuals with the various stem/precur- peroxisome proliferator activated receptor (PPAR)-γ-2
sor cells, different types of adipocytes (white, beige, brown), expression, which is required for adipogenesis both in vivo
endothelial cells, and even pericytes.114 The quality of AT- and in vitro. The older patients only have elevated PPAR-γ-2
MSCs can also fluctuate based on the purifying method and expression in the arm and thigh depots.152
storage conditions.109 In addition to age and harvest location influencing the
The most common locations to extract adipose tissue composition and effectiveness of AT-MSCs, a systematic
include the abdomen and hip/thigh region, with the infrapa- review by Varghese and colleagues noted decreased prolif-
tellar fat pad being a less commonly used location.115,140,146 eration and differentiation potential of the AT-MSCs with
More studies illustrate that the abdomen is the optimal increasing body mass index, diabetes mellitus, exposure to
location to harvest adipose tissue.146,148 radiotherapy, and tamoxifen.153 In one study, ASCs in adi-
Depending on the methods of extracting adipose tissue, pose tissue of obese patients had lower capacity for repair
the yield, number of viable cells, and growth characteris- than ASCs from nonobese patients, likely due to higher inci-
tics of AT-MSCs may differ. The viability of ADSCs may dence of metabolic syndrome in obese patients.154 Another
be affected by the stress applied to the adipose tissue dur- study showed that ASCs from obese donors had shorter life
ing harvesting and processing. Oedayrajsingh-Varma and spans, increased DNA damage, and more adipogenic differ-
colleagues compared adipose tissue resection, tumescent, ential potential than ASCs from normal-weight donors.155
conventional liposuction, and UAL, and their effects on the ASCs from type 2 diabetics showed higher levels of senes-
ACS yields and growth characteristics.140 The number of cence and apoptosis, and reduced osteogenic and chondro-
viable cells in SVF was similar regardless of the harvesting genic potential, while enhancing adipogenic potential.156
 CHAPTER 7 Autologous Orthobiologics 79

Furthermore, it appeared that there is not a significant collaborated and called for establishing high-quality patient
impact of hypertension, renal disease, physical exercise, registries that can assist with continued surveillance and
peripheral vascular disease, and total cholesterol on AT- quality assessment.163
MSC yield, though the authors noted it is very difficult to
make conclusive recommendations due to the variability in Caveats/Side Effects
studies.153
Adverse reactions include general procedural risks including
Mechanism of Action and Clinical Applications but not limited to pain, swelling, bleeding, infection, and
damage to nearby structures. Kuah and colleagues evaluated
MSCs are adult stem cells that can differentiate into a the safety and tolerability of in vitro expanded MSCs derived
variety of cell types, including osteoblasts, chondrocytes, from human donor adipose tissue combined with cell cul-
and adipocytes.75,157 MSCs assist with tissue regeneration ture supernatant, and did not find any severe side effects
by differentiating into damaged cell types or indirectly when administered as a single IA injection to patients with
by stimulating angiogenesis, limiting inflammation, and symptomatic knee osteoarthritis.116 Swelling of injected
recruiting local tissue-specific progenitor cells. MSCs also joints can be a common side effect, and is thought to be
secrete growth factors and cytokines, including but not lim- associated with the death of stem cells.164 Other potential
ited to prostaglandins, TGF-B1, nitrous oxide, IL-4, IL-6, side effects, though less common, include tenosynovitis and
and IL-10, and IL-1 receptor antagonist.75,157 HCSs can tendonitis, arthralgia, joint stiffness, effusion, and paresthe-
support the vascular system by differentiating into blood sia or malaise.117,164,165
cells and stimulating osteogenesis with direct contact with Theoretically, MSCs can divide into unwanted onco-
MSCs.75 A study by Ceserani and colleagues on MFAT har- logic cell lineages, and could contribute to tumor behavior
vested using Lipogems Systems reported that the MFAT has by influencing the tumor microenvironment and promot-
the capacity to induce vascular stabilization and even retain ing angiogenesis; however, this has not been seen with
antiinflammatory effects.142 adult-derived MSCs.166 No literature documenting neo-
A study by Vezzani and colleagues noticed that the plastic complications at ADSC implantation sites have
microanatomy of MFAT is similar to that of intact adipose been reported, and a longitudinal cohort study by Pak and
tissue, with capillaries, microvessels, and pericytes wrapped colleagues on SVF with PRP into various joints found no
around endothelial cells; however, they noted a higher fre- evidence of neoplastic complications in any implantation
quency of pericytes in MFAT than in manual lipoaspirate site.164
and SVF.158 It is notable that recent literature has suggested The cost of the procedure is generally not covered by
that in vivo the main functionality of MSCs may not be insurance, and can be prohibitive for some.
multipotency.159 While pericytes have been widely believed
to function as MSCs, others speculate that all MSCs could FDA Regulations
be pericytes due to the locations and cell marker signa-
tures.160 Crisan and colleagues observed the expression of There are some FDA-compliant devices that can make
MSC markers on the surface of perivascular cells, suggest- MFAT with intact stromal vascular niche and MSCs such
ing blood vessel walls may harbor a reserve of progenitor as Lipogems, PureGraft, and IntelliFat,143–145 which can
cells.161 Guimarães-Camboa and colleagues’ lineage-tracing then be injected back into the patients through the use in
experiments suggest that the plasticity observed in vitro, or orthopedic applications, and whether it counts as homolo-
following transplantation in vivo, may be due to the artifi- gous use is debatable. The FDA defines the basic function of
cial cell culture environment.159 adipose tissue as providing cushioning and support. Some
Microvascular fragments from adipose tissue exhibit argue MFAT acts to cushion and/or support orthopedic tis-
a high angiogenic activity, representing a rich source of sue injuries, such as tendon and meniscal tears, and should
MSCs, and can rapidly develop into microvascular net- be considered homologous.
works.162 When the resulting MFAT is processed, such Recently published guidelines that indicate enzymati-
as with Lipogems, pericytes can be retained within the cally or mechanically processed lipoaspirate (PLA) alters
intact stromal vascular niche as well as retaining the these relevant characteristics and is not considered homolo-
MSCs.143 gous use or minimal manipulation by the FDA.57,167 SVF
AT-MSCs isolated from younger donors are anticipated is adipose tissue that undergoes further processing (such as
to be a more useful cell source for tissue engineering and with enzymatic digestion) to break down and eliminate the
regenerative medicine applications. There is theoretical adipocytes and surrounding structural components that
potential for cell-based therapies for the elderly by bank- provide cushioning and support, and thus is considered
ing adipose tissue at a younger age, preserving the stem more than minimally manipulated.57,167 Further laboratory
and progenitor cells when biologic activity is at its greatest cell sorting and culture expansion would also be considered
potential.79 more than minimally manipulated due to the steps involved
Acknowledging a need for further high-quality research, in isolating and culturing of cells. Adipose tissue that is pro-
the American Academy of Orthopaedic Surgeons in 2018 cessed into SVF or cultured ASC is more than minimally
80 SEC T I O N I I Injectates

manipulated and not FDA approved based on the current chondrogenic, adipogenic, cardiomyocytic, hepatic, and
guidelines. Minimally manipulated ADSC used for carti- neurogenic differentiation.109,177,178
lage resurfacing therapies is not regulated by 21 CFR 1271 BM-MSCs and AT-MSCs have comparable immu-
and therefore does not require premarket approval, preclini- nophenotypes; however, AT-MSCs retain their phenotype
cal research, or clinical trials to be marketed for treatment more consistently over BM-MSCs across multiple culture
in the United States. Consequently, some products are not passages, and also have higher proliferation capacities in part
FDA approved and may qualify instead for investigational due to their lower senescence ratio.179 A donor-matched
new drug process.167 study comparing culture-expanded AT-MSCs vs BT-MSCs
showed that AT-MSCs underwent faster proliferation and
Bone Marrow–Derived Versus Adipose- doubling times.180 They had longer life spans possibly due
Derived Stem Cells to the fact they had longer telomeres, which may suggest a
smaller dose is required in vivo.180 Both had similar differ-
MSCs can be obtained from different sources, includ- entiation capacity and decreased proliferation the longer the
ing bone marrow, adipose tissue, dental pulp, synovium, in vitro expansion was performed.180 On the other hand,
muscle, and other tissues.111 To date, bone marrow–derived Mohamed-Ahmed and colleagues found BM-MSCs were
MSCs are the best characterized and studied.151 Recently, superior to AT-MSCs in terms of osteogenic and chondro-
other MSC sources, particularly adipose tissue, have gained genic differentiation, while AT-MSCs had higher prolifera-
clinical interest for use in regenerative medicine.168,169 Zuk tion and adipogenic potential.77 Chondrogenesis was more
and colleagues were one of the initial researchers to assess efficient in human BM-MSCs versus AT-MSCs in vitro.181
PLA cells obtained from liposuctioned adipose tissue, and Human BM-MSCs showed more chondrogenic poten-
found it represented a potential source of multilineage tial in vitro compared to AT-MSCs.182 Xu and colleagues
mesodermal stem cells.170 Few studies have compared the noted that BM-MSCs possessed stronger osteogenic and
efficacy of BMAC and MFAT.171,172 lower adipogenic differentiation potentials compared to AT-
There are vast differences in the reported stem cell yields MSCs, but found no significant difference in the chondro-
in adipose and bone marrow, with some studies report- genic differentiation potential.177 Xu and colleagues’ results
ing 100 to 500 times higher stem cell numbers found in demonstrated that the DNA methylation status of the main
adipose versus bone marrow.109 However, based on donor- transcription factors controlling MSC fate influenced their
matched studies the differences volume per volume or gram expression, and subsequently different differentiation capac-
for gram appear far less than that. In one study, patients ities of AT-MSCs and BM-MSCs.177
undergoing ACL reconstruction donated samples of several Clinically, there are limited clinical data comparing
tissues including bone marrow and adipose.173 Bone mar- BMAC to MFAT. Mautner and colleagues conducted a ret-
row had about 93× more TNCs per volume compared to rospective study of 110 patients comparing the pain and
adipose (2045 vs 22).173 Adipose had about 148.5× more functional outcomes of patients with symptomatic knee
CFUs per 1000 TNCs, but bone marrow had the most cells osteoarthritis who received BMAC or MFAT or injec-
per colony.173 Given that bone marrow had more TNCs, tions.183 At a mean follow-up time for BMAC of 1.8 years
adipose contained about 1.6× as many MSCs per vol- and 1.0 years for MFAT, they noted both groups had sig-
ume compared to bone marrow.173 BMC was also found nificant improvement in Emory Quality of Life, VAS for
to contain 6x more nucleated cells compared to SVF.174 pain, and Knee Injury and Osteoarthritis Outcome Score
SVF contained 4× more adherent cells.174 Colony-forming questionnaire (P < .001) without a significant difference
frequency was 0.5% in SVF versus 0.01% in BMC. MSC between BMAC and MFAT.183
population was 4.28% of the TNC in SVF versus 0.42%
in BMC or about 10× more in SVF.174 In summary, bone Cultured Cellular Injectates
marrow has more nucleated cells than adipose but only a
small percentage are MSCs. Adipose has less nucleated cells Mesenchymal stem cells/stromal cells (MSCs) have a vast
but a higher percentage of those are MSCs. Pending vari- potential in regenerative medicine due to their ability to
ability in harvesting techniques and patient characteristics, proliferate and differentiate into multiple lineages includ-
adipose per volume likely has 1.6 to 10× as many MSCs ing adipocytes, chondrocytes, myocytes, and osteoblasts.77
as bone marrow. It has been reported that the lipoaspirate Cultured cells are in theory attractive, given their ability to
harvesting, when compared to bone marrow harvesting, potentially differentiate to the desired cell type of an injured
can yield more absolute MSCs, the MSCs have faster rapid tissue. MSCs can be obtained from different sources.
in vitro expansion, and may yield more stem cells per gram
of tissue.169,175,176 Mesenchymal Stem Cells/Stromal Cells From
While there are similar and varying cell surface marker Bone Marrow
profiles between bone marrow–derived mesenchymal stem
cells (BM-MSCs) and adipose tissue–derived mesenchy- After harvesting BMA, the sample is processed in a cen-
mal stem cells (AT-MSCs), they both have the potential to trifuge and subsequent buffy coat layer and platelet-poor
differentiate into multiple lineages, including osteogenic, plasma layers are removed. The cells are subsequently
 CHAPTER 7 Autologous Orthobiologics 81

isolated, generally by their adherence to plastic, and then When SVF cells are cultured, a subset of cells adheres
cultured.75,184 Culturing methods can vary, though one to the tissue culture plasticware. After purification with
method by DiGirolamo and colleagues includes diluting the washing and culture expansion with media, the HCSs
aspirate marrow with Hank’s balanced salt (HBS; Gibco), (nonplastic adhesive cells) are separated from the SVF cells,
washing gently with inversion, adding a layer of Ficoll leaving behind the adipose tissue–derived stromal cells
(Ficoll‐Paque; Pharmacia) beneath the sample, and then which include the stem cells, which can be expanded in a
spinning the sample at 2500 g for 30 minutes at room tem- culture medium.78,109 The cells are then resuspended in a
perature.184 The mononuclear cell layer was then washed mixture of culture medium and cryoprotective medium and
again with HBS and the cells spun at 1500 g for 15 minutes frozen and stored under good manufacturing practice. Cells
and resuspended in complete medium (Minimum Essential can then be expanded in a culture medium for extended
Medium, alpha medium without deoxyribonucleotides or periods and utilized later.77,140 Digesting the triple helix
ribonucleotides, Gibco; 20% fetal calf serum lot‐selected region of the peptide bonds in the collagen of adipose tissue
for rapid growth of human marrow stromal cells (hMSCs) with collagenase can be both time consuming and expen-
FCS, Atlanta Biologicals; 100 units/mL penicillin, 100 sive.141 In some cases, it may be possible to obtain ASCs
μg/mL streptomycin, Gibco; and 2 mm L‐glutamine, without enzymatic digestion.141,185 Baptista and colleagues
Gibco).184 Cells were then plated in a 25 cm2 tissue cultured isolated a population of MSC from lipoaspirate samples
flask (Nunc), incubated at 37°C with 5% humidified CO2 without tissue digestion and found that it is possible to store
for 1 day before the non-adherent cells were removed.184 freshly isolated mechanically processed lipoaspirate adipose
Adherent cells were then washed twice with PBS and shaken tissue (MPLA) cells by cryopreservation without a signifi-
to remove adherent hematopoietic precursors, and fresh cant loss of MSCs.185
complete medium was added.184 The medium was replaced Jurgens and colleagues investigated whether the yield
every 3 to 4 days until the cells grew to 70% to 90% con- and functional characteristics of ASCs are affected by the
fluency, and harvested with trypsin and ethylenediamine- adipose tissue-harvesting site and reported that the percent-
tetraacetic acid (EDTA), with the entire process generally age of ASCs in the SVF of adipose tissue harvested from
repeated to expand the cells through various passages.184 the abdomen was significantly greater than those harvested
from the hip/thigh region (P < .05).146 The authors noted
Mesenchymal Stem Cells/Stromal Cells From that while there not was a significant difference in the ASC
Adipose Tissue proliferation or differentiation capacity from cells harvested
in the abdomen compared to cells harvested from the hip
After harvesting adipose tissue, the raw lipoaspirate can be and thigh, there was a significantly increased yield of ASCs
processed using various methods and protocols to produce found in SVF of abdominal adipose tissue compared to
an injectable, including MFAT, enzyme-digested SVF, or SVF of adipose from hip/thigh regions.146 Furthermore,
cultured ASC.78,141 After isolation from the raw lipoaspi- Iyyanki and colleagues similarly found higher total SVF,
rate (refer to formulation section in Adipose Tissue sec- but not tissue–derived stem cell yields in fat harvested from
tion above), the SVF can either be used directly in clinical the abdomen compared to the flank or axilla.148 Tsekouras
procedures or can be cultured to increase the number of and colleagues assessed 53 lipoaspirates in various locations
cells before using them clinically. With cell culturing, only (inner thigh, outer thigh, abdomen, waist, and inner knee)
ASCs and their precursor cells (supra-adventitial cells and and found that the outer thigh exhibited significantly higher
pericytes) are able to adhere and survive.147,170 It is thought SVF cell count compared to other donor sites and both the
that the predominant benefit of SVF relies on the presence inner and outer thigh showed a significantly higher num-
of ASCs.147 The process of isolating and culturing ASCs is ber of ASCs.186 No significant differences in the viability
generally a long procedure that is not performed at the same of SVF cells and ASCs were noted.186 Fraser and colleagues
time as surgery.78,147 evaluated the stem and progenitor cell content of subcuta-
When the adipose tissues are further processed into the neous adipose tissue in the hips and the abdomen of 10 sub-
SVF or cultured ASC, they are considered more than mini- jects undergoing elective liposuction.187 Using clonogenic
mally manipulated and do not meet the criteria established culture assays and a paired analysis of tissue obtained from
by the FDA and do not comply with current regulations. To the different subcutaneous sites, the authors noted that tis-
make SVF, the raw lipoaspirate is washed with PBS and sub- sue harvested from the hip yielded a statistically significant
sequently undergoes enzymatic digestion with collagenase, 2.3-fold more fibroblast CFU volume and a 7-fold higher
dispase, trypsin, or other enzymes (ranging from 30 minutes frequency of alkaline phosphatase-positive colony-forming
to 1 to 2 hours).78 After neutralization of the enzymes, the unit (CFU-AP, a widely used marker for osteogenesis) than
remaining elements are now called the stromal vascular frac- that obtained from the abdomen.187 One caveat is that the
tion or SVF, and are separated from the mature adipocytes results could reflect the differences in ratio of deep and
by centrifugation.78 The SVF is composed of a heteroge- superficial subcutaneous adipose tissue collected from the
neous mixture of cells, including pre-adipocytes, pericytes, two sites, as deep subcutaneous adipose tissue generally has
mast cells, fibroblasts, smooth muscle cells, endothelial cells, a higher frequency of blood vessels, and thus more pericytes
hematopoietic stem cells, and AT-MSCs.78,148 which may be detected by the CFU-AP assay188 Pericytes,
82 SEC T I O N I I Injectates

as mentioned before, have been shown to possess an adipo- 8. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo
genic potential.159 SA. Platelet-rich plasma. Am J Sports Med. 2009;37(11):2259–
2272. https://doi.org/10.1177/0363546509349921.
9. Laver L, Marom N, Dnyanesh L, Mei-Dan O, Espregueira-
FDA Regulations Mendes J, Gobbi A. PRP for degenerative cartilage disease: a
systematic review of clinical studies. Cartilage. 2017;8(4):341–
Cultured MSCs are currently prohibited in the United 364. https://doi.org/10.1177/1947603516670709.
States, as the methods for culture and isolation are currently 10. Milants C, Bruyère O, Kaux J-F. Responders to platelet-rich
considered more than minimal manipulation of the cells. plasma in osteoarthritis: a technical analysis. Biomed Res Int.
The culturing method is performed outside of the United 2017;2017:7538604. https://doi.org/10.1155/2017/7538604.
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8
Allograft Tissues
ALBERTO J. PANERO, ALAN M. HIRAHARA, LUGA
PODESTA, AMIR A. JAMALI, WYATT ANDERSEN, AND
ALYSSA A. SMITH

Introduction Cellular Versus Acellular Allografts

Allograft tissues are obtained from a donor source and trans- Allografts in interventional orthopedics should be cat-
planted into a different recipient or host, while autologous egorized as either cellular or acellular. For musculoskel-
tissues are obtained and redirected into the same individual. etal purposes, cellular allografts theoretically contain living
Allograft tissue has been used in interventional orthopedics nucleated cells, including leukocytes, hematopoietic stem
to provide structural support, act as a scaffold for the growth cells, or mesenchymal stem cells (MSCs), in addition to
of new tissue, or initiate and regulate the body’s innate heal- platelets, growth factors, and other cytokines. These tissues
ing response. Allografts offer several advantages over auto- are typically derived from blood, bone marrow, adipose, or
grafts. Use of an autologous tissue requires harvesting of the placental tissues. The MSC has traditionally been the focus
blood, bone, bone marrow, or adipose tissue, which can be of cellular allografts for interventional orthopedics. Out-
painful, require additional time to process the tissue, and side of the United States, clinicians are allowed to isolate
carry procedural risks not associated with allografts. More- and expand cells like MSCs in culture prior to transplan-
over, allograft tissues can provide patients with access to tation into a patient. Culture-expanded products contain
orthobiologic treatments when autologous are not feasible, a greater concentration of MSCs than their nonexpanded
such as in the setting of systemic comorbidities or when counterparts; however, this practice is not currently allowed
pharmacologic interactions may not allow for autologous within the United States per Food and Drug Administration
harvesting. (FDA) regulations and is considered more than “minimal
The potential therapeutic benefits of allogenic tissues are manipulation.”4 Per current FDA regulations, use of bio-
apparent; however, their true cellular composition and role logic tissues must fall under the Human Cells, Tissues, and
in clinical practice is still debated. Furthermore, potential Tissue Based-Products (HCT/Ps) guidance reports4:
risks of cellular allografts include contamination with bac-
teria during tissue processing or graft rejection as a result of
1. The HCT/P is minimally manipulated;
the allograft’s donor cell population persisting. The greatest
2. The HCT/P is intended for homologous use only,
risk of cell-based treatments is graft versus host disease. In
as reflected by the labeling, advertising, or other
large-scale allograft transplantation, a chimeric cell popula-
indications of the manufacturer’s objective intent;
tion has been noted in soft tissue transplants1 and osteo-
3. The manufacture of the HCT/P does not involve
chondral allograft transplantation.2 Fortunately, in some
the combination of the cells or tissues with another
applications, the cellular allograft elements may exert their
article, except for water, crystalloids, or a sterilizing,
beneficial effects and subsequently be cleared from the
preserving, or storage agent, provided that the
recipient. The risk of disease is always possible when trans-
addition of water, crystalloids, or the sterilizing,
planting tissue from one source to another, and although
preserving, or storage agent does not raise new
rare, this possibility must always be considered when evalu-
clinical safety concerns with respect to the HCT/P;
ating potential allograft products for clinical use.3
and
The goal of this chapter is to review the basic science,
4. Either:
clinical applications, and logistic considerations of sev-
i. The HCT/P does not have a systemic effect and
eral allograft tissues within the spectrum of interventional
is not dependent upon the metabolic activity of
orthopedic procedures.
living cells for its primary function; or

89
90 SEC T I O N I I Injectates

ii. The HCT/P has a systemic effect or is dependent Vascular endothelial growth factor
upon the metabolic activity of living cells for its • P otent stimulator of angiogenic cascade
primary function, and: • Regulates endothelial migration and proliferation
a. Is for autologous use; • Induces vascular permeability for increased nutrient
b. Is for allogeneic use in a first-degree or delivery
second-degree blood relative; or • Promotes epithelization
c. Is for reproductive use.
The Mesenchymal Stem Cell
Acellular allografts are those that have been irradiated or The name “mesenchymal stem cell,” first coined in 1991,7
processed in such a manner where the product contains no has undergone multiple iterations. This is due, in part, to
nucleated cells or the cells that are present are no longer the fact that upon transplantation in clinical practice the
viable. These products rely on growth factor and cytokine cell may differentiate into the target tissue, but it is unclear
content to mediate the healing processes. The presence of whether the cell retains its stem capabilities. Recently, terms
various growth factors and cytokines can be tested by per- like “connective tissue progenitor cell,”8 “mesenchymal
forming enzyme-linked immunosorbent assay (ELISA) and stromal cell,”9 and “medicinal signaling cell”10 have been
further confirmed with tests such as a Western blot analysis. offered as successors to the term “mesenchymal stem cell”
Acellular allografts, like demineralized bone matrix (DBM), in hopes of more accurately representing the true capabili-
also have the capability to provide structural support or act ties and biology of this type of cell. As the terminology and
as a scaffold for the proliferation of cellular components. precise role of these cells in clinical practice remains a topic
Placental-derived products (amnion, cord blood, Whar- for debate, we will utilize the traditional name “mesenchy-
ton jelly) and exosome preparations characterize this sub- mal stem cell” (MSC) for the purposes of this chapter. The
set of acellular allogenic products. While these tissues are specific name notwithstanding, the International Society of
known to have or be associated with MSCs in vivo, com- Cellular Therapy (ISCT) has offered explicit criteria that
mercial processing techniques have been shown to nega- must be met in order to be considered an MSC (Table 8.1).9
tively affect the viability of these cells.5 Therefore, even A tissue sample can be evaluated for MSCs by identify-
though these products possess the potential to stimulate ing nucleated cells using a hemocytometer or cell counter.
healing, they should not be considered “stem cell therapies.” The mere presence of cells in a sample does not indicate
Despite being acellular, there are many growth factors viability; fluorescent dyes and various assays need to be used
and cytokines that are relevant to interventional orthope- to properly determine a cell’s viability. Even so, clinicians
dics.6 Growth factor and cytokine concentrations present should pay specific attention to the type of test and fluores-
in the allograft tissue may vary by the host donor tissues cent marker used, as some dyes only indicate a cell’s pres-
utilized. Additionally, the concentrations of growth factors ence without regard to whether the cell is alive or dead. If
and cytokines may also be altered by the time between tis- viable cells have been identified, additional testing must be
sue acquisition and processing, and administration by the performed to confirm the presence of MSCs based on the
clinician. Highlighted below are just some examples of these definition put forth by the ISCT (see Table 8.1).9 Simply
biomolecules along with their respective roles and functions. assuming MSCs are present based on the expression or lack
Bone morphogenetic protein-2 (BMP-2) of expression of a single or few of the cluster of differentia-
• Induces chondrogenic and osteogenic differentiation tion (CD) surface molecules can lead to an improper deter-
• Vital in regulating cell interactions mination of MSC content in a given product.
• Role in cartilage restoration has been theorized, but not MSCs are derived from various sources, either autolo-
thoroughly proven (fully elucidated gously or allogenically, and have been employed in animal
Platelet derived growth factor-β (PDGF-β) and human studies for a variety of conditions in the non-
• Accelerates extracellular matrix deposition and collagen operative setting and as a surgical adjunct.11–18 MSCs are
formation perivascular cells that, when activated in response to injury,
• Upon injury, stimulates influx of inflammatory factors migrate to the damaged site and serve as the main repair
and fibroblasts modulator of the musculoskeletal system. Upon arrival,
Transforming growth factor-β1 (TGF-β1) they secrete various trophic and immunomodulatory factors
• Important mediator of tissue repair that direct the body’s healing response. Clinically, isolating
• Released by platelets during acute injury response and applying multipotent MSCs can assist, or even gener-
• Influx to a wound is critical for macrophage and fibro- ate, a healing cascade.
blast chemotaxis Autologous MSCs derived from bone marrow and adi-
Interleukin-8 (IL-8) pose have been used to treat osteoarthritic conditions,
• Induces neutrophil chemotaxis particularly knee osteoarthritis19–26; however, autologous
• Increases vascular endothelial growth factor expression MSCs used in the setting of tendinopathies, bone pathol-
• Secreted by monocytes in response to inflammatory ogies, and other soft tissue injuries have also garnered
stimuli attention.27–33 Application of allogenic MSCs and other
 CHAPTER 8 Allograft Tissues 91

TABLE   International Society of Cellular Therapy been shown to yield fewer total MSCs than those isolated
8.1 Definition of Mesenchymal Stromal Cells. from bone marrow, adipose tissue, Wharton jelly, or umbili-
cal cord matrix.65–70 Furthermore, isolation efficiency is sig-
1. Display plastic-adherence in standard culture
nificantly lower when attempting to expand MSCs from
conditions
umbilical cord blood compared to the other sources.66,69,71
2. Capacity for tri-lineage differentiation into osteoblasts, Umbilical cord matrix MSCs have demonstrated faster
adipocytes, or chondroblasts in vitro
doubling times than bone marrow isolates,72 as well as dis-
3. Expression of: CD105, CD73, and CD90; Lack playing minimal to no deterioration in division and growth
expression of: CD45, CD34, CD14 or CD11b, CD79α power, or senescence, after multiple cell expansion pas-
or CD19, and HLA-DR surface molecules
sages.73,74 Reports on the proliferative capacities of various
International Society of Cellular Therapy Mesenchymal Stromal Cell Defi- tissue sources are conflicting and continue to be debated in
nition. CD, Cluster of differentiation; HLA-DR, human leukocyte antigen– the literature.66,69,71,72,75–78
DR isotype.
From Dominici M, Le Blanc K, Mueller I, et al. Minimal criteria for defin-
As MSCs can be derived from different sources, it must
ing multipotent mesenchymal stromal cells. The International Society for be considered whether these various isolates carry the same
Cellular Therapy position statement. Cytotherapy. 2006;8(4):315–317. biologic potential. It has been well established that MSCs
expanded from adult and neonatal tissues have the capac-
ity for chondrogenic differentiation; however, the capability
for osteogenic and adipogenic differentiation is less con-
biologics mimic those described in autologous studies, but sistent across cell sources. MSCs derived from adult bone
a paucity of human studies using these products are present marrow or adipose tissue have been thoroughly established
in the literature. There are numerous studies using animal to have tri-lineage differentiation,66,79,80 and cells isolated
models for the treatment of various muscular and tendon from Wharton jelly have been shown to exhibit similar dif-
pathologies34–37; however, degenerative joint disease is the ferentiation capacities to adult bone marrow.78,81 Umbilical
most thoroughly studied.38–44 cord matrix MSCs have also proven capable of tri-lineage
In the few human trials available, the focus has been on differentiation.72 MSCs expanded from the amniotic mem-
osteoarthritis and these studies have demonstrated good brane have displayed poor adipogenic and superior osteo-
results.45–52 Allogenic tissues have also been used as surgi- genic differentiation capabilities compared to those derived
cal adjuncts in spinal fusions and osteochondritis dissecans from the chorionic plate, which have exhibited superior
(OCD).53–55 The current literature for other soft tissue adipogenicity and poor osteogenicity.78,82 Umbilical cord
pathologies, including lateral epicondylitis, plantar fasciitis, blood-derived MSCs represent the most conflicting source
Achilles tendinopathy, and meniscal injury is limited, but of cells. It has been confirmed these MSCs have the capa-
the initial studies are promising.56–58 There is still a great bility of adequate osteogenic and chondrogenic differentia-
degree of research to be done to properly evaluate the true tion, with reports of reduced matrix formation,67 but their
potential of allogenic biologic therapies and to identify capacity for adipogenicity is debated in the literature (Table
whether each donor source carries the same therapeutic 8.2).66,67,69,83
potential. Neonatal tissues have been suggested to be the optimal
sources of MSCs compared to adult tissues due to a theo-
Culture-Expanded Allografts retically greater capacity for expansion, differentiation, and
engraftment.60,84–86 Ultimately, Wharton jelly may be the
Culture-expanded allografts are an attractive source of MSC, most promising source of MSCs for musculoskeletal tis-
due to the ability to deliver a homogenized product with sue engineering due to its cellular yield, immunocompat-
a high yield of MSCs. MSCs have classically been derived ability, proliferative capacity, and noninvasive collection
from autologous bone marrow or adipose tissue; however, procedure.78,87
patients are not always amenable to these types of harvests. Cellular expansion has classically been completed in a
Autologous aspirations may not be possible for patients two-dimensional (2D) monolayer characterized by repeated
with significant comorbidities and may yield a collection culturing of stem cells in plates or flasks. These methods
with a heterogeneous cell population with varying volumes ultimately lead to cell senescence and diminished multi-
of MSCs. Allogeneic sources offer numerous advantages. potent capabilities. As such, three-dimensional (3D) cul-
Cells can be derived from bone marrow and adipose, as well ture systems have been developed, including perfusion cell
as placental tissues like the amnion, chorion, or umbilical systems,88 rotatory culture systems,89 stirred suspension
cord. The opportunity to expand cells prior to administra- systems,90 and microcarrier systems.91–94 These 3D expan-
tion and deliver a standardized, homogeneous product with sion techniques are simple, reproducible, efficient, and offer
low immunogenic properties makes MSCs isolated from advantages not observed in 2D systems. 3D cultures more
allogeneic sources an attractive therapeutic option. favorably mimic the in vivo microenvironment of stem cells
MSCs can be isolated from various portions of the and ultimately increase their therapeutic potential.95–97
umbilical cord: Wharton jelly, umbilical cord blood, or the These systems are not influenced by substrate attachments
umbilical cord as a whole.59–64 Umbilical cord blood has as heavily as 2D systems, which improves cellular fortitude
92 SEC T I O N I I Injectates

TABLE
8.2   Tri-lineage Differentiation Capacity of Mesenchymal Stem Cells Isolated From Various Tissue Sources.

Tissue Source Chondrogenic Adipogenic Osteogenic

BM + + +
AT + + +
WJ + + +
AM + − +
CP + + −
UCB + ± +

AM, Amniotic membrane; AT, adipose tissue; BM, bone marrow; CP, chorionic plate; UCB, umbilical cord blood; WJ, Wharton jelly. +, Significant capacity for
differentiation; −, poor or absent capacity for differentiation; ±, inconclusive capacity for differentiation.

and differentiation capacity.95,98 Additionally, they exhibit dendritic cells and diminishing T-cell proliferation.102 The
numerous advantages at the genomic level.96,99 Expression amniotic membrane and fluid also have numerous anti-
of OCT4, SOX2, NANOG, and C-MYC is better main- microbial and antiviral effects.102,106–113 The amniotic
tained in 3D culturing systems than 2D.96,99 These core membrane and amniotic fluid have been identified in vivo
transcription factors develop networks that preserve stem as substantial sources of pluripotent and MSCs, and are
cells’ pluripotent state and capacity for self-renewal, are considered advantageous due to minimal ethical concerns
found in various sources of MSCs, and gradually disappear regarding the harvest of these tissues.105,114–119 Cells derived
as cells are continuously cultured.96,99 MSCs isolated from from amniotic tissues have been used to treat human skin
bone marrow have been shown to demonstrate a greater wounds,120 induce corneal reepithelization,121 and pro-
expression of these transcription factors than Wharton jelly mote neochondrogenesis and peripheral nerve regenera-
or umbilical cord blood.69 tion.122,123 The pluri- and multipotent potential of these
While there are studies that show that higher quantities of cells have made amniotic tissues attractive sources of MSCs
autologous MSCs yield better clinical results,14 this premise in orthopedic tissue regeneration.105,114–119
has not yet been substantiated. It is theorized that allogenic While the amniotic membrane can be used intraopera-
cells may be immune evasive, but not immune privileged tively in the form of tissue sheets, the membrane can also
and after transplantation eventually get removed by the host be lyophilized and pulverized to particulate matter and
immune system. The closer a donor is to a human leuko- used as an injectable. These products are often a combina-
cyte antigen (HLA) match the more likely cells are to survive. tion of amniotic membrane and umbilical cord tissue and
Their potential therapeutic effects may be reduced as they have functioned as an anti-inflammatory, anti-scarring, and
have less time to secrete their paracrine factors. It would be regenerative agent.124–133 A primary therapeutic efficacy of
unlikely that these allogenic cells could differentiate success- amniotic membrane-umbilical cord tissue is due to its unique
fully to target tissue, as they may be removed by the host prior biochemical complex: heavy chain-hyaluronan-PTX3 (HC-
to differentiation.100,101 Furthermore, clinical evidence sup- HA/PTX3). This complex assists in the promotion of mac-
porting the use of culture-expanded autologous or allogenic rophage phagocytic activity,126 neutrophil apoptosis,124,126
MSC grafts over nonculture-expanded MSC grafts for mus- and suppression of TGF-β activity.130,134 The amniotic
culoskeletal disease is not currently available. It is worth again membrane-umbilical cord products are received in a solid
emphasizing that culture-expansion of MSCs is not currently state. These can be stored at room temperature in the office,
allowed in clinical practice in the United States. have a longer shelf life, and are reconstituted with saline
prior to transplantation.
Amniotic fluid is typically harvested at the time of
Placental-Derived Allografts birth or in the second trimester, and is known to contain
Amniotic Tissue a heterogeneous population of cells in vivo, including
MSCs.117,119,135,136 The composition of the amniotic fluid
The placental membrane is composed of the outer chorion varies dependent on the gestational age at the time of har-
and the thin, innermost amniotic membrane (Fig. 8.1). vest,137 which likely affects the therapeutic potential of the
The amniotic membrane, in conjunction with the amniotic tissue. Typically, the commercial fluid preparations are cryo-
fluid, envelop the developing fetus and provide nutritional, preserved at −80°C and are shipped to the provider over-
immunomodulatory, and structural benefits.102–105 Stem night in dry ice. Upon receipt, the product must be thawed
cells present in the amniotic membrane contribute and out and transplanted into patient. Alternatively, the clinic
interact with the developing innate and adaptive immune may store the product in a freezer at −80°C until ready for
systems in part by hindering leukocyte differentiation into use.
 CHAPTER 8 Allograft Tissues 93

Epithelium
Basement membrane
Compact layer
Amnion
Fibroblast layer
Intermediate
(spongy) layer

Reticular layer

Basement membrane

Chorion

Trophoblasts

• Fig. 8.1 Anatomy of Amniotic and Chorionic Tissue Layers of the Placenta.

Umbilical Cord Blood preservation and storage, affects the viability of cells in the
products.5,145–147 In an analysis of commercial amniotic
Umbilical cord blood is a rich source of progenitor cells that fluid products, it was found that those advertised as “stem
has the potential to be used as a therapeutic.138 Hematopoi- cell” and cellular products either did not contain any cells,
etic progenitor and stem cells from cord blood have a high or if cells were present, were unable to be cultured to an
recovery efficiency even after years of cryopreservation.139 appreciable level.5 Known to be a potent source of growth
First used to treat hematologic malignancies,140 umbilical factors and cytokines in vivo, the products were found to
cord blood is currently being explored for orthopedic appli- retain a number of these biomolecules—although the spe-
cations. Cord blood has been employed in surgical carti- cific proteins present and volume of each varied across prod-
lage repair with promising results when used in conjunction ucts. Such studies indicate that the therapeutic potential of
with a hyaluronate hydrogel,141 allowing clinicians to theo- allogenic amnion-derived products likely does not depend
rize about its use in nonsurgical interventions. The main solely on cellular viability.5,145–148 While the content of
limitations of the use of cord blood are the current need MSCs in commercial products is debatable,5 both amniotic
for HLA matching as well as the risk of graft versus host membrane and amniotic fluid-derived products offer the
disease.142 opportunity to deliver growth factors and cytokines that can
be used to treat a variety of orthopedic injuries. While the
Wharton Jelly legal aspects regarding the use of such products are largely
outside of the scope of this section, the concepts of mini-
Wharton jelly, the connective tissue of the umbilical cord, mal manipulation and homologous use as laid out by the
has also gained increasing interest as a potential source of FDA still apply.4 The processing and packaging methods of
stem and progenitor cells. Compositionally, Wharton jelly the amniotic membrane must be considered. Methods that
is agreed to have progenitor populations in the various tis- compromise the original relevant characteristics of the tis-
sue layers; however, there is no consensus on whether the sue may change the product’s consideration as an HCT/P.
cells in the regions are phenotypically identical.143,144 It Furthermore, while cells derived from secreted body fluids
has been postulated that the MSCs derived from Wharton like amniotic fluid are considered HCT/Ps, the body fluids
jelly originate as perivascular cells, but recent literature has themselves are generally not considered HCT/Ps.4 Human
brought this assertion into question.143 Similar to umbilical clinical evidence on these commercial products for safety
cord blood, Wharton jelly as a source of MSCs is currently and efficacy for orthopedic issues is lacking as well.
being examined in interventional orthopedics. There are
currently registered clinical trials underway for its use for a Exosomes
variety of orthopedic conditions.
The true capacity for these tissues to deliver MSCs as Use of allogenic and autologous MSCs in interventional
commercial products have come into question as it is orthopedics has failed to completely fulfill clinical expec-
unclear whether commercial processing, including tissue tations due to concern over a lack of cell differentiation,
94 SEC T I O N I I Injectates

loss of cells, and poor engraftment at target sites.149,150

Research regarding the structure, makeup, physiologic, and
pathologic function of the numerous substances secreted
by MSCs (secretomes) has exponentially increased over
the past several years. These unique MSC secretomes have
anti-apoptotic and immunoregulatory properties and have
been utilized for a wide variety of diagnostic and therapeutic
applications.151 MVB
Secretomes have both a vesicular and soluble part. The
vesicular components secreted by MSCs are categorized as Early
extracellular vesicles, and further subcategorized based on endosome
cellular origin, size, and biologic function.152,153 A vari-
ety of extracellular vesicle subtypes have been described,
including exosome, microvesicles, membrane particles, • Fig. 8.2 The Formation and Mechanism of Exosomes. Exosomes
peptides, and cytokines. Exosomes are small, spherical par- originate through endocytic internalization and follow three stages:
the endosomes stage, the multivesicular bodies (MVBs) stage, and
ticles (70 to 150 nm) that are enclosed by a phospholipid
the exosomes stage. When exosomes are released from the cell, they
bilayer and capable of passing through a 0.1-μm filter.154 act as intercellular communication molecules that interact with cell
They were first described by Pan and Johnstone in 1983155 receptors and elicit various actions. (Image retrieved from Ju C, Liu
and were initially believed to eliminate unwanted cellular R, Zhang Y, et al. Exosomes may be the potential new direction of
components and waste during sheep reticulocyte matura- research in osteoarthritis management. Biomed Res Int. 2019. https://
doi.org/10.1155/2019/7695768.)
tion.155,156 Recently, exosomes have received a great deal
of interest due to their role in intracellular communica-
tion and immunomodulatory function, and their poten- transmembrane proteins CD9, CD63, and CD81, in addi-
tial for use in identifying and treating a variety of disease tion to other proteins.150,154
states.150,151 To be able to utilize exosomes for diagnostic or thera-
Exosomes originate from the cell membrane by endocytic peutic applications, it will become necessary to establish
internalization (budding inward). The most well-established efficient and effective methods to isolate exosomes with
mechanism of exosome biogenesis has three stages: the minimal alteration to their structure and/or content.150
endosomes stage, the multivesicular bodies (MVBs) stage, Additionally, it is imperative to identify and only isolate
and the exosomes stage.157 First, endocytic vessels are trans- exosomes with the desired trait. Several isolation methods
ferred to early endosomes—tube-like structures that are have been developed and are currently in use.150,162
located near the outer edge of the cytoplasm. Early endo- The currently accepted gold standard for isolation of
somes eventually mature into late endosomes, which are exosomes involves differential ultracentrifugation. This is
more spherical and located closer to the nucleus of the cell. performed by applying sequentially increasing centrifugal
Late endosomes, or MVBs, carry intraluminal vesicles that forces to a solution with exosomes to separate them from
contain a variety of biomolecules, including proteins, lipids, cells, large debris, and organelles.163 Ultracentrifugation is
and various types of RNAs. In the second stage, MVBs are typically used in combination with sucrose density gradients
either degraded by fusing with lysosomes or transported to or sucrose cushions to remove contaminants with densities
the cell’s plasma membrane. Upon fusion with the plasma different from exosomes. This method produces high-purity
membrane, the MVB releases its contents into the extra- exosomal preparations,164 but is limited to only generat-
cellular space as exosomes—completing the third stage.153 ing exosome-enriched samples. Pure exosome isolates are
In the extracellular space, recipient cells take up exosomes difficult to obtain due to the large number of similar-sized
through paracrine or juxtracrine actions (exosomal fusion) nanoparticles in samples.
or endocytosis (Fig. 8.2).158 As research continues to expand our knowledge regard-
The function and composition of exosomes are highly ing these cellular secretions, exosomes have the potential to
dependent on the physiologic state of the parent MSCs, become a truly disease-modifying orthobiologic drug with a
where the MSCs are derived from, and the medium in number of clinical benefits. As a therapeutic tool, exosomes
which the MSCs are grown.159,160 Exosomes act as cellu- could potentially be produced and available as an “off-the-
lar messengers conveying information to distant tissues shelf ” product with a defined composition, potency, and
through proteins and genetic material contained within that dose. These products could provide immediate bioavailabil-
can ultimately alter the recipient cell’s physiology and func- ity of the active allogenic agents, with consistent content
tion. Exosomes can be released by most cell types, normal and quality independent of the patient’s age and underlying
and pathologic, and are present in conditioned cell medium health.165
in vitro, especially when derived from MSCs.161 They are Based on basic science research, exosomes exhibit a range
stable in biologic fluids including blood, urine, saliva, breast of biologic capabilities including regulation of angiogen-
milk, synovial fluid, and amniotic fluid.158 The major- esis and apoptosis, antigen presentation, and endocyto-
ity of exosomes express surface protein Alix; Tsg 101; and sis.166 Through their miRNA contents, exosomes have the
 CHAPTER 8 Allograft Tissues 95

potential to regulate chondrocyte apoptosis and promote

cartilage proliferation in the setting of osteoarthritis.167–169
In tendinopathies, the therapeutic application of exosomes
has been shown to promote tendon healing by establishing
a balanced microenvironment and increasing the expres-
sion of tenogenic markers.170 The ability of exosomes to
play a crucial role in cell-to-cell signaling and mediate dis-
ease responses make them attractive options in regenerative
medicine.
The legal considerations regarding these products remain
out of the scope of this text; however, it should be noted
that there are currently no FDA-approved exosome prod-
ucts. Given that these products require cell culture expan-
sion, they are regulated as a drug as opposed to an HCT/P
and are not approved for clinical use in the United States.
Furthermore, to date there are no current human clinical • Fig. 8.3 StimuBlast (Arthrex, Inc., Naples, FL), a demineralized bone
matrix allograft product, can be used in minimally invasive procedures
trials evaluating the efficacy or safety of exosome treatments with a wide range of clinical applications.
for any condition.
Of note, extracellular vesicles and exosomes have also
been studied diagnostically. The presence of exosome- combination of collagens (predominantly type I), noncol-
derived lncRNA has the potential to function as an indica- lagenous proteins, residual calcium phosphate, and resid-
tor of osteoarthritis progression.171 Disease-state biomarkers ual cellular debris.175 DBM has a long history of clinical
are often low in bodily fluids and can be masked by other use dating back more than a century.177 The decalcifica-
proteins in the sample. Extracellular vesicles can reflect the tion process used in the preparation of DBM causes the
biologic state of the host cell, and if isolated have the poten- release of bone morphogenetic proteins into the surround-
tial to prove information of various disease states. While ing tissue when it is implanted, leading to the osteoinduc-
exosomes have immense potential diagnostically and are an tive properties of the material.176
ideal choice for biomarker analysis, this field is also still in In its pure form, DBM exists as a powder. This form
its infancy make them.170 is difficult for the clinician to control and to conform to
various skeletal defects. As a result, DBM is often combined
Demineralized Bone Matrix with a number of carrier materials. These carrier materials
are divided into two broad categories. The first category is
One of the most powerful tools in interventional ortho- composed of polymer materials such as collagen, chitosan,
pedics is in the percutaneous treatment of skeletal defects hyaluronic acid, or carboxymethylcellulose; the second
associated with fracture nonunion, osseous cysts, and avas- category is characterized by low molecular weight carriers
cular necrosis. In these conditions, the capacity for bone such as glycerol, calcium sulfate, and bioactive glass.173 The
healing is diminished and, as a result, it is necessary to carrier materials have specific advantages based on biocom-
deliver bone grafts. Bone grafts are generally considered patibility, viscosity, and rates of resorption. For most inter-
along two spectrums: osteoconductive and osteoinductive. ventional orthopedic procedures, the selected DBM should
Osteoconductivity refers to the ability of the material to strike the balance of viscosity, in order to be injectable, but
act as a scaffold for the ingrowth of vessels and osteopro- also to be physically viscous enough to remain at the deliv-
genitor cells.172,173 Osteoinductivity is the ability to pro- ery site to exert its effect.
mote the mitogenesis and differentiation of nearby cells The clinical applications of the DBM were initially lim-
into the osteogenic lineage.173–176 Bone grafts employing ited to open surgeries.174,178–180 The percutaneous use of
these factors must be combined with an appropriate source DBM was first reported in the treatment of simple bone
of progenitor cells that are either found in vivo in the sur- cysts.181–183 More recently, DBM has been explored in the
rounding perivascular tissue or delivered concurrently augmentation of core decompression for the treatment of
with the graft.172 avascular necrosis of the femoral head.184,185 The value of
Autologous iliac crest bone graft is widely considered DBM in minimally invasive surgery has been expanded
the gold standard in bone grafting of skeletal defects. It using both arthroscopic treatment of degenerative bone
possesses all three characteristics of osteoconductivity, cysts186 as well as the percutaneous treatment of degenera-
osteoinductivity, and osteogenic cells.173 Unfortunately, tive bone cysts.187,188
donor site morbidity and the high costs of graft harvesting In the future, we anticipate that DBM will remain an
can be limiting. Furthermore, iliac crest bone grafts are excellent option for the delivery of osteoinductive and
not easily delivered percutaneously. A valuable alternative osteoconductive bone grafts through minimally invasive
to autogenous bone is the use of DBM (Fig. 8.3). DBM techniques in combination with an extensive array of carri-
is manufactured by acid digestion of bone, leading to a ers and cell populations.
96 SEC T I O N I I Injectates

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9
Therapeutic Dextrose Injection:
Prolotherapy, Perineural Injection
Therapy, and Hydrodissection
KENNETH D. REEVES, STANLEY K.H. LAM AND DAVID RABAGO

KEY POINTS Initially called “sclerotherapy” due to the scarring produced

• D extrose prolotherapy has level B strength of by early caustic injectants, clinicians treated the same condi-
recommendation for chronic pain in eight areas based tions as today, but also chronic, repetitive joint subluxations
on a growing number of RCTs and meta-analyses. and inguinal hernias.2 George Hackett, MD, a general
• Dextrose, when used in perineural and hydrodissection surgeon in the United States, formalized these injection
procedures, often has a prompt analgesic effect and techniques in the 1950s based on clinical experience and
is an alternative to anesthetic injection for treatment of
neuropathic pain. research.3 Considering proliferation of injected tissue to be
• The evidence base supporting dextrose prolotherapy, an essential aspect of prolotherapy’s effects, he renamed the
perineural injection therapy, and hydrodissection of procedure: “To the treatment of proliferating new cells I
nerves is growing. have applied the name prolotherapy.”4
• Treatment of individual regions of the body should One of the most common agents used for prolotherapy is
consider nociceptive sources in joints, connective
tissue, and their related nerves due to shared neural hypertonic dextrose5 but several other injectates can be uti-
origins (Hilton’s law). lized as well.6 Hackett’s early injection protocols and com-
• Image guidance is often crucial in the performance prehensive textbook informed the field’s procedural work
of dextrose prolotherapy, and ultrasound guidance is for the rest of the 20th century.4 His central diagnostic prin-
required to visualize nerves for hydrodissection. ciple was that ligament laxity led to pain and disability. The
   location of laxity was understood to be the entheses of liga-
ments and tendons. This was prescient, as we now under-
stand that degenerative change7 and laxity8 are core features
Introduction of overuse tendinopathies. Injections at tender entheses
and adjacent joint spaces defined the core procedure and
Therapeutic injection of dextrose is a potentially disease- could be done at any joint. Out of necessity, identification
modifying treatment for chronic pain. Three related but of bony anatomy for localization was based on palpation,
discreet approaches have emerged using dextrose injec- and a cadre of clinicians with advanced skills in superficial
tates, comprising dextrose prolotherapy (DPT), perineural anatomy comprised the early clinical and research endeav-
injection therapy (PIT), and hydrodissection (HD). These ors, and published clinically based research reports.9 While
approaches have significant overlap but are distinct enough palpation guidance was the previous gold standard, teach-
to merit individual consideration. This chapter addresses ing organizations are in the process of developing protocols
the evidence associated with each, and the contribution of including high-resolution ultrasound (HRUS) and fluoros-
ultrasound guidance. copy to augment palpation guidance, particularly for diffi-
cult-to-identify and higher-risk anatomic targets.
Prolotherapy
Mechanism/Animal Model Research
Prolotherapy is the oldest regenerative injection technique
for chronic musculoskeletal pain conditions, emerging as a The in vitro mechanism of action of DPT has received little
modality to treat chronic pain in the early 20th century.1 attention, and it is unclear how cellular changes associated

102
 CHAPTER 9 Therapeutic Dextrose Injection: Prolotherapy, Perineural Injection Therapy, and Hydrodissection 103

with dextrose affect pain. Small concentrations of dextrose TABLE   Organizations Offering Training With a Focus
(15 mM, 0.27%) have been shown to alter the expression 9.1 on Prolotherapy.
of various cytokines in multiple cell lines with less than 20
Organization Website
minutes of exposure,10,11 while exposure to 0.6% dextrose
in culture for 24 hours results in significant cellular death Australia
and dysfunction.12,13 However, in vitro studies have not Australian Association of aamm.org.au
attempted to simulate the declining concentrations and Musculoskeletal Medicine
limited exposure time seen in vivo. Asia
Research using an in vivo rabbit model reported a pro- Hong Kong Institute of hkimm.hk
liferative effect of 10% dextrose in ligament tissue in the Musculoskeletal Medicine
absence of an inflammatory response or cellular death.14 The Taiwan Association of taprm.org
same researchers confirmed organized connective tissue pro- Prolotherapy and
liferation with 10% dextrose injections in three randomized Regenerative Medicine
controlled trials (RCTs) using the same rabbit model.15-17 Europe
All three studies demonstrated nearly a doubling of the liga-
European School of proloterapia.it/en
ment’s thickness after the dextrose injection, greater force was Prolotherapy
required to rupture the ligament, and histologic findings were
normal.17 Studies have not compared the relative proliferative North America
effect of differing dextrose concentrations in vivo. Although a American Association of aaomed.org
Orthopaedic Medicine
proliferative effect of hypertonic dextrose injection has been
documented,17 the therapeutic effects of hypertonic dextrose The American Osteopathic prolotherapycollege.org/
injection are likely multifactorial and a combination of pro- Association of Prolotherapy
Regenerative Medicine
liferative and other biologic effects.
Canadian Association of caom.ca
Orthopaedic Medicine
Clinical Research and Strength of
Recommendations Hackett Hemwall Patterson hhpfoundation.org/
Foundation /International iart.org
Clinical research has been limited to relatively small studies. Association of Regenerative
Therapy
Despite modest sample sizes, numerous rigorous RCTs have
reported a clinically meaningful effect of DPT in knee osteo- South America
arthritis (OA),18-21 temporomandibular dysfunction,22-24 Latin American Association of www.laomed.org
rotator cuff tendinopathy,25,26 lateral epicondylosis,27,28 Orthopaedic Medicine
wrist pain,29 finger/thumb OA,30,31 sacroiliac pain,32 hip
OA due to hip dysplasia,33 Osgood-Schlatter disease,34,35
Achilles tendinosis,36 and plantar fasciosis.37,38 including the Hackett Hemwall Patterson Foundation
Strength of recommendation (SOR) criteria39 are com- (HHPF) and American Association of Orthopedic Medi-
monly used to summarize the cumulative status of evidence cine (AAOM), offer conferences and training worldwide.
in a given area with level A or B SOR indicating likely (Table 9.1). HHPF has recently released “The Prolotherapy
benefit. DPT for knee OA has level A evidence.5,40-48 In Procedural and Study Guides,” using an iterative consensus
a clinical model of grade IV knee OA, exposure to intra- model.62
articular 12.5% dextrose injection was followed by the
appearance of new, metabolically active, type I and II car- Perineural Injection Therapy
tilage in post-treatment arthroscopies.49 While patients in
this small case series improved clinically, the relationship The injection of dextrose around painful peripheral nerves
between such improvement and apparent cartilage growth emerged from the prolotherapy tradition, and was first
is not clear. Assessment of prolotherapy for several condi- introduced in 200663 as “neural prolotherapy.” The more
tions meet B SOR criteria including temporomandibular descriptive term “perineural injection therapy” was soon
dysfunction,50 rotator cuff tendinopathy,5,46,47,51-53 lateral adopted, since the proposed goal of treatment was restora-
epicondylosis,5,28,45-47,51,54,55 wrist pain,29 painful finger or tion of nerve function, and not proliferation.
thumb OA,5,42,46,47,51 sacroiliac pain,32 Osgood-Schlatter
disease,5,45-47,56 and Achilles tendinopathy.5,45-47,56-59 Treat- Mechanism/Clinical Research
ment of plantar fasciosis has level B-C evidence.37,56
Neurogenic inflammation is characterized by an absence of
Training and Protocols leukocytes,64 and is due to peptidergic nerve fibers releasing
pain-producing and degenerative neuropeptides.64 These
Over time, individual clinicians have refined the injection neuropeptides, including calcitonin gene–related peptide
protocols and developed consensus-based guidelines.60,61 (CGRP) and substance P, are primarily released by type C
Professional medical societies with a focus on prolotherapy, peptidergic nerve fibers.64 Clinical findings of allodynia and
104 SEC T I O N I I Injectates

hyperalgesia are common due to alteration of C nerve fiber saline79 and triamcinolone80 in treatment of CTS. PRP and
firing rates and thresholds. The rapid analgesic (not anes- D5W injection resulted in similar symptomatic benefit in a
thetic) effect after subcutaneous 5% dextrose (D5W) injec- treatment-comparison trial in CTS.81
tion over painful peripheral nerves suggests a neurogenic Dextrose may offer advantages compared with other
effect of dextrose.65 injectants. The risk of potential lidocaine toxicity is avoided
In an RCT assessing caudal epidural injection of D5W with use of D5W or PRP without lidocaine.76 In addition,
versus normal saline in participants with back and buttock D5W HD without lidocaine does not result in nerve depo-
or leg pain, dextrose provided a significant analgesic effect larization. In contrast, lidocaine depolarizes the nerve and
within 15 minutes, lasting 48 hours or more,66 and this pat- renders distal fibers non-functional, limiting precise local-
tern was repeated after each of the 4 consecutive biweekly ization of the primary nociceptive source.
treatments.67 Proposed mechanisms for an apparent calm-
ing effect of dextrose in the presence of neurogenic pain Training and Protocols
include alteration of key cation channels68 or restoration
of the normal cation-pump-maintained transmembrane HD procedures will be discussed in this chapter and
potential by correction of relative neural hypoglycemia.69 throughout this Atlas.
Multiple case series report pain reduction from subcuta-
neous dextrose injections over painful superficial cutaneous
nerves in the knee, shoulder, elbow,70 Achilles tendon,71 and Regional Injection Approaches Utilizing
lumbar region,72 though assignment of causality is not possible Dextrose and Current Clinical Evidence
in the absence of control.72 One randomized controlled trial
has been reported using PIT in chronic Achilles tendinopa- The goal of this section is to briefly review relevant research
thy, with injections about the Achilles tendon showing results for each of the three modalities and identify key nociceptors.
comparable with eccentric lengthening exercises (ELE).36 Detailed injection methods are covered in later chapters.

Training and Protocols Head/Facial Region

Neurogenic inflammation is common with dysfunction of Publications regarding the head/facial region have focused on
superficial sensory or mixed motor and sensory nerves,65,73 DPT in or about the temporomandibular joint (TMJ). Three
which can be located by palpation with training and injected small RCTs with moderate to high bias compared the effect of
with minimal risk using small-gauge needles. Training in PIT dextrose to anesthetic injection in participants with painfully
is largely outside of conventional medical education and is subluxing TMJs.22,23,82 The protocols included injections
often taught without ultrasound guidance. Conference-based of the TMJ capsule on multiple occasions in addition to an
training was introduced by and remains available from con- intra-articular injection. In all three studies, there was signifi-
tent experts John Lyftogt and HHPF/IART.70-72,74 cant improvement in TMJ pain in both the dextrose and con-
trol injection groups, favoring dextrose upon meta-analysis.50
Hydrodissection Despite a consistent reduction in frequency of perceived sub-
luxation, a single-arm prospective study showed no change
HD is the process of injecting fluid around a nerve to release in measurable subluxation upon comparison of pre- and
the nerve from potentially constricting fascia. Symptomatic post-injection tomography of joint motion.83 The one com-
nerve compression or entrapment can result in fusiform plication observed in both the RCTs22,23,82 and open-label
swelling or flattening of the nerve,75 and ultrasound-guided studies83-87 was a significant reduction in mouth opening.50
injection of fluid between the nerve and surrounding fas- Louw et al., in a larger, low-bias, RCT, injected the TMJ
cia can release adherent fascial tissue. With the constriction intra-articular space and avoided capsular injection.24 They
removed, the nerve is free to resume a normal, more circular reported similar clinical benefit favoring dextrose over lido-
cross-section appearance.76 caine injection in all types of TMJ dysfunction (myofascial,
disc dysfunction, and arthritic), but the dextrose group
Mechanism/Clinical Research showed improved mouth opening at the 3- and 12-month
follow-up. The results argue for avoidance of capsular injec-
A hypothesized mechanism of action for dextrose HD follows tion clinically and in future study protocols.24,50
Bennett’s sciatic ligature model,77 where even mild constric-
tion of a nerve caused neurogenic inflammation with sciatic Key Nociceptors
nerve swelling, loss of axons distal to the ligatures, and neu- Nociceptive sources that are implicated in difficult pain pre-
roma formation at the level of the ligatures. A variety of injec- sentations involving the head and/or face include:
tates have been used, and saline, dextrose, corticosteroid, and 1. Superficial nerves: Auriculotemporal, zygomaticotempo-
platelet-rich plasma (PRP) HD injectates have been compared ral, lacrimal, supraorbital, supratrochlear, zygomaticofa-
in the treatment of carpal tunnel syndrome (CTS). A favor- cial, infraorbital, external nasal, buccal, mental, greater
able effect of HD using saline was reported in a study of CTS auricular, greater occipital, lesser occipital, third occipi-
participants.78 Wu et al. reported that D5W outperformed tal, and suboccipital.
 CHAPTER 9 Therapeutic Dextrose Injection: Prolotherapy, Perineural Injection Therapy, and Hydrodissection 105

SCM

MS
NR
AT
LCo

SCM

MS
LCo AT NR

B
• Fig. 9.1 (A) Cervical plexus location: The lesser occipital and greater auricular nerves are branches of the cervi-
cal plexus. Pandit et al. demonstrated through cadaveric dye study that fluid injected about the cervical plexus
travels through the deep cervical fascia and is found about the cervical nerve roots.97 The cervical plexus can be
accessed through the posterior investing fascia of the sternocleidomastoid (arrow indicates needle placement
location). Injection of the cervical plexus should avoid the carotid artery and internal jugular vein (large and small
circles, respectively). The external jugular may also need to be avoided by adjusting needle entry slightly cepha-
lad or caudal. Because the vagus nerve is located within the nearby vascular sheath, and the phrenic nerve has
partial supply from the cervical plexus, lidocaine should not be included in this injection to avoid a vagal and
phrenic nerve block. (B) Hydrodissection of the cervical plexus: The arrow tip (representing the 30-gauge needle
tip which is not visible in this image) is in the same location as in image A. Shown here is the area of expansion
of the space under the investing fascia of the sternocleidomastoid. AT, Anterior tubercle of transverse process;
LCo, longus coli; MS, middle scalene; NR, nerve root; SCM, sternocleidomastoid.

2. Deeper nerves/ganglion/plexi: Cervical plexus (Fig. 9.1A Key Nociceptors

and B). Nociceptive sources that are commonly important in dif-
3. Entheses: Capiti and trapezius. ficult pain presentations involving the neck include:
4. Joints: Temporomandibular. 1. Superficial nerves: Posterior supraclavicular and superfi-
cial cervical rami.
Cervical Spine/Neck 2. Deeper nerves/ganglion/plexi: Cervical dorsal rami and
cervical plexus.
DPT was studied in a small group of participants (n = 6) with 3. Entheses: Cervical multifidi and facet ligaments 3 to 7
cervical laxity with greater than 2.7 mm of cervical translation on (Fig. 9.2A), levator scapulae origin (Fig. 9.2B), and C2
flexion-extension x-rays and referred shoulder pain.88 Using flu- facet ligament (Fig. 9.3A and B).
oroscopic guidance, subjects underwent injections with 12.5%
dextrose into the involved posterior elements, lamina, and spi-
Thoracic Spine/Upper to Mid Back
nous processes. Reduced cervical translation in flexion-extension
x-rays, along with a significant reduction in pain, was observed. In a study of 70 subjects with chronic axial spine pain treated
For facet-mediated pain, Hooper et al., in a small case series (n with 20% DPT targeting the ligaments and facet joint cap-
= 18) involving 20% dextrose injection into the zygapophysial sules at symptomatic levels, Hooper et al. reported clinically
joint at 2 to 4 levels using fluoroscopic guidance in post whip- significant improvement as measured by the patient-specific
lash patients, found DPT improved pain and function.89 functional scale (PSFS).90 Of interest is that 50 of the 70
106 SEC T I O N I I Injectates

Sp Cap
Sm Cap

Sm Cerv
Sp Mult
Lamina

LS
Sp Cap

Sm Cap
C4 SP C4 TP

C4 Lamina
C4

B
• Fig. 9.2 (A) Injection of posterior cervical structures: The posterior cervical elements, including the poste-
rior capsular ligaments and enthesis along the lamina and spinous process, can be accessed with a single
entry and needle redirection, illustrated by the three arrows on the right. The interspinous ligament between
posterior spinous processes (not depicted) can be targeted using a similar approach. (B) Injection of levator
scapulae origin: Ultrasound visualization is important to inject the levator scapulae origin from the C2 to C4
posterior tubercles, either by advancing a few millimeters anterior to the cervical facets to avoid nerve root
contact using an axial view to visualize the posterior tubercle (arrow) or using a sagittal view showing multiple
tubercles (not depicted). LS, Levator scapulae; Mult, multifidus; Sm Cap, semispinalis capitis; Sm Cerv,
semispinalis cervicis; Sp Cap, splenius capitis; SP, spinous process; TP, transverse process.

participants were litigants, with outcomes comparable to at the enthesis and superficially.25 Seven et al., in an open
non-litigants. label RCT (n = 101), compared ultrasound-guided dextrose
injections into the subacromial bursa and tender entheses
Key Nociceptors to extensive physiotherapy.26 While both groups had sig-
For the thoracic spine region, nociceptive sources that are nificant improvement from baseline measures, the dextrose
commonly important include: group significantly outperformed the control at 6 and 12
1. Superficial nerves/penetrators: Posterior supraclavicular weeks in pain score reductions, Western Ontario Rotator
and medial and lateral penetrators of the posterior tho- Cuff (WORC) index, and Shoulder Pain and Disability
racic rami. Index (SPADI).
2. Deeper nerves/ganglion/plexi: Dorsal scapular nerve In a pairwise and network meta-analysis by Lin et al.
(Fig. 9.4A), thoracic dorsal rami, and the paravertebral comparing all injection therapies in the treatment of rota-
ganglia/space (Fig. 9.4B). tor cuff tendinopathy,53 platelet-rich plasma and prolo-
3. Entheses: Thoracic multifidi and facet ligaments (Fig. therapy injections yielded better outcomes than control
9.5). injections in the long term (>24 weeks). Study heteroge-
4. Joints: Costotransverse (Fig. 9.6A and B). nicity limited conclusions to level B confidence. A system-
atic review by Catapano et al. of DPT for symptomatic
Shoulder Girdle rotator cuff tendinopathy52 concluded that dextrose dem-
onstrated at least short-term improvements in pain and
DPT for rotator cuff tendinopathy has been the object of function compared to physical therapy alone. There was
considerable research. Bertrand et al. conducted a three-arm a high risk of bias and variable efficacy within the studies,
blinded RCT (n = 73) comparing landmark-guided injec- but repeated multisite injections showed more consistent
tion with dextrose into the painful enthesis to lidocaine improvements.
 CHAPTER 9 Therapeutic Dextrose Injection: Prolotherapy, Perineural Injection Therapy, and Hydrodissection 107

SCM
Sm Cap
RCPMa Sp Capitis

SC

Sm Cap
Sp Cap
RCPMa

OCI

SC

B
• Fig. 9.3 (A) Visualization of the vertebral artery by Doppler: This is critical when targeting the C1 to C2
capsular ligaments and the lateral occipitoatlantal capsular ligament (latter not depicted). (B) Injection of C2
superior articular facet: Injections in this region should utilize hydrodissection technique when advancing the
needle to push away the vertebral artery until bone contact. Lidocaine concentions of 0.1% or less and aspi-
ration at the point of bone contact is advised to minimize the risk of complications from inadvertent vertebral
artery injection. OCI, Obliquus capitis inferior; RCPMa, rectus capitis posterior major; SC, spinal cord; SCM,
sternocleidomastoid; Sm Cap, semispinalis capitis; Sp Capitis, splenius capitis; VA, vertebral artery.

to watchful waiting for lateral epicondylosis.27 Patient-

Key Nociceptors Rated Tennis Elbow Evaluation scores at 16 weeks in
Nociceptive sources of particular importance for this region both prolotherapy injection groups were significantly
include: better than in the watchful waiting group, and there
1. Superficial nerves/penetrators: Posterior and intermedi- was no difference between the dextrose and dextrose-
ate supraclavicular, suprascapular, axillary, subscapular, morrhuate injection groups. Bayat et al. compared DPT
and musculocutaneous nerves. to methylprednisolone. While both injections resulted
2. Deeper nerves/ganglion/plexi: Suprascapular, intersca- in significant clinical improvements at 3-month follow-
lene, supraclavicular, and axillary brachial plexus. up, dextrose was superior in Quick DASH (Disabilities
3. Entheses: Supraspinatus insertion, infraspinatus inser- of Arm, Shoulder and Hand) and pain improvements.28
tion, subscapularis insertion, inferior and anteroinferior In the most rigorous study of dextrose injection therapy
glenohumeral ligament, and origins of the infraspinatus, for lateral epicondylosis, Yelland et al. conducted a sin-
teres major, and teres minor. gle-blind RCT (n = 120) comparing 20% DPT, physio-
4. Joints: acromiocalvular (AC) joint, sternoclavicular (SC) therapy, and combined treatment with prolotherapy and
joint, and glenohumeral (GH) joint. physiotherapy.54 At 1 year, all groups showed significant
5. Other: Subscapular bursa, subdeltoid bursa, and biceps improvement with no significant differences between
long head. groups.55 Dong et al., in a systematic review and Bayesian
network meta-analysis of all injection therapies for lateral
Elbow epicondylalgia,54 concluded that botulinum toxin, plate-
let-rich plasma, autologous blood injection, hyaluronate
Rabago et al., in a three-arm RCT, compared prolo- injection, and prolotherapy can be considered for lat-
therapy with dextrose and dextrose-morrhuate injections eral epicondylitis, but cortisone was not recommended.
108 SEC T I O N I I Injectates

LS
SS

ICM
Scapula
Pleura

T
Sp Th

L
M
TP ICM
Lamina

B
• Fig. 9.4 (A) Hydrodissection (HD) of dorsal scapular nerve: The dorsal scapular nerve branches off the
brachial plexus and can be involved in a whiplash injury. The dorsal scapular nerve travels with the dorsal
scapular artery (both nerve and artery are within the dashed circle), lateral and inferior to the levator scapu-
lae (dotted red triangle). The needle is represented by the arrow. (B) HD of the paravertebral space: This
can be helpful in severe neuropathic pain such as in post-herpetic neuralgia. HD into the paravertebral
space surrounds the spinal nerves as they emerge from the intervertebral foramen and surrounds the
sympathetic ganglion. The needle passes just lateral to the transverse process. As the needle approaches
the target (path shown by the long arrow), the bevel of the needle is down to avoid contacting the parietal
pleura with a sharp needle tip. The paravertebral space is seen opening between the intercostal muscle
and the parietal pleura (area between small arrows). ICM, Intercostal muscles and membrane; L, longis-
simus: LS, levator scapulae; M, multifidus; Sp Th, splenius thoracis; SS, supraspinatus; T, trapezius; TP,
transverse process.

Sp Th L
SP
M
Lamina Facet

• Fig. 9.5Injection of posterior elements of thoracic spine: The posterior elements, including the facet liga-
ments, entheses along the lamina, and spinous process can be accessed with a single entry and multiple
needle redirections (arrows in image). L, longissimus; M, multifidus; SP, spinous process; Sp Th, splenius
thoracis.
 CHAPTER 9 Therapeutic Dextrose Injection: Prolotherapy, Perineural Injection Therapy, and Hydrodissection 109

Sp C R
I
Semi L
I
TP
M

Rib
Lamina
A

LD
LT
SPI

L I

Rib
M TP
ICM

B
• Fig. 9.6 (A) Injections of T1 to T2 costotransverse junctions: The costotransverse junctions of the upper
rib levels can be injected by visualizing the rib blocking the lung and injecting the joint between rib and
transverse process. (B) Option for injecting lower (T3 to T12) costotransverse junctions: At lower rib levels
(3 to 12) an easier approach with good visualization involves altering the angle of the probe parallel with the
rib but below the rib so the rib is not seen in ultrasound. All that is seen then is the transverse progress with
intercostal muscle to its right. This allows for a clear view of the pleura (arrows) with injection maximizing
safety by visualizing the needle while infiltrating against or close to the transverse process. This injection
appears to be a reasonable substitute for intra-articular injection at each level. ICM, Intercostal muscles
and membrane; I, iliocostalis; L, longissimus; LD, latissimus dorsi; LT, lower trapezius, M, multifidus; R,
rhomboid; Sp C, splenius cervicis; SPI, serratus posterior inferior; TP, transverse process.

Hyaluronic acid injection and prolotherapy might be 2. Deeper nerves/ganglion/plexi: Radial nerve in spiral
superior, but Dong and colleagues suggested additional groove, at elbow, and within the supinator.
research is needed. 3. Entheses: Common flexor origin.

Key Nociceptors
Wrist/Hand
Nociceptive sources/targets for dextrose proliferant or peri-
neural injection are grouped below according to lateral or Reeves et al. compared hypertonic dextrose (10%) solution
medial elbow: to lidocaine alone injection for proximal interphalangeal
  
(PIP), distal interphalangeal (DIP), and trapeziometacarpal
Lateral elbow:
(TMC) OA at 0, 2, and 4 months.30 There was no signifi-
1. Superficial nerves/penetrators: Posterior and lateral
cant difference at rest, but a significant improvement in pain
antebrachial cutaneous nerves.
with finger function and finger flexion range of motion in
2. Deeper nerves/ganglion/plexi: Median nerve under
the dextrose group was reported at 6-month follow-up. Jah-
pronator teres, and ulnar nerve across elbow.
angiri et al.31 in an RCT (n = 60) compared 3 monthly
3. Entheses: Common extensor origin, and radial head
dextrose injections for TMC OA to a group with saline (at
ligament.
0 and 1 months) and methylprednisolone (at 2 months).
Medial elbow:
At 6-month follow-up, pain and pinch improvements were
1. Superficial nerves/penetrators: Medial antebrachial
significantly more in the dextrose group. The above stud-
cutaneous nerve.
ies were included in two systematic analysis of RCTs for
110 SEC T I O N I I Injectates

the treatment of knee and hand OA.42,44 Krsticevic et al. reported a clinically significant improvement in pain and
in a narrative review44 concluded that there was limited disability at the 2-year follow-up irrespective of the solu-
evidence indicating a beneficial effect of prolotherapy for tion injected, suggesting that needling of entheses has a
finger/thumb OA management, and Hung et al. in a sys- therapeutic effect. These findings are consistent with other
tematic review and meta-analysis42 concluded that dextrose DPT studies with a needling control,25,29 and imply that
injection reduced pain in patients with hand OA. needling controls should not be considered as a control in
At the wrist, Hooper et al. in an RCT (n = 39) compared future research design. Instead, inclusion of a non-injection
periscaphoid and perilunate injections with hypertonic dex- control should be considered.
trose to lidocaine in participants with dorsal wrist pain and Maniquis-Smigel et al. in a prospective uncontrolled
normal x-rays.29 At 3 months there was no difference in cohort study (n = 32) evaluated the effect of caudal epi-
outcomes, but at 12 months the Patient Rated Wrist Evalu- dural injection of D5W (without an anesthetic or cortico-
ation (PRWE) scores were significantly improved in the steroid component) in participants with chronic low back
DPT group compared to the lidocaine group. Both groups pain radiating to the gluteal area or lower extremities.67
improved more than the minimal clinically important dif- Participants received 10 mL D5W caudally biweekly (x4)
ference (MCII) for PRWE, indicating a clinical benefit from and then as needed. At the 1-year follow-up, 66% of par-
lidocaine needling as well. ticipants reported a 50% or more reduction in chronic
Wu et al. have reported three RCTs on HD for CTS. pain, and improved disability ratings on Oswestry Dis-
One trial (n = 34) compared saline HD (5 mL) into the ability Index.66
intracarpal region to superficial injection of saline outside Kim et al. in a single-blind RCT (n = 48) compared 25%
the carpal tunnel, and found a therapeutic benefit to HD dextrose to triamcinolone injections into the sacroiliac joint
in mild-to-moderate CTS.78 A second study (n = 49) com- using fluoroscopic guidance with up to three biweekly injec-
pared a single HD with 5 mL of D5W to HD with saline tions.32 At 15-month follow-up, dextrose injection showed
around the median nerve, and showed the D5W group had a significant improvement in pain compared to cortisone,
a significant reduction in pain and disability, improvement with more subjects reporting a ≥50% reduction in back
on electrophysiologic response measures, and decreased pain (58.7% vs. 10.2%). For coccygodynia, Khan et al.
cross-sectional area of the median nerve compared to the published the largest case series with 37 consecutive patients
saline HD control group.79 A third study (n = 54) compared with > 6 months of pain treated with 25% DPT at the area
a single HD with 5 mL of D5W to triamcinolone injection of maximum pain.92 There was a reduction in VAS pain
3 mL, and showed a significant reduction in pain and dis- score in excess of 70% after 2 injections, but only 2-month
ability compared to triamcinolone.80 Shen et al., in an RCT follow-up was reported. Thirty patients had good relief and
(n = 52) comparing HD with dextrose to HD with PRP for seven had minimal or no relief.
the treatment of mild to moderate CTS, reported signifi-
cant and comparable improvements in pain and functional Key Nociceptors
status in both groups.81 For this area important nociceptive sources to consider in
Studies by Wu et al. are among the most rigorous RCTs treatment of the complex pain patient using therapeutic
for any dextrose-related therapy and strongly support an dextrose injection include:
independent biologic action for dextrose D5W HD com- 1. Superficial nerves/penetrators: Superficial dorsal rami
pared to saline or corticosteroid injection. medial and lateral branches, superficial superior, middle,
and inferior cluneal nerves, and superficial iliohypogas-
Key Nociceptors tric and ilioinguinal nerves.
Nociceptive sources about the hand include: 2. Deeper nerves/ganglion/plexi: Dorsal rami, superior cluneal
1. Superficial nerves/penetrators: Superficial ulnar, median, (Fig. 9.7A), and middle cluneal nerves, iliohypogastric and
and radial cutaneous nerves. ilioinguinal nerves, and lumbar plexus (see Fig. 9.7B).
2. Deeper nerves/ganglion/plexi: Radial, median, and ulnar 3. Entheses: Lumbar multifidi, facet ligaments and inter-
nerves at the elbow, median nerve at the wrist, and inter- transversarii (Fig. 9.8A), sacroiliac (SI) ligament (see Fig.
digital nerves. 9.8B), and iliolumbar (IL) ligaments.
3. Entheses: Radiocarpal, ulnocarpal, and intercarpal liga- 4. Other: Sacrococcygeal joint, and caudal epidural injec-
ments, triangular fibrocartilage complex, 1st dorsal inter- tion.
osseous, adductor pollicis, and abductor pollicis brevis.
4. Joints: Trapeziometacarpal joint/capsule, wrist joint, Hip/Pelvic Area
metacarpophalangeal (MCP), PIP, or DIP joints.
There are no randomized trials of DPT for primary hip OA.
Lumbosacral Area Gul et al. in an open-label RCT33 treated 41 patients (46
hips) with hip OA secondary to developmental dysplasia
Yelland et al. assessed the efficacy of needling the entheses with hypertonic dextrose injections to tender periarticu-
of symptomatic lumbo-pelvic ligaments and sacroiliac joints lar tendons at 21-day intervals for a maximum of 6 injec-
with dextrose versus lidocaine (n = 110).91 Both groups tions versus 30 sessions of supervised progressive resistance
 CHAPTER 9 Therapeutic Dextrose Injection: Prolotherapy, Perineural Injection Therapy, and Hydrodissection 111

LD
GMx
IC
SCN

GMe
IIium

LD
LT

M IC

L2/3 L3 TP
ES Facet
QL
CE

B Psoas
• Fig. 9.7 (A) Superior cluneal nerve hydrodissection (HD): superior cluneal nerve (SCN) entrapment can
be a source of low back and leg pain. The SCN can be localized as it crosses the iliac crest by finding the
accompanying vessel. If the vessel is difficult to localize, HD under the fascia both above and below the
iliac crest at the maximal area of tenderness is likely to release the entrapment of the SCN in its osteofi-
brous tunnel (two arrows in figure A showing injection under fascia above [left] and below [right] the iliac
crest and under the fascial layer). (B) Lumbar plexus HD: HD of the lumbar plexus can downregulate neu-
rogenic pain originating at mid to lower lumbar levels. If the needle passes lateral to the transverse process,
and infiltration occurs bevel down for optimum safety, fluid will be observed filling the space posterior to the
psoas. That space (located at the arrow tip) communicates with the lumbar plexus. CE, Cauda equina; ES,
epidural space; GMe, gluteus medius muscle; GMx, gluteus maximus muscle; IC, iliocostalis lumborum
muscle; LD, latissimus dorsi muscle; LT, longissimus thoracis muscle; M, multifidus muscle; TP, transverse
process; QL, quadratus lumborum.

training. DPT outperformed the exercise control for gluteal, iliohypogastric, ilioinguinal, femoral component
improvements in Harris Hip Score (HHS) and pain scores of genitofemoral, inferior cluneal gluteal branches, peri-
at the 6-month and 1-year follow-ups.9 These improve- neal branches of inferior cluneal and pudendal nerves,
ments were clinically significant, exceeding twice the mini- lateral femoral cutaneous, and common fibular nerves.
mal clinically important difference (MCID) for VAS pain 2. 
Deeper nerves/ganglion/plexi: Ilioinguinal nerve at
improvement and above the MCID for HHS. its quadratus lumborum penetration point, sacral and
DPT has been reported as a treatment for athletic pub- potentially lumbar ganglia via caudal epidural injection,
algia. Topol et al. reported on a case series of 72 consecutive and femoral nerve proximal just distal to the inguinal
elite soccer or rugby athletes with chronic adductor ori- ligament, inferior cluneal nerve at ischial tuberosity
gin or pubic symphysis pain. Subjects received 3 monthly level, pudendal medial to ischial spine, pudendal nerve
treatments of palpation-guided 12.5% DPT, and 66 of 72 in Alcock canal, and along ischiopubic ramus.
(92%) returned to full sport within 3 months.93 3. 
Entheses: Inferior gemellar origin (Fig. 9.9A), superior
gemellar origin, gemellar and obturator externus insertions
Key Nociceptors at base of trochanter and piriformis on top edge of trochan-
Primary nociceptive sources to consider in therapeutic dex- ter (see Fig. 9.9B), ischiofemoral and iliofemoral ligaments
trose injection in this area include the following: (Fig. 9.10A) proximal gluteal origins, gluteal insertions onto
1. 
Superficial nerves/penetrators: Ventral rami medical the greater trochanter, gluteus maximus junction with the
branches, superior cluneal, middle and inferior cluneal, iliotibial band (see Fig. 9.10B), mid to distal iliotibial band,
112 SEC T I O N I I Injectates

SP LT

M IC

IAP
SAP

MB TP

LD

GMx LT

SIL
GMe M

Ilium
Sacrum
B
• Fig. 9.8 (A) Injection of posterior elements of lumbar spine: The intertransverse ligament, facet ligaments,
and multifidi/posterior lumbar rami can be treated from the same needle insertion. Targeting transverse
processes requires the use of ultrasound for accuracy, and for avoidance of pleural contact at L1 and L2.
(B) Sacroiliac ligament injection: The sacroiliac ligament can be targeted at both deep and superficial levels.
The deeper injection is below the ligament and may be intra-articular. GMe, Gluteus medius muscle; GMx,
gluteus maximus muscle; IAP, inferior articular pillar; IC, iliocostalis lumborum muscle; LD, latissimus dorsi
muscle; LT, longissimus thoracis muscle; M, multifidus muscle; MB, medial branch; SAP, superior articular
pillar; SIL, sacroiliac ligament; SP, spinous process TP, transverse process.

pectineus origin, pyramidalis insertion, rectus abdominus 29.5% improvement and 11.9 point decrease in WOMAC
insertion, adductor origins, posterior insertions on ischio- scores beyond that of exercise alone. Sert et al. in an RCT
pubic ramus, and rectus femoris origin. of participants with Kellgren-Lawrence grade II or III OA
4. Joints: Sacrococcygeal joint, symphysis pubis, and ilio- (n = 66) randomized into DPT, saline, or control home
femoral joint. exercise treatment groups,20 found a significant decrease
in WOMAC pain and VAS activity scores at 18 weeks in
Knee the DPT group treated with intra- and extra-articular pro-
lotherapy at 0, 3, and 6 weeks. Multiple meta-analyses and
For knee OA, Rabago et al. in an RCT (n = 90) of landmark systematic reviews evaluating DPT for knee OA have shown
guided intra-articular (25% dextrose) and extra-­articular favorable results.40,42-44
(15% dextrose) injections at 1, 5, and 9 weeks reported In cases of Osgood-Schlatter disease, Topol et al. in
that DPT outperformed both the saline control and exer- an RCT (n = 54; 65 knees) compared physical therapy to
cise groups at 1 year.18 All groups reported improved com- double-blind injection of lidocaine with or without 12.5%
posite Western Ontario and McMaster Universities Index dextrose monthly for 3 months. Asymptomatic return to
(WOMAC) scores compared to baseline, but the DPT sport was significantly more common in the DPT cohort
group exceeded the MCID for WOMAC scores. Dumais than the lidocaine-only or usual care group at 1 year. Nakase
et al., using a randomized open-label crossover trial (n = et al. compared 3 monthly injections of 20% dextrose or
36), compared landmark guided intra-articular (20% dex- lidocaine into the deep infrapatellar bursa.35 Neither treat-
trose) and collateral ligaments (15% dextrose) DPT to exer- ment was reported as superior, with both showing a decrease
cise.19 At the 36-week follow-up, hypertonic dextrose was in VISA score. However, the dextrose cohort had a greater
significantly better than exercise alone, accounting for a change in pain scores than the lidocaine group (27 vs. 19.8
 CHAPTER 9 Therapeutic Dextrose Injection: Prolotherapy, Perineural Injection Therapy, and Hydrodissection 113

GMx
STL

OI GT
P SG IG

SP

GMx

GMe

PT
GT GMi

SGOI
IFJ
IIium

B
• Fig. 9.9 (A) External rotator origins. Ultrasound offers the ability to accurately target the origin of several
external rotators of the hip, including the inferior gemellus (at arrow tip) and superior gemellus. (B) External
rotator insertions. Ultrasound also allows for targeting of insertions of the gemelli and obturator externus
at the base of the greater trochanter (right arrow), and the piriformis insertion (left arrow) at the top edge of
the greater trochanter laterally. GMe, Gluteus medius muscle; GMi, gluteus minimus muscle; GMx, gluteus
maximus muscle; GT, greater trochanter; IFJ, iliofemoral joint; IG, inferior gemellus muscle; P, piriformis
muscle; PT, piriformis tendon; SG, superior gemellus muscle; SGOI, tendons of superior gemellus, obtura-
tor internus and inferior gemellus; SP, sacral plexus.

points), and statistical results may have favored dextrose if Ankle/Foot

the study was appropriately powered or used change scores
rather than raw scores.94 In addition, unlike Topol et al., Pilot studies and case series have examined prolotherapy
Nakase et al.’s method did not target entheses, which may for Achilles tendinosis95,96 and subcutaneous PIT.71 Yelland
be important for successful management of Osgood-Schlat- et al. in an RCT (n = 43) compared dextrose injection along
ter disease. the midsubstance Achilles tendon to eccentric lengthening
exercises (ELE) or dextrose plus exercise.36 Forty patients
Key Nociceptors completed the study and at 12 months’ dextrose and the com-
Nociception about the knee in the difficult-pain patient, as bined dextrose and ELE treatment had a higher percentage of
with other regions, is heavily influenced by multiple neuro- participants reaching the MCID for VISA-A. The combined
genic sources, including: dextrose and ELE group had more rapid improvement than
1. Superficial nerves/penetrators: Saphenous, anterior fem- ELE alone. Morath et al. in a meta-analysis on sclerotherapy
oral cutaneous, and common fibular. and prolotherapy included four RCTs with a low risk of selec-
2. Deeper nerves/ganglion/plexi: Femoral at inguinal canal, tion bias and concluded sclerotherapy and prolotherapy are
saphenous in Hunter canal, common fibular at knee, safe and possibly effective treatments for Achilles tendinosis.57
obturator nerve to the medial joint line, and the tibial For plantar fasciosis, Ersen et al. in an RCT (n = 50)
nerve at the knee. compared three sonographically guided 15% DPT injec-
3. Entheses: Lateral and medial coronary and collateral liga- tions every 21 days to an exercise control.37 The VAS pain,
ments, anterior cruciate ligament (ACL), medial and lateral Foot and Ankle Outcome Score (FAOS), and Foot Function
retinaculum, quads insertion, and patellar tendon origin. Index (FFI) were significantly improved in both groups. The
4. Other/Joints: Infrapatellar (Hoffa) fat pad, tibiofemoral prolotherapy group did have higher VAS and FAOS scores
joint, and large Baker cysts. than the control group at 42, 90, and 360 days, but both
114 SEC T I O N I I Injectates

GMx/ ITB

GMe

GT
IIium
IFJ

FH
A

ITB

VL
GT

B
• Fig. 9.10 High-resolution ultrasound (HRUS) application examples about the mid and lateral gluteus,
posterolateral hip, and iliotibial band. (A) Hip capsular injection posterolaterally: For the patient with hip lax-
ity, the origins of ischiofemoral and iliofemoral ligaments can be targeted at the iliac edge just proximal to
the iliofemoral joint (arrow indicates needle direction and injection site). (B) Proximal iliotibial band injection.
The junction of the gluteus maximus muscle (GMx) with the iliotibial band (ITB) can be a source of pain and
requires ultrasound localization to treat the appropriate layers. This shows needling within the iliotibial band
(multiple arrow tip) as it condenses over the greater trochanter. FH, Femoral head; GMe, gluteus medius
muscle; GT, greater trochanter; IFJ, iliofemoral joint; P, piriformis muscle; VL, vastus lateralis.

groups had similar FFI scores at 360 days. Kim and Lee, in spring ligament origin and insertion, and naviculocuboi-
an RCT comparing sonographically guided PRP and 15% dal ligament origin and insertion.
dextrose injection for plantar fasciosis,38 reported significant 4. Joints/other: Subtalar and tibiotalar joints, cubometa-
improvement in mean FFI and found no statistically signifi- tarsal, cuneometatarsal, cuneonavicular, and metatarso-
cant difference between PRP and prolotherapy at 6 months. phalangeal (MTP) joints, posterior tibial synovium, and
Kager fat pad/injection about the Achilles tendon.
Key Nociceptors
Common sources of nociception within/affecting the ankle Summary
and/or foot include:
1. Superficial nerves/penetrators: Saphenous, superficial Dextrose injection has been reported in numerous RCTs to
fibular, and lateral sural cutaneous. be clinically effective in a variety of pain conditions. While
2. Deeper nerves/ganglion/plexi: Tibial nerve at knee, pos- its mechanism of action is not well understood, dextrose is
terior tibial in tarsal tunnel, fibular nerve at knee, fibu- hypothesized to be biologically active in the treatment of
lar nerve about the fibular head, interdigital nerves, and connective tissue: for example, ligament, tendon, cartilage,
nerves dorsal to the plantar fascia. and nerve. It is used in three related but distinct modali-
3. Entheses: Talofibular ligament origin and insertion, cal- ties: prolotherapy, perineural injection therapy (PIT), and
caneofibular ligament origin and insertion, talocalcaneal HD. The use of ultrasound is increasingly used to guide or
ligament origin and insertion, plantar fascia origin, short confirm needle placement in many prolotherapy procedures
plantar ligament insertion, bifurcate ligament origin and that have historically been palpation-guided, and is essential
insertion, tibiofibular ligament origin and insertion, in performing safe HD and some prolotherapy techniques.
 CHAPTER 9 Therapeutic Dextrose Injection: Prolotherapy, Perineural Injection Therapy, and Hydrodissection 115

References 19. Dumais R, Benoit C, Dumais A, et al. Effect of regenera-

tive injection therapy on function and pain in patients with
1. Schultz LW. A treatment for subluxation of the temporoman- knee osteoarthritis: a randomized crossover study. Pain Med.
dibular joint. J Am Med Assoc. 1937;109(13):1032–1035. 2012;13(8):990–999.
2. Rice CO, Mattson H. Histologic changes in the tissues of 20. Sert AT, Sen EI, Esmaeilzadeh S, Ozcan E. The effects of dex-
man and animals following the injection of irritating solutions trose prolotherapy in symptomatic knee osteoarthritis: a ran-
intended for the cure of hernia. Ill Med J. 1936:271–278. domized controlled study. J Altern Complement Med. Pain Med.
3. Hackett GS. Prolotherapy in whiplash and low back pain. Post- 2020;26(5):409–417.
grad Med. 1960;27:214–219. 21. Sit RWS, Wu RWK, Rabago D, et al. Efficacy of intra-articular
4. Hackett GS, Hemwall GA, Montgomery GA. Ligament and hypertonic dextrose (prolotherapy) for knee osteoarthritis: a ran-
Tendon Relaxation Treated by Prolotherapy. 5th ed. Madison, WI: domized controlled trial. Ann Fam Med. 2020;18(3):235–242.
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5. Reeves KD, Sit RWS, Rabago D. Dextrose prolotherapy: a bility: a preliminary prospective, randomized, double-blind,
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6. Scarpone M, Rabago DP, Zgierska A, Arbogast G, Snell E. The placebo for the treatment of temporomandibular joint hypermo-
efficacy of prolotherapy for lateral epicondylosis: a pilot study. bility? A randomized clinical trial. Int J Oral Maxillofacial Surg.
Clin J Sport Med. 2008;18(3):248–254. 2016;43(7):813–819.
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Sport Med. 2005;15(5):376–380. 26. Seven MM, Ersen O, Akpancar S, et al. Effectiveness of prolo-
10. Murphy M, Godson C, Cannon S, et al. Suppression subtrac- therapy in the treatment of chronic rotator cuff lesions. Orthop
tive hybridization identifies high glucose levels as a stimulus for Traumatol Surg Res. 2017;103(3):427–433.
expression of connective tissue growth factor and other genes 27. Rabago D, Lee KS, Ryan M, et al. Hypertonic dextrose and mor-
in human mesangial cells. J Biol Chem. 1999;274(9):5830– rhuate sodium injections (prolotherapy) for lateral epicondylosis
3834. (tennis elbow): results of a single-blind, pilot-level, randomized
11. Grosick R, Alvarado-Vazquez PA, Messersmith AR, Romero-San- controlled trial. Am J Phys Med Rehabil. 2013;92(7):587–596.
doval EA. High glucose induces a priming effect in macrophages 28. Bayat M, Raeissadat SA, Mortazavian Babiki M, Rahimi-Dehgo-
and exacerbates the production of pro-inflammatory cytokines lan S. Is dextrose prolotherapy superior to corticosteroid injection
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12. Ekwueme EC, Mohiuddin M, Yarborough JA, et al. Prolotherapy cal trial. Orthop Res Rev. 2019;11:167–175.
induces an inflammatory response in human tenocytes in vitro. 29. Hooper RA, Hildebrand K, Faris P, Westaway M, Freiheit E.
Clin Orthop Relat Res. 2017;475:2117–2127. Randomized controlled trial for the treatment of chronic dorsal
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collagen deposition in MC3T3-E1 and patellar tendon fibroblast 30. Reeves KD, Hassanein K. Randomized prospective placebo-
populations. Transl Res. 2011;158:132–139. controlled double-blind study of dextrose prolotherapy for
14. Oh S, Ettema AM, Zhao C, et al. Dextrose-induced subsy- osteoarthritic thumbs and fingers (DIP, PIP and trapeziometa-
novial connective tissue fibrosis in the rabbit carpal tunnel: a carpal joints): evidence of clinical efficacy. Jnl Alt Compl Med.
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2008;3(1):34–40. 31. Jahangiri A, Moghaddam FR, Najafi S. Hypertonic dextrose ver-
15. Yoshii Y, Zhao C, Schmelzer JD, Low PA, An KN, Amadio PC. sus corticosteroid local injection for the treatment of osteoarthri-
Effects of hypertonic dextrose injections in the rabbit carpal tun- tis in the first carpometacarpal joint: a double-blind randomized
nel. J Orthop Res. 2011;29(7):1022–1027. clinical trial. J Orthop Sci. 2014;19(5):737–743.
16. Yoshii Y, Zhao C, Schmelzer JD, Low PA, An KN, Amadio PC. 32. Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A ran-
The effects of hypertonic dextrose injection on connective tissue domized controlled trial of intra-articular prolotherapy versus
and nerve conduction through the rabbit carpal tunnel. Arch Phys steroid injection for sacroiliac joint pain. J Altern Complement
Med Rehabil. 2009;90(2):333–339. Med. 2010;16(12):1284–1290.
17. Yoshii Y, Zhao C, Schmelzer JD, Low PA, An KN, Amadio PC. 33. Gul D, Orselik A, Akpancar S. Treatment of osteoarthritis sec-
Effects of multiple injections of hypertonic dextrose in the rab- ondary to developmental dysplasia of the hip with prolotherapy
bit carpal tunnel: a potential model of carpal tunnel syndrome injection versus a supervised progressive exercise control. Med Sci
development. Hand (N Y). 2014;9(1):52–57. Monit. 2020;26:e919166.
18. Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy 34. Topol GA, Podesta LA, Reeves KD, Raya MF, Fullerton BD, Yeh
for knee osteoarthritis: a randomized controlled trial. Ann Fam HW. Hyperosmolar dextrose injection for recalcitrant Osgood-
Med. 2013;11:229–237. Schlatter disease. Pediatrics. 2011;128(5):e1121–1128.
116 SEC T I O N I I Injectates

35. Nakase J, Oshima T, Takata Y, Shimozaki K, Asai K, Tsuchiya 52. Catapano M, Zhang K, Mittal N, Sangha H, Onishi K, de Sa D.
H. No superiority of dextrose injections over placebo injections Effectiveness of dextrose prolotherapy for rotator cuff tendinopa-
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37. Ersen O, Akpancar S, Seven MM, Akyildiz F, Yildiz Y, Ozkan 54. Dong W, Goost H, Lin XB, et al. Injection therapies for lateral
H. A randomized-controlled trial of prolotherapy injections epicondylalgia: a systematic review and Bayesian network meta-
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40. Sit RWS, Chung VCH, Reeves KD, et al. Hypertonic dextrose (8):57.
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43. Hassan F, Trebinjac S, Murrell WD, Maffulli N. The effectiveness shock wave therapy, prolotherapy, radiofrequency ablation). C
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45. Covey CJ, Sineath MHJ, Penta JF, Leggit JC. Prolotherapy: can tion Manual. St. Cloud, Minnesota: Baumgartner, J.J.; 2011.
it help your patient? J Fam Pract. 2015;64(12):763–768. 62. Hackett Hemwall Patterson Foundation. Basic Prolotherapy Study
46. Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A sys- Guide. Madison, Wisconsin; 2010. https://hhpfoundation.org.
tematic review of dextrose prolotherapy for chronic musculo- 63. Lyftogt J. Chronic exertional compartment syndrome and prolo-
skeletal pain. Clin Med Insights Arthritis Musculoskelet Disord. therapy. Aust M Med. 2006;11:83–85.
2016;9:139–159. 64. Ji R, Nackley A, Huh Y, Terrando N, Maixner W. Neuroinflam-
47. Borg-Stein J, Osoaria HL, Hayano T. Regenerative sports medi- mation and central sensitization in chronic and widespread pain.
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award presentation; AAPMR; October 2016). Pharm Manag PM 65. Lyftogt J. Pain conundrums: which hypothesis? Central nervous
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injectable therapies. Pain Res Manag. 2020:3873098. https://doi. analgesic effects of 5% dextrose epidural injection for chronic
org/10.1155/2020/3873098. low back pain. A randomized controlled trial. Anesth Pain Med.
49. Topol GA, Podestá L, Reeves KD, et al. Hypertonic-dextrose 2017;7(1):e42550.
intra-articular injections in severe knee osteoarthritis: a pilot 67. Maniquis-Smigel L, Reeves KD, Rosen JH, et al. Analgesic effect
study suggesting disease modification through chondrogenesis and potential cumulative benefit from caudal epidural D5W in
(Abs). Arch Phys Med Rehabil. 2015;96(10):e104. consecutive participants with chronic low back and buttock/leg
50. Nagori SA, Jose A, Gopalakrishnan V, Roy ID, Chattopadhyay pain. Jnl Alt Compl Med. 2018;12(12):1189–1196.
PK, Roychoudhury A. The efficacy of dextrose prolotherapy over 68. Bertrand H, Kyriazis M, Reeves KD, Lyftogt J, Rabago D.
placebo for temporomandibular joint hypermobility: a system- Topical mannitol reduces capsaicin-induced pain: results of
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51. Dwivedi S, Sobel AD, DaSilva MF, Akelman E. Utility of 69. MacIver MB, Tanelian DL. Activation of C fibers by metabolic
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70. Lyftogt J. Subcutaneous prolotherapy treatment of refrac- 84. Ungor C, Atasoy KT, Taskesen F, et al. Short-term results of pro-
tory knee, shoulder and lateral elbow pain. Aust M Med. lotherapy in the management of temporomandibular joint dislo-
2007;12(2):110–112. cation. J Craniofac Surg. 2013;24(2):411–415.
71. Lyftogt J. Subcutaneous prolotherapy for Achilles tendinopathy. 85. Zhou H, Hu K, Ding Y. Modified dextrose prolotherapy for
Aust M Med. 2007;12(11):107–109. recurrent temporomandibular joint dislocation. Br J Oral Maxil-
72. Lyftogt J. Prolotherapy for recalcitrant lumbago. Aust M Med. lofac Surg. 2014;52(1):63–66.
2008;13(5):18–20. 86. Fouda AA. Change of site of intra-articular injection of hyper-
73. Jancsó N, Jancsó-Gábor A, Szolcsányi J. Direct evidence for tonic dextrose resulted in different effects of treatment. Br J Oral
neurogenic inflammation and its prevention by denervation Maxillofac Surg. 2018;56(8):715–718.
and by pretreatment with capsaicin. Br J Pharmacol Chemother. 87. Majumdar SK, Krishna S, Chatterjee A, Chakraborty R, Ansari
1967;31(1):138–151. N. Single injection technique prolotherapy for hypermobility
74. Lyftogt J. Neuopathic pain therapies. 2020. lyftogtmed.com. disorders of TMJ using 25% dextrose: a clinical study. J Maxil-
2020. Accessed April 21. lofac Oral Surg. 2016;16(2):226–230.
75. Klauser AS, Halpern EJ, De Zordo T, et al. Carpal tunnel syn- 88. Centeno CJ, Elliott J, Elkins WL, Freeman M. Fluoroscopically
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volunteers. Radiology. 2009;250(1):171–177. 89. Hooper RA, Frizzell JB, Faris P. Case series on chronic whiplash
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body and torso. Method description and results from a ret- 90. Hooper RA, Yelland MJ, Fonstad P, Southern D. Prospective
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2017:7920438. (Available at https://www.hindawi.com/journals 2011;33(1):15–20.
/bmri/2017/7920438/). 91. Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon
77. Bennett GJ, Xie YK. A peripheral mononeuropathy in rat that M. Prolotherapy injections, saline injections, and exercises for
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1988;33:87–107. 2004;29(1):9–16.
78. Wu YT, Chen SR, Li TY, et al. Nerve hydrodissection for carpal 92. Khan SA, Kumar A, Varshney MK, Trikha V, Yadav CS. Dex-
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trolled trial. Muscle Nerve. 2019;59(2):174–180. 2008;16(1):27–29.
79. Wu YT, Ho TY, Chou YC, et al. Six-month efficacy of perineural 93. Topol GA, Reeves KD. Regenerative injection of elite athletes
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80. Wu YT, Ke MJ, Ho TY, Li TY, Shen YP, Chen LC. Randomized 94. Rabago D, Reeves KD, Topol GA, Podesta LA, Cheng AL, Fuller-
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2018;84(4):601–610. editor for: no superiority of dextrose injections over placebo injec-
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10
Sclerosing Agents
COLTON L. WOOD, DAVID J. BERKOFF, AND
JUSTIN R. LOCKREM

Introduction chronic post-traumatic prepatellar bursitis refractory to rest,

nonsteroidal antiinflammatory drugs (NSAIDs), compres-
Sclerotherapy is the process of injecting a proinflammatory sion bandage, and bursa aspiration in conjunction with a
agent into an enlarged potential space (e.g., bursa, Morel- corticosteroid injection. Both patients had resolution of pre-
Lavallee lesion, tendon sheath) with the goal of alleviating patellar swelling after blind aspiration and injection of the
pain, restoring function, and achieving cosmetic normalcy. sclerosing agent sodium morrhuate. The agent was combined
Published literature to date details the sclerosing effects of an with methylprednisone and lidocaine to prevent previously
array of agents, including fibrin glue, doxycycline, other tet- described post-injection flares. At a 17-month follow-up,
racycline derivatives, ethyl alcohol, polidocanol, and sodium there was no recurrence of prepatellar swelling or pain.12,13
morrhuate. Case reports, case series, and a limited number of In 2016, Hong et al. completed a case series of two
randomized controlled trials (RCTs) report how these agents patients with aseptic olecranon bursitis and 22 patients with
can serve as therapeutic options for numerous orthopedic aseptic malleolar bursitis at the ankle with over 4 months of
conditions, including aseptic olecranon bursitis, aseptic prepa- symptoms refractory to NSAIDs, bandaging, and aspiration
tellar bursitis, subacromial bursitis, malleolar bursitis, Morel- with corticosteroid injection. All patients were treated with
Lavallee lesions, chronic idiopathic finger flexor tenosynovitis, ultrasound (US)-guided bursa aspiration followed by irriga-
chronic Achilles tendinosis, intraosseous low-flow vascular tion with 50% dehydrated ethyl alcohol. After 1 minute the
lesions, and chronic shoulder impingement syndrome. alcohol was aspirated and a compressive bandaging applied.
This chapter reviews the current body of evidence and This was repeated weekly if the bursa was not smaller on
sets forth evidence-based treatment guidelines regarding follow-up. In 13 of 24 study participants (54%), decreased
sclerotherapy for orthopedic conditions. Prolotherapy is bursal size was noted after one injection and patients went
discussed within a separate chapter. on to have complete resolution of the bursitis. The remain-
ing 11 patients began to show clinical response after the
second injection and these patients went on to a partial
Indications for Use resolution of their bursitis. The mean follow-up period was
Sclerotherapy in Bursitis: Theory and Clinical 16 months, with no recurrence of bursa fluid or pain after
Evidence initial resolution, with “local heat with tolerable pain” the
only side effect reported in 4 of 24 patients. Patients with
Initial reports of using injectable caustic agents to accom- >3 months of symptoms required fewer injections (2.4 ± 1.7
plish sclerodesis in refractory bursitis date back to the injections) compared to those with <3 months of symptoms
1930s.1 Sclerodesis for recalcitrant bursitis fell out of favor (4.7 ± 5.5 injections), suggesting ethyl alcohol sclerotherapy
with the increased popularity of surgical resection, percu- be reserved for patients who have failed >3 months of con-
taneous drain placement, or autologous blood injection servative therapy.11
(“blood patch”).2–5 However, surgical resection is not with- In 2016, Berkoff et al. published a case report on the
out significant complications, including recurrent bursitis, novel use of fibrin glue for persistent aseptic olecranon
iatrogenic infection, chronic sinus tract formation, nerve bursitis for patients who failed four prior aspirations and
damage, scar formation, increased pain, reduced range of one steroid injection with compressive wrapping. In this
motion (ROM), and delayed return to sport.6,7 In the past case report, after aspiration of the olecranon bursa 2 mL of
10 years, there has been a reemergence of interest in percu- TISSEEL fibrin glue was injected using US guidance and
taneous sclerotherapy as a treatment for refractory bursitis. compression wrap was applied. Follow-up evaluation at 3
In 2009, Ike detailed a case series of two patients (one weeks, 2 months, and 6 months showed no recurrence of
with systemic lupus erythematosus, the other healthy) with the bursitis or pain.14

118
 CHAPTER 10 Sclerosing Agents 119

In 2018, Parker and Leggit authored a case report of a In 2013, Bansal et al. focused on chronic MLL in a case
soldier with an 8-month history of refractory prepatellar series of 16 patients with MLL persisting for greater than
bursitis treated successfully with two rounds of US-guided 6 months. Patients had lesions located at the thigh, greater
aspiration, injection with the sclerosing agent polidocanol trochanter, gluteus, lower back, or abdominal wall. Most
(based on hospital formulary), and compression bandage. patients had undergone conservative therapy and multiple
Improved function was reported at the 2-week follow-up aspirations, and all patients underwent a blind MLL aspi-
visit, and at the 10-month follow-up no bursal fluid had ration and sclerotherapy with 25 mL of doxycycline. The
reaccumulated and the patient had returned to prior level of doxycycline was left in the lesion for 60 minutes with posi-
function with no adverse effects.8 tion changes every 10 minutes to ensure distribution, fol-
Concomitantly in 2018, Close and Hill published a case lowed by aspiration of the sclerosing agent and compression
series of three patients with aseptic olecranon bursitis, including wrapping for 4 weeks. At 4-week follow-up, 11 of the 16
one with recurrent bursitis after a surgical bursectomy, refrac- patients (69%) had complete resolution of MLL. Four of
tory to over 1 month of conservative treatment. All patients had the five remaining patients had MLL located on the anterior
a single-blind injection with doxycycline 100 mg diluted in 10 abdominal wall and were instructed to continue continu-
mL sterile saline and compressive wrap for 2 weeks, and had ous compression wrapping. At 8-week follow-up, 15 of the
improvement in bursal swelling and pain within 3 weeks. One 16 patients (94%) had complete resolution of MLL. The
patient reported mild burning at the injection site, controlled remaining patient was found to be noncompliant with com-
with over-the-counter analgesics. At the 6-month follow-up, pression therapy, and 13 of the 16 patients had no recurrent
no patient had recurrence of pain or swelling.9 swelling or pain at the 3-year follow-up. The remaining three
patients were lost to follow-up. Side effects included mild to
Sclerotherapy in Morel-Lavallee Lesions and moderate post-procedural pain and low-to-high grade fever
Seromas: Theory and Clinical Evidence for the first day post-procedure in the first 3 subjects. The
remaining patients were treated with 1 day of Tylenol (acet-
Morel-Lavallee lesions (MLLs) result from traumatic shear- aminophen) prophylaxis and reported no adverse effects.33
ing forces to the tissue plane between subcutaneous fat and Fibrin agents have also been used over the years in vari-
underlying muscle. The closed degloving-type injury dis- ous surgeries and procedures.34–36 Berkoff et al. reported
rupts the vessels that penetrate the fascia, leading to rapid successfully using US-guided fibrin glue sclerodesis for
accumulation of blood within the potential space between a chronic post-arthroscopic knee seroma. In a 2013 case
the subcutaneous fat and fascia. Complications include risk report, a persistent 7.5 × 7 cm seroma over the posterolateral
of secondary infection, fat necrosis and resultant deformity, knee that did not resolve with three US-guided aspirations
or persistent pseudocyst formation.15–18 Although MLL has and a corticosteroid injection was treated with aspiration
historically been treated with open debridement and heal- and fibrin glue injection across the fascial defect and adja-
ing by secondary intention or drain placement, there is an cent stalk. There was complete resolution at 2 weeks, with
emerging push toward minimally invasive treatments to no re-accumulation at the 1-year follow-up.37 In 2017, Koc
avoid disturbing the subdermal arterial plexus. This plexus et al. described the use of fibrin glue injection following
is the only remaining vascular supply to the overlying cuta- endoscopic debridement of a suprapatellar MLL in a pro-
neous flap, and its disruption can result in tissue flap necro- fessional soccer player following failed conservative man-
sis.15,17,19,20 Drainage and sclerotherapy is one proposed agement, including doxycycline sclerodesis. The patient
alternative to surgery for MLL, and includes sclerodesis returned to sport at 6 weeks following treatment. US at 6
with talc, bleomycin, and doxycycline. Talc can lead to weeks showed complete resolution of MLL, with no recur-
severe pain as well as increased infection risk and bleomycin rence at the 1-year follow-up.38
is very costly, making doxycycline is an appealing sclerosing
agent for treating MLL.15,20–32 Sclerotherapy in Tendinosis and Tenosynovitis:
In 2007, Tejwani et al. reported a case series of 24 Theory and Clinical Evidence
National Football League players who sustained a MLL to
their knee(s) after a shearing blow from field impact or a Sclerosing agents have also been investigated for treat-
tackle. Players presented an average of 3 days from the date ment of chronic, refractory tendinopathy. Neonerves usu-
of injury, and a total of 27 knees were included in this study. ally travel with neovessels inside the tendon. These sensory
All 27 lesions were initially treated with ice, compression nerves have been implicated as possible pain generators, and
wrapping of the knee and thigh, and immediate passive/ it has been hypothesized that destroying the local neonerves
active ROM exercises; 13 lesions ultimately required aspira- adjacent to neovessels can decrease pain. Polidocanol is an
tion. Three lesions (11%) persisted after three aspirations, analgesic and vascular irritant with established tolerability
but all subsequently resolved with one intralesional injec- and efficacy in the treatment of varicose veins at various sites
tion with 20 mg/mL doxycycline and compression wrap- such as lower extremity varicosities, esophageal varices, tel-
ping. The doxycycline sclerodesis group had a successful full angiectasias, and hemorrhoids.39–41
return to play within 1 day post-injection, but no extended In 2002 and 2003, two case series by Öhberg and Alfred-
follow-up was reported.27 son reported the effects of polidocanol injections at sites of
120 SEC T I O N I I Injectates

neovascularization in chronic Achilles tendinosis with a Few studies have examined the association between
symptom duration greater than 4 months. The polidoca- neovascularization and pain, and results have been con-
nol was injected under US-guided and Doppler imaging flicting.48–50 Due to the conflicting results and limited
into the area adjacent to the neovessels as they entered the high-quality evidence, it is difficult to make a recommen-
Achilles tendon until all vessels were sclerosed and no fur- dation for sclerosing injection.51 In addition, while fibrin
ther Doppler flow was visualized. These pilot studies both products and fibrin carriers have been extensively studied in
revealed clinically and statistically significant improvements animal models for promotion of postsurgical healing of ten-
in visual analog scale (VAS) pain levels, patient satisfaction dons, tendinopathy, and tendon ruptures,52–57 no research
ratings, and Achilles tendon neovascularization for the first has been published with human subjects for tendonitis or
6 months after polidocanol sclerotherapy.42,43 Unpublished tendinosis.
follow-up data for the 2002 case series revealed all eight
patients had no recurrence of pain or neovascularization at Sclerotherapy in Intraosseous Lesions: Theory
2 years, with normalization of tendon diameter and fibrillar and Clinical Evidence
structure on US.44
Öhberg and Alfredson also conducted a double-blind Although limited evidence exists, doxycycline has been used
randomized controlled trial that randomized 20 consecu- for treatment of postoperative lymphoceles, head and neck
tive patients with chronic mid-portion Achilles tendinopa- lymphatic malformations, and intramuscular and intraosse-
thy to US-guided polidocanol injections versus US-guided ous vascular lesions with good results.58–61 In 2009, Wible
lidocaine injections into sites of tendon neovasculariza- and Mitchell published a case report of a 19-year-old male
tion. At 3 to 6 weeks post-injection, VAS pain scores with with a chronic, severely painful intraosseous lymphatic mal-
Achilles-loading activity, patient satisfaction ratings, and formation. Following two sequential injections with doxycy-
neovascularization were significantly improved (P < .005) cline under US guidance, the patient’s pain decreased from a
in 5 of the 10 patients (50%) randomized to polidocanol pre-injection rating of 9 on a 10-point pain scale to 2/10 at
compared to 0% of patients in the control group (P < .878). rest 9 months after injection and 3/10 after running 1 mile at
Neovascularization was fully resolved in all polidocanol the same time point; his lymphatic lesion filling dimensions
subjects who reported no pain but remained present in all on magnetic resonance imaging (MRI) were also slightly
patients with persistent pain. At the trial’s completion, sub- reduced as well. No adverse effects were found or reported
jects were allowed to cross over to the polidocanol group; after 9 months of follow-up.62
14 of the 15 crossover subjects (93%) noted statistically
significant (P < .04) improvement in pain, satisfaction, Suggested Sclerosing Agents and Dosing
and neovascularization on US. No adverse effects were
reported by any patients.44 Similar improvements in pain See Table 10.1.
and return to preinjury level of activity have been reported
Patient Selection, Management, and Rationale
after US-guided polidocanol sclerotherapy in seven elite
and eight recreational-level athletes with chronic patellar Olecranon and Patellar Bursitis
tendinosis refractory to more than 3 months of rest and Based on the current limited evidence, a treatment guide-
NSAIDs.45 line for aseptic superficial bursitis should include the follow-
Polidocanol also showed promising results in a 2006 case ing patient-oriented, resource-conscientious steps:
series as a treatment for chronic shoulder impingement syn- 1. Trial period of conservative therapy for 2 weeks includ-
drome. Alfredson et al. reported the results of US-guided ing rest from aggravating activities, elbow or patellar
polidocanol injections at sites of supraspinatus or subacro- padding, ice twice daily for 20 minutes, NSAID (i.e.,
mial bursa neovascularization in 15 patients who had failed naproxen 500 mg by mouth twice daily), and compres-
rest, NSAIDs, physical rehab, and/or multiple subacromial sion bandage.
corticosteroid injections. After a median of two polidocanol 2. Aspiration of bursa contents (preferably with US guidance)
injections and gentle ROM exercises over at least 4 months, followed by compression bandage for 12 to 24 hours.
14 of 15 patients (93%) reported clinically and statistically 3. US-guided aspiration of bursa followed by injection of
significant (P < .05) improvement in VAS shoulder pain a corticosteroid injection with concomitant conservative
scores with daily movements. No adverse outcomes were therapies as listed in step 1.
reported.46 4. US-guided aspiration of bursa followed by injection of
There is one case report of a 56-year-old male with a sclerosing agent (preferably doxycycline given current
chronic idiopathic finger flexor tenosynovitis successfully safety, cost, efficacy, and tolerability data) with concomi-
treated with two injections of 50% ethyl alcohol. Injections tant conservative measures and scheduled follow-up in 2
were 10 months apart with initial improvement in pain to 4 weeks.
after first injection and gradual resolution of swelling after 5. If no improvement by 12-week follow-up, repeat step 4
two injections. Follow-up at 22 months revealed no adverse or discuss role of US-guided fibrin glue injection.
effects, pain-free normal ROM, and complete resolution of 6. If suboptimal or no response, offer surgical referral for
symptoms.47 bursal resection.
 CHAPTER 10 Sclerosing Agents 121

TABLE
10.1  Recommended Sclerosing Agents and Dosing for Various Pathologies  

Tendinosis/ Morel-Lavallee
Sclerosing Agent Bursitis Tenosynovitis Lesions/Seromas Intraosseous Lesions
Doxycycline 100 mg of doxycycline No prior studies. 100 mg of doxycycline 100 mg of doxycycline
powder in 10 mL of powder in 5 mL of powder in 10 mL of
sterile saline (10 mg/ sterile saline (20 mg/ sterile saline (10 mg/
mL).9,a mL).27,a mL).62,a
Fibrin glue Off-label use. No prior human trials. Off-label use. No prior studies.
Polidocanol 4–6 mL of polidocanol 1–4 mL of 5 mg/mL No prior studies. No prior studies.
(unspecified polidocanol.42–45,a
concentration).8,a
Ethyl alcohol Anesthesia with 3 mL 1 mL of 50% ethanol No prior studies. No prior studies.
of 2% lidocaine injected (tendon
aspirated to the sheath of finger).47,a
bursa sac. After
lidocaine aspiration,
inject a mixture
of 2.5 mL of 50%
dehydrated ethyl
alcohol and 2.5 mL
normal saline
into the bursa sac.11,a
Sodium morrhuate Aspirate bursa, then No prior studies. No prior studies. No prior studies.
instill 2 mL of 50
mg/mL sodium
morrhuate (NDC
0517-3065-01),
40 mg of
methylprednisolone,
and 1 mL of 1%
lidocaine.13,a

aAdjust injectate volume to size of lesion.

This table compiles the recommended doses of sclerosing agents for the pathologies of bursitis, tendinosis, tendinitis, Morel-Lavallee lesions, seromas, and
intraosseus lesions as discussed in this chapter.

Morel-Lavallee Lesions • F
 or resistant MLL: consideration of US-guided fibrin
Based on the current limited evidence, a treatment guideline sealant following aspiration.
for MLLs should include the following patient-oriented,
resource-conscientious steps: Techniques for Administration
• For acute MLL characterized by small fluid collections
and full ROM: compressive wrapping, ice for 20 min- Bursal (olecranon, prepatellar, etc.), Morel-Lavallee, and
utes twice daily, and immediate physical therapy target- seroma injections
ing active/passive joint ROM. • Identify lesion and para-lesion structures with US
• For acute MLL with large fluid collections or limited • Note any neurovascular structures and alter proce-
ROM: compression wrapping, ice, and lesion aspiration. dural approach to avoid them
Attempt three series of aspirations prior to doxycycline • Mark site of lesion
sclerodesis. • Sterilize field
• For chronic MLL: aspiration followed by doxycy- • Take care to avoid contamination of sterile field with
cline sclerodesis and compression wrapping for at least US probe/gel
4 weeks; may reattempt sclerodesis if not optimally • Alternatively, consider sterile draping over US probe
resolved at follow-up. • Anesthetize aspiration/injection tract
122 SEC T I O N I I Injectates

• 1 % lidocaine w/o epinephrine drawn up in 5 to 10 5. Fisher RH. Conservative treatment of distended patellar and
mL syringe olecranon bursae. Clin Orthop. 1979;123:98.
• Use higher-gauge needle with appropriate needle 6. Baumbach SF, Lobo CM, Badyine I, Mutschler W, Kanz KG.
length for anesthetizing (i.e., 25- or 27-guage, 1.5-inch Prepatellar and olecranon bursitis: literature review and devel-
opment of a treatment algorithm. Arch Orthop Trauma Surg.
needle)
2014;134(3):359–370.
• Consider use of anesthetizing cold (i.e., ethyl chlo- 7. Quayle JB, Robinson MP. An operation for chronic prepatellar
ride) spray over the site of needle entry bursitis. J Bone Joint Surg Am. 1976;58-B(4):504.
• Introduce needle into skin and raise small wheal 8. Parker CH, Leggit JC. Novel treatment of prepatellar bursitis.
within subcutaneous tissue Military Med. 2018;183(11-12):e768–e770.
• Under US guidance, advance needle along the planned 9. Close E, Hill G. Doxycycline as sclerotherapy for recurrent asep-
aspiration-needle trajectory and gradually inject anes- tic olecranon bursitis, a new application of an existing therapy.
thetic along the entire tract EC Orthopaedics. 2018;9(4):211–217.
• Continue advancing needle into lesion as well and 10. Hassell AB, Fowler PD, Dawes PT. Intra-bursal tetracycline in
inject a small bolus of anesthetic within lesion the treatment of olecranon bursitis in patients with rheumatoid
• Retract needle slowly along entry trajectory, slowly arthritis. Br J Rheumatol. 1994;33(9):859–860.
11. Hong JS, Kim HS, Lee JH. Ultrasound-guided 50% ethyl alco-
injecting the remaining anesthetic along the tract
hol injection for patients with malleolar and olecranon bursitis: a
• Aspirate prospective pilot study. Ann Rehabil Med. 2016;40(2):310–317.
• Use lower-gauge needle with appropriate needle 12. Menninger H, Reinhardt S, Söndgen W. Intra-articular treat-
length (i.e., 18- or 20-gauge needle) ment of rheumatoid knee-joint effusion with triamcinolone hex-
• Under US guidance, introduce aspiration needle into acetonide versus sodium morrhuate. A prospective study. Scand J
skin and retrace the trajectory of previously anesthe- Rheumatol. 1994;23:249–254.
tized tract and advance tip of needle to the lesion and 13. Ike RW. Chemical ablation as an alternative to surgery for treatment
aspirate contents of persistent prepatellar bursitis. J Rheumatol. 2009;36(7):1560.
• Leave needle in place and exchange syringe for scle- 14. Berkoff DJ, Sandbulte ZW, Stafford HC, Berkowitz JN. Fibrin
rosant-containing syringe glue for olecranon bursitis: a case report. Ther Adv Musculoskelet
• Make use of a hemostat to facilitate maintaining nee- Dis. 2016;8(1):28–30.
15. Hak DJ, Olson SA, Matta JM. Diagnosis and management
dle position during syringe exchange.
of closed internal degloving injuries associated with pelvic
• Use US to confirm needle position after syringe exchange and acetabular fractures: the Morel-Lavallée lesion. J Trauma.
and inject sclerosant 1997;42(6):1046–1051.
• Fibrin use is off label 16. Hudson DA. Missed closed degloving injuries: late presentation
• Doxycycline or tetracycline derivative as a contour deformity. Plast Reconstr Surg. 1996;98(2):334–337.
• Apply compression wrap (i.e., Coban wrap) 17. Kottmeier SA, Wilson SC, Born CT, Hanks GA, Ianna-
• Confirm neurovascular status post-application, tak- cone WM, DeLong WG. Surgical management of soft tissue
ing care to avoid high pressure that may lead to limb lesions associated with pelvic ring injury. Clin Orthop Relat Res.
ischemia 1996;(329):46–53.
• Review post-procedure instructions 18. Kudsk KA, Sheldon GF, Walton RL. Degloving injuries of the
• Leave or reapply Coban to complete compressive extremities and torso. J Trauma. 1981;21(10):835–839.
19. Helfet DL, Schmeling GJ. Complications. In: Tile M, ed. Frac-
wrapping for 24 hours post-procedure
tures of the Pelvis and Acetabulum. 2nd ed. Baltimore, Md: Wil-
• Patient should be instructed on how to take down and liams & Wilkins; 1995:451–467.
reapply Coban wrapping if paresthesia or discomfort 20. Routt Jr ML, Kregor PJ, Simonian PT, Mayo KA. Early results
develops of percutaneous iliosacral screws placed with the patient in the
• Post-procedure rehab supine position. J Orthop Trauma. 1995;9(3):207–214.
• Minimal movement for initial 72 hours 21. Hudson DA, Knottenbelt JD, Krige JE. Closed degloving inju-
Gentle passive ROM at 72 hours with gradual pro- ries: results following conservative surgery. Plast Reconstr Surg.
gression to full active ROM and subsequent strengthen- 1992;89:853–855.
ing exercises, 22. Mir Y, Mir L, Novell AM. Repair of necrotic cutaneous lesions,
secondary to tangential traumatism over detachable zones. Plast
Reconstr Surg. 1950;6:264–274.
References 23. Luria S, Applbaum Y, Weil Y, Liebergall M, Peyser A. Talc
sclerodhesis of persistent Morel-Lavalle´e lesions (posttrau-
1. Kaplan L, Ferguson LK. Bursitis. Am J Surg. 1937;37:455–465.
matic pseudocysts): case report of 4 patients. J Orthop Trauma.
2. Nontraumatic soft tissue disorders. Knee. Prepatellar bursitis. In:
2006;20(6):435–438.
Canale ST, ed. Campbell’s Operative Orthopedics. 10th ed. Phila-
24. Gericke KR. Doxycycline as a sclerosing agent. Ann Pharmaco-
delphia: Mosby; 2003:894–895.
ther. 1992;26(5):648–649.
3. Nardella FA. Blood-patch treatment for prepatellar bursitis
25. Caliendo MV, Lee DE, Queiroz R, Waldman DL. Sclerotherapy
(housemaid’s knee). New Engl J Med. 1982;306:1553.
with use of doxycycline after percutaneous drainage of postopera-
4. Stimson H. Bursitis. Am J Surg. 1940;50:527–533.
tive lymphoceles. J Vasc Interv Radiol. 2001;12:73–77.
 CHAPTER 10 Sclerosing Agents 123

26. Robinson LA, Fleming WH, Galbrainth TA. Intrapleural doxy- 46. Alfredson H, Harstad H, Haugen S, Ohberg L. Sclerosing poli-
cycline control of malignant pleural effusions. Ann Thorac Surg. docanol injections to treat chronic painful shoulder impingement
1993;55:1115–1121. syndrome—results of a two-centre collaborative pilot study. Knee
27. Tejwani SG, Cohen SB, Bradley JP. Management of Morel- Surg Sports Traumatol Arthrosc. 2006;14(12):1321–1326.
Lavallee lesion of the knee: twenty-seven cases in the National 47. Shin JE, Park JH, Yi HS, Ye BK, Kim HS. Treatment of chronic
Football League. Am J Sports Med. 2007;35(7):1162–1167. isolated finger flexor tenosynovitis through 50% dehydrated alco-
28. Harma A, Inan M, Ertem K. The Morel-Lavallee lesion: a con- hol installation. Ann Rehabil Med. 2013;37(4):586–590.
servative approach to closed degloving injuries. Acta Orthop Trau- 48. de Vos RJ, Weir A, Cobben LP, Tol JL. The value of power Dop-
matol Turc. 2004;38:270–273. pler ultrasonography in Achilles tendinopathy: a prospective
29. Kothe M, Lein T, Weber AT, Bonnaire F. Morel-Lavallee lesion: study. Am Journal Sports Med. 2007;35(10):1696–1701.
a grave soft tissue injury. Unfallchirurg. 2006;109:82–86. 49. Tol J, de Jonge S, Weir A, de Vos RJ, Verhaar J. Relationship
30. Luria S, Yaakov A, Yoram A, Meir L, Peyser A. Talc sclerodhesis between neovascularization and clinical severity in Achilles tendi-
of persistent Morel-Lavallee lesions (posttraumatic pseudocysts): nopathy: a prospective analysis of 556 paired measurements. Knee
case report of 4 patients. J Orthop Trauma. 2006;20:435–438. Surg Sports Traumatol Arthrosc. 2012;20(suppl 1):S63.
31. Tseng S, Tornetta P. Percutaneous management of Morel-Laval- 50. van Sterkenburg MN, de Jonge MC, Sierevelt IN, van Dijk CN.
lee lesions. J Bone Joint Surg Am. 2006;88:92–96. Less promising results with sclerosing ethoxysclerol injections for
32. Tsur A, Galin A, Kogan L, Loberant N. Morel-Lavallee syndrome midportion Achilles tendinopathy: a retrospective study. Am J
after crush injury. Harefuah. 2006;145:111–113. 166. Sports Med. 2010;38(11):2226–2232.
33. Bansal A, Bhatia N, Singh A, Singh AK. Doxycycline sclerode- 51. Tol JL, Spiezia F, Maffulli N. Neovascularization in Achilles ten-
sis as a treatment option for persistent Morel-Lavallée lesions. dinopathy: have we been chasing a red herring? Knee Surg Sports
Injury. 2013;44(1):66–69. Traumatol Arthrosc. 2012;20:1891–1894.
34. Kulber DA, Bacilious N, Peters ED, Gayle LB, Hoffman L. The 52. Chong AK, Ang AD, Goh JC, et al. Bone marrow-derived mes-
use of fibrin sealant in the prevention of seromas. Plast Reconstr enchymal stem cells influence early tendon-healing in a rabbit
Surg. 1997;99:842–849. Achilles tendon model. J Bone Joint Surg Am. 2007;89:74–81.
35. Schwabegger AH, Ninkovic MM, Anderl H. Fibrin glue to pre- 53. Andres BM, Murrell GA. Treatment of tendinopathy: what
vent seroma formation. Plast Reconstr Surg. 1998;101(6):1744– works, what does not, and what is on the horizon. Clin Orthop
1745. Relat Res. 2008;466(7):1539–1554.
36. Shigeno Y, Harada I, Katayama S. Treatment of cystic lesions 54. Hohendorff B, Siepen W, Staub L. Treatment of acute Achilles
of soft tissue using fibrin sealant. Clin Orthop Relat Res. tendon rupture: fibrin glue versus fibrin glue augmented with the
1995;321:239–244. plantaris longus tendon. J Foot Ankle Surg. 2009;48(4):439–446.
37. Berkoff DJ, Kanaan M, Kamath G. Fibrin glue as a non-invasive 55. Kim HJ, Park JH, Lim HC, et al. The healing effect of bone
outpatient treatment for post-arthroscopic knee seromas. Knee morphogenic protein with fibrin glue on an injury of the tendon-
Surg Sports Traumatol Arthrosc. 2013;21:1922. bone junction. J Korean Orthop Assoc. 2007;42(1):115–124.
38. Koc BB, Somorjai N, Kiesouw PM, Egid, et al. Endoscopic 56. He M, Gan AWT, Lim AYT, et al. The effect of fibrin glue
debridement and fibrin glue injection of a chronic Morel-Lavallée on tendon healing and adhesion formation in a rabbit model
lesion of the knee in a professional soccer player: a case report and of flexor tendon injury and repair. J Plast Surg Hand Surg.
literature review. The Knee. 2017;24(1):144–148. 2013;47(6):509–512.
39. Conrad P, Malouf GM, Stacey MC. The Australian polidoca- 57. Kuskucu M, Mahirogullari M, Solakoglu C, et al. Treatment of
nol (aethoxysklerol) study. Results at 2 years. Dermatol Surg. rupture of the Achilles tendon with fibrin sealant. Foot & Ankle
1995;21:334–336. International. 2005;26(10):826–831.
40. Guex JJ. Indications for the sclerosing agent polidocanol. J Der- 58. Nehra D, Jacobson L, Barnes P, Mallory B, Albanese C, Sylves-
matol Surg Oncol. 1993;19:959–961. ter K. Doxycycline sclerotherapy as primary treatment of head
41. Winter H, Drager E, Sterry W. Sclerotherapy for treatment of and neck lymphatic malformations in children. J Pediatr Surg.
hemangiomas. Dermatol Surg. 2000;26:105–108. 2008;43:451–460.
42. Ohberg L, Alfredson H. Ultrasound guided sclerosis of neoves- 59. Cordes B, Seidel F, Sulek M, Giannoni C, Friedman E. Doxy-
sels in painful chronic Achilles tendinosis: pilot study of a new cycline sclerotherapy as the primary treatment for head and
treatment. Br J Sports Med. 2002;36(3):173–175; discussion neck lymphatic malformations. Otolaryngol Head Neck Surg.
176–177. 2007;137:962–964.
43. Ohberg L, Alfredson H. Sclerosing therapy in chronic Achilles 60. Caliendo MV, Lee DE, Queiroz R, et al. Sclerotherapy with use
tendon insertional pain—results of a pilot study. Knee Surg Sports of doxycycline after percutaneous drainage of postoperative lym-
Traumatol Arthrosc. 2003;11(5):339–343. phoceles. J Vasc Interv Radiol. 2001;12:73–77.
44. Alfredson H, Ohberg L. Sclerosing injections to areas of neo- 61. Mautner KR, Sussman WI. Intramuscular vascular malforma-
vascularisation reduce pain in chronic Achilles tendinopathy: a tions: a rare cause of exertional leg pain and a novel treatment
double-blind randomized controlled trial. Knee Surg Sports Trau- approach with ultrasound-guided doxycycline sclerotherapy. Am
matol Arthrosc. 2005;13(4):338–344. J Sports Med. 2015;43(3):729–733.
45. Alfredson H, Ohberg L. Neovascularisation in chronic painful 62. Wible BC, Mitchell S. Doxycycline sclerotherapy of an intraos-
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Sports Traumatol Arthrosc. 2005;13(2):74–80.
11
Toxins for Orthopedics
ZACH BOHART, WALTER I. SUSSMAN, JACOB SELLON,
AND NATALIE SAJKOWICZ

Introduction interchangeable between different commercial formula-

tions. For example, 20 units of onabotulinumtoxin A
Botulinum toxin (BTX) is produced by the bacteria Clos- (ONA) (Botox) does not have the same potency as 20 units
tridium botulinum as a complex of proteins containing of abobotulinumtoxin A (ABO) (Dysport) or rimabotu-
neurotoxin and various non-toxic proteins. There are seven linumtoxinB (RIMA) (Myobloc). The dose required to
immunologically distinct serotypes of the botulinum neu- effectively weaken a muscle varies with the density of neu-
rotoxin, named A to G.1,2 Botulinum toxin A (BTX-A) romuscular junction in any given muscle and the pathology
is the most commonly used in clinical practice. Commer- being treated. Toxicity can occur, and recommendations
cially available in the United States as onabotulinumtoxin A for a safe total body dose are 12 units/kg for ONA and 30
(Botox), abobotulinumtoxin A (Dysport), incobotulinum- units/kg for ABO.3a
toxin A (Xeomin). BTX-B is also used in clinical practice
and is available as rimabotulinumtoxinB (Myobloc). There Reconstitution of Botulinum Toxin
are no clear differences in effectiveness between the com-
mercial formulations.2 Botulinum toxin typically is available in a vacuum-dried
crystalline form. The toxin appears as a barely visible thin
Mechanism of Action crystalline complex at the bottom of the vial (Figs. 11.1
and 11.2) and must be reconstituted with sterile preserva-
Botulinum toxin prevents the release of the neurotrans- tive-free normal saline (0.9% sodium chloride injection).
mitter acetylcholine into the neuromuscular junction. RimabotulinumtoxinB (Myobloc) does not require recon-
The toxins bind to cholinergic neurons and prevent ace- stitution. These authors routinely use a dilution of 2 mL
tylcholine-containing vesicles from fusing with the synap- preservative-free saline per 100 units of onabotulinumtoxin
tic membrane, inhibiting muscular activity. Traditionally, A, though for small muscles concentration of 1 mL normal
pain relief has been attributed to a reduction in muscle saline per 100 units has been used. For ABO, 1.5 mL nor-
hyperactivity. Recent studies have suggested that there is a mal saline per 300 units or 2.5 mL per 500 units is used.
direct analgesic effect based on BTX action on neurotrans- For reconstitution, saline should be slowly injected into
mitters other than acetylcholine, including substance P the BTX vial, checking that vacuum is present in the vial to
and glutamate.1 ensure sterility; the vacuum can then be released by discon-
Clinically, muscle weakness occurs after 2 to 5 days and necting the syringe from the needle. The botulinum toxin
lasts for about 2 to 3 months before starting to wear off. is gently mixed with the saline by moving vial side to side
The duration of effect varies among patients, and subjective prior to drawing up the botulinum toxin solution. Reconsti-
effects may be seen up to 6 months. There is a correlation tuted BTX should be refrigerated, but there is some concern
between the amount of BTX used and duration of action, that BTX may lose potency if stored.
though even with higher doses the duration appears to pla-
teau at about 3 months.1 Techniques for Administration

Dosing of Botulinum Toxin To maximize clinical effectiveness of BTX, the toxin must
be injected into the fascial compartment of the muscle, and
The potency of commercially available BTX is determined the dose must be sufficient to neutralize the neuromuscu-
by in vivo mouse assays. One unit of BTX is defined as lar junction. Localization of the target muscle can be aided
the intraperitoneal amount of toxin lethal to 50% (LD50) using electrical stimulation. Ultrasound (US), fluoroscopy,
of Swiss Webster mice.1,3 Units are not comparable or and computed tomography (CT) can also ensure accurate

124
 CHAPTER 11 Toxins for Orthopedics 125

TABLE Supplies utilized for botulinum toxin injection

11.1   

Supplies
• 3 -mL syringe
• 21-gauge 2-inch needle for reconstitution
• Sterile, preservative-free normal saline (0.9% sodium
chloride)
• 2-inch needle for injection (EMG needle if EMG
guidance being used)
• Alcohol to prepare skin
• EMG machine if being used with sticker electrodes
(Fig. 11.3)
• Ultrasound

EMG, Electromyography.

•Fig. 11.1 Vial Containing Onabotulinumtoxin A. (© 2020 Allergan.

Used with permission. All rights reserved.)

• Fig. 11.3 Electromyography Amplifier With Electrodes Attached.

(© 2020 Allergan. Used with permission. All rights reserved.)

for strabismus in the 1980s,5 but its role in musculoskeletal

medicine has continued to expand. Food and Drug Adminis-
tration (FDA)-approved indications for BTX are limited, and
there has been a growing interest in exploring the broader
• Fig. 11.2 Posterior view of a vial of onabotulinumtoxin A illustrating
role of BTX in musculoskeletal medicine. The literature has
that the toxin is in dried crystalline form which is a barely visible thin explored the value of BTX in different musculoskeletal dis-
complex at the bottom of the vial. (© 2020 Allergan. Used with permis- orders. The following clinical indications are considered off-
sion. All rights reserved.) label uses of BTX, and many of these emerging applications
require further validation.
placement of the BTX (Table 11.1). The number of injection Muscle
sites should take into account the spread of medication, with
animal studies showing that the toxin diffuses 30 to 45 mm Researchers have utilized BTX-A for various muscle pathol-
from the injection site.4 ogies, primarily to treat muscle spasm or hypertrophy.

Indications for Use Myofascial Pain Syndrome (Trigger Points)

The use of BTX has evolved since its discovery in the 19th The exact pathogenesis of myofascial pain is unknown,
century.1 BTX was first applied therapeutically as a treatment and diagnostic criteria have varied across the literature.
126 SEC T I O N I I Injectates

Myofascial pain is characterized by “trigger points,” defined TABLE   Botulinum Toxin Dosing for Muscle
as “a hyperirritable spot in skeletal muscle that is associ- 11.2 Applications
ated with a hypersensitive palpable nodule in a taut band.
Area Targeted (Dose per
The spot is tender when pressed and can give rise to char-
Toxin (Total Dose) Injection Site)
acteristic referred pain, motor dysfunction, and autonomic
phenomena.”6 While the mechanism of BTX on myo- Myofascial Pain (Trigger Points)
fascial pain is unclear, one theory is that BTX interrupts BTX-A NOS (20–600 U) Trapezius (5–20 U ONA; 40 U
the pathologic muscle contraction allowing the muscle to BTX-B NOS ABO; 25–50 U BTX-A NOS)
relax.7 BTX may be an alternative treatment for recalcitrant (2500–20,000 U) Splenius capitis (20 U ONA; 5–40
ONA (50–150 U) U ABO, 50 U BTX-A NOS)
trigger points that have not responded to dry needling or ABO (240–480 U) Cervical and thoracic paraspinal
anesthetic injections. Despite not clearly understanding the muscles (25–100 U NOS)
pathology, multiple studies have reported improved pain Sternocleidomastoid (25 U
following BTX-A injections, including three randomized BTXA-NOS)
controlled trials (RCTS) comparing BTX-A injection to Infraspinatus (5–50 U ONA)
Scalene (80 U ONA)
injection of saline and one RCT comparing BTX-A injec- Levator scapulae (5 U ONA; 50
tion to dry needling.8–15 Five RCTs found no significant U BTX-A NOS)
difference between a single BTX injection and placebo.16–21 Piriformis (100 U ONA)
In one study, some subjects were asymptomatic after a sec- Iliopsoas (150 U ONA)
ond injection,17 and an additional RCT has shown signifi- Chronic Exertional Compartment Syndrome
cant improvement with a second dose,22 suggesting possible ABO (76–108 U) Anterior compartment (tibialis
benefit with sequential injections. Studies comparing BTX BTX-A NOS (20–65 U) anterior, extensor hallucis
to local anesthetic or methylprednisolone have had hetero- INCO (20 U) longus, extensor digitorum
geneous results, some suggesting the injectates are equally longus) (25–108 U ABO)
beneficial.8,14,23 Lateral compartment (peroneus
brevis and longus) (25–108
Most studies used palpation for localization, injecting U ABO)
into the most tender area. A local twitch response can help First dorsal interossei (10 U INCO)
confirm the trigger point. Electromyography (EMG) guid- Adductor pollicis (10 U INCO)
ance and fluoroscopic guidance have also been used.18,24–26
ABO, abobotulinumtoxin A (Dysport); INCO, incobotulinumtoxin A (Xeo-
All studies except one used BTX-A, with onabotulinum- min); NOS, not otherwise specified; ONA, onabotulinumtoxin A (Botox);
toxin A dosages ranging from 10 to 100 units per injection RIMA, rimabotulinumtoxinB (Myobloc); U, units.
site, up to 300 units total, and ABO dosages ranging from
40 to 120 units per site, 480 units total (Table 11.2). A
randomized open-label prospective study comparing ABO
doses of 60, 80, and 120 units for lower back trigger points including RCTs is still lacking. In one case series with 16
found no dose–response relationship.27 A retrospective patients, BTX-A was used to treat CECS involving the
chart review compared BTX-A and BTX-B for myofascial anterior compartments (targeting tibialis anterior, extensor
pain and found BTX-A had a significantly greater mean hallucis longs, extensor digitorum longs) and lateral com-
reduction in pain scores and longer duration of relief.28 partments (targeting peroneus brevis and longus muscles).33
The current body of literature provides no strong evi- Subjects showed a significant decrease in intra-compartmen-
dence to recommend or reject this treatment modality.29–31 tal pressures for up to 9 months.33 Three other case reports,
RCTs comparing BTX to saline placebo injection are com- including a case of CECS involving the forearm, have shown
plicated by the fact that the saline is an active control.32 sustained benefit at end of follow-up period at 10 to 15
Further investigation is needed to determine the most effi- months post treatment.34,35 Some loss of muscle strength
cacious BTX dosing and injection techniques. was noted as a potential side effect, though in all cases, post-
treatment weakness resolved over the course of months.34–36
Chronic Exertional Compartment Syndrome
Chronic exertional compartment syndrome (CECS) is Tendon and Fascia
caused by a reversible increase in the pressure within a fascial Plantar Fasciitis
compartment. CECS most often involves the anterior and
lateral compartments of the leg, leading to decreased tissue Plantar fasciitis has been associated with hyperprona-
perfusion during periods of exertion. The symptoms quickly tion and mechanical overload resulting in excessive
resolve with rest. The diagnosis is confirmed by checking the tension on the fascia.37 Nonoperative management of
compartment pressures at rest and after exercise with needle plantar fasciitis includes nonsteroidal antiinflammatory
manometry. drugs (NSAIDs), corticosteroid injections, and physical
Initial treatment is typically nonoperative, and chemode- therapy.38 Corticosteroids have been a mainstay of treat-
nervation with BTX has been reported. Robust research ment, but studies have shown similar or superior results
 CHAPTER 11 Toxins for Orthopedics 127

with BTX injections. The plantar fascia is not composed TABLE   Botulinum Toxin Dosing for Tendon and
of muscle, but palpation- or EMG-guided botulinum 11.3 Fascia Applications.
toxin injections have targeted the adjacent abductor hal-
Toxin (Total Area Targeted (Dose per
lucis and flexor digitorum brevis (FDB) muscles39–42
Dose) Injection Site)
or the gastrocnemius and soleus43 with significant pain
relief. Ultrasound (US)- and landmark-guided injections Plantar Fasciitis
directly into the plantar fascia have also been used,44–46 BTX-A NOS Origin of plantar fascia (50–200 U
resulting in significant pain relief. (70–250 U) BTX-A NOS)
BTX-A to treat plantar fasciitis has been studied in mul- Tender area of heel medial to base of
plantar fascia insertion (40–50 U
tiple RCTs comparing BTX-A to placebo,39,46–48 three of BTX-A NOS)
which showed significant improvement in pain compared Tender area between 1 inch anterior
to placebo, one finding no difference in treatment groups. to heel and midpoint of the plantar
Studies have also compared BTX to steroids40 (concluding arch (30–50 U BTX-A NOS)
no difference in pain relief between treatment groups) and Gastrocnemius (200 U BTX-A NOS)
Soleus (50 U BTX-A NOS)
extracorporeal shock wave (ECSW)42 therapy (suggesting Point of maximal tenderness along
the ECSW group had greater pain relief ). Studies showed plantar arch (100 U BTX-A NOS)
benefit from single BTX-A injection lasting from follow-up
Lateral Epicondylitis
at 8 weeks39 up to 12 months.41,48 The dose of BTX-A has
ranged from 50 units up to 250 units, with the most com- BTX-A NOS ECRB (30–40 U BTX-A NOS;
(20–40 U) 50–100 U ONA; 40 U ABO;
mon dose being 70 units divided between the FDB muscle ONA (50–100 U) 20 U INCO)
and abductor hallucis muscle.39–42,49 ABO (60 U) EDC (20–40 U BTX-A NOS);
INCO (10–30 U) Distance 1/3 length of forearm
from lateral epicondyle on course
Lateral Epicondylitis of PIN (60 U ABO)
Extensor carpi ulnaris (20 U INCO)
Lateral epicondylitis is often an overuse injury leading to Extensor digiti minimi (10 U INCO)
degenerative changes of the common extensor tendon.50 Extensor digitorum longus
Standard treatment involves antiinflammatories, physical (30 U INCO)
therapy, bracing, and corticosteroid injections. Corticoste- 5 cm distal to maximum point of
roid injections have shown a short-term improvement in tenderness at lateral epicondyle
(50 U ONA)
pain, but one study showed worse clinical outcomes with Tender point 1 cm from lateral
cortisone compared to placebo at the 1-year follow-up.51,52 epicondyle (60 U ABO, 20 U ONA)
Botulinum toxin for lateral epicondylitis was initially 3–4 cm distal to tender lateral
reported in case studies and an early prospective study.53,54 epicondyle (60 U ABO)
Since then, four randomized placebo-controlled trials have ABO, Abobotulinumtoxin A (Dysport); ECRB, extensor carpi radialis
been performed which support BTX-A injection as ben- brevis; EDC, extensor digitorum communis; INCO, incobotulinumtoxin
eficial treatment for lateral epicondylitis,55–58 though three A (Xeomin); NOS, not otherwise specified; ONA, onabotulinumtoxin A
(Botox); RIMA, rimabotulinumtoxinB (Myobloc); U, units.
studies have not shown significant superiority in pain relief
in the BTX treatment group compared to placebo59 or
steroids.61,56
BTX is thought to ease the tension on the enthesis site, Intra-Articular Applications
allowing the tendon to heal.60 BTX-A doses have ranged
from 20 to 50 units onabotulinumtoxin A59,61–63 and 40 Most clinical applications of BTX are based on blocking
to 60 units ABO55–58,64 with the extensor carpi radialis bre- the release of acetylcholine and causing muscle paraly-
vis most commonly targeted using EMG guidance,58,64,65 sis. Intra-articular (IA) BTX for painful joint conditions
palpation guidance,57 or electric stimulation (Table 11.3).61 likely works through a different mechanism. BTX has been
EMG and palpation guidance have been used to tar- shown to suppress the release of various neuropeptides and
get the extensor digitorum communis.54,57 Other studies inflammatory mediators, and inhibiting the release of these
have injected the most tender spot using landmark guid- neurotransmitters is thought to reduce neurogenic inflam-
ance,55,56,59 with one recent study using US to inject 10 mation and pain.66 While the exact mechanism of pain
to 30 units incobotulinumtoxin A to specific symptomatic relief is still unsertain, there is a growing interest in intra-
forearm extensor muscles. Sustained benefit after a single articular applications for BTX.
injection has been seen up to 18 months in one study.56 BTX was first described for intra-articular pain in 11
The most significant adverse effect is weakness of fin- patients with refractory joint pain from osteoarthritis (OA),
ger and wrist extensors, with studies showing mild paresis rheumatoid arthritis, and psoriatic arthritis by Mahowald
lasting from 2 to 16 weeks.55–57 This weakness may not be et al. in 2006.67 In this case series, 15 joints (ankle, knee,
tolerated by patients whose work requires intricate hand and shoulder) were treated with BTX, and patients reported
movements. decreased pain and improved quality of life lasting for
128 SEC T I O N I I Injectates

3 to 13 months. The majority of studies have examined the TABLE   Botulinum Toxin Dosing for Intra-Articular
role of IA BTX for OA, but BTX also been used for rheu- 11.4 Applications.
matoid or psoriatic arthritis,67–69 persistent pain after total
Area Targeted (Dose per
joint replacement,70–72 adhesive capsulitis,73 sacroiliac joint
Toxin (Total Dose) Injection Site)
pain,74,75 and patellofemoral pain syndrome.30,76–78
Knee

Osteoarthritis ONA (25–300 U) Intra-articular (25–300 ONA;

ABO (300–700 U) 250 U ABO)
OA is the most common type of arthritis.79 There are no Vastus lateralis (120–500 U
ONA; 500–700 U ABO)
treatments to cure or reverse the disease process, and various
therapeutic and lifestyle interventions have been proposed Hip
for the management of symptomatic OA. In recent years, ABO 400 U Adductor longus (250 U)
there has been a growing interest in new applications of Adductor magnus (150 U)
BTX. A 2018 meta-analysis showed IA BTX has beneficial Sacroiliac Joint
and significant short-term effects in decreasing refractory ONA (50–100 U)
joint pain, but a nonsignificant improvement at 6 months.80 ABO (100 U)
BTX has been studied in ankle, knee, hip, and shoulder OA, RIMA (5000 U)
with the majority of studies examining the impact of BTX Ankle
on knee OA. RCTs have compared BTX to a 0.9% normal ONA (25–100 U) Intra-articular ankle (25–100
saline control,67,81–84 hyaluronate injection,83 corticosteroid U)
injection,85 and education.86 Most studies showed that pain MTP joint (25 U)
and quality-of-life parameters improved with IA BTX, but Intra-Articular Shoulder
not all studies found IA BTX to be superior to placebo,81,87
ONA (50–300 U)
steroids,87 or hyaluronic acid.83 ABO (200 U)
The evidence for IA BTX is limited, and the clinical value INCO (100 U
is unclear. The severity of OA, type and dose of BTX, location
ABO, Abobotulinumtoxin A (Dysport); INCO, incobotulinumtoxin A (Xeo-
of injection, and number of injections may impact results. min); NOS, not otherwise specified; ONA, onabotulinumtoxin A (Botox);
One study showed benefit of BTX in Kellgren-Lawrence RIMA, rimabotulinumtoxinB (Myobloc); U, units.
stage III OA, but no improvement in stage IV OA.88 For
the knee, shoulder, and ankle OA, ONA (100 units) was the
most common botulinum toxin and dose used (Table 11.4), (PAES). While the literature is limited, clinical applications
with doses ranging from as low as 25 units for ankle and knee are promising.
OA67,68,72 to 300 units for knee OA.72 Higher doses of BTX BTX has been reported for the treatment of carpal tun-
may be less effective, with one study showing benefit with nel syndrome (CTS), but literature is limited.91,92 Only one
100 units, but that 200 units of IA BTX had no effect.70,81 randomized, double-blind, placebo-controlled study has
The IA application of BTX is novel, but the evidence explored BTX for CTS and showed BTX was not superior
is still limited. Most studies have been uncontrolled, single to placebo.91
center, and with a small sample size and short-term follow-
up. Studies have varied in BTX brand and dosing, number Thoracic Outlet Syndrome
of injections, and protocols (i.e., multiple injections, co-
administration with other injectates). In addition, not all IA TOS is due to compression of the neurovascular bundle
pathology has been treated with IA BTX. Hip OA has been in the neck. Compression can occur at the interscalene
treated with BTX injected into the adductor longus and triangle, costoclavicular space, or retropectoralis minor
magnus muscle to reduce pressure on the femoral head and space. Patients can present with neurogenic or vascular
acetabulum84,89 and patellofemoral pain syndrome treated symptoms. Neurogenic TOS resulting in irritation of the
with BTX injection into the vastus lateralis muscle.76–78,90 brachial plexus trunk or cords accounts for the majority
More studies are needed to better define BTX’s role in man- of all TOS cases.93 Botulinum toxin has been used for the
aging IA pathology. management of TOS, weakening the muscles that impinge
the brachial plexus. Successful treatment of neurogenic94–96
Entrapment Syndromes and arterial TOS97,98 has been reported. BTX was superior
to corticosteroid in a prospective longitudinal study,99 but
Botulinum toxin has been studied for a number of entrap- the majority of studies are case reports97,98,100 or retrospec-
ment syndromes. The proposed mechanism is chemode- tive.94,96,101 Only one randomized double-blind controlled
nervation of the muscles decreasing neural or vascular trial exists, which found no clinically or statistically signifi-
compression. BTX treatments have been successful in treat- cant difference between BTX and the normal saline con-
ing thoracic outlet syndrome (TOS), piriformis syndrome trol at 6 months.95 The use of imaging can help minimize
(PS), and functional popliteal artery entrapment syndrome complications from the inadvertent spread of toxin. There is
 CHAPTER 11 Toxins for Orthopedics 129

TABLE   Botulinum Toxin Dosing for Entrapment BTX for PS, the piriformis muscle was targeted alone. In
11.5 Syndromes. one retrospective study, the piriformis and obturator inter-
nus muscle were targeted.105 The majority of studies used
Muscle Targeted (Dose per
onabotulinumtoxin 100 units,103,105–109 but doses as low as
Toxin (Total Dose) Injection Site)
50 units have also been used.108 Myobloc (5000 to 12,000
Thoracic Outlet Syndrome units),110,111 Dysport (150 units),112 and Xeomin (40 to 130
ONA (100–150 U) Anterior scalene (12–30 U) units)113–115 have also been used. Chronic PS treated with
Middle scalene (12–30 U) botulinum toxin has been shown to cause atrophy106,107,112
Trapezius and levator scapula and fatty infiltration of the piriformis muscle.105 Sustained
(75–100 U)
Subclavius (12–20 U)
clinical benefits have been reported up to 9 months after the
Pectoralis minor (15–35 U) treatment.107
Piriformis Syndrome
ONA (50–103 U) Piriformis Popliteal Artery Entrapment Syndrome
ABO (150 U) Obturator internus
INCO (40–130 U) PAES is a compression of the neurovascular structures in
RIMA (5–12,000 U) the popliteal fossa resulting in exercise-induced claudica-
tion. There are two types of PAES: anatomic and functional.
Popliteal Artery Entrapment Syndrome
­Anatomic PAES is caused by an anatomic lesion directly
ONA (100–200 U) Medial gastrocnemius
ABO (400 U) (50–100 U)
causing entrapment and occlusion of the artery. Functional
Lateral gastrocnemius popliteal artery entrapment syndrome (FPAES) is more
(50–100 U) common,116 and involves overcrowding of the popliteal
plantaris (50 U) fossa and compression of the artery. Bilateral presentation is
ABO, Abobotulinumtoxin A (Dysport); INCO, incobotulinumtoxin A (Xeo-
common, and can occur in 25% to 76% of cases.117
min); NOS, not otherwise specified; ONA, onabotulinumtoxin A (Botox); Dynamic duplex US can confirm the diagnosis if there
RIMA, rimabotulinumtoxinB (Myobloc); U, units. is a 75% or more reduction in the diameter of the popliteal
artery at the two heads of the gastrocnemii with the ankle in
plantar flexion.118 Stress-position magnetic resonance imag-
no statistically significant difference in complication rate or ing (MRI) with the ankle at rest and in plantar flexion can
outcomes with a combination of US and EMG versus fluo- confirm vascular occlusion, and rule out anatomic anoma-
roscopy with EMG.101 Studies have targeted the anterior lies of the popliteal fossa or artery. A patient may not be able
scalene,94,95,97–99,101,102 middle scalene,95,99–101 trapezius,101 to hold active plantarflexion during US and MRI due to
subclavius,94,101 and pectoralis minor94,101 muscles. The discomfort and fatigue, making diagnosis challenging. BTX
majority of studies used onabotulinumtoxin A, with doses has been described as both a diagnostic tool and therapeutic
ranging from 15 to 100 units depending on the number of alternative to surgery, and post-BTX imaging has demon-
muscles being targeted (Table 11.5).a One study suggested strated resolution of arterial occlusion.119,120 The majority
improved outcomes when targeting the scalenes, subclavius, of studies targeted the medial gastrocnemius118–122 with 50
and pectoralis minor, compared to the anterior and middle units of onabotulinumtoxin A,118–120,122 with some stud-
scalene alone.101 Long-term outcomes are limited, with ies also injecting the lateral gastrocnemius121,122 or plantaris
the majority of studies providing outcomes at 3 months or muscle.118,119 The injection can be repeated if recurrent
less and only 1 study showing benefit at 6 months.101 It is symptoms present.119 No major complications have been
unclear from the literature if repeat injections provide any reported, but denervation atrophy of the medial gastrocne-
additive benefit. mius has been reported in one study.120

Piriformis Syndrome Adverse Effects

PS is a compression neuropathy of the sciatic nerve as it Botulinum toxin is generally considered safe for therapeu-
passes between the piriformis and obturator internus mus- tic indications, though adverse effects should be discussed
cle. Various etiologies may account for PS, but the diagnosis during the consent process. BTX is not recommended in
is complicated as PS lacks a well-established laboratory or pregnant or lactating women. BTX-A and BTX-B have
imaging study. been associated with systemic adverse reactions including
US-guided injections for PS have been validated, with an dysphagia, muscle weakness and atrophy, allergic reaction,
accuracy of 90% to 95%.103,104 Fluoroscopy-assisted con- injection-site trauma, myocardial infarction, respiratory
trast injections have a reported accuracy of only 30%, with failure, and death. In the majority of these cases with seri-
the majority of missed injections into the gluteus maximus ous adverse events, significant comorbidities existed and
muscle in a cadaveric study.104 In the majority of studies of may have had a causal role.4,123 These adverse events are
rare, and in one review the most common adverse event was
a References 94, 95, 97, 99, 101, 102. dysphagia and was reported in only 26 of 1437 patients.123
130 SEC T I O N I I Injectates

Patients with neuromuscular disorders are at increased risk pain syndrome and pain from chronic muscle spasm. Pain.
of a serious adverse event. 2000;85(1-2):101–105.
There have been reports of antibody formation to 14. Kim DY, Kim JM. Safety and efficacy of prabotulinumtoxinA
the toxin, considered a long-term adverse event, though (Nabota((R))) injection for cervical and shoulder girdle myofas-
cial pain syndrome: a pilot study. Toxins (Basel). 2018;10(9).
newer formulations of BTX-A appear to be associated with
15. Ferrante FM, Bearn L, Rothrock R, King L. Evidence against
reduced antibody formation.124 In general, BTX is contra- trigger point injection technique for the treatment of cervico-
indicated in patients with disorders of the neuromuscular thoracic myofascial pain with botulinum toxin type A. Anesthe-
junction. The authors also would recommend avoiding siology. 2005;103(2):377–383.
botulinum toxin in patients with joint instability, especially 16. Wheeler AH, Goolkasian P, Gretz SS. A randomized, double-
in the cervical region. Patients with genetic hypermobility, blind, prospective pilot study of botulinum toxin injection for
such as Ehlers-Danlos syndrome or other diseases that affect refractory, unilateral, cervicothoracic, paraspinal, myofascial
collagen synthesis, rely more on muscular strength to com- pain syndrome. Spine (Phila Pa 1976). 1998;23(15):1662–
pensate for ligamentous laxity, and therefore weakening of 1666; discussion 1667.
muscle strength by BTX injection may worsen symptoms 17. Qerama E, Fuglsang-Frederiksen A, Kasch H, Bach FW, Jensen
caused by joint hypermobility. TS. A double-blind, controlled study of botulinum toxin A in
chronic myofascial pain. Neurology. 2006;67(2):241–245.
18. Ojala T, Arokoski JP, Partanen J. The effect of small doses of
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2121. ley JK. Botulinum toxin injection in the treatment of tennis
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J Rehabil Med. 2010;42(2):136–140. randomized, double-blind, active drug-controlled pilot study.
47. Peterlein CD, Funk JF, Holscher A, Schuh A, Placzek R. Is bot- Am J Phys Med Rehabil. 2010;89(8):653–659.
ulinum toxin A effective for the treatment of plantar fasciitis? 63. Guo YH, Kuan TS, Chen KL, et al. Comparison between ste-
Clin J Pain. 2012;28(6):527–533. roid and 2 different sites of botulinum toxin injection in the
132 SEC T I O N I I Injectates

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Number of botulinum toxin injections needed to stop requests cacy of intra-articular botulinum toxin in osteoarticular joint
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 S E C T I ON III Atlas

12
Cervical Injection
Techniques
M ARKO BODOR, STEPHEN DERRINGTON, JOHN PITTS,
JASON MARKLE, SAIRAM ATLURI, NAVNEET BODDU, AND
VIVEK MANOCHA

Ultrasound Guided Techniques insert on the spinous processes and laminae of the vertebrae
above.1
Posterior Muscles
Cervical Common Pathology
   Atrophy of the multifidus can occur with cervical pathol-
Cervical multifidus ogy, including radiculopathy and myelopathy.2,3 Suboccipi-
Rectus capitis posterior major tal muscles can become atrophied after whiplash4 and have
Rectus capitis posterior minor been shown to be associated with cervicogenic headaches.5
Obliquus capitus superior The rectus capitis posterior minor has been noted to be
Obliquus capitus inferior hypertrophied following trauma, possibly leading to head-
  
aches related to its myodural connection.6
KEY POINTS All of these muscles can become tight and painful from
compensatory overactivity in the setting of segmental
These paraspinal muscles are important in postural control of
instability.
the head on the neck and assist with rotation and extension
of the head and upper neck. The suboccipital muscles can
become overworked following ligament injuries with resulting Equipment
instability in the upper cervical spine. An ultrasound with high-frequency linear or curvilinear
   transducers. Transducer choice is dependent on body habi-
tus and clinician preference.
27 to 25 gauge 1.25 to 2 inch needle
Pertinent Anatomy
Obliquus capitis inferior runs from the spinous process of Common Injectates
the axis (C2) to the transverse process of the atlas (C1). Orthobiologics (PRP, PPP, etc.)
Obliquus capitis superior runs from the transverse pro-
cess of the atlas (C1) to the occiput, below the superior Injectate Volume
nuchal line. 0.25 to 1 mL
Rectus capitis posterior major runs from the posterior Technique
tubercle of the axis (C2) to the lateral occiput, inferior to Patient Position. Prone
the nuchal line. Clinician Position. At the side of the patient, contralat-
Rectus capitis posterior minor runs from the posterior eral to the side of the muscle being treated, with the ultra-
tubercle of the atlas (C1) to the medial occiput, inferior to sound monitor next to or on the opposite side of the patient.
the nuchal line. Transducer Position. Short axis to the target muscle
The cervical multifidus muscles originate from the facet (Figs. 12.1 to 12.3)
joint capsules in the lower cervical and transverse processes Rectus capitis posterior minor visualization and injection
of the upper thoracic spine, span 2 to 5 segments, and can be performed in the long axis to the muscle belly (Fig. 12.4)

134
 CHAPTER 12 Cervical Injection Techniques 135

Trapezius

SC

Spinalis cervicis SC

RCPM OCI

Multifidus

Lamina

• Fig 12.3 Transverse view of multifidus muscle, immediately superfi-

cial to the cervical lamina. Arrow demonstrating needle trajectory from
medial to lateral into muscle belly. SC: Semispinalis cervicis and upper
• Fig 12.1 Transverse view of rectus capitis posterior major (RCPM) and
trapezius.
obliquus capitis inferior (OCI) muscles. Arrow demonstrating needle
trajectory from medial to lateral into muscle bellies. SC, Semispinalis
cervicis.

SCM

Splenius capitis
OA Semispinalis capitis

OCI
Occiput
RCPM

• Fig 12.2 Obliquus capitis superior (OCS) transverse view. Occipital

artery (OA) located lateral and superficial to OCS. Arrow demonstrat-
ing needle trajectory from medial to lateral into muscle belly. SCM:
Sternocleidomastoid muscle cervical facet figure: Cervical facet. • Fig 12.4 Longitudinal view of rectus capitis posterior minor, with
Inferior articular process (IAP) from cephalad vertebra and superior semispinalis capitis running superficially. Arrow demonstrating needle
articular process (SAP) from caudal vertebra are identified. Needle can trajectory from caudal to cephalad into muscle belly. RCPM, Rectus
be visualized from anterior approach (right of image) with needle tip in capitis posterior major.
the joint. OCI, Obliquus capitis inferior.

The obliquus capitis inferior can be visualized, and the Cervical Supraspinous and Interspinous
injection can be performed in the long axis with the same Ligaments
positioning as for a GON injection (Fig. 12.5)
Needle Position. In-plane needle visualization, lateral to KEY POINTS
medial approach
Target. Muscle belly These ligaments can be targeted in isolation for specific
injuries, but more commonly are targeted in combination with
PEARLS AND PITFALLS other components of the functional spinal unit,7,8 including
the spinal nerves in the epidural space, facet joints, paraspinal
Care should be taken when performing these injections, with muscles, and sometimes the intervertebral discs.
ultrasound visualization of the needle tip at all times for Treatment with prolotherapy has demonstrated a reduction
in-plane injections and starting shallow and doing a careful in translation with cervical spine flexion and extension
walk-down for out-of-plane injections to avoid going too deep. associated with pain reduction.9
     
136 SEC T I O N I I I Atlas

Pertinent Anatomy Equipment

The interspinous ligament is a thin membranous ligament Ultrasound machine with linear or curvilinear transducer.
that traverses adjacent spinous processes. The ligament runs Transducer choice is dependent on patient body habitus
from the root to the apex of each spinous process and con- and clinician preference.
nects anteriorly with the ligamentum flavum and posteri- 27 to 25 gauge 1.25 to 2 inch needle
orly with the nuchal ligament.
The nuchal ligament is a large midline ligament lying Common Injectates  
superficial (posterior) to the spinous processes of the cervi- Prolotherapy
cal spine spanning from the inion to C7, where it becomes Orthobiologics (PRP, PPP, etc.)
continuous with the supraspinous ligament. The nuchal
ligament connects anteriorly with the interspinous ligament Injectate Volume  
(Fig. 12.6). 0.25 to 1 mL
Technique
Common Pathology Patient Position. Prone, with the neutral cervical spine and
Ligament strain, partial tear,10,11 relative laxity related to head position.
disc and facet pathology Clinician Position. At the side of the patient with the
ultrasound monitor next to or on the opposite side of the
patient.
Transducer Position. Long axis to the ligaments, with
visualization of both the ligament and spinous processes
(Fig. 12.7)
Needle Position. In-plane needle visualization, caudal to
SC cephalad approach
Target. Direct injection into the ligaments at the desired
spinal level, injecting into areas of hypoechogenicity and
throughout the ligaments, including the bony insertion.
Filling of interstitial injuries can be seen with injectate
OCI

PEARLS AND PITFALLS

• F luoroscopic contrast-dye confirmation may be used to
ensure accurate placement of injectate
• These ligaments are difficult to visualize entirely, so
adjacent and adjoining anatomy needs to be visualized
• Fig 12.5 OCI figure labeled. OCI, Obliquus capitis inferior; SC, semi-
spinalis cervicis.   

Posterior
Atlanto-occipital
Membrane

Nuchal Ligament

Anterior
Atlanto-occipital
Membrane

Interspinous Ligament Posterior

Longitudinal
Ligament
Supraspinous Ligament
Anterior
Longitudinal
Ligament

• Fig 12.6Cervical spine ligamentous anatomy. The posterior ligament are relatively easily to inject under
image guidance.
 CHAPTER 12 Cervical Injection Techniques 137

NL x

SP SC
ISL

OCI
• Fig 12.7 Nuchal ligament/interspinous figure: Long-axis view of the
Nuchal ligament (NL), spinous process (SP), and interspinous ligament
(ISL). Arrow demonstrating multiple targets for injection throughout the
nuchal and interspinous ligaments.

Greater and Lesser Occipital Nerve Block • Fig 12.8 GON figure: GON (open arrow) visualized between the
obliquus capitis inferior (OCI) and semispinalis cervicis (SC) muscles.
KEY POINTS Arrow demonstrating needle trajectory from medial to lateral immedi-
ately adjacent to the nerve.
Occipital neuralgia can come from compression or irritation
of the greater or lesser occipital nerves, with greater occipital
nerve (GON) irritation being much more common.12
  

Pertinent Anatomy
The greater occipital nerve originates from the dorsal ramus
of the C2 spinal nerve, loops around the obliquus capi- SCM
tis inferior (OCI), then courses medially and superiorly LS
through the semispinalis capitis to reach the skin of the
occiput, where it provides sensory innervation.
The lesser occipital nerve (LON) originates from the ventral
ramus of the C2 and C3 spinal nerves, emerging from under the
posterior margin of the sternocleidomastoid muscle to provide
sensory innervation to the lateral occiput and posterior ear.13,14

Common Pathology • Fig 12.9 LON figure: The LON (open arrow) is visualized posterior to
the sternocleidomastoid (SCM) muscle. Arrow demonstrating needle
Compression between muscles, acute or repetitive trauma, or trajectory from medial to lateral immediately adjacent to the nerve. LS,
other irritation resulting in pain between the posterior occiput Levator scapulae muscle.
and temporal region (GON) or posterior auricle (LON).12
Transducer Position. GON: The bifid C2 spinous process
Equipment   is located, then the ultrasound transducer is translated later-
Ultrasound with a high-frequency linear transducer. ally and superiorly in the direction of the transverse process
27 to 25 gauge 1.25 to 2 inch needle of the C1 vertebra. The obliquus capitis inferior muscle is
identified along its long axis. The GON can be visualized in
Common Injectates   its short axis between the obliquus capitis inferior and the
Local anesthetics for blocks +/− corticosteroids overlying semispinalis capitis (Fig. 12.8)
Neuroprolotherapy (5% dextrose solution) LON. Scan the sternocleidomastoid (SCM) transversely,
Orthobiologics: (preferably platelet lysate, PRP, etc.) inferior to the mastoid. The LON will be visualized at the
posterior margin of the SCM, traversing superiorly towards
Injectate Volume the lateral occiput. (Fig. 12.9)
1 to 3 mL Needle Position   
Technique GON: In-plane needle visualization, posteromedial to an-
Patient Position. Prone, or seated, arms crossed, leaning terolateral.
with head on hands. LON: In-plane needle visualization, medial to lateral
Clinician Position. At the side of the patient, contralat- Target   
eral to the nerve being treated for prone position, or stand- GON: Perineural injection, in the fascial layer between
ing behind the patient for a seated position. obliquus capitis inferior and semispinalis capitis muscles
138 SEC T I O N I I I Atlas

LON: perineural injection, superficial to the levator scapu- cause occipital headaches.16 X) [7 (link from fluoro cervical
lae muscle and posterior to the SCM   facet anatomy section)].?

PEARLS AND PITFALLS Common Pathology

Visual assessment of pulsations and Doppler imaging should Osteoarthritis, post-traumatic microfractures, and capsu-
be performed prior to needle insertion to help identify and lar ruptures. Capsular ruptures may be present when the
avoid the vertebral artery. The needle tip must be kept in view capsule does not distend or distends then collapses during
at all times as it is advanced and during injection to ensure injection.
safety.
Indications   
   Neck Pain
Trapezius Pain
Cervical Facets Occipital Headache
Impaired Neck Rotation
KEY POINTS Facet Joint Tenderness
The cervical facet joints are the most common cause of
chronic neck pain, most often secondary to osteoarthritis or Equipment
trauma.15 Ultrasound can be used for the precise identification High-performance ultrasound machine with high-fre-
of painful facets and treatment but requires advanced skills, quency (5-12 MHz) linear transducer
capability, and equipment.
27-gauge 1.25 inch needle.
  
Common Injectates
Pertinent Anatomy Local anesthetics for diagnostics, corticosteroids, Orthobio-
Cervical facet joints are diarthrodial joints formed by the logics (PRP).
articular pillars of adjacent vertebrae. Each joint is stabilized
by a tough collagen capsule enclosing a fine synovial mem- Technique
brane, with joint fluid and hyaline-cartilage-covered articular Patient Position. Side-lying with the head on a pillow,
surfaces inside. The joints are gradually inclined 40° to 60° slightly tilted and rotated away from the side being injected,
the neck relaxed.
posteriorly and 20° to 0° medially from C2-3 to C6-7. The
Clinician Position. Standing next to the patient’s head
medial branches of the dorsal rami of the respective spinal
and neck, looking at and over the transducer and needle
nerves innervate the joints, with the exception of the third
(aerial view) as the needle is advanced in-plane to ensure
occipital nerve (TON), which innervates the top half of C2-3.
correct angle and alignment.
Pain from the facet joints is experienced in the neck,
Transducer Position. The initial position is with the
radiating to the trapezius and typically exacerbated by neck
long axis of the transducer placed along the lateral aspect
rotation (Fig. 12.10). Pain from the C2-3 facet joint can
of the neck (Figs. 12.11 to 12.14). The cervical facet joints
appear as undulations. The C2-3 facet joint is the most
superior and a bit posterior, beyond which the pulsations of
the vertebral artery can be seen (see Fig. 12.13B). Younger
joints have smooth undulations with small joint openings,
whereas older ones have a rough appearance, larger gaps,
C2-3

C3-4
C4-5

C5-6

C6-7

•Fig 12.10 Cervical facet joint pain provocation patterns, composite • Fig 12.11 Right side cervical facet joint scan depicted with an ana-
map from 5 subjects. (From Dwyer et al.) tomical model.
 CHAPTER 12 Cervical Injection Techniques 139

• Fig 12.14Cervical facet joints in an older individual. The joints have

a rough appearance with osteophytes, enlarged joint spaces, and
effusions.

• Fig 12.12 Left side cervical facet joint scan depicted with an anatomi-
cal model.

• Fig 12.15 Cervical facet joint Doppler ultrasound showing normal

location of a medial branch nerve (white circle) next to an artery (red).

the desired joint is selected for injection, the transducer is

aligned with the ramus of the mandible and adjusted to
optimize the joint opening. The needle is inserted typically
using an anterior or posterior approach, typically anterior
for a right hand dominant physician injecting the patient’s
right side, but also depending on the orientation of the joint
A opening (Figs. 12.17 and 12.18).
Needle Position. In-plane.
Target. Joint opening, effusion, or capsule.

Injectate Volume
0.25 to 1 mL

PEARLS AND PITFALLS

The transducer is kept immobile over the target during the
injection. This is done via the two-tripod technique, with the
first consisting of the thumb, index, and middle finger holding
the transducer, and the second consisting of the ring and little
finger and transducer maintaining a stable position on the
B neck. Cervical facet joint openings are very small, so a slight
slip of the transducer means that the target disappears from
• Fig 12.13 Left side cervical facet joint scan in a young subject with a view. Successful performance of this procedure requires steady
muscular neck: (A) Photo; (B) ultrasound image, optimized for the C3-4 alignment of the transducer, needle, and the joint opening,
facet joint. The tip of the arrow is touching the capsule and pointing to requiring superior equipment, experience, skill, and hand-eye
the joint opening. The C2-3 joint is on the left, beyond which no further coordination. Patients with thick necks and difficult to see
joints are seen. Scale on the right is in centimeters. anatomy are not candidates for this procedure. Once the
needle enters the joint, it should not be advanced more than
osteophytes, and effusions (Fig. 12.15; see also Fig. 12.13B). a few millimeters because of the unlikely possibility of passing
The transducer is rotated carefully over the opening of the through the joint. Particulate injectates should not be used
C2-3 facet joint to obtain a transverse view (Fig. 12.16). because of the remote possibility of an intra-arterial injection.
Sonopalpation is then performed, one joint at a time. Once   
140 SEC T I O N I I I Atlas

A A

B
• Fig 12.17 Cervical facet injection. (A) Non-dominant hand keeps the
B transducer immobile while the dominant hand advances the needle to
the target; (B) ultrasound image of needle in the joint.

Interscalene Brachial Plexus Block

KEY POINTS
• T he Interscalene brachial plexus block is performed at the
interscalene groove where the roots of the plexus pass
between anterior scalene and middle scalene muscles, at
the level of C6 tubercle or Chassaignac’s tubercle.
• The block can be performed by paresthesia technique,
neuromuscular stimulation, or by using ultrasound.
• It can be used as an anesthetic or adjunct to general
anesthesia or postoperative pain control.
• Ultrasound is used for defining anatomic landmarks,
identification of blood vessels, and identification of
C nerves. The use of ultrasound has increased the safety
and accuracy of the block.
• Fig 12.16 C2-3 facet joint scan following transducer rotation: (A) Photo,
(B) ultrasound image with arrow pointing to joint opening, and (C) depic-   
tion with an anatomical model, seen from a posterior-inferior view.
Pertinent Anatomy
• Th
 e brachial plexus is a network of nerves formed by the
ventral rami of the lower four cervical nerves (C5-C8)
and 1st Thoracic nerve.
• The plexus is responsible for sensory innervations of the
upper extremity with the exception of the axilla and motor
innervations of all the upper extremity muscle groups with
the exception of trapezius and levator scapulae.
 CHAPTER 12 Cervical Injection Techniques 141

x x

A B
• Fig 12.18 Ultrasound images taken (A) before and (B) after a cervical facet injection, showing normal
distention of the joint capsule (arrowheads).

• Th
 e plexus communicates with the sympathetic chain. Clinician Position
• The brachial plexus can be divided into roots, trunks, • I psilateral side of the patient if supine or standing behind
divisions, and cords which can be further divided into the patient if in the lateral decubitus position.
peripheral nerves. Transducer Position
• Interscalene block is performed at the posterior border • The probe is placed transversely over the anterolateral
of sternocleidomastoid muscle at the level of C6 anterior part of the neck at the level of Chassaignac’s tubercle
tubercle known as Chassaignac or carotid tubercle. • The ultrasound view shows a pulsating anechoic struc-
• This is most prominent among the anterior tubercle of ture, which is the Carotid artery, then the ultrasound
the transverse process of the cervical vertebra, and it cor- probe is moved posterior-laterally, maintaining the same
responds with the level of Cricoid cartilage. level at C6 to view the Internal Jugular vein and anterior
• Chassaignac’s tubercle separates the carotid artery and scalene muscle (ASM).
vertebral artery. • The roots of the brachial plexus can be visualized laterally
• Internal Jugular vein and anterior scalene muscles are to ASM in the interscalene groove between the anterior
located lateral to the carotid artery (Fig. 12.20). scalene and middle scalene muscles.
• The ultrasound probe can be rotated or tilted slightly
Common Pathology to obtain a clearer view. The probe can be moved cra-
• I nterscalene block is used in surgeries or procedures of niocaudal directions to see the formation of the brachial
the shoulder joint, upper arm, and clavicle. plexus trunks and divisions from the cervical roots and
to obtain an optimal site for injection where 2 or 3 roots
Equipment
are visualized.
• H igh frequency (9 to 18 MHz) linear ultrasound probe
• Sternocleidomastoid (SCM) muscle lies superficial to
• 25 to 22 gauge 2-inch short bevel needle
the plexus and is seen as a triangle structure on ultra-
Common Injectates sound. The plexus lies 1 to 3 cm deep from the skin
• Local anesthetic level.
Needle Position
Injectate Volume • In-plane technique going from lateral to medial.
• 5 to 20 mL • Avoiding the external jugular vein.
Technique • Needle travels through interscalene groove, crossing the
Patient Position middle scalene muscle
• The patient can be placed supine or in the lateral decubi- • Injectionists may feel the pop entering the prevertebral
tus position. fascia.
• Instruct the patient to rotate his neck at an angle of 45 Target
degrees and raise his head off the bed keeping the head • Needle tip should end just adjacent to the plexus
rotated. This contracts the scalene muscles, and one can • Aspirate to check for blood or CSF, then inject, visualiz-
palpate the interscalene groove between the muscles run- ing the spread of the injectate as it infiltrates the vicinity
ning in craniocaudal direction. of nerve roots keeping the roots intact.
142 SEC T I O N I I I Atlas

PEARLS AND PITFALLS Pertinent Anatomy

• S urface Anatomy
• Intravascular injection: • Supraclavicular block can be performed in the supracla-
• Brachial plexus lies lateral to carotid artery, external
vicular fossa at the midpoint of the superior border of the
and Internal jugular vein and vertebral artery; therefore,
there is a high risk for intravascular injection. clavicle.
• Visualize the needle tip at all times with ultrasound • The plexus forms three trunks, upper (C5 & C6), middle
during the procedure. (C7), and lower (C8 &T1).
• Confirm the tip of the needle seen under ultrasound • Both the brachial plexus and subclavian artery lie on top
is the real tip and not the needle falling off the
of the 1st rib between the insertions of the anterior sca-
ultrasound beam by injecting small amounts of local
anesthetic and watch it exiting the needle tip. lene muscle and the middle scalene muscle.
• Phrenic nerve block: • The brachial plexus is located posterior and lateral to
• Performing the interscalene block higher than the C6 the subclavian artery, and in very close proximity to the
level or injection of high volumes of local anesthetics pleura.
can cause ipsilateral phrenic nerve block.
• You can palpate pulsations of the subclavian artery and
• Healthy patients may not be symptomatic, but
patients with compromised pulmonary function may the 1st rib in the midclavicular area above the clavicle.
have shortness of breath or difficulty maintaining • Ultrasound Anatomy:
oxygen saturation. • The ultrasound probe is placed horizontally above
• Using a lower concentration of local anesthetic and the clavicle in the midclavicular area. The subclavian
keeping local anesthetic injection to lower volumes
artery is seen as a round anechoic pulsating structure.
may avoid phrenic nerve block.
• Horner’s syndrome: • Located underneath the subclavian artery, you can see
• Horner’s syndrome is due to sympathetic block the hyperechoic 1st rib. Since the ultrasound waves
caused by an accidental spill of local anesthetic into are completely reflected back, it casts a dark shadow
the stellate ganglion. underneath the rib.
• A patient complains of ptosis, anhydrosis, mydriasis,
• On either side of the first rib, you can see a hyper-
redness of the eye on the ipsilateral side.
• Pneumothorax: echoic pleural shadow.
• It can rarely occur with lower cervical injection site, • Some of the ultrasound waves pass through the pleura
though patients with obstructive lung disease can be into lung tissue filled with air, so it gives the charac-
prone because of the higher pleural dome, and it should teristic appearance of cosmic dust under the pleura.
be suspected if the patient complains of shortness of
• Make a mental note of the location and depth of the
breath or is unable to maintain normal saturation.
• Pneumothorax may share the same clinical picture as 1st rib and pleura since you have to make sure the
phrenic nerve paralysis; however, there are reduced or needle does not pass beyond this depth.
absent breath sounds in patients with pneumothorax. • Now focus your attention on the subclavian artery,
• An upright chest x-ray will help diagnose both where the brachial plexus can be seen as hypoechoic
conditions.
fascicles both superficial and deep to the artery.
• Subarachnoid injection:
• Although rare, injection into dural sleeves of cranial • The ultrasound probe can be moved proximally and
nerves or spread of local anesthetic injection into distally along the brachial plexus to visualize its trunks
cervical epidural space can cause a high spinal and divisions.
block, resulting in hypotension, difficulty breathing, • The brachial plexus lies at 1 to 2 cm depth below the
numbness and muscle weakness of upper
skin at this location.
extremities, and loss of consciousness.17-21
   Common Pathology
Supraclavicular Brachial Plexus Block • U sed for anesthesia for upper extremity procedures
• Also, consider for brachial plexus neuritis or plexopathy
KEY POINTS
• S upraclavicular block can be used as an alternative or Equipment
adjunct to general anesthesia or used for postoperative • L inear ultrasound transducer
pain control for the upper extremity from the upper part • 25 gauge 2-inch spinal needle
of the arm to the hand.
• The brachial plexus above the clavicle area forms trunks
and divisions as they pass under the clavicle in very Common Injectates
close proximity to the chest cavity. • Local Anesthetic
• Brachial plexus trunks and divisions are arranged very
close, so the local anesthetic spreads easier, and a Injectate Volume
superior block can be obtained.
• The plexus passes over above the 1st rib between
• 10 to 25 mL
the insertions of middle scalene and anterior scalene Technique
muscles roughly at the midpoint of the clavicle. Patient Position
• The plexus is in very close proximity to the pleura and • S upine position with neck in the midline position. Turn
lung, increasing the risk of pneumothorax. the patient’s chin to 45 degrees in the opposite direction
   to open up the supraclavicular fossa
 CHAPTER 12 Cervical Injection Techniques 143

Splenius capitis (cut)

Semispinalis capitis

Longissimus
capitis
Longissimus
Thoracic cervicis
multifidus Spinalis
thoracis
Diaphragm Erector
Longissimus spinae
(ribs removed) thoracis
Iliocostalis
Quadratus
thoracis
lumborum
Iliocostalis
Lumbar lumborum
multifidus

Thoracodorsal fascia

• Fig 12.19
Spinal muscular anatomy. Note Splenius capitis is more superficial that semispinalis capitus
and suboccipital muscles and cervical multifidus are deep to these.

Trachea

Thyroid gland
Internal carotid artery
Sternocleidomastoid
muscle
Jugular vein
Esophagus
Longus colli
Cervical vertebra
Vagus nerve
Stellate ganglion
Scalene muscles

Interscalene plexus
Transverse process

Spinal cord Vertebral artery

and vein
Suboccipital muscles

Spinous process

• Fig 12.20Cervical spine cross-sectional anatomy. Note the relationship between the interscalene plexus
and scalene muscles and the longus colli muscle and the stellate ganglion.

• L ateral decubitus with 1 pillow under the head so that • I dentify the hyperechoic line that the 1st rib casts and the
the neck is tilted slightly away from the targeted side. pleura on either side of the rib. It is mandatory to stay
• It can be done in a sitting position but is not preferred. superficial to 1st rib and pleura
Clinician Position Needle Position
• Ipsilateral side of the patient. • Introduce the needle in-plane from the lateral side of the
Transducer Position probe using ultrasound guidance.
• The transducer is placed transversely above the clavicle in • Visualize the needle tip and direct it towards the bra-
the midclavicular area. chial plexus, which is seen as hypoechoic fascicles. It is
144 SEC T I O N I I I Atlas

mandatory that the needle tip stays superficial to 1st rib • Th

 e branches of the superficial cervical plexus pierce the
and pleura. deep fascia of the neck at the midpoint of the posterior
Target margin of sternocleidomastoid muscle to emerge, form-
• Enter the fascia that covers the brachial plexus; a pop ing the lesser occipital nerve, greater auricular nerve,
may be felt transverse cervical nerve, and supraclavicular nerve.
• Target injection inside the fascia sheath in between the • It supplies the skin area of the anterior neck and shoulder
brachial plexus trunks area.
• The deep cervical plexus supplies the deep structures of
PEARLS AND PITFALLS the anterior and lateral neck and also gives branches to
the phrenic nerve.
• V  ascular Injection: The brachial plexus is close to the
subclavian artery and lies superficial and deep to the
• To locate the deep cervical plexus, a straight line is drawn
artery. from the tip of the mastoid process to Chassaignac’s (C6)
• Intra-arterial injection can be minimized by aspirating tubercle; the line will indicate the positions of cervical
the needle prior to injection, watching the spread of transverse processes.
local anesthetic live as the injection is performed, and • On this line, the transverse process of C2 is located 2 cm
using incremental doses during the injection.
• Pneumothorax: Brachial plexus block has the highest
below the tip of the mastoid process corresponding to
incidence of pneumothorax. It is mandatory to identify the level of the hyoid bone; the transverse processes of C3
the 1st rib and pleura prior to insertion of the needle and C4 are located 1.5 and 3 cm below the mark for the
and keep needle tip superficial to those structures. C2 transverse process.
Nerve injury: The use of ultrasound has reduced the risk • C4 transverse process corresponds to the level of the
of nerve injury. Nerve injury can be avoided by performing
the block in-plane technique, making sure the nerve bundle
superior border of the thyroid cartilage.
maintains its integrity during the injection, and performing it on
an awake or minimally sedated patient so that the patient can Common Pathology
alert the practitioner to nerve pain.22-26 • Th
 e cervical plexus can be used as an anesthetic or
   adjunct to general anesthesia or postoperative pain relief
for surgeries of the neck and shoulders.
Cervical Plexus Block
Equipment
• High frequency (9 to 18 MHz) linear ultrasound probe
KEY POINTS
• C ervical plexus blocks were first performed by Halsted Common Injectates
in 1884. • Local anesthetics
• The cervical plexus can be done by the posterior or
lateral approach.
Injectate Volume
• Currently, the most commonly performed is the lateral
approach of cervical plexus block. • 5 to 10 mL
• Superficial cervical plexus block is used for superficial Technique
surgeries of the neck and shoulder. Patient Position
• Deep cervical plexus block is used for surgeries on • Th
 e patient is positioned in a supine position
deeper structures of the anterior and lateral neck, like
• The head is rotated 45 degrees away to slide the SCM
surgeries of the carotid artery, thyroid, neck lymph
nodes, etc. muscle away from the site of injection.
Clinician Position
  
• Ipsilateral to targeted side
Transducer Position
Pertinent Anatomy • The superficial cervical plexus block is performed by
• Th
 e cervical plexus is formed by anterior divisions of placing the probe transversely over the posterior border
upper cervical nerve nerves C2 to C4. of SCM at the midpoint of the muscle.
• The cervical nerves emerge for their respective fora­ • Visualize hypoechoic fascicles under the posterior border
mina and divide into anterior and posterior divisions. or emerging out through the fascia posterior to the SCM
The anterior divisions exit behind the vertebral artery muscle.
in a gutter formed by the anterior and posterior tuber- • The deep cervical plexus block is performed by placing
cle of the transverse process at corresponding cervical the high-frequency linear ultrasound probe over the pos-
vertebrae. terior border of the SCM muscle; therefore, SCM is seen
• The anterior rami divide into ascending and descending as a triangle.
branches forming series of loops known as the cervical • The transverse process of the C4 vertebra can be seen as a
plexus. hyperechoic structure.
• The plexus divides into superficial and deep branches • By tilting the probe in the craniocaudal direction, you
giving rise to a series of nerves. can visualize the C4 nerve root exiting the foramen
 CHAPTER 12 Cervical Injection Techniques 145

SCM

ASM
IJV

BP MSM

CA

A B

SCM SCM

IJV
IJV ASM
ASM
Needle LA
LA MSM
MSM

BP
BP
CA
LA

C D
• Fig 12.21ASM, Anterior scalene muscle; BP, brachial plexus; CA, carotid artery; IJV, internal jugular vein;
LA, local anesthetic; MSM, middle scalene muscle; SCM, sternocleidomastoid muscle.

SCM
DCP

LC Levator
VA Scapulae

C4 TP

A B
• Fig 12.22C4 TP, transverse process of 4th cervical vertebra; DCP, deep cervical plexus; LC, Longus Coli;
VA, vertebral artery; SCM, Sternocleidomastoid muscle.
146 SEC T I O N I I I Atlas

and going in between the anterior and middle scalene • R adiculitis at the cervical region can be secondary to
muscles. disc, uncovertebral joint, or cervical facet pathology.
Needle Position • Transforaminal epidural steroid injection is done to
• For a superficial cervical plexus block, enter the skin over suppress the inflammation of the cervical nerve root
and treat radicular pain.
the midpoint of the posterior border of SCM muscle.
• Under fluoroscopy, the cervical facets joints look
• Guide the needle through the long axis to pass through like pillars on both sides of the vertebral column and
the superficial part of the deep cervical fascia. therefore are called lateral masses or articular pillars.
• For the deep cervical plexus block, the needle is inserted • The location of the needle tip in relation to the articular
and directed towards the C4 nerve root in the groove pillar during the cervical injections is crucial to avoid
complications.
between the anterior and middle scalene muscles
• In the cervical region, the dural sleeve around the
Target cranial nerve can extend up to the midpoint of the
• For a superficial cervical plexus injection, under the articular pillar.
superficial layer of deep cervical fascia near the superficial   
cervical plexus
• Aspirate first to ensure no vascular uptake and make sure
there is an adequate spread of injectate near the nerve Anatomic Consideration
branches • Th
 e roof of the intervertebral foramen is formed by the
• For the deep cervical plexus, the needle should contact corresponding vertebral pedicle, and the floor of the fora-
the anterior tubercle of the C4 transverse process men is formed by the pedicle of the vertebra below. The
• Aspirate to make sure there is no blood or cerebrospinal anterior part foramen is formed by the uncovertebral joint,
fluid, then inject and the posterolateral part is formed by the facet joints.
• Apply gentle pressure over the C5 tubercle to prevent the • The facet joints are formed by the inferior articular pro-
local anesthetic spread in the caudal direction cess of the corresponding vertebra and the superior artic-
ular process of the vertebral below.
PEARLS AND PITFALLS • The transverse process of the cervical vertebra has a fora-
men called the transverse foreman.
• Intravascular injection: The neck is highly vascular; • The vertebral artery (VA) runs through the transverse
accidental intravascular injection of local anesthetic can
occur into external and internal jugular veins, external
foramen of C1 to C6 vertebra and lies medial to the
and internal carotid arteries, or vertebral artery. A midline of the lateral masses or articular pillar; however,
very small amount of local anesthetic injected into the there is significant variation of the position of VA along
carotid artery, or vertebral artery can cause seizures or the lateral masses.
loss of consciousness. • The cervical intervertebral foramina are positioned antero-
• High spinal block: Local anesthetic injection into epidural
and subdural spaces can occur due to penetration of
laterally at 45 degrees and directed slightly inferior.
the dural sleeve. Careful aspiration prior to injection can • The cervical spinal nerves from C3 to C7 exit in the
avoid intravascular or subarachnoid injection. groove for the spinal nerve. The groove has an inferior
• Phrenic nerve block: Transient phrenic nerve block bony floor and anterior and posterior tubercle formed
occurs in 100% of the patients as the phrenic nerve by the transverse process of the vertebra (see Figs 12.23
mainly arises from the C4 nerve root with minor
branches from C3 and C5 nerve roots. Cervical plexus
and 12.24).
block should be avoided in patients who have severe
respiratory illnesses. Equipment
• Horner’s syndrome: Upper and middle cervical • C -arm fluoroscopy
sympathetic ganglion can be blocked during this • Needle: 25 gauge 2 to 3.5 inch spinal needle depending
procedure if the local anesthetic spreads anteriorly to
the prevertebral fascia.27-31
on neck girth
• non-ionic contrast material (Omnipaque or Isovue)
  
Common Injectates
Fluoroscopy Guided Techniques • local anesthetics for diagnostics, nonparticulate
corticosteroids
Transforaminal Cervical Epidural Injections • Orthobiologics (platelet lysate)
• Do not use particulate steroids epidurally
KEY POINTS Injectate Volume
• A transforaminal cervical epidural injection can be used • 1 to 3 mL
for both diagnostic and therapeutic purposes. Technique
• Since the injection is done at a specific level, it has a Patient Position
higher diagnostic value as long as the injectate volume • Th
 e patient is in the supine position, and the head should
is kept low.
be turned away from the side of the procedure. This will
 CHAPTER 12 Cervical Injection Techniques 147

C3
C3

C4
C4

C5
C5

C6
C6

C7
C7
TP
TP

TP
TP

• Fig 12.23C3 to C7 Neural foramen openings seen in the initial scout • Fig 12.24Openings of the neural foramen especially at C5, C6, C7 levels
oblique view. TP, Large transverse process of TI. when compared to the image in Figure 12.23. Sometimes caudal angula-
tion may be additionally required to maximize the foraminal opening.
prevent the overlap of the jaw and facial bones and opti-
mizes the visualization of the foramen.
Clinician Position X
• Ipsilateral side of the injection
C-Arm Position
• The C-arm is turned into oblique position significantly, X
usually 30 degrees or more, to maximize the opening of
the neural foramen (Fig. 12.23).
• Caudal angulation [image intensifier angled to the feet]
is usually required to additionally maximize the opening X
of the neural foramen.
• Sometimes cranial angulation may be needed. The goal is
to optimally visualize the opening of the neural foramen X
at the level of the injection being performed (Fig. 12.24).
• The most superior neural foramen seen is the C3 level.
This is used as a landmark to count the level of the neural X
foramen of interest.
• Alternatively, the large transverse process of T1 can also
be used to count (see Fig. 12.24).
Needle Position
• Skin is marked over the posterior and inferior part of the
foramen (Fig. 12.25).
• The needle is introduced under fluoroscopic guidance • Fig 12.25X: Site of needle entry in the posterior and inferior part of
using the hub shot technique. the foramen.
• As soon as the needle is stabilized in the tissues, further
advancement is stopped in the oblique view to avoid • A nterior deviation of the needle would bring it near
entering the spinal canal. It is absolutely critical for the the vertebral artery, which can lead to dangerous
needle to remain in the posterior part of the foramen. consequences.
• The author prefers to have the needle touch the posterior • True AP view [spinous process in the middle of the ver-
boney wall of the foramen (anterior lateral border of the tebral body] is now obtained.
inferior articular pillar IAP) to ascertain the depth and • The needle can be advanced here and can begin to direct
for safety. Then, the needle can be "walked off" just ante- the needle slightly superior as the nerve root exits ante-
rior to the IAP but remaining in the posterior foramen. rior and inferiorly into the foramen.
148 SEC T I O N I I I Atlas

Target
• T arget the tip of the needle at the middle of the lateral
masses (articular pillars). Needle position beyond the
middle of the articular pillar risks entry into the spinal
canal (Fig. 12.26).
• A small extension tube (K 50) can be used to minimize
the mobilization of the needle during the procedure.
• Aspiration should be negative for blood or CSF.
• Under real-time fluoroscopy, inject 0.5 to 1 mL of con-
trast dye to confirm the correct position of the needle.
The dye should be seen entering the epidural space and
tracking the nerve exiting the foramen. A second still
image can be taken a few seconds later to confirm there
is no change in the dye pattern.

PEARL AND PITFALLS

Complications
• P enetration of great vessels:
• Carotid artery and Internal Jugular vein are present
anterior lateral to the intervertebral foramen. The
artery and vein lie over the body of the cervical • Fig 12.26 Needle tip in the center of the facet column. The needle
vertebra in an oblique view. should not be advanced more medial. Dye spread along the nerve root.
• The vertebral artery lies over the anterior border of Orange lines depict the medial and lateral margins of the facet column.
the intervertebral foramen in the oblique fluoroscopic
view. One can avoid injury to the vertebral artery
by targeting the posterior part of the intervertebral Pertinent Anatomy
foramen. • E pidural space lies between the dura mater and osteoliga-
• Staying lateral to the midline of lateral masses in AP mentous structure lining the vertebral canal.
view does not guarantee avoiding vertebral artery • The epidural space starts at the foramen magnum and
injection. terminates at the sacral hiatus at S4 and S5 levels.
• There have been case reports of injection into the
radicular artery at the corresponding level causing • Epidural space is subdivided into anterior and posterior
spinal cord injury.32 compartments.39,40
• Intrathecal injection: • The anterior epidural space is bordered anteriorly by
• Cervical spinal nerves have dural sleeves that extend the vertebral body, discs, and the posterior longitudinal
up to the midline of the lateral masses or articular ligament.
pillars.
• Make sure the needle tip is lateral to the midline of • The posterior epidural space is bordered anteriorly by
the articular pillar. the thecal sac and posteriorly by ligamentum flavum and
• Intrathecal injection causes high spinal block where lamina.41
the patient may have numbness and weakness • The epidural space contains fat, areolar tissue, and the
of upper extremities, difficulty breathing, and internal vertebral venous plexus.42
hypotension.
• The symptoms should be managed accordingly. • Posterior epidural space varies throughout the length of
• Nerve Injury: the spine.
• The exiting nerve lies in the anterior and inferior • It is widest at the upper thoracic levels, where the poste-
part of the intervertebral foramen. One can avoid rior space measures 7.5 mm. The dimensions at C7-T1
nerve injury by targeting the posterior part of the are 0.4 mm.43
foramen.33-38
   Equipment
• C -arm fluoroscopy
Cervical Interlaminar Epidural • Needle: Tuohy 18 gauge 3.5 inch if using a catheter OR
20 gauge if not using a catheter.
KEY POINTS • Option to use an 18 gauge Tuohy for patients with higher
BMI for better maneuverability.
• C ervical epidural injections are done to treat neck and
radicular pain.
• Radiopaque catheter
• The proposed mechanism of action of steroids in the • non-ionic contrast material (Omnipaque or Isovue)
epidural space includes anti-inflammatory effect, direct
membrane stabilization, and perhaps modulating the Common Injectates
input of peripheral nociceptors. • C orticosteroids
   • Orthobiologics (platelet lysate)
 CHAPTER 12 Cervical Injection Techniques 149

C7

X X

T1 SP

A B
• Fig. 12.27 C7-T1 Paramedian cervical interlaminar needle placement. A. Contralateral oblique view of
Touhy needle posterior to ligamentum flavum. B. AP view of contrast showing epidural flow.

• A
 void local anesthetics in the epidural space as the upper • O nce the needle touches the lamina, the C-arm is rotated
cervical nerve block could arrest breathing in the contralateral oblique position.
• At this point, the needle should be behind the "interlam-
Injectate Volume inar line" (ligamentum flavum) (see Fig. 12.27A, shown
• 1 to 3 mL in red ).
Technique • Generally, a loss of resistance syringe is attached to the
Patient Position needle after removing the stylet. The author also prefers
• P lace the patient in a prone position with a pillow or two to fill the needle all the way to the hub with contrast
under the chest. material.
• The neck should be slightly flexed (to increase the intra- • Following this, the LOR syringe is attached, and the
laminar space). needle is directed upward using the loss of resistance
• The head could be turned to the contralateral side to technique.
injection to improve visualization of the interlaminar • Attention should be kept at the hub as the contrast mate-
space. rial is seen getting sucked in as the loss is achieved.
Clinician Position Target
• Opposite of the C-arm base • The needle should be just past the interlaminar line,
Transducer Position or C-Arm Position Fluoro Technique when the loss of resistance occurs. Loss of resistance can
• The C-arm is placed in a position to get an AP view. occur further posterior as well.
• Then the image-intensifier is tilted caudally or cranially • Attach a syringe connected to a small volume extension
to maximize the interlaminar space. tubing containing the contrast to the needle.
• The edges of the inferior and superior lamina should be • Gently aspirate for the presence of any blood or CSF.
sharp and well seen. • Once negative aspiration is confirmed, slowly inject
• Although epidural injections can be done at C5-6 and contrast under live fluoroscopy to assess its spread within
C6-7, C7-T1 has the most space and is the preferred the epidural space in contralateral oblique and AP views
site. (Figs 12.28 and 12.29).
Needle Position Needle and Catheter technique:
• One side of the T1 lamina [T1 is identified with a large • If the target pathology is at a higher level, use an epidural
spinous process] is marked on the skin (Fig. 12.27B). catheter.
• The entry point is anesthetized with a local anesthetic • Use an 18 gauge Tuohy needle to access the epidural
• The Touhy needle is advanced using a paramedian space.
approach, preferably on the side where the patient is • After confirming the needle tip in the epidural space
experiencing radicular pain. using the above technique, a radiopaque 20 gauge cath-
• The needle is aimed at the upper border of the T1 lamina. eter can be threaded cephalad within the epidural space
• Touch the lamina for safety. to the specific target level.
150 SEC T I O N I I I Atlas

PEARLS AND PITFALLS

• Interlaminar epidural injections in the levels above C5-6
are not recommended even for experienced clinicians
as the ligamentum flavum is very thin.
• MRI or CT scan should be reviewed to assess the
spinal anatomy prior to doing the injection.
• Should not attempt the procedure if stenosis or large
disc herniation is present at the target entry point.
• Use a catheter to deliver the medication if the pathology
is higher up, at C3-4, C4-5, C5-6.
• IV access should be obtained in the patient prior to
doing the procedure.
• Potential complications are rare and are usually
attributable to the needle placement and include the
following:
• Spinal cord injury (if the needle is advanced too
far)
• Epidural hematoma (anticoagulation medications
should be held per ASRA guidelines prior to doing
the procedure)
• Infection (procedure should be done with full sterile
protocol)
• Postdural puncture headaches
• Allergic reaction to the contrast material
   • Fig. 12.28 Contralateral Oblique view on interlaminar injection with
epidural contrast flow.
Facet Joints • Th
 e normal AA joint allows for 5 degrees of flexion and
Atlanto-Occipital and Atlanto-Axial Interventions 10 degrees of extension. The axial rotation is 70 degrees
which allows for over 40% of total cervical spine rotation.
• The C2 dorsal ramus innervates both the AO and AA
KEY POINTS joints.
• T he atlanto-occipital (AO) joint is an ellipsoid (bean-like)
joint with its lateral edges sloping upwards. It allows Common Pathology
passive flexion, an extension of 10 degrees, as well as • Th
 e AO joint and the AA joint are implicated in
10 degrees of rotation.44 approximately 9% of cervicogenic headaches. Dreyfuss
• The atlanto-axial (AA) joint is not a true facet joint. It
et al. showed that noxious stimulation of these joints
is an anterior structure rather than a posterior one.
It lies ventral to the vertebral artery, spinal cord, and in normal volunteers with injections of contrast
C2 dorsal root ganglion and is innervated by the C2 medium produces pain in the suboccipital region and
root. the occiput.46
   • Typical pain patterns:
• Deep pain in the suboccipital region, often unilateral
• Pain with rotation, flexion, and extension of the neck
Pertinent Anatomy • Crepitus/pain associated with movement
• Th
 e atlanto-occipital (AO) joint is the articulation of the • Cervicogenic headaches impairing function
superior articular facet of C1 (Atlas) and the occiput.
• The atlanto-axial (AA) joint is the articulation of the Equipment
Atlas and C2 (Axis). •  mergency equipment (crash cart)
E
• AO and AA joints have a high degree of mobility and • C-arm fluoroscopy
are primarily supported by ligaments, whose function is • 25 to 22 gauge, 3 to 3.5 inch spinal needle
to transmit information to the Central Nervous System • Non-ionic contrast (omnipaque or Isovue)
concerning head and neck position. No discs or unci-
nate processes are present. Common Injectates
• The vertebral artery runs on the lateral aspect of the AA • L
 ocal anesthetics for diagnostics, corticosteroids, orthobio-
joint, however, variations could be present, including logics (Dextrose prolotherapy, PRP)
bypass of the transverse foramen of C1, close relation
to the C1-2 facet joints, and variable course along the Injectate Volume
posterior arch of C1.45 • 0.5 to 1 mL
 CHAPTER 12 Cervical Injection Techniques 151

AO

AA

• Fig. 12.29AP view C7-T1left paramedian interlaminar injection with

contrast showing epidural flow.
• Fig. 12.30 Target entry points for AO and AA joint with relation to
the vertebral artery. AA, Atlanto-axial; AO, Atlanto-occipital. (Photo
Courtesy: Dr. Paul Dreyfuss.)

Technique: AO (C0-1) joint PEARLS AND PITFALLS

Patient Position
• C are should be taken not to advance the needle too far in.
• Th
 e patient is placed in a prone position with the neck • NOTE: if venous runoff is seen, you are not in the joint
slightly flexed. The head and neck should be supported, as there is a rich venous plexus present. If arterial runoff
and the mouth should be unobstructed as the patient is seen or the contrast material is seen in the epidural
may need to open it during the procedure. space, the injection should be terminated.
• The joint volume is around 1 mL.
• Another technique described by Centeno et al.47 suggests
• BMAC and lipoaspirates should be considered
placing the patient in a prone position with the head particulate injections with potential to occlude vessels if
slightly flexed and rotated to the ipsilateral side (approxi- injected intravascularly.
mately 30 degrees). Ipsilateral rotation of the head dis-   
places the vertebral artery medially.
Clinician Position Technique: AA (C1-2) joint
• The opposite side of the base of the C-arm Patient Position
C-Arm Position Fluoro Technique • Th
 e patient is placed in a prone position with the neck
• Caudal tilt to move occiput from needle trajectory slightly flexed. The head and neck should be supported,
• Slight C-arm rotation along the long axis of the joint to and the mouth should be unobstructed as the patient
visualize the joint in the nasal cavity. may need to open it during the procedure.
Needle Position Clinician Position
• The needle is placed in the palpable groove between the • The opposite side of the base of the C-arm
mastoid process and the occipital rim. C-Arm Position Fluoro Technique
• A reliable entry point is the posterolateral aspect of the • Direct AP view with cephalad tilt to "open" the AA joint.
joint capsule, which is drawn upwards, above the edge Needle Position
of the cup, over the posterolateral edge of the occipital • In AP view, the start point is over the lateral third of the
condyle.47 lower end of the posterior surface of the lateral mass of
• The "gun barrel" approach should be used. the Atlas (see Fig. 12.30).
Target • Make sure that the needle does not stray from this path.
• Target is the most superior and posterior aspect of the Target
joint just inside its lateral edge (Fig. 12.30). • Target is the lateral third of the joint. After the needle
• After negative aspiration, inject a small amount of non- touches bone, redirect intraarticularly
ionic contrast • Confirm depth in the lateral view.
• Confirm proper needle placement and contrast flow in • Inject contrast and confirm intra-articular flow in the AP
the AP and lateral views. and lateral views.
152 SEC T I O N I I I Atlas

A B

C D
• Fig. 12.31(A) Contrast filling the AO joint oblique. (B) Lateral view. (C) Lateral view of AA joint (D) AP view
of the AA joint. (Courtesy Dr. Paul Dreyfuss.)

PEARLS AND PITFALLS

There is a 45 degree joint inclination with increased
angulation inferiorly. It is a relatively flat joint.
• K
 eep the needle in lateral 1/3 area of the joint/lateral • The articular facets are covered by articular cartilage, and
mass. If the needle strays laterally, it could enter the a synovial membrane bridges the margins of the articular
vertebral artery and if it strays medially the C2 ganglion
or spinal cord.
cartilage of the two facets in each joint.
• Z-Joints are innervated by the medial branches of the
   dorsal rami.
• The C2-3 joint is innervated by the third occipital nerve
(TON), while the joints below C2-3 are innervated by
C2-3 to C7-T1 Facet Joints the medial branches of the cervical dorsal rami of above
Pertinent Anatomy and below the joint.
• Th
 e cervical facet joint or zygapophysial joint (Z-joint)
is a diarthrodial, synovial joint formed by the superior Common Pathology
articular pillar of the inferior vertebral segment and the • B
 ased on multiple studies, the prevalence of cervical
inferior articular pillar of the superior vertebral segment. facet joint pain has been shown to be 36% to 67% in
 CHAPTER 12 Cervical Injection Techniques 153

A B
• Fig. 12.32(A and B) Lateral approach. AP and lateral views: needle in the C3-4 facet joint along with the
contrast seen in the superior and inferior recesses. (Courtesy Vivek Manocha.)

patients with chronic neck pain suspected of facet joint • I n a lateral decubitus position, this can be achieved by
pain.48 putting a folded towel under the head to keep the head
• Typical pain patterns: Dwyer et al. mapped out referred and neck parallel to the table.
pain patterns by performing facet joint injections in nor- • In most patients, C2-3, C3-4, and C4-5 facets can be
mal volunteers.49 blocked in supine and/or lateral decubitus positions.
• Axial neck pain, upper back pain However, C5-6, C6-7, and C7-T1 will require access
• Crepitus/pain associated with movement using the posterior approach while the patient is in the
• Cervicogenic headaches prone position.
• No radicular pattern Clinician Position
• No evidence of discogenic pain • Physician preference when the procedure is performed
in a lateral decubitus position as long as the fluoroscope
Equipment base is on the opposite side of the physician.
•  mergency equipment (crash cart)
E • For a supine position, the physician should stand on the
• C-arm fluoroscopy side of the neck being injected.
• 25 to 22 gauge, 3 to 3.5 inch spinal needle Fluoroscope Position
• Non-ionic contrast (omnipaque or Isovue) • Position the C-arm to obtain a true lateral view. This
minimizes the risk that the needle will be aimed toward
Common Injectates the contralateral side.
• L
 ocal anesthetics for diagnostics, corticosteroids, orthobio- • The silhouettes of the articular pillars at each segmental
logics (Prolotherapy, PRP, bone marrow concentrate, etc.) level should be superimposed.
• The joint line should be clear and visible.
Injectate Volume Needle Position
• 0.5 to 1 mL • Start over the inferior or superior articular process just
below or above the joint line.
Technique • The needle should be advanced in small increments, and
This procedure can be done in a posterior or lateral approach. the directional adjustments should be made in a subtle
The prone position is preferred for joints C5-6 and below as manner (Fig. 12.32A and B).
these are easily accessible from a posterior approach. For C2-3, • Touch needle down on bone for depth safety.
C3-4, and C4-5 facet joints, the lateral approach is preferable. • A lateral view is obtained at this time.
Technique for lateral approach Target
Patient Position • The needle is then walked off into the joint capsule.
• Lateral Decubitus or supine position. The key element • A small dose (0.2 mL) of contrast material is injected,
to successfully performing this block is to obtain a near- which can be seen filling the superior and inferior recesses
perfect, true lateral view. (Fig. 12.32A).
154 SEC T I O N I I I Atlas

A B
• Fig. 12. 33
(A and B) Posterior approach. AP and contralateral oblique view with contrast within the joint.
(Courtesy Vivek Manocha.)

PEARLS AND PITFALLS Target

• Th
 e lateral third of the joint should be the target entry point.
• M ust have a true lateral view to see an accurate target • Inject a small amount of contrast to confirm intraarticu-
• Use lateral view to ensure needle not advancing too lar spread in the AP view (Fig. 12.33A and B).
deep through the joint, which can risk puncturing the
dura or spinal cord. • Most patients have a communicating pathway between
the facet joints and the extradural, interlaminar, and even
  
the contralateral facet joint space (Okada50).

Technique for the Posterior Approach PEARLS AND PITFALLS

Patient Position
• Th
 e patient is placed in a prone position with a pillow • A
 curved needle tip helps to navigate the needle more
precisely with this approach
under the chest and the neck in a slight flexion.
• The head should be turned to the contralateral side to get   
the molars out of the way.
Clinician Position Cervical Medial Branch Block
• Opposite the fluoroscope base.
Fluoroscope Position KEY POINTS
• The C-arm is brought in the AP position, and a caudal
tilt is given to the image intensifier to obtain a pillar view • T he main purpose of cervical medial branch blocks is
to test if the patient’s pain stems from a particular facet
(Fig. 12.33A).
joint.
• Align the spinous processes in the center of the pillars. • Cervical medial branch blocks have diagnostic utility, in
Needle Position that if positive, they identify the source of pain
• The needle entry point is selected half to a full segment • A positive response predicts a good chance of
below the target joint. obtaining complete relief of pain from radiofrequency
ablation.
• The needle is passed upwards and ventrally through the
• A good history and physical exam and imaging review
posterior neck muscles until it makes contact with the should be conducted to exclude serious possible
posterior surface of the articular pillar just below the causes of neck pain, such as infections, tumors, or
joint line vascular disease.
• At this point, the contralateral oblique view is obtained, • Pain maps are used to select which nerves to target.
and the needle is "walked off" into the joint.   
 CHAPTER 12 Cervical Injection Techniques 155

• 2 5 to 22 gauge, 1.5 to 2 inch needle for lateral approach

• 25 to 22 gauge 3 to 3.5 inch spinal needle
• Non-ionic contrast (omnipaque or Isovue)

Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids
• Typically 2% lidocaine or 0.5% bupivacaine (preserva-
C3
tive free). Comparative blocks using a short-acting anes-
Articular thetic and a long-acting anesthetic are recommended to
C4 Pillar decrease the false-positive response.

Injectate Volume
• 0.25 to 1 mL
Technique—Lateral Approach
Patient Position
• L ateral Decubitus or supine position. The key element
to successfully performing this block is to obtain a near-
perfect, true lateral view.
• In a lateral decubitus position, this can be achieved by
putting a folded towel under the head to keep the head
and neck parallel to the table.
• Fig. 12.34 A lateral view of the cervical spine showing the articular
• In most patients, the third occipital nerve and C3-5
pillar (C3 and C4 marked in red). Needle shown at the middle of the C5 medial branches can be blocked in supine and/or lateral
articular pillar over the C5 medial branch. (Courtesy Vivek Manocha.) decubitus position. However, C6 and C7 will require
access using the posterior approach while the patient is
Pertinent Anatomy in the prone position.
• Medial branches arise from the dorsal rami of the spinal Clinician Position
nerves, and innervate the facet joints. • The physician’s preference while the procedure is per-
• Each joint receives articular branches from the nerve formed in a lateral decubitus position as long as the fluo-
above and the nerve below the joint. roscope is on the opposite side of the physician.
• Those nerves have the same segmental numbers as the • For a supine position, the physician should stand on the
joint. side of the neck being injected.
• Each nerve (except C7) crosses the middle of the articu- Fluoroscope Position
lar pillar, which is the suitable target point for the block • Position the fluoroscope in such a fashion that a true lat-
(Fig. 12.34). eral view is obtained.
• Lord et al. described the variation in the location of the • The silhouettes of the articular pillars at each segmental
medial branches. At C5, the medial branches are located level should be superimposed.
over the middle of the C5 articular pillar; but are located Needle Position
higher on the pillars at levels above.48 • The needle should start directly over the targeted MBB
• The third occipital nerve and C3 medial branch provides and use the "gun barrel" approach.
innervation to the C2-3 facet joint. It also innervates the Target
semispinalis capitis muscle. • For medial branches C3-6:
• The target point is the centroid of the articular pillar
Common Pathology with the same segmental number as the target nerve.
•  nilateral or bilateral neck pain.
U • This centroid is found at the intersection of the two
• Decreased range of motion of the neck. diagonals of the articular pillar (Fig. 12.34).
• Local tenderness over the affected facet joint(s) • For medial branch C7:
• Upper neck pain with associated headaches • The target point lies high on the apex of the superior
• Pain referring to the shoulder girdle. It should not radi- articular process of C7.
ate distally to the elbow. The pain should follow a non- • Keep in mind that the transverse process of the C7,
dermatomal (non-radicular) pattern. which is often not visible in the lateral view, can
• Referred pain from the C2-3 facet joint leads to headaches. obstruct the needle placement.
• For third occipital nerve block:
Equipment • The target area is a rectangular area bounded by the
• E mergency equipment (crash cart) anterior edge of the superior articular process of C3;
• C-arm fluoroscopy upper and lower lines perpendicular to this edge
156 SEC T I O N I I I Atlas

A B
• Fig. 12.35(A) The three red dots represent the target area for the Third occipital nerve block. (B) shows
contrast over the location of the third occipital nerve. (Courtesy Vivek Manocha).

passing posteriorly from the apex of the superior artic- Target

ular process and from the bottom of the C2-3 inter- • T
 arget is the lateral concavity of the articular pillar.
vertebral foramen, and a posterior line approximately
through the posterior edge of the inferior articular PEARLS AND PITFALLS
process of C2 (Fig. 12.35). • In the posterior approach, a curved needle tip is
• The needle is inserted in the middle of the three target required to navigate the needle safely and more
points. accurately to the target
• When the bone is contacted, the needle should be • The patient may not experience 100% pain relief as it
is possible that the patient may have other sources of
slightly withdrawn prior to injecting the contrast.
pain.
Technique—Posterior Approach • Diagnostic medial branch blocks should be performed
Patient Position only if the clinician is trained to proceed with performing
• Place the patient in the prone position. the RFA.
• Patient positioning is the same as described above for the   
cervical facet injection.
Clinician Position Cervical Radiofrequency Neurotomy of the Medial
• Same as described above for cervical facet injections Branches
Fluoroscope Position
• The C-arm is positioned to get the pillar view of the cer- KEY POINTS
vical spine which is obtained by tilting the C-arm cau-
dally. (Fig. 12.36A). • Indication: A diagnostic block of the target medial
branches has provided 80% or better relief for the
• A pillar view is obtained by reorienting the plane of the
duration of the anesthetic.
fluoroscope so that it passes parallel to the plane of the • A radiofrequency lesion is created with a temperature
z-joint at the target level. over 80 degrees. However, the higher the temperature,
Needle Position the bigger the lesion.
• The needle should be inserted starting directly over and   
at the lateral margin of the target pillar.
• It is advisable to directly contact the bone immediately Equipment
medial to the target pillar. •  mergency equipment (crash cart)
E
• The C-arm should then be rotated to a contralateral • C-arm fluoroscopy
oblique position. • A 100 mm or 140 mm RF needle with a curved tip
• In this view, the needle can be rotated 180 degrees and • Radiofrequency generator that displays impedance, volt-
advanced to the target age, current, and temperature
 CHAPTER 12 Cervical Injection Techniques 157

A B
• Fig. 12.36(A) Waist of the articular pillars. Site for the placement of the needle (red dots). (B) Contralateral
oblique view. (Courtesy Vivek Manocha.)

• Grounding pad • I t is recommended that the patient report sensation dur-

• Local anesthetic ing stimulation at 50 Hz at less than 0.5 volts and have
Technique—C3-6 Medial Branch no motor stimulation to the affected myotome at 2 Hz at
Patient Position no less than 3 times the sensory threshold or 3 volts.
• Place the patient in the prone position. Patient position- • A twitching response is seen, which is due to the stimula-
ing is the same as described above for the cervical facet tion of the multifidus muscle.
injection. • Then the level is anesthetized with 0.5 mL of local anes-
Clinician Position thetic, and the lesions are carried out at 80 degrees for 90
• Same as described above for cervical facet injections seconds.
Fluoroscope Position • The cannula can be retracted and repositioned for a sec-
• The C-arm is positioned to get the pillar view of the cer- ond lesion for 60 seconds.
vical spine which can be obtained by tilting the image
intensifier in a caudate position (see Fig. 12.36A). Technique—C7 Medial Branch Neurotomy
• A pillar view is obtained by reorienting the plane of the • S etup is the same as C3-6 Medial Branch Neurotomy
fluoroscope so that it passes parallel to the plane of the • The C7 medial branch neurotomy follows the same
z-joint at the target level. principles and precautions as the other nerves. However,
Needle Position there are some differences, given that the C7 nerve exhib-
• A 100 mm 20 gauge with a 10 mm curved active tip is its significant variation in location.
inserted starting directly over and at the lateral margin of • It can lie on the lateral aspect of the superior articular
the target pillar. process, as high as the apex of this process, or it may be
• It is advisable to directly contact the bone immediately found on the superior aspect of the proximal end of the
medial to the target pillar. C7 transverse process.52
• The C-arm can be rotated in a contralateral oblique posi- Moreover, the C7 medial branch crosses the superior
tion (Fig. 12.37B). articular process rather than the waist of the articular pillar.
• In this view, the needle can be rotated 180 degrees and Needle Position
advanced to enter the lateral concavity of the articular • A 100 mm 20 gauge with a 10 mm curved active tip is
pillar (see Fig. 12.37A). inserted starting directly over and at the lateral margin of
Target the superior articular pillar of C7.
• For the C5 medial branch, this will be the center of the • It is advisable to directly contact the bone immediately
articular pillar, whereas, for C3, C4, and C6, the target medial to the target pillar.
region is more cephalad on the pillar.51 Target
• Once the correct placement has been achieved and con- • Once the bone has been contacted, the needle is redi-
firmed, sensory and motor stimulation is done. rected so as to pass into the lateral surface of the superior
158 SEC T I O N I I I Atlas

A B
• Fig 12.37(A) RF needle position in an AP view. (B) Needle position in the contralateral oblique view.
(Courtesy Vivek Manocha.)

articular process. Care should be taken not to advance

PEARLS AND PITFALLS
more than 3 mm.
• Once the placement is confirmed, the lesion is created as • C omplications from intra-articular facet joints, medial
previously described. branch blocks, and radiofrequency ablation are
exceedingly rare. However, serious complications
can occur from incorrect placement of needles or
Technique—Third Occipital Nerve Neurotomy administration of various drugs.51
• S etup is the same as C3-6 Medial Branch Neurotomy • The proximity of the needle to the vertebral artery, spinal
• Third occipital radiofrequency neurotomy follows the cord, and nerve root creates risk for injury, and so it is
same principles and precautions as the other nerves. extremely important to place the needle in a precise
• Two separate lesions are typically performed to ade- and accurate location.
• Complications may include dural puncture, spinal cord
quately ablate the third occipital nerve. The neurotomies trauma, subdural injections, neural trauma, intravascular
are performed with both an oblique and sagittal pass.51,52 injections.
Target • Complications from RFA lesion include worsening of
• For the oblique pass the usual pain, burning or dysesthesias, decreased
• The target area is the entire anterolateral surface of the sensation and/or allodynia in the skin in the region of
the facets denervated.
superior articular process of the C3, from its apex to
its base opposite to the base of the C2-3 foramen.   
• On lateral views, the uninsulated portion of the elec-
trode should lie over the anterior third of the SAP of Cervical Intradiscal Technique
C3, and its tip should coincide with the anterior mar-
gin of the process but should not project beyond this
margin. KEY POINTS
• On AP view, the tip of the electrode should proj- • T he technique for cervical discography was first
ect just medial to the lateral silhouette of the C2-3 described in 1957 by Smith and Nichols.53
Z-joint. • The utility of cervical provocative or analgesic
• For the sagittal pass: discography as a diagnostic tool has been
• A direct posterior-anterior approach is used, and the controversial54 and hence infrequently used.
• However, with the evolution of intradiscal biologics to
pillar view is not required. successfully treat lumbar discogenic pain,55,56 there has
• In lateral views, the uninsulated portion of the elec- been a resurgence of interest in cervical disc needle
trode should lie over the middle third of the C2-3 placement and injection.
joint. • IV access is recommended for emergent complications
• In AP views, it should abut directly against the lateral • Surgical prep and drape are strongly encouraged. The
proceduralist should also wear a surgical cap, mask,
convexity of the joint.
 CHAPTER 12 Cervical Injection Techniques 159

KEY POINTS—CONT’D
and gown. C-arm should have a sterile cover. Every
possible sterile precaution should be undertaken to
reduce the risk of discitis.
• Prophylactic antibiotics can be given even though there
is no strong evidence to support this reduces infection
rates. The author prefers 1 to 2 g of cefazolin or 600 to
900 mg of clindamycin infused half an hour before the
start of the procedure.
  

C5

Pertinent Anatomy
• Th
 e cervical disc annulus does not consist of concentric C6
ring-shaped laminae of collagen fibers as found in lum- TP
bar discs. C7
• Rather, a crescent-shaped mass of collagen fibers thicker
anteriorly and tapered laterally toward the uncinate pro-
T1
cess characterizes the annulus fibrosus. TP
• Healthy cervical discs accept small amounts of contrast
media, usually on the order of 0.25 mL to 0.5 mL, due • Fig 12.38 TP, The large transverse process of T1.
to the very small nucleus and small size of the disc.
• Injection of greater volumes usually means extravasation
of contrast from the posterolateral or uncovertebral por- • M
 esenchymal stem cells with known secretory and para-
tions of the annulus, with little resistance upon injection crine abilities have the potential to modify inflammation
being appreciated.57,58 and provide pain relief by producing potent anti-inflam-
• Intervertebral disc innervation in the cervical spine is matory proteins like interleukin receptor antagonist
analogous to that in the lumbar spine, with cervical discs protein [IRAP], transforming growth factor [TGF], inter-
receiving innervation posteriorly from the sinuvertebral leukin 10, prostaglandin E2 [PGE2], etc. (Chapter 7).
nerves, laterally from the vertebral nerve, and anteriorly
from the sympathetic trunks.54 Equipment
• Cervical sinuvertebral nerves have an upward course in • C -arm fluoroscopy
the vertebral canal and supply the disc at their level of • 25 gauge 2 to 3.5 inch spinal needle
entry as well as the more cranial disc.57
• Both nerve fibers and proprioceptive receptors are found Common Injectates
in the outer third of the annulus fibrosus. • C ontrast for a provocative discogram
• Orthobiologics (PRP, bone marrow concentrate, etc.)
Common Pathology
• A fter facet joints, the cervical discs are the second Injectate Volume
most common cause of neck pain.59 Symptoms solely • 0.25 to 0.5 mL
due to disc herniation are less common in the cervi- Technique
cal region than in the lumbar region because of three Patient Position
reasons.57 • Th
 e patient is in the supine position.
• Herniation laterally is first prevented by cervical facet • The head should be tilted to the patient’s left.
joints, which form a bony barrier between the disc • A pillow can be placed under the shoulder blades to
and the nerve root. extend the cervical spine.
• The dense posterior longitudinal ligament limits the • The patient’s face is turned to the left so that the jaw does
posterior herniations not obscure the visualization of the cervical spine(see Fig.
• The nucleus also lies much more anteriorly in the cer- 12.38).
vical disc than in the lumbar disc, and its movement Clinician Position
posteriorly is correspondingly much more difficult • The interventionist should be on the patient’s right side,
and less likely. with the C-arm on the left side.
• Inflammation in the disc, usually from injury or degen- C-Arm Position
eration, can fire up the nociceptors in the annulus. • AP view will identify the cervical disc levels. T1 level
• Inflammatory cytokines leaking from the disc can irri- can be distinguished by the large transverse process (see
tate or sensitize the annulus, adjacent spinal nerves, liga- Fig. 12.38). This is a useful landmark to count the disc
ments, and muscles. levels.
160 SEC T I O N I I I Atlas

F D

D
F

D
F U

D
F U

• Fig 12.39 Ipsilateral oblique view of cervical foramen. • Fig 12.41 D, Entry site into disc; F, neural foramen maximized; U,
uncincate process.

of the procedure is done in this oblique view, and it is

important to do the following.
• Maximize the neural foramen
• The uncinate process should be clearly seen. This is an
important landmark as most of the procedure revolves
around it.
• Disc endplates are maximally squared. If this step is
not done, it is very difficult to enter the disc.
Needle Position
• Cervical disc entry should always be from the right side
in order to avoid the esophagus. This is mandatory.
• A curved needle is highly encouraged.
• Skin entry after local anesthetic infiltration is done just
anterior to the uncinate process, after palpating to ensure
that the carotid artery is not in the way.
• The needle should be advanced parallel to the x-ray beam
using the "gun barrel" approach.
• The goal is to contact the anterior border of the uncinate
process (see Fig. 12.41).
• It is imperative that the needle does not stray anterior
• Fig 12.40 Squaring the endplates is a vital step. Usually, the caudal to the uncinate on its way.
angulation helps. Notice that the discs are much better visualized in • Anterior diversion increases the risk of encoun-
this figure compared to Fig. 12.37.
tering the carotid artery/jugular vein and the
esophagus.
• O blique the C-arm towards the right side of the patient • Posterior deviation of the needle risks the vertebral
until the neural foramen at the level of disc entry is artery and the spinal nerve (see Fig. 12.42).
maximized and the uncinate process is well seen (see Fig. • The carotid sheath should be palpated and manually
12.39). moved to the left during needle placement.
• Next, craniocaudal angulation of the C-arm is done • Once the anterior border of the uncinate process is con-
until the disc endplates are maximally squared off (see tacted, the needle is advanced a few millimeters slightly
Fig. 12.40). Usually, caudal angulation [image intensifier anteriorly and medially into the disc, again with the needle
angled towards the feet of the patient] is required. Most as close as possible to the uncinate process (Fig. 12.43).
 CHAPTER 12 Cervical Injection Techniques 161

• Fig 12.42 Ipsilateral Oblique view for cervical intradiscal access. Blue, • Fig 12.44 Lateral view of intradiscal placement.
Internal jugular vein; bright red: carotid artery; brown, esophagus; D,
disc entry point; dark red, vertebral artery.
• O nly in the lateral view, further needle advancement
is done to prevent the needle from violating the spinal
canal and cord.
• In this view, the needle should not be advanced beyond
the midpoint of the disc (Fig. 12.44).
• Since the nucleus is anterior to the midline compared to
the lumbar spine, the needle will be in the nucleus.
• Option to use dye confirmation to ensure the needle is
within the nucleus pulposus and for diagnostic discography.
• The injectionist may choose to avoid dye also as
the volume of the nucleus is usually 0.5 mL or less
and want to use that volume for the orthobiologic.
Contrast dye has been observed to have a dose-depen-
dent effect on MSC in regard to cytotoxicity.
• Injection should be done slowly with as minimal pres-
sure as possible to prevent disc rupture. After injection,
remove the needle slowly.

PEARLS AND PITFALLS

• D
 iscitis: Although rare, discitis is a devastating complica-
tion. Unfortunately, it is also a very painful condition.
• If not recognized early, it can spread to the vertebral
• Fig 12.43 Needles very close to the uncinate process. bodies resulting in their collapse and possible
serious neurological sequelae.
• Increasing pain 1 to 2 weeks after the procedure
Target
should alert the suspicion of discitis.
• A s soon as the disc is entered, further advancement • MRI with contrast is the best diagnostic tool to
should be stopped immediately. detect discitis.
• A true lateral view is obtained where the vertebral bodies • Usually, the erythrocyte sedimentation rate (ESR)
are seen as squares and the discs seen clearly. and C-reactive protein [CRP] are elevated. The WBC
count may or may not be elevated.
• Occasionally, the shoulders impair the view at the
• Fever is not a consistent finding.
C6-7 and C7-T1 levels. • If the diagnosis of discitis is made, the patient
• An assistant should pull the arms down, then imaging should be admitted, and an infectious disease
is repeated. consult should be obtained. Neurosurgical
• This maneuver usually enhances the visualization of consultation is also recommended, especially if any
neural deficits are noted.
the lower cervical discs.
162 SEC T I O N I I I Atlas

PEARLS AND PITFALLS—CONT’D lies in front of the C7 transverse process, and the first
thoracic ganglion lies in front of the neck of the first
• D  iscitis requires aggressive intravenous antibiotics. It
is imperative to get blood cultures and disc cultures
rib.
prior to the initiation of antibiotics. In most cases, • The stellate ganglion measures approximately 2.5 cm in
the cultures are negative. However, if they are length, 1 cm in width, and 0.5 cm in thickness (see Fig.
positive, it will help in selecting the right antibiotics. 12.20A).60
• Needle transgression through the esophagus on its
way into the disc increases the chances of discitis.
• Penetration of the great vessels:
Common Pathology
• The location of the vertebral artery is highly variable. • Th
 ere is increasing evidence for SB effectiveness in
If the needle is anterior to the uncinate process • CRPS types 1 and 2
in the oblique view, the risk of encountering the • postherpetic neuralgia (PHN)
vertebral artery is low. • intractable angina
• Violating the spinal canal:
• As soon as the needle is in the annulus, it is
• hyperhidrosis
mandatory to check the lateral view before • trigeminal neuralgia
advancing the needle further. The needle should be • arrhythmias.61
advanced very cautiously in the lateral view. The final • post-traumatic stress disorder (PTSD)
needle position should never be beyond the middle
of the disc in the lateral view.
• Avoiding the Spinal Nerve:
Equipment
• Avoid the spinal nerve by staying anterior to the • L inear transducer ultrasound and/or C-arm fluoroscopy
neural foramen. • 25 gauge 2.0 to 3.5 inch spinal needle
• Risk of Pneumothorax: • Contrast agent (omnipaque or isovue) if using fluoroscopy
• This complication is possible at the C7-T1 level.
   Common Injectates
• Local anesthetics
Clinical Studies
Injectate Volume
Stellate Ganglion Block
• 2 to 5 mL if using ultrasound, 10 mL if using fluoroscopy
KEY POINTS Ultrasound Technique
• S tellate ganglion block (SGB) is one of the oldest and Patient Position
a very common sympathetic block that is applied • Th
 e patient is in a supine position.
today. • The head is turned away from the side of the procedure.
• SGB can be done, under fluoroscopy or with Clinician Position
ultrasound. • Ipsilateral side of the patient
• The authors feel that ultrasound guidance is preferred
for the following reasons: Transducer Position
• SG lies in the fascial plane between the carotid • The transducer is placed at the base of the neck in the
artery and longus colli muscle which can be easily midline around the C6-7 level.
appreciated with ultrasound. This increases the • After the trachea and thyroid are visualized, it is then
accuracy of the block. moved laterally until the carotid artery is seen.
• Moreover, only bony landmarks are seen under
fluoroscopy, and they are only surrogate markers for • Posterolateral to the carotid artery, the longus colli mus-
the SG. cle should be identified (Fig. 12.45).
• The location of the carotid artery, vertebral artery, • Identification of the carotid artery and longus colli mus-
and the recurrent laryngeal nerve can be assessed cle is key to the performance of this block.
under ultrasound, making it a safer procedure. • The SG lies in the plane between these two structures.
• If available, confirm with fluoroscopy and contrast after
ultrasound-guided procedure. Needle Position
• Using an "in-plane" approach, the needle is advanced
  
from the lateral side towards the medial structures.
Target
Pertinent Anatomy • The needle should be targeted posterolateral to the
• The cervical sympathetic chain is composed of superior, carotid artery and anterior to the longus colli muscle.
middle, and inferior cervical ganglia. • Do not inject if the needle if the needle tip is not visual-
• In about 80 % of the cases, the inferior cervical ganglion ized. This is mandatory as there is a risk of injecting into
is fused with the first thoracic ganglion, forming the cer- the carotid resulting in seizures, immediate loss of con-
vicothoracic ganglion, also known as the stellate ganglion sciousness, and respiratory arrest.
[SG]. • Separation of the carotid artery from the longus colli by
• If the inferior cervical ganglion and the first thoracic the local anesthetic should be seen.
ganglion are not fused, the inferior cervical ganglion • 2 to 10 cc of local anesthetic is injected.
 CHAPTER 12 Cervical Injection Techniques 163

CA

NT

LC VA

• Fig 12.45 Needle seen in between the carotid artery and the longus
colli muscle. CA, Carotid artery; LC, longus colli; NT, needle tip; VA,
vertebral artery.
O

CA

• Fig 12.47 Right oblique view of the cervical spine showing the site for
stellate ganglion block. This is marked by "O", which is the junction of
the uncinate process and the vertebral body (C6 or C7).

LC Fluoroscopic Technique
Patient Position
• P lace the patient in a supine position with the new
slightly extended (roll under the neck and shoulders),
• Fig 12.46 Separation of carotid artery from longus colli with local
and the head rotated slightly to the contralateral side to
anesthetic. Needle is away from the carotid artery. CA, Carotid artery;
LC, longus colli. be blocked.62
Clinician Position
• Th
 e presence of Horner’s syndrome [ptosis, myosis, • The opposite side of the base of the C-arm
and redness of the ipsilateral eye] within 5 minutes and Transducer Position or C-Arm Position Fluoroscopy
increased temperature of the arm within 10 minutes Technique
indicates a successful block. • In the AP view, caudocranial angulation of the C-arm is
done to maximize the disc space of the C5-6 disc.
PEARLS AND PITFALLS
• Subsequently, the fluoroscope is rotated obliquely, ipsi-
lateral to the side where the blockade is desired.
• T he most dreaded complication is seizures, loss of • Rotate until the C5-6 neural foramen is maximized.
consciousness and respiratory arrest from injecting the Needle Position
local anesthetic into the carotid or vertebral artery.
• The airway should be supported, and if needed the
• Start the needle at the junction of the uncinate process
patient should be intubated. and the vertebral body.
• If seizures do not abate, intravenous valium or sodium • Palpate for the carotid artery, which should be medial to
pentothal should be administered. the entry point using this technique.
• If arrhythmias are noted, ACLS protocol should be • Under real-time fluoroscopy, a single pass is made with a
followed.
• If this procedure is done in an office setting, 911 should
spinal needle to contact the bone.
be called immediately. Target
• The risk of injecting the vertebral artery is extremely • The needle tip should be contacting and resting at the
low with the technique described above, as it is further junction between the uncinate process and the vertebral
away from the injection site (see Fig. 12.45). body (Fig. 12.47).
• Since the vagus nerve lies in the carotid sheath, care
must be taken to avoid injecting the carotid sheath.
• Withdraw the needle 2 to 3 mm
• The recurrent laryngeal nerve can be blocked and will • Inject a small amount of contrast material, ideally using
lead to temporary hoarseness. digital subtraction angiography, to confirm no intravas-
• Injecting the spinal canal and the spinal nerves is rare cular uptake and dye spread along the longus colli muscle
with this procedure if done as described above. (Fig. 12.48A and B).
   • Inject local anesthetic after negative aspiration of blood.
164 SEC T I O N I I I Atlas

A B
• Fig 12.48 (A) Right oblique view showing the spread of the contrast material. (B) AP view showing the
contrast spread from C5 to C7 (Courtesy Vivek Manocha.)

9. Centeno C, Elliot J, Elkins WL, Freeman M. Pain Physician.

PEARLS AND PITFALLS
2005;81:67–72.
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lalba. Rare case of ischemic stroke following cervical transforimi- diagnosis of acute intravertebral disc injuries in the cervical
nal injection. Eur J Case Rep Intern Med. 2019;6(3):001082. spine. ROFO Fortschr Geb Roentgenstr Neuen Bildgeb Verfahr.
38. Ziai WC, Ardelta AA, Llinas RH. Brainstem stroke following 1983;139:651–657.
uncomplicated cervical epidural steroid injection. Arch Neurol. 59. Yin W, Bogduk N. The nature of neck pain in a private pain
2006;63(11):1643–1646. clinic in the United States. Pain Med. 2008;9(2):196–203.
39. Bogduk N. In: Clinical Anatomy of the Lumbar Spine and Sacrum. 60. Narouze S, et al. Ultrasound-guided stellate ganglion block:
3rd ed. New York: Churchill Livingstone; 1997. safety and efficacy. Curr Pain Headache Rep. 2014.
40. Hogan QH. Epidural anatomy examined by cryomicrotome 61. Gunduz OH, Kenis-Coskun O. Ganglion blocks as a treatment
section: influence of age, vertebral level and disease. Reg Anesth. of pain: current perspectives. J Pain Res. 2017;10:2815–2826.
1996;21:295–306. 62. Abdi S, Zhou Y, Patel N, Saini B, Nelson J. A new and easy
41. Fenton DS, Czervionke LF. Image-guided Spine Intervention. technique to block the stellate ganglion. Pain Physician.
Saunders; 2003:101. 2004;7(3):327–331.
42. Parkin IG, Harrison GR. The Topographical anatomy of the lum-
bar spine. J Anat. 1985;141:211–217.
13
Thoracic Injection
Techniques
M ARKO BODOR, STEPHEN DERRINGTON, JOHN PITTS,
JASON MARKLE, AND ORLANDO LANDRUM

KEY POINTS • Th
 e thoracic spine has a major impact on alignment of the
entire spine. These changes in alignment can have both clini-
• T he thoracic spine is a common source of mid-back cal and subclinical effects on a person’s biomechanical health.
pain and is frequently overlooked despite it having the
• Three important measurements affecting biomechanics
greatest number of levels and the greatest diversity
between vertebral levels. and pain are:
• For injections, it is important to confirm the correct level. • Coronal balance
Identify the appropriate level by starting at either the first • Sagittal vertical axis
or twelfth rib and counting from there. • Pelvic incidence.
   • The artery of Adamkiewicz may originate from a seg-
mental artery between T7 and L4, typically on the left
side.
Pertinent Anatomy1–6 • Concerns with thoracic injections include adjacent
• Th
 e thoracic spine contains 12 levels, compared to 7 in vascular structures (bleeding from non-compressible
the cervical and 5 in the lumbar spine. arteries and/or veins), lung puncture (resulting in
• See Figs. 13.1–13.3. pneumothorax), cardiac (direct cardiac injury or sec-
• The T2-T9 thoracic vertebrae have costovertebral and ondary tamponade), sympathetic chain side effects
costotransverse articulations of the rib with the verte- (hypotension) spinal cord or intrathecal injection (see
bral body and the rib with the transverse process. The Fig. 13.3).
wedge shape of these vertebrae results in the kyphotic Ultrasound Guided
curve of the thoracic spine.
• The other vertebrae of the thoracic spine are similar Supraspinous and Interspinous Ligaments
to either the cervical vertebrae (T1) or lumbar spine
(T10-T12). KEY POINTS
• Typical ligamentous anatomy includes anterior longitu-
These ligaments can be targeted in isolation for specific
dinal ligament (ALL), posterior longitudinal ligament injuries but are more commonly treated in combination with
(PLL), ligamentum flavum, interspinous ligament, supra- other components of the functional spinal unit,7,8 including
spinous ligament (SSL), and intertransverse ligaments. the spinal nerves in the epidural space, facet joints, paraspinal
• Qualities unique to the thoracic spine include: muscles, and occasionally the intervertebral discs.
• Radial and intraarticular ligaments (costovertebral   
articulation—connection of the head of the rib with
the vertebral body)
• Superior and lateral costotransverse ligaments (cos- Pertinent Anatomy
totransverse articulation—connection of the neck/ The interspinous ligament (ISL) is a thin membranous
tubercle with the vertebral body) ligament that connects adjacent spinous processes. The lig-
• Thoracic facet joints have a different orientation than ament spans from the root to the apex of each spinous pro-
cervical or lumbar facets, approximately 60 degrees cess, anteriorly to the ligamentum flavum and posteriorly to
superiorly and 20 degrees anteriorly. the nuchal ligament.

166
 CHAPTER 13 Thoracic Injection Techniques 167

Subarachnoid space Dorsal root ganglion

Intervertebral disc
Epidural space

Medial branch of
spinal nerve

Spinous process
Facet joints

• Fig. 13.1 Thoracic Spine Anatomy. Note the relationship of the medial branch nerve as it innervates the
joint.

Pedicle

Safe triangle

Kambin's triangle

Intervertebral disc

Dorsal root ganglion

• Fig. 13.2 Thoracic Spine Anatomy of the Neural Foramen.

Posterior
longitudinal ligament

Costotransverse
joint
Supraspinous
ligament
Anterior
Intertransverse
longitudinal ligament
ligaments

Interspinous
ligament

Costovertebral
joint Costotransverse
ligament

• Fig. 13.3 Thoracic Spine Ligamentous Anatomy.

168 SEC T I O N I I I Atlas

The supraspinous ligament (SSL) is a thin membranous Injectate Volume

ligament and lies superficial to the spinous processes of the 0.25 to 1 mL at each spinal level
thoracic spine overlying the interspinous ligament. Prolotherapy, orthobiologics
Common Pathology Needle: 25- to 27-gauge 1.5- to 2-inch needle
Ligament strain, partial tear,9 relative laxity related to disc,
PEARLS AND PITFALLS
and facet pathology.10
• T
 hese ligaments are difficult to visualize entirely, so
Equipment adjacent and adjoining anatomy needs to be visualized.
Ultrasound machine with high-frequency linear transducer.   

Technique
Thoracic Facet Joints
Patient Position
Prone
KEY POINTS
Clinician Position Whereas the fluoroscopic approach to the lumbar facet
At the side of the patient, with the ultrasound monitor next joints is typically at 0 to 45 degree rotation, the thoracic
to or on their opposite side. facet joint is oriented at 90 to 110 degrees, which needs to
be taken into consideration when assessing the joints with
ultrasound.
Transducer Position
Long axis to the ISL and SSL with visualization of ligaments   
and spinous processes (Fig. 13.4).
Pertinent Anatomy
Needle Position Facet joint
In plane (author preference) or out of plane
Common Pathology
Target Osteoarthritis, rotational scoliosis
Direct injection into the ligaments at the desired spinal
level, injecting into areas of hypoechogenicity and through- Equipment
out the ligament, including the bony attachments. Filling of Ultrasound machine with low-frequency linear or a cur-
interstitial injuries can be seen with injectate. vilinear transducer, which provides better visualization of
• In plane: deeper structures and a wider field of view.
• With ligaments in long axis, introduce the needle
in plane to the transducer with or without a gel Technique
stand-off to minimize anisotropy. Needle tip should Patient Position
be advanced to the spinous process to inject at the Prone
SSL, then walked and advanced into the interspi-
nous space for the ISL. Clinician Position
Clinician preference for optimal needle guidance and ultra-
sound transducer control, typically at the patient’s side with
ultrasound monitor next to or on their opposite side.
SSL
Transducer Position
Midline along the long-axis, initially flat on the skin, but then
SP angled 10 to 20 degrees medially to be perpendicular to the artic-
SP ISL
ular processes, which slope down from the midline to laterally.

Needle Position
Caudad-cephalad needle direction, in-plane visualization
(Fig. 13.5).

Target
Facet joint opening
• Fig. 13.4 Supraspinous and Interspinous Ligaments. Longitudinal
view of supraspinous ligament (SSL) and interspinous ligament (ISL) Injectate Volume
with adjacent spinous processes (SP). Needle visualized in plane,
passing through the SSL into the ISL. Needle will be repositioned to 0.25 to 1 mL
cover the entire ISL and SSL of the target spinal segment. Dextrose prolotherapy, orthobiologics
 CHAPTER 13 Thoracic Injection Techniques 169

SP

TP Rib
Lung pleura
IAP SAP

• Fig. 13.5Thoracic Facet. Inferior articular process (IAP) from cepha-

• Fig 13.6 Thoracic Costal Facet. Target is articulation of the rib to the
transverse process (TP). Lung pleura can be seen deep to the rib if the
lad vertebra and superior articular process (SAP) from caudal vertebra.
rib is not parallel to the cartilage throughout the length of the transducer.
Arrow demonstrates needle trajectory into joint.
Arrow demonstrates needle trajectory into joint. SP, Spinous process.

Transducer Position
Transverse, with ultrasound transducer overlying the head
PEARLS AND PITFALLS of the rib and transverse process (Fig. 13.6).
Advanced ultrasound skills are required. Keep the needle and
target in view at all times. Missing the target and going too deep
Needle Position
laterally risks penetration into the lung, while going too medially In-plane needle visualization, lateral to medial approach
risks penetrating the thecal sac. An echogenic or large-caliber
can be helpful to optimize visualization, which can otherwise be Target
difficult because of multiple overlying fascial planes. Posterior costal facet, costotransverse ligaments
  
Injectate Volume
Thoracic Costotransverse Joints 0.25 to 0.75 mL
Dextrose prolotherapy, orthobiologics

KEY POINTS PEARLS AND PITFALLS

Important structure to consider in patients with chest and Keep the needle and target in view at all times. Missing the
abdominal pain, difficulty breathing, or paresthesia in this area. target risks going into the pleura or thecal sac.
     

Costochondral Joints
Pertinent Anatomy
Rib head, transverse process (TP) of thoracic vertebra KEY POINTS

Common Pathology Important structure to consider in patients with chest pain,

abdominal pain, difficulty breathing, or paresthesia in this
Damaged or stretched ligaments from trauma11,12 or hyper- area. It is important to visualize the sternum, adjacent costal
mobility syndromes, osteoarthritis cartilage (typically hypoechoic), and rib (hyperechoic with
typical bony acoustic shadowing).
Equipment Identify rib, costal cartilage, articulation at desired level,
and lung pleura.
Ultrasound machine with high-frequency linear transducer
  
Technique
Patient Position Pertinent Anatomy
Prone Sternum, rib cartilage, lung pleura

Clinician Position Common Pathology

At the side of the patient, with the ultrasound monitor next Damaged or stretched ligaments from trauma11,12 or hyper-
to or on the opposite side mobility syndromes, osteoarthritis
170 SEC T I O N I I I Atlas

Costal cartilage

Sternum
Costal cartilage

Rib

Lung pleura

• Fig. 13.7 Costochondral Joint. The articulation of costal cartilage

and rib can be visualized. Arrow demonstrates needle trajectory into
• Fig. 13.8 Sternocostal Joint. Lung pleura can be visualized deep
to the costal cartilage if the transducer is not parallel to the cartilage
joint from lateral to medial.
throughout the length of the transducer. Arrow demonstrates needle
trajectory into joint.
Equipment
Ultrasound machine with high-frequency linear transducer Pertinent Anatomy
Sternum, costal cartilage, sternocostal joint, pleura of the lung.
Technique
Patient Position Common Pathology
Supine Damaged or stretched ligaments from trauma11,12 or hyper-
mobility syndromes, osteoarthritis
Clinician Position
At the side of the patient, with the ultrasound monitor next Equipment
to or on the opposite side Ultrasound machine with high-frequency linear transducer

Transducer Position Technique

In plane, with costochondral joint (Fig. 13.7). Patient Position
Supine
Needle Position
In plane: lateral to medial approach Clinician Position
At the side of the patient, with the ultrasound monitor next
Target to or on the opposite side
Costochondral joint
Transducer Position
Injectate Volume Axial to the patient, in line with the sternocostal joint (Fig.
0.5 to 1.0 mL 13.8).
Prolotherapy, orthobiologics
Needle Position
PEARLS AND PITFALLS Medial to lateral or vice-a-versa depending on the side
Keep the needle and target in view at all times. If the needle
deviates away from view, it can easily bypass the target, go Target
into the pleura, and cause a pneumothorax. Sternocostal joint
  
Injectate Volume
Sternocostal Joints 0.5 to 1 mL
Dextrose prolotherapy, orthobiologics
KEY POINTS
Important structure to consider in patients with chest pain, PEARLS AND PITFALLS
abdominal pain, difficulty breathing, or paresthesia in this
area. It is important to visualize the sternum, adjacent costal Keep the tip of the needle in view at all times to avoid going too
cartilage (typically hypoechoic), and rib (hyperechoic with deep and causing pneumothorax. Avoid vascular structures
typical bony acoustic shadowing). and aspirate prior to injection to avoid intravascular injection.
     
 CHAPTER 13 Thoracic Injection Techniques 171

Sternoclavicular Joints Clinician Position

For in-plane needle visualization, at the side of the patient
KEY POINTS with the ultrasound monitor next to or on the opposite side
of the patient.
Clarify anatomy of sternum and clavicle; use real-time For out-of-plane visualization, at the patient’s side and
ultrasound visualization to maintain safe depth. ipsilateral to the joint being treated, with the ultrasound
   screen at or near the patient’s head.

Pertinent Anatomy Transducer Position

Clavicle, sternum, sternoclavicular (SC) joint Overlying the clavicle and sternum, spanning the SC joint

Common Pathology Needle Position

Damaged or stretched ligaments from trauma, osteoarthri- Author’s preference: in-plane needle visualization. Slide
tis, capsular strain the ultrasound transducer so that the SC joint lies close to
its edge, reducing the distance from needle to target (Fig.
Equipment 13.9).
Ultrasound machine with high-frequency linear transducer. Alternative: out of plane. Ensure the transducer is cen-
tered and perpendicular to the joint; use the scale on the
Technique monitor to determine target depth, then insert needle, err-
Patient Position ing on the side of being shallow at first.
Supine

Sternum

C
Sternum Clavicle

B
• Fig. 13.9(A to C) Sternoclavicular (SC) joint. Transducer parallel to the clavicle and spanning the SC joint.
Out of plane: needle insertion midline to the transducer. White dot demonstrates target location. In plane:
needle insertion lateral to medial (arrow), with joint offset near edge of transducer to reduce the distance
the needle will travel to get to the target.
172 SEC T I O N I I I Atlas

Target Clinician Position

Sternoclavicular joint • T
 o the side of the patient contralateral to fluoroscopy
unit base
Injectate Volume
0.5 to 1 mL C-Arm Position Fluoroscopy
Prolotherapy, orthobiologics • A ngulate the C-arm to “square off” the level to be
injected.
PEARLS AND PITFALLS • Rotate 25 to 45 degrees to optimize foraminal view
between superior articular process (SAP) of the lower
Use three fingers to hold the transducer and the remaining vertebral bone and rib. Keep the lung field line lateral to
two to stabilize the transducer on the joint. Keep the needle in
view at all times for an in-plane approach, and err on the side the vertebral body.
of going shallow for an out-of-plane approach. Missing the • Use lateral view to check depth as needle nears target.
joint risks penetration into the pleura or great vessels. • Use anteroposterior (AP) view to check needle position
   and confirm epidural contrast flow.

Fluoroscopy Guided Needle Position

Thoracic epidurals • A im for the posterior lateral disc space passing between
the rib head laterally and the SAP medially (Fig. 13.10A
and B).
KEY POINTS • Visualize the lung field and keep the needle medial to the
• T o appropriately identify level, “square off” endplates to lung.
adjust for parallax error. • Guide the needle with “tunnel” view orientation, peri-
• Epidural approach is similar to intradiscal approach. odically checking the AP view to ensure the needle does
   not go spinal medial to the pedicles.
• Once the needle is advanced deeper, the tip can be
positioned over the vertebra to avoid entering the disc.
• If the needle touches the periosteal surface, it should be
Pertinent Anatomy pulled back 1 to 2 mm.
•  ambin’s
K
• spinal nerve Target
• rib head • I nferior aspect of intervertebral foramen at level of disc
• vertebral body (Fig. 13.2). • Once the needle is close to the foramen, check the
• intervertebral disc lateral view. Needle should be in the central to ante-
rior aspect of the foramen posterior to the inferior
Common Pathology endplate.
•  adiculitis
R • Check the AP view; the needle should not be beyond
• Disc herniation the 6 o’clock position of the inferior aspect of the
• Endplate modic changes pedicle.
• Intervertebral narrowing • Inject and observe contrast flow using live fluoroscopy,
ideally digital subtraction angiography. There should be
Equipment anterior epidural flow in the lateral view and flow medial
• C -arm fluoroscopy to the pedicle and around the nerve in the AP view (see
• 25- to 22-gauge 3- to 3.5-inch spinal needle for transforami­ Fig. 13.10C and D).
nals
• 20- to 21-gauge 3.5-inch Tuoy needle for interlaminar

Common Injectates PEARLS AND PITFALLS

• L ocal anesthetics • T
 he rib and SAP position can vary, so observe the
• Corticosteroids spaces between the bones before starting the injection
• Orthobiologics (platelet lysate, dextrose neuroprolotherapy) but maintain trajectory in Kambin’s triangle.
  
Injectate Volume
• 1 to 5 mL

Technique for Transforaminal Infraneural Approach Technique: interlaminar

Patient Position Patient Position
• Prone • Prone
 CHAPTER 13 Thoracic Injection Techniques 173

Clinician Position Needle Position

• To the side of the patient, opposite the C-arm • Th
 e authors prefer paramedian approach, so start needle
slightly off from midline on the more symptomatic side.
C-Arm Position Fluoroscopy • The needle should be started in the interlaminar space
Angulate the C-arm to “square off” the vertebrae at level (Fig. 13.11A and B).
to be injected; make sure the laminae are clearly visualized. • Advance the needle in the AP view, periodically check-
• Obtain a true AP view at the desired level. ing depth in the contralateral oblique view. Stop at the
• Use the contralateral oblique view to assess depth once ligamentum flavum behind the spinolaminar line in the
the needle is near the target. contralateral oblique view.

A B

C D
•Fig. 13.10 (A) Thoracic transforaminal epidural fluoroscopy setup. (B) Thoracic transforaminal epidural
oblique view of needle trajectory. (C) Thoracic transforaminal epidural lateral view with contrast. (D)
Thoracic transforaminal epidural AP view with contrast.
174 SEC T I O N I I I Atlas

• A lternatively, the needle can be advanced towards the Target

superior border of the caudal lamina to touch the perios- • O nce loss of resistance is met, the needle should be in the
teal surface and ascertain depth in the AP view. Once the posterior epidural space.
needle touches the lamina, “walk” the needle superior to • Aspirate first to ensure no cerebrovascular fluid (CSF) or
the ligamentum flavum and confirm in the contralateral vascular flow, then slowly inject contrast.
oblique view. • Confirm epidural flow in both contralateral oblique and
• Once the needle is at the ligamentum flavum, attach a AP views.
loss of resistance syringe filled with normal saline. • In the contralateral oblique view, the contrast should
• Advance the needle in the contralateral oblique view, obtain- be just anterior to the spinolaminar line (see Fig.
ing an image after each advancement (see Fig. 13.11C). 13.11D).

A B C

D E F
• Fig. 13.11 (A) Thoracic interlaminal epidural (ILE) paramedial approach setup. (B) Thoracic ILE anteroposte-
rior (AP) needle trajectory. (C) Thoracic ILE contralateral oblique view setup with loss of resistance syringe. (D)
Thoracic IL contralateral oblique view with contrast. (E) Thoracic IL AP view with contrast. (F) Thoracic ILE lateral
view with contrast.
 CHAPTER 13 Thoracic Injection Techniques 175

• I n the AP view, it should look irregular due to epi-

dural fat and mostly on the side of the needle (see Fig.
13.11E).
• Option to view in the lateral view as well (see Fig.
13.11F).

PEARLS AND PITFALLS

• In the contralateral oblique view, the needle can appear
more anterior than it actually is.
• If the needle is advanced where it appears too far
anterior, but loss of resistance is not met, check the AP
view to ensure the needle did not travel too far laterally.
• Possible complications include CSF leak or epidural Clavicle
hematoma.
  
Sternum

Sternoclavicular and Sternocostal Joints

KEY POINTS
• Fig. 13.12 Sternoclavicular joint injection with contrast.
• Identify and clarify anatomy of sternum and clavicle
prior to injection.
• Palpate tender joint(s) prior to the injection.
  

Technique
Pertinent Anatomy Patient Position
• Th
 e sternoclavicular joint is a diarthrodial saddle joint • Supine
with an intraarticular disc.14
• The sternocostal joints are formed between the sternum Clinician Position
and medial end of the costal cartilage from ribs one to • Standing on the side of patient opposite the C-arm
seven. The first rib joint is cartilaginous, and the remain-
der are synovial joints surrounded by a capsule.15 Fluoroscopy Position
• D irect AP view, optimizing view of desired joint
Common Pathology • Cephalad tilt is often required to best visualize joint
•  raumatic, degenerative, or inflammatory arthritis16
T space best.
• Osteitis condensans of the clavicle17
• Costochondritis Needle Position
• Tietze’s syndrome: rare inflammation, swelling, and pain • “ Tunnel” view orientation in anterior to posterior
at sternocostal joints18 approach, starting over the desired joint (Fig. 13.12A).

Equipment Target
• C -arm fluoroscopy • S ternoclavicular joint or costochondral joint
• 25-gauge 2-inch needle • Inject a small amount of contrast to confirm intraar-
ticular placement and no vascular uptake (see Fig.
Common Injectates 13.12B)
•  nesthetic for diagnostics
A • Can also inject joint capsules while using orthobiologics
• Corticosteroids if there is instability
• Prolotherapy
• Orthobiologics (platelet-rich plasma [PRP], bone mar-
row concentrate) PEARLS & PITFALLS
Injectate Volume • Avoid going too deep to avoid pneumothorax.
• 0.5 to 1 mL   
176 SEC T I O N I I I Atlas

Thoracic Rib Facets (Costotransverse Joints)

KEY POINTS
• P
 ain coming from the costotransverse joints is often
underdiagnosed.
  

Pertinent Anatomy
• Th
 e joints form from the tubercle of the rib and the
transverse process.
• The articular surface is curved in the cephalad 5 to 6
joints and flattened in the caudal joints.
• The joint openings are at 45 to 60 degrees rotation; thus
for straight needle path the C-arm needs to be rotated.
• The joints are surrounded by a thin capsule.
• Costotransverse ligament and the superior and lateral
costotransverse ligaments19 (see Fig. 13.1)

Common Pathology
A
• J oint degeneration is most likely due to trauma or
inflammation20
• Joint instability due to trauma.21
• The pain pattern is superficial and adjacent to the joint.22

Equipment
• C -arm fluoroscopy machine
• 25-gauge 2- to 3-inch needle

Common Injectates
•  nesthetic for diagnostics
A
• Corticosteroids
• Dextrose prolotherapy
• Orthobiologics (PRP, bone marrow concentrate)

Injectate Volume
• 0.5 to 1 mL

Technique
Patient Position B
• Prone • Fig. 13.13
(A) Costotransverse joint injection with contrast. (B). Upper
costotransverse injection with contrast.
Clinician Position
• Standing on the side of patient opposite the C-arm Target
• R ib joint connection to the TP
Fluoroscopy Position • Inject a small amount of contrast to confirm intraarticu-
• “ Square off” endplates with cephalad angulation for lar placement (Fig. 13.13A and B).
upper levels; possible caudal angulation for lower levels. • Can also inject joint capsule if instability is present and
• Ipsilateral oblique 15 to 45 degrees rotation to optimize using prolotherapy or orthobiologics.
joint visualization.
PEARLS AND PITFALLS
Needle Position • B e sure the needle stays over the boney structures to
• “ Tunnel” view posterior-lateral to anterior-medial approach. avoid going too deep and risking pneumothorax.
• Can start needle just over the lateral border of the trans- • Avoid injury to the subcostal neurovascular structure
verse process to touch down on the periosteal surface, just below the ribs.
then slightly redirect into the joint.   
 CHAPTER 13 Thoracic Injection Techniques 177

Thoracic Intraarticular Facet Joint Injection • Th

 e needle will be angled close to about 60 degrees, aim-
ing towards the targeted pedicle/inferior aspect of the
KEY POINTS SAP.
• The needle should be about 1cm from the middle; be
• T
 horacic facet joints have different angulation than sure not to advance more lateral to avoid the lung field.
lumbar and cervical facets.
• Once the needle touches the inferior SAP, switch to the
   contralateral oblique view. Advance the needle superior
and anterior into the joint.
Pertinent Anatomy
• Th
 oracic facets are oriented much more coronal than cer- Target
vical and lumbar facets. • M id portion of the facet joint in the AP view.
• The medial border of the thoracic facets is about 9 to 10 • Inject contrast to confirm intraarticular flow in the con-
mm from the posterior midline of the spine. tralateral oblique and AP views (see Fig. 13.14C and D).
• The superior articular process (SAP) emanates from
the upper part of the pedicle and lies caudal with the
articular surface facing dorsal. PEARLS AND PITFALLS
• The inferior articular process emanates from the lower • H aving a curve on the needle helps navigation.
part of the pedicle and lies cephalad with the articular • On AP view keep needle in line with the pedicles to
surface facing ventral23 (see Fig. 13.1). avoid migrating medially into the spinal canal or laterally
into the lung.
Common Pathology • Use the contralateral oblique view to ensure the needle
does not travel too far anterior into the epidural space/
• F acet arthropathy; 34% to 48% of patients’ pain with intradural.
upper and mid-back pain comes from the thoracic facets.24 • Use a shallow angle to enter the joints due to the
• Scoliosis can lead to facet arthropathy.25 coronal orientation of the joints.
  
Equipment
• C -arm fluoroscopy
• 25- to 22-gauge 3- to 3.5-inch needle Medial Branch Blocks and Radiofrequency
Common Injectates Ablation for Facet Joint Pain
•  ocal anesthetic
L
• Corticosteroids KEY POINTS
• Dextrose prolotherapy • B e mindful of medial branch block (MBB) numbering
• Orthobiologics (PRP, bone marrow concentrate) and varying position of the nerves at the lowest 2
thoracic levels.
Injectate Volume • For radiofrequency ablation (RFA), a successful
• 0.5 to 1 mL diagnostic blockage must first be performed to confirm
facetogenic pain.
• To denervate one joint, two medial branch nerves must
Technique be targeted.
Patient Position
  
• Prone

Clinician Position Pertinent Anatomy

• Standing on the side of patient opposite the C-arm • Th
 e medial branch arises from the dorsal ramus and
travels in the intertransverse space before curving
Fluoroscopy Position dorsally over the superior lateral aspect of the trans-
• A P view and identify target level. Use this view to start verse process (target for block) for the T1-T10 medial
needle trajectory, particularly for medial and lateral branches.
alignment. • After crossing the transverse process, the nerve travels
• Contralateral oblique view to make final needle adjust- dorsally, inferior, and medially along the TP. It then
ments and ascertain depth safety. branches to the inferior aspect of the joint at the level
and the superior aspect of the joint below the level.
Needle Position • The thoracic facets are innervated by two median
• I n the AP view start the needle over the pedicle 2 lev- branches: one from the somatic nerve at the level of the
els below the targeted facet. For example, if injecting the joint and one from above.
T7-8 facet, start the needle over the T10 pedicle (Fig. • The medial branches are named by the somatic nerve
13.14A and B). they originate from, which in the thoracic spine are
178 SEC T I O N I I I Atlas

B C D
• Fig. 13.14 (A) Thoracic facet setup. (B) Thoracic facet needle start point over T10 pedicle for injection of
T8-9 facet. (C) Thoracic facet injection with contrast contralateral oblique view. (D) Thoracic facet injection
with contrast contralateral AP view.

from one level above the transverse process they tra- Common Pathology
verse over. For example, the T8-9 thoracic facet joint • Th
 oracic facet–mediated pain secondary to trauma, defor-
is innervated by the T7 and T8 medial branches. The mity, osteoarthritis.
T7 medial branch innervates the inferior aspect of
the T7-8 facet and superior aspect of the T8-9 facet, Equipment
whereas the T8 medial branch innervates the inferior • C -arm fluoroscopy
aspect of the T8-9 facet and superior aspect of the • 25- to 22-gauge 3- to 3.5-inch needle
T9-10 facet.
• The T11-T12 medial branches travel over the SAP and Common Injectates
transverse process junction at T12 and L1, similar to the • L ocal anesthetic
lumbar medial branches26 (see Fig. 13.1). • Corticosteroids
 CHAPTER 13 Thoracic Injection Techniques 179

Injectate Volume
• 1 to 2 mL

Technique for Medial Branch Block

Patient Position
• Prone

Clinician Position
• Standing on the side of patient opposite the C-arm

Fluoroscopy Position
• A
 P view and “square off” vertebrae of the targeted area,
then rotate 10 degrees contralateral oblique.

Needle Position
• “ Tunnel” view with needle tip starting over the superior
lateral aspect of the transverse process for T1-T10 medial
branches, and over SAP TP junction for T11-T12 medial
branches.
• Fig. 13.15 Thoracic medial branch block using a 10 degree contralat-
Target eral oblique view to optimize visualization of the transverse processes.
• F or the T1-T10 medial branches, target over T2-T11 A needle is seen targeting the left T7 medial branch (arrow) on the left T8
transverse processes (Fig. 13.15). transverse process (arrowhead). The image is centered away from the
• For the T11-T12 medial branches, target over junction vertebral bodies to reduce beam intensity via the auto-adjust feature.
of SAP and transverse process of T12-L1.
• To denervate the joint, block the 2 corresponding medial
branches. For example, to block T9-10, block the T8 and
• F
 or the T11-T12 medial branches
T9 medial branches over the T9 and T10 transverse pro-
• “Square off” endplates of the desired level, then
cess, respectively.
oblique about 10 degrees contralaterally
• Option to confirm no vascular uptake with contrast
• Use lateral view to track depth
injection.
Needle Position
PEARLS AND PITFALLS For the T1-T10 medial branches:
• K eep the needle tip over the bone at all times to avoid • For RFA, the needle tip starts inferior and medial to the
advancing too anterior or causing a pneumothorax. target so that the final position will cover more area of
• Collimating the image to exclude most of the vertebrae the nerve.
and rotating the C-arm 10 degrees contralateral oblique
• Start over the medial aspect of the rib below the target
can enhance visualization of the TPs.
level.
   • Advance the needle superior lateral and touch down on
the superior lateral transverse process; then obtain a lat-
eral view.
Technique for Medial Branch Radiofrequency For the T11-T12 medial branches, the approach will be
Ablation similar to the lumbar medial branch RFA:
Patient Position • Start inferior one level to the targeted level and guide the
• Prone needle to the SAP TP junction from caudal to cephalad.
• Use contralateral oblique or lateral view to ascertain
Clinician Position depth.
• Standing on the side of the patient opposite the C-arm
Target
Fluoroscopy Position • F or the T1-T10 medial branches: target is just superior and
• F
 or the T1-T10 medial branches: lateral to the T2-T11 transverse processes (Fig. 13.16A).
• AP view and “square off” endplates of the targeted Depth in the lateral should be at the level of the transverse
area process (see Fig. 13.16B).
• Lateral view to advance the needle after touching the • For T11-T12 medial branches: target is over junction of
TP SAP and transverse process of T12-L1.
180 SEC T I O N I I I Atlas

A B
• Fig. 13.16 (A) Radiofrequency ablation (RFA) at target in AP view. (B) RFA at target in lateral view.

• T o denervate, the joint must block the two correspond- Pertinent Anatomy
ing medial branches. For example, block T9-10, block • Th
 e thoracic spinal cord accounts for 40% of the canal
the T8 and T9 medial branches over the T9 and T10 size and the spinal cord lies just posterior to the PLL and
transverse process. disc. Small disc herniation can cause significant ventral
• Option to confirm no vascular uptake with contrast injection. cord compression.27
• spinal nerve
PEARLS AND PITFALLS
• rib head
• U se lateral or contralateral oblique views to ensure the • vertebral body (Fig. 13.2)
needle is not advanced too anteriorly. • intervertebral disc
• Ensure that the needle is placed at an angle so that
there is parallel placement of the tip along the nerve.
• Before the ablation, motor and sensory stimulation
Common Pathology
should be performed to ensure there are no radicular •  isc annular tear
D
symptoms or signs of muscle movement. • Disc bulge/protrusion
• 0.5 mL to 1 mL of local anesthetic is typically injected • Endplate modic changes
after stimulation and before the ablation to improve the
patient’s comfort.
• Thoracic discs are most at risk for injury with combined
• Practitioners vary in their ablation settings; it can be 80 bending and torsion, but less so than lumbar discs due to
to 85 degrees for 60-90 seconds. Some may do 2 or 3 the stability of the ribcage.27
rounds of the ablation, adjusting the RF cannula each
time by a few millimeters to widen the ablation zone. Equipment
   • C -arm fluoroscopy
• 25- to 22-gauge 3- to 5-inch spinal needle
Thoracic Intradiscal
Common Injectates
KEY POINTS • C ontrast for provocative discography
• Orthobiologics (PRP, bone marrow concentrate)
• S ymptomatic thoracic disc herniation is rare. Greater
incident occurs in patients between 40 and 60 years Injectate Volume
old with a slight male predominance.
• At the time of writing, there is no published literature • 1 to 2 mL
for the role of orthobiologics in thoracic disc
disease. Technique
• Intradiscal approach is similar to epidural approach.
Patient Position
   • Prone
 CHAPTER 13 Thoracic Injection Techniques 181

Clinician Position • Th
 e needle should be directed between the rib laterally
• To the side of the patient contralateral to the C-arm and the SAP medially (Fig. 13.17A).
• Visualize the lung field and keep the needle medial to the
C-Arm Position Fluoroscopy lung.
• “ Square off” the disc space at the level to be injected. • Guide the needle in the “tunnel” view orientation.
• Align 25 to 45 degrees oblique view, optimize forami- • Advance the needle into the disc.
nal view between SAP of the lower vertebral bone and • Once the needle enters the disc, adjust using the lateral
the rib. Keep the lung field line lateral to the vertebral and AP views.
body.
• Use the lateral view to confirm depth once the needle is Target
at the target. • M iddle of the disc space in the AP and lateral views (see
Fig. 13.17B and C)
Needle Position • Inject a small amount of contrast to show nucleogram if
• Start the needle over the posterior lateral disc space doing a discogram

A B

• Fig. 13.17 (A) Thoracic intradiscal oblique needle trajectory. (B)

C Thoracic intradiscal needle in the nucleus in AP view. (C) Thoracic intra-
discal needle in the nucleus with contrast lateral view.
182 SEC T I O N I I I Atlas

PEARLS AND PITFALLS Clinician Position

• Standing on the side of the patient opposite of the C-arm
• V isualize and stay medial to the lung line.
• Stay lateral to the dura to avoid intrathecal or spinal
C-Arm Position Fluoroscopy
cord injury.
• Don’t advance too ventral into the disc. • T rue lateral view
• The upper levels can be difficult to have a clear lateral
  
view due to the rib cage and organs.
Superspinous and Interspinous Ligament Needle Position
Injection • P alpate the spinous processes to ascertain midline; con-
sider marking the skin prior to or at the time of the injec-
tion with a marker.
KEY POINTS
• Insert needle aiming for spinous process at the desired
• T he thoracic supraspinous and interspinous ligaments level to ensure midline placement.
are important structures to consider when patients have
thoracic pain with excess kyphosis, hypermobility, or
traumatic injury.
Target
• The thoracic intertransverse ligaments are important to • G ently touch down on the spinous process and inject the
consider in patients with thoracic pain and scoliosis, SSL (Fig. 13.18A).
traumatic injury, or side bending pain. • Redirect the needle superior between the spinous
   processes to inject the interspinous ligaments (see
Fig. 13.18B).
Pertinent Anatomy
PEARLS AND PITFALLS
• Th
 e supraspinous (SS) ligaments course between and just
over the spinous processes28 • U se smallest-length needle possible.
• The interspinous (IS) ligaments course between the spi- • Use two hands when injecting the deeper ligaments to
nous processes28 ensure adequate control of the needle and also to limit
accidental advancement of the needle too deep.
• The intertransverse (IT) ligaments course between and • If unable to obtain a clear lateral picture, only advance
just anterior to the transverse processes28 (see Fig. 13.3) about 1 cm deep so as to not place the needle too
anterior into the thecal sac or spinal cord.
Common Pathology
  
• T raumatic injury
• Thoracic spondylosis, degenerative disease, and wedge frac-
Technique for Intertransverse
tures can cause thoracic ligament laxity (and vice versa).
• Scoliosis: for a lateral curve, the intertransverse ligaments Patient Position
are over stretched with potential increased laxity at the • Prone
convexity of the segmental curve and are possible targets
Clinician Position
for injection.
• Standing on the side of the patient opposite of the C-arm
Equipment
C-Arm Position Fluoroscopy
• C -arm fluoroscopy • T rue AP view, so the spinous process of the desired level
• 25- to 22-gauge 3- to 3.5-inch spinal needle is centered between the vertebral bodies.
• “Square off” vertebral endplate of the desired level
Common Injectates
• Center the transverse process
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.) Needle Position
• Avoid intraligamentous corticosteroids. • Th
 e needle starts over the lateral border of the targeted
transverse process. (For instance, if targeting the T7-8 IT
Injectate Volume ligament, start one needle over the T7 TP and redirect
• 0.5 to 1 mL per area/ligament inferiorly. A second needle will start over the T8 trans-
verse process and redirect superiorly.)
Technique for Supraspinous and Interspinous
Ligaments Target
Patient Position • T
 ransverse ligaments:
• P rone • Either just superior and deep/anterior or inferior and
• Arms above the head to remove the arms from view on deep/anterior to the transverse process to target the
the lateral projection desired superior or inferior band.
 CHAPTER 13 Thoracic Injection Techniques 183

A B C
• Fig. 13.18 (A) Supraspinous ligament in lateral view. (B) Interspinous ligament in lateral view. (C) Interspinous ligament in AP view.

• I nject a small amount of contrast that should show

vertical flow along the ligament superiorly or inferi-
orly, depending on the target.
• Inject both the superior and inferior aspects of the
ligament (Fig. 13.19).

PEARLS AND PITFALLS

• A lways start over and touch down on the periosteal
surface of the transverse process to ascertain depth
and for safety.
• Only advance 1 to 2 mm deep/anterior to the TP to
avoid going too anterior or causing a pneumothorax.
• Medial branches are in close proximity.
• The authors recommend using contrast to confirm
ligamentous spread. This can serve as a diagnostic
injection using an anesthetic agent.
  

Intercostal Nerve Block

KEY POINTS
• U sed for short- or long-term pain relief for thoracic
dermatomal and abdominal pain.29 • Fig. 13.19 Thoracic Intertransverse Ligament with Contrast in AP View.
• Can be done with either fluoroscopy or ultrasonography.30
  
Common Pathology
Pertinent Anatomy •  ainful rib fractures
P
• Th
 e intercostal nerves are the anterior branches of the • Intercostal neuropathy
thoracic nerves. They provide sensory input from the • Herpes zoster32
chest and abdominal walls, and motor innervation to the • Pain related to thoracotomies, cardiothoracic, and breast
intercostal and abdominal muscles. surgeries33-35
• The intercostal neurovascular structures travel through the
intercostal space between the pleura and intercostal membrane. Equipment
• They travel below the rib margin with the vein, artery, • C -arm fluoroscopy
and nerve, from cranial to caudal, respectively.31 • 25-gauge 2- to 3-inch needle
184 SEC T I O N I I I Atlas

PEARLS AND PITFALLS

• D ue to the close proximity of the vasculature, there is a
higher risk of anesthetic uptake, and care that should
be given to the amount of anesthetic used.
Initial contrast flow
• The needle should not be advanced more than 1 to 2
too superficial mm past the dorsal rib margin due to risk of going too
anterior and pneumothorax.
• Avoid bilateral intercostal nerve blocks due to risk of
pneumothorax.
Rib border
  

Contrast
along nerve References
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53486-6.00032-6.
2. Chiou-Tan FY, Miller JS, Goktepe AS, Zhang H, Taber KH.
Sectional neuroanatomy of the upper thoracic spine and chest
[published correction appears in J Comput Assist Tomogr.
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3. Miller JS, Chiou-Tan F, Zhang H, Taber KH. Sectional neuro-
• Fig. 13.20 Intercostal Nerve Block with Contrast in AP View. anatomy of the lower thoracic spine and chest. J Comput Assist
Tomogr. 2007;31(1):160–164. https://doi.org/10.1097/01.
rct.0000237813.26301.73.
4. Miller JS, Goktepe AS, Chiou-Tan F, Zhang H, Taber KH. Sec-
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Common Injectates chest. J Comput Assist Tomogr. 2006;30(1):161–164. https://doi.
org/10.1097/01.rct.0000187415.07698.56.
• L ocal anesthetic
5. Vollmer DG, Banister WM. Thoracolumbar spinal anatomy.
• Corticosteroids Neurosurg Clin N Am. 1997;8(4):443–453.
6. Maiman DJ, Pintar FA. Anatomy and clinical biomechanics of
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the thoracic spine. Clin Neurosurg. 1992;38:296–324.
• 2 to 5 mL 7. Oxland TR. Fundamental biomechanics of the spin—What we
have learned in the past 25 years and future directions. J Biomech.
Technique 2016;49(6):817–832.
Patient Position 8. Panjabi MM, White AA 3rd. Basic biomechanics of the spine.
• Prone Neurosurgery 1980;7(1):76–93.
9. Panjabi MM, Pearson AM, Ito S, et al. Cervical spine ligament
Clinician Position injury during simulated frontal impact. Spine. 2004;29(21):2395–
• Stand on the side of the patient 2403.
10. Benedetti PF, Fahr LM, Kuhns LR, Hayman LA. MR. imag-
ing findings in spinal ligamentous injury. Am J Roentgenol.
Fluoroscopy Position
2000;175:661–665.
• A P view and clearly visualize the rib 11. Turcios NL. Slipping rib syndrome: an elusive diagnosis. Paediatr
• Can use the lateral view to confirm depth Respir Rev. 2017;22:44–46.
12. Laurie L, Peterson, Cavanaugh DG, Two years of debilitating
Needle Position pain in a football spearing victim: slipping rib syndrome. Med Sci
• S tart about 3 inches lateral to the costotransverse joint Sports Exerc. 2003;35(10):1634–1637.
or anywhere along the rib, proximal to the patient’s pain 13. Fanous AA, Tumialán LM, Wang MY. Kambin’s triangle: defini-
generator. tion and new classification schema [published online ahead of
• Start a few millimeters below the rib margin and aim print, 2019 Nov 29]. J Neurosurg Spine. 2019:1–9. https://doi.
slightly superior to touch down on the rib, then walk off org/10.3171/2019.8.SPINE181475.
14. Brossmann J, Stäbler A, Preidler KW, Trudell D, Resnick D, Ster-
rib inferiorly.
noclavicular joint: MR imaging—anatomic correlation. Radiol-
ogy. 1996;198(1):193–198.
Target 15. Norris CM. Managing Sports Injuries. 4th ed. 2011:292–309.
• I ntercostal space 1 to 2 mm inferior to rib and 1 to 2 mm 16. Edwin J, Ahmed S, Verma S, Tytherleigh-Strong G, Karuppaiah K,
deep to posterior rib border (Fig. 13.20). Sinha J. Swellings of the sternoclavicular joint: review of traumatic
• Inject contrast to confirm flow along the nerve parallel to and non-traumatic pathologies. EFORT Open Rev. 2018;3(8):471–
the rib with no vascular uptake. 484. https://doi.org/10.1302/2058-5241.3.170078.
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17. G alla R, Basava V, Conermann T, Kabazie AJ. Sternoclavicular 27. V anichkachorn JS, Vaccaro AR. Thoracic disc disease: diagno-
steroid injection for treatment of pain in a patient with osteitis sis and treatment. J Am Acad Orthop Surg. 2000;8(3):159–169.
condensans of the clavicle. Pain Physician. 2009;12(6):987–990. https://doi.org/10.5435/00124635-200005000-00003.
18. Jurik AG, Graudal H. Sternocostal joint swelling—clinical 28. Behrsin JF, Briggs CA. Ligaments of the lumbar spine: a review.
Tietze’s syndrome. Report of sixteen cases and review of the Surg Radiol Anat. 1988;10(3):211–219. https://doi.org/10.1007/
literature. Scand J Rheumatol. 1988;17(1):33–42. https://doi. BF02115239.
org/10.3109/03009748809098757. 29. Niesel HC, Klimpel L, Kaiser H, al-Rafai S. Die einzeitige Inter-
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description of technique. Australas Radiol. 1987;31(1):47–49. single intercostal block—surgical and therapeutic indications].
https://doi.org/10.1111/j.1440-1673.1987.tb01781.x. Reg Anaesth. 1989;12(1):1–12.
20. Sanzhang C, Rothschild BM. Zygapophyseal and costoverte- 30. Shankar H, Eastwood D. Retrospective comparison of ultrasound
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impact. Br J Rheumatol. 1993;32(12):1066–1071. https://doi. tions. Pain Pract. 2010;10(4):312–317. https://doi.org/10.1111/
org/10.1093/rheumatology/32.12.1066. j.1533-2500.2009.00345.x.
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Musculoskelet Disord. 2008;9:140. https://doi.org/10.1186/1471- ous injection for acute thoracic herpes zoster and incidence of
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Comparison of intra-articular thoracic facet joint steroid injec- 34. Zinboonyahgoon N, Luksanapruksa P, Piyaselakul S, et al. The
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14
Lumbar Injection
Techniques
DI CUI, LISA FOSTER, BRIAN HAR T KEOGH JR.,
JASON MARKLE, HASSAN MONFARED, JAYMIN PATEL,
SHOUNUCK I. PATEL, JOHN PITTS, AND DIYA SANDHU

Ultrasound-Guided Techniques  rthobiologics9 (platelet-rich plasma [PRP], bone mar-

• O
row concentrate, etc.)
Facet Joints
Injectate Volume
KEY POINTS • 0 .25 to 0.5 mL into the joint, +/− peppering the capsule
• T he facet joints (zygapophyseal or Z joints) can be
outside of the joint
targeted individually for isolated pathology or targeted
in combination with treating other components of Technique
the functional spinal unit,1,2 along with ligaments Patient Position
(supraspinous/interspinous, intertransverse, iliolumbar, • P
 rone with a pillow under the lower abdomen/pelvis
ligamentum flavum), paraspinal multifidus muscles, the to allow lumbar spine to be in a flattened or rounded
thoracodorsal fascia, nerve roots in the epidural space,
and the intervertebral discs. kyphotic position. This allows the spinous processes to
• Injections can be accomplished using a low-frequency be gapped and the ligaments to be taut.
curvilinear transducer with similar accuracy as
fluoroscopy- or CT-or computed tomography (CT)- Clinician Position
guided techniques.3,4 • S tanding at the side of the patient with the ultrasound
• Fluoroscopic contrast-dye confirmation may be used to
ensure accurate placement of the injectate.
screen on the opposite side.
   Transducer Position
• S hort axis with visualization of spinous process, lamina,
Pertinent Anatomy and facet joint. Identification of levels should be done by
• Th
 e facet joints or zygapophyseal Z joints are the synovial starting in the region of the sacrum. The L5 spinous pro-
interface between the inferior and superior articular pro- cess and lamina are much steeper, and together with the
cesses (SAPs) of adjacent vertebral bodies (Figs. 14.1–14.4). bilateral facets and transverse processes further laterally
• The orientation of facet joints may cause5 or be otherwise form the appearance of a “crown.” This is just cephalad
associated with degenerative processes such as spondylo- to the S1 spinous process which comes off of a relatively
sis,6 spondylolisthesis, and/or disc degeneration.7 flat sacral base that has more of a “tiara” appearance. After
identifying your target level, scan so that the lateral aspect
Common Pathology of the lamina is midline to the probe, then scan cephalad/
• Facet arthropathy, facet capsule sprain, tropism. caudad incrementally to visualize the facet joint which is
lateral to the lamina but medial to the deeper transverse
Equipment process—with the appearance of two small teeth (the
• U ltrasound machine with low-frequency curvilinear probe superior and inferior articular processes). You may or may
• 22 to 25 gauge, 2- to 3-inch needle not be able to visualize a thin hyperechoic joint capsule
overlying the facets (Figs. 14.5–14.7).
Common Injectate • Identification of levels can also be done with long-axis
• L ocal anesthetics with or without corticosteroid8 view; visualizing spinous processes from a midline axial
• Prolotherapy position helps identify levels, starting caudally with the

186
 CHAPTER 14 Lumbar Injection Techniques 187

Dorsal
Sacroiliac Ligament

Sacrospinous
Labrum
Ligament

Iliofemoral
Capsule Ligament

lschiofemoral
Ligament

Transverse
Ligamentum Acetabular Sacrotuberous Sacrococcygeal
Teres Ligament Ligament Ligament
• Fig. 14.1 Lumbosacral Pelvis Ligamentous Anatomy.

withdrawn back from the plane of the transducer, and

walked down to the gap between the superior and
inferior articular processes (Fig. 14.8).
Interspinous
Ligament Target
• D
 irect placement into the desired facet joint and or
Supraspinous capsule.
Anterior Ligament
Longitudinal
Ligament Posterior
PEARLS AND PITFALLS
Longitudinal • T he facet joint may be difficult to visualize in situations
Ligament
with significant facet hypertrophy.
• For in-plane injections, a gel stand-off may be beneficial
at reducing anisotropy.
• Care must be taken to stay midline when doing an out-of-
plane injection with a curvilinear probe because straying to
one direction or the other can be skewed drastically due
to the convex nature of the ultrasound beam.
  
• Fig. 14.2 Lower Lumbar Sagittal Key Ligamentous Anatomy.

shallow relatively flat sacral spinous processes, cephalad Supraspinous and Interspinous Ligaments
to the steeper lumbar spinous processes. With target level
in mid-screen, turn the probe 90 degrees. KEY POINTS
• Switching back and forth may optimize targeting of nee-
• T he supraspinous and interspinous ligaments can
dle tip. be targeted in isolation for specific injuries, but more
commonly are targeted in combination with treating
Needle Position other components of the functional spinal unit,11,2
• I n-plane10 along with other ligaments (intertransverse, iliolumbar,
• With spine in short axis, introduce the needle lateral to ligamentum flavum), paraspinal multifidus muscles,
the thoracodorsal fascia, zygapophysial (Z joints or
medial at a steep angle with or without gel stand-off, facet) joints, nerve roots in the epidural space, and the
directed into the gap between the superior and infe- intervertebral discs.
rior articular processes (Fig. 14.6). • Injections can be accomplished using a high-frequency
• Out-of-plane linear transducer; however, a low-frequency curvilinear
• With spine in short axis, introduce the needle out- transducer is preferred to have a wider visualization of
the region and allow for steeper in-plane injections with
of-plane just caudad to the mid-point of the trans- minimized anisotropy.
ducer which is placed just lateral to the facet joint.
Needle tip should be advanced superficially at first,   
188 SEC T I O N I I I Atlas

Supraspinous Ligament

Lumbar Facets
Ligamentum Flavum
Medial Branch Nerve
Epidural Fat

Epidural Space
Venous Plexous

• Fig. 14.3
Lumbar Axial Anatomy with Key Relationship Between the Supraspinous, Infraspinous, and
Ligamentum Flavum.

Dorsal
Sacroiliac Ligament Facet Joints

L4

L5

S1

Sacrospinous
Labrum
Ligament

Iliofemoral
Capsule Ligament

lschiofemoral
Ligament

Transverse
Ligamentum Acetabular Sacrotuberous Sacrococcygeal
Teres Ligament Ligament Ligament
• Fig. 14.4 Lumbosacral anatomy demonstrating facet joint innervation and pertinent ligaments.

Pertinent Anatomy Equipment

• Th
 e supraspinous ligament (SSL) is a strong fibrous cord- • U ltrasound machine with low-frequency curvilinear
like structure that adjoins and overlies adjacent spinous pro- probe. Alternatively, a high-frequency linear probe can
cesses.12 The SSL is contiguous dorsally with the thoracodorsal be utilized in individuals with low body fat and minimal
fascia and ventrally with the interspinous ligament (ISL). subcutaneous tissue.
• The ISL is a thin membranous structure that traverses • 22 to 25 gauge, 2- to 3-inch needle.
adjacent spinous processes from the root to the apex. The
ISL connects dorsally with the SSL and ventrally with Common Injectate
the ligamentum flavum (see Figs 14.2 and 14.3). • P rolotherapy
• Orthobiologics (PRP, bone marrow concentrate, etc.)
Common Pathology
 igament strain, partial tear,13 relative laxity secondary
• L Injectate Volume
to or underlying disc, and facet pathology.14 • 0.25 to 1 mL at each site
 CHAPTER 14 Lumbar Injection Techniques 189

• Fig. 14.5 Ultrasound-Guided Lumbar Facet Short-Axis In-Plane • Fig. 14.7 Ultrasound-Guided Lumbar Facet Out-of-Plane Setup.
Setup.

TDL

SP
Needle Needle di

SP
ltifi
Mu

Facet
Lamina

LT TP Facet

• Fig. 14.8 Ultrasound-Guided Facet Short-Axis Out-of-Plane

• Fig. 14.6
Ultrasound Lumbar Facet Short-Axis In-Plane Injection. Injection. SP, Spinous process; TP, transverse process; TDL, thora-
SP, Spinous process. codorsal fascia; LT, left.

Technique Transducer Position

Patient Position • S hort and/or long axis to the ligaments, with visualiza-
• P
 rone with a pillow under the lower abdomen/pelvis tion of spinous processes (Figs 14.9 and 14.16).
to allow lumbar spine to be in a flattened or rounded • Switching back and forth may optimize targeting of nee-
kyphotic position. This allows the spinous processes to dle tip.
be gapped and the ligaments to be taut. • In short-axis view, identification of levels should be done
by starting in the region of the sacrum. The L5 spinous
Clinician Position process and lamina are much steeper and together with
• S tanding at the side of the patient with the ultrasound the bilateral facets and transverse processes further lat-
screen on the opposite side. erally form the appearance of a “crown.” This is just
190 SEC T I O N I I I Atlas

cephalad to the S1 spinous process, which comes off of a

relatively flat sacral base that has more of a “tiara” appear-
ance (Figs 14.9 and 14.13).
• Identification of levels can also be done with long-axis
view; visualizing spinous processes from a midline axial
position helps identify levels, starting caudally with the
shallow relatively flat sacral spinous processes, cepha-
lad to the steeper lumbar spinous processes (Figs 14.11
and 14.15).

Needle Position
• I n-plane
• With ligaments in short axis, introduce the needle
in-plane lateral to medial to SSL superficial to the
spinous process. Needle tip is walked cephalad or
caudad and anteriorly into the interspinous gap. This
is done while pivoting or fanning the ultrasound
transducer to maintain the needle length in-plane
(Fig. 14.10).
• With ligaments in long axis, introduce the needle in-
plane with the transducer from caudad to cephalad,
with or without a gel stand-off to minimize aniso­
tropy. Needle tip should be advanced to the spinous
process to inject at the SSL, then walked cranially into
the interspinous space for the ISL (Fig. 14.12).
• Out-of-plane
• With ligaments in short axis, introduce the needle • Fig. 14.9 Ultrasound-Guided Supraspinous and Interspinous
out-of-plane just caudad to the mid-point of the Ligament Short-Axis In-Plane Injection Setup.
transducer. Needle tip should be advanced to the spi-
nous process to inject at the SSL, then walked crani- Multifidus Muscles
ally into the interspinous space for the ISL. This is
done while the transducer glides cephalad to follow KEY POINTS
the needle tip (Fig. 14.14).
• With ligaments in long axis, introduce the needle • T he multifidus muscles can be targeted in isolation
out-of-plane just lateral to the mid-point of the trans- for specific injuries, but more commonly are targeted
in combination with treating other components
ducer. Advance needle tip to the SSL superficial to of the functional spinal unit, including ligaments
or between the dorsal aspect of the spinous processes, (supraspinous/interspinous, intertransverse, iliolumbar,
then walk anteriorly into the interspinous space for ligamentum flavum), the thoracodorsal fascia,
the ISL (Fig. 14.16). zygapophysial (Z joints or facet) joints, nerve roots in the
epidural space, and the intervertebral discs.
• Injections can be accomplished using a low-frequency
Target curvilinear transducer.
• D
 iffusely through the SSL and ISL as deep as can safely
be visualized.   

PEARLS AND PITFALLS Pertinent Anatomy

• T hese ligaments may be difficult to visualize entirely, so • Th
 e multifidus muscles are the most medial column of
adjacent and adjoining anatomy need to be visualized. the three main lumbar paraspinal muscles, which are all
• For in-plane injections, needle angle and anisotropy enclosed between the thoracodorsal fascia posteriorly, the
need to be considered. With the ligaments in lamina, facet joints, transverse processes, and intertransverse
short axis, the needle can be obscured in the
thoracodorsal fascia while approaching the SSL. With (IT) ligaments anteriorly, and the spinous processes and ISLs
the ligaments in long axis, a gel stand-off may be medially. Unlike the erector spinae (the other two columns
required to limit anisotropy. of the paraspinal muscles that run the length of the spine),
• For out-of-plane injections, the needle tip could inadver- the multifidus muscles consist of several fascicles that tra-
tently be advanced beyond the plane of the transducer verse three to six vertebral segments, attaching the spinous
Use doppler to see injectate flow can help (see Fig. 14.17).
processes to the vertebral bodies, sacrum, posterior superior
   iliac spine (PSIS). and posterior sacroiliac ligaments.15,16
 CHAPTER 14 Lumbar Injection Techniques 191

Needle TDL
Gel
stand-off
Skin
SSL Needle
SSL

Spinous SP
process
SP
ISL

Lamina

• Fig. 14.10 Ultrasound-Guided Supraspinous and Interspinous • Fig. 14.12

Ultrasound-Guided Lumbar Supraspinous and Interspinous
Ligament Short-Axis In-Plane Injection. SSL, Supraspinous ligament. Ligament Long-Axis In-Plane Injection. ISL, Interspinous ligament; SP,
spinous process; SSL, supraspinous ligament.

• Fig. 14.11
Ultrasound-Guided Lumbar Supraspinous and Interspinous
Ligament Long-Axis In-Plane Setup.
• Fig. 14.13
Ultrasound-Guided Supraspinous and Interspinous Lig-
• Th
 e multifidus muscles provide functional stabilization, ament Short-Axis Out-of-Plane Injection Setup.
with deep and superficial fibers playing different roles in
segmental motion.17 • W
 hile often not mentioned in magnetic resonance imag-
ing (MRI) radiology reports, pathology of the multifidus
Common Pathology muscles is readily visible.27
• Th
 e multifidus muscles have been controversially linked to
various low back conditions,18,19 but ultimately they are Equipment
involved as a part of the functional spinal unit. Pathology • U ltrasound machine with low-frequency curvilinear
includes multifidus muscle atrophy associated with probe. Alternatively, a high-frequency linear probe can
chronic degenerative spine pathology,20,21 chronic low be utilized in individuals with low body fat and minimal
back pain,22,23 chronic radiculopathy,24 or iatrogenically subcutaneous tissue
from radiofrequency denervation,25,5 or prior surgery.26 • 22 to 27 gauge, 1.5- to 3-inch needle
192 SEC T I O N I I I Atlas

TDF
SSL Needle SSL
Needle

ISL
SP
ISL SP

• Fig. 14.14
Ultrasound-Guided Lumbar Supraspinous and Interspinous • Fig. 14.16
Ultrasound-Guided Lumbar Supraspinous and Interspinous
Ligament Short-Axis Out-of-Plane Injection. ISL, Interspinous ligament; Ligament Long-Axis Out-of-Plane Injection. ISL, Interspinous ligament;
SSL, supraspinous ligament. SP, spinous process; SSL, supraspinous ligament.

SP Doppler SP

• Fig. 14.17 Ultrasound-Guided Lumbar Supraspinous and Interspi-

nous Ligament Long-Axis Out-of-Plane Injection with Doppler Flow.
SP, Spinous process.

Clinician Position
• S tanding at the side of the patient with the ultrasound
screen on the opposite side.

Transducer Position
• S hort axis to the multifidus muscles, with visualization of
spinous processes and lamina (Figs 14.18A and 14.19A).
• In short-axis view, identification of levels should be done
by starting in the region of the sacrum. The L5 spinous
• Fig. 14.15
Ultrasound-Guided Supraspinous and Interspinous Liga- process and lamina are much steeper and together with
ment Long-Axis Out-of-Plane Setup. the bilateral facets and transverse processes further laterally
form the appearance of a “crown.” This is just cephalad to
Common Injectate
the S1 spinous process, which comes off of a relatively flat
• L ocal anesthetic for trigger point injection sacral base that has more of a “tiara” appearance.
• Orthobiologics (PRP, platelet-poor plasma [PPP]) • Identification of levels can also be done with long-axis view,
visualizing spinous processes from a midline axial position
Injectate Volume
helps identify levels, starting caudally with the shallow rela-
• 0.25 to 2 mL at each site tively flat sacral spinous processes, cephalad to the steeper
lumbar spinous processes. Turn 90 degrees at desired level.
Technique
Patient Position Needle Position
• P
 rone with a pillow under the lower abdomen/pelvis • I n-plane
to allow lumbar spine to be in a flattened or rounded • Introduce the needle in-plane lateral to medial
kyphotic position. directed to lamina. Needle tip is walked anterior/
 CHAPTER 14 Lumbar Injection Techniques 193

posterior and cephalad/caudad while injectate is PEARLS AND PITFALLS

administered (Fig 14.18B).
• Out-of-plane • T ake care to keep track of the needle tip. If a longer
needle is used, the tip could be advanced into the
• Introduce the needle out-of-plane just caudad to the
interlaminar epidural space.
mid-point of the transducer, which is centered over • For out-of-plane injections, the needle tip could
the spinous process. Needle tip should be advanced to inadvertently be advanced beyond the plane of the
the spinous process, then walked off laterally into the transducer. As the needle tip is advanced deeper, it
multifidus muscle (Fig. 14.19B). can be tracked by tilting the probe in the direction of
advancement.
Target   
• M
 ultifidus lying just lateral to the spinous process and
just superficial to the laminae.

A A

Needle Multifidi

Multifidi Needle

SP

B Multifidi B Multifidi
A
• Fig. 14.18 Ultrasound-Guided Lumbar Multifidis Short Axis In-Plane • Fig. 14.19 (A) Ultrasound-Guided Lumbar Multifidis Short-Axis Out-
(A) Setup; (B) Injection. SP, Spinous process. of-Plane (A) Setup; (B) Injection.
194 SEC T I O N I I I Atlas

Thoracodorsal Fascia Clinician Position

• S tanding at the side of the patient with the ultrasound
KEY POINTS screen on the opposite side.
• T he thoracodorsal fascia (also called the thoracolumbar
Transducer Position
fascia) can be targeted in isolation for focal injuries, but
more commonly is targeted in combination with treating • S hort axis to the SSL, ISL, and multifidus muscles, with
other components of the functional spinal unit,28,29 along the thoracodorsal fascia arching laterally off the midline
with ligaments (supraspinous/interspinous, intertransverse, spinous processes and SSL (Figs 14.20 and 14.22).
iliolumbar, ligamentum flavum), paraspinal multifidus • In short-axis view, identification of levels should be done
muscles, zygapophysial (Z joints or facet) joints, nerve
by starting in the region of the sacrum. The L5 spinous
roots in the epidural space, and the intervertebral discs.
• Injections can be accomplished using a low-frequency process and lamina are much steeper and together with
curvilinear transducer. the bilateral facets and transverse processes further lat-
  
erally form the appearance of a “crown.” This is just
cephalad to the S1 spinous process, which comes off
of a relatively flat sacral base that has more of a “tiara”
Pertinent Anatomy appearance.
• Th
 e thoracodorsal fascia is a thick retinaculum around • Identification of levels can also be done with long-axis
the paraspinal muscles of the lumbar and sacral regions, view; visualizing spinous processes from a midline axial
composed of aponeurotic fascial tissue continuous with position helps identify levels, starting caudally with the
the paraspinal fascia throughout the spine from the cra- shallow relatively flat sacral spinous processes, cephalad
nial base to the sacrum.30 to the steeper lumbar spinous processes. Turn 90 degrees
• Several muscles of the trunk and extremities insert into at desired level.
the thoracodorsal fascia.
• Laterally, the thoracodorsal fascia is in continuity with Needle Position
the fascia of all of the abdominal muscles, ultimately • I n-plane
providing synchronization throughout the core muscles • Introduce the needle in-plane lateral to medial directed
between the rectus abdominis and paraspinals.31 along the thoracodorsal fascia. Can redirect superior and
• Medially, the bilateral thoracodorsal fascia converges into inferior to get broader coverage (Fig. 14.21).
the midline SSL, which in turn is contiguous ventrally • Out-of-plane
with the ISLs into the ligamentum flavum (see Fig. 14.3).

Common Pathology
• Th
 e thoracodorsal fascia can be injured spontaneously with
a hernia32 or iatrogenically from even minimally invasive
procedures like vertebroplasty33 or LASER spine surgery.34
• In the absence of specific injury, the thoracodorsal fascia is
ultimately involved as a part of the functional spinal unit.

Equipment
• U ltrasound machine with low-frequency curvilinear
probe. Alternatively, a high-frequency linear probe can
be utilized in individuals with low body fat and minimal
subcutaneous tissue.
• 22 to 25 gauge, 2- to 3-inch needle.

Common Injectate
• P rolotherapy solution35
• Orthobiologics (PRP, etc.)

Injectate Volume
• 0.25 to 10 mL at each site

Technique
Patient Position
• P
 rone with a pillow under the lower abdomen/pelvis
to allow lumbar spine to be in a flattened or rounded
kyphotic position. • Fig. 14.20 Ultrasound-Guided Superficial TDF In-Plane Setup.
 CHAPTER 14 Lumbar Injection Techniques 195

Needle TDL

SSL

Spinous
process

Lamina

• Fig. 14.21
Ultrasound-Guided Superficial TDF In-Plane Injection. SSL,
Supraspinous ligament.

• I ntroduce the needle out-of-plane just caudad to the

mid-point of the transducer, which is centered over
the spinous process. Needle tip should be advanced
to the spinous process, then walked off laterally and
superficially into the thoracodorsal fascia (Fig. 14.23).

Target
• T
 DF fibers overlying the erector spinae muscles from the
spinous process out as lateral as desired.
• Fig. 14.22 Ultrasound-Guided Superficial TDF Out-of-Plane Setup.
PEARLS AND PITFALLS
• F or in-plane injections, needle angle and anisotropy
need to be considered. With the ligaments in short
axis, the needle can be obscured in the thoracodorsal
fascia while approaching the SSL. With the ligaments
in long axis, a gel stand-off may be required to limit TDF
anisotropy.
• For out-of-plane injections, the needle tip could
inadvertently be advanced beyond the plane of the SP
transducer.
  

Iliolumbar, Intertransverse Ligaments

KEY POINTS • Fig. 14.23Ultrasound-Guided Superficial TDF Out-of-Plane Injection.

SP, spinous process; TDF; thoracodorsal fascia; Star, needle tip in TDF.
• Injured iliolumbar intertransverse ligaments may
or may not be primary pain generators but should
be considered as part of the spinal functional unit processes of the lowest lumbar vertebra (typically L5)
(adjacent vertebrae, intervertebral disc, ligaments,
and facet joints) in which injury to any part can cause and the iliac crest.12
biomechanical alterations leading to degeneration and
pain.36 Common Pathology
• These ligaments can get stressed with scoliosis. • T raumatic injury.
   • Lumbar ligament injuries are common after motor vehi-
cle accidents (MVAs) or traumas.
• Lumbar spondylosis, degenerative disease, and loss
Pertinent Anatomy of lordosis can cause lumbar ligament laxity and vice
• Th
 e IT ligaments course between and just anterior to the versa.
transverse processes. • Scoliosis: for a lateral curve the IT ligaments are stretched/
• The iliolumbar (IL) ligament can have several anatomic lax at the convexity of the curve at that segment and are
variations but mostly courses between the transverse the targets for injection.
196 SEC T I O N I I I Atlas

• B uckling and hypertrophy of the ligamentum flavum

associated with degenerative disk disease, segmental
motion abnormalities, spondylosis, and contributes to
spinal stenosis.36
• Iliolumbar syndrome has been described as unilateral
low back pain at the posterior iliac crest, reproduced by
hip flexion and the Patrick test. One small study showed
that 25% dextrose solution helped pain in 6/7 patients.37

Equipment
• U ltrasound machine with low-frequency curvilinear probe
• 22 to 25 gauge, 2- to 3-inch needle

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.) • Fig. 14.24 Ultrasound-Guided Long-Axis Interspinous Ligament In-
• Avoid intraligamentous corticosteroids Plane Setup.

Injectate Volume
• 0.5 to 1 mL per area/ligament

Technique
Patient Position
• P
 rone with a pillow under the lower abdomen/pelvis
to allow lumbar spine to be in a flattened or rounded
kyphotic position.

Clinician Position
• S tanding at the side of the patient with the ultrasound
screen on the opposite side.

Transducer Position
• L ong axis to spine, short axis to the transverse processes
(Fig. 14.24).
• Start scanning at the sacrum and count L5 up to targeted • Fig. 14.25 Ultrasound-Guided Long Axis Interspinous Ligament In-Plane
Injection.
region.
• Scan laterally until the most lateral aspect of the trans-
verse process are visualized. Quadratus Lumborum Origins Off the Iliac Crest

Needle Position KEY POINTS

• I n-plane, distal to proximal or proximal to distal
approach (Fig. 14.25). • T he quadratus lumborum (QL) has great anatomic
variability; thus, ultrasound to visualize it is the best
• Alternatively, can inject out-of-plane medial to lateral modality
(Figs 14.26 and 14.27). • QL injury or pain syndromes are likely an underdiagnosed
problem but typically result in myofascial pain.38
Target • The injection describes the tendon injections if typical
• I L ligament distal to the L5 spinous process. myofascial treatments for QL pain fail or there is
suspected tendon injury form trauma.
• IT ligaments at levels above L5.
• Target the fibers traversing between the spinous processes   
just deep to bony tip.

PEARLS AND PITFALLS Pertinent Anatomy

• H eel toe maneuver with gel stand-off can be helpful to
• O riginates on the superior wing of the posterior
visualize the needle better. iliac crest (extends up to 5 to 7 cm laterally) and IL
• Always visualize needle tip and be careful not to go ligament
deep into the retroperitoneal space (higher risk with out- • Inserts on the anterior inferior border of the 12th rib
of-plane injections). (extending 4.5 to 7 cm laterally) and off the lateral bor-
   ders of the L1-4 transverse processes
 CHAPTER 14 Lumbar Injection Techniques 197

• U nilateral contraction causes ipsilateral trunk flexion;

bilateral contraction extends the trunk and flexes the
12th rib during inspiration
• These muscle actions are small and so may play more of
a role in lumbar stability.39

Common Pathology
• M
 uscle and tendon injury after traumatic event
via hyper-flexion or hyper-contralateral flexion
mechanisms.

Equipment
• U ltrasound machine with low-frequency curvilinear
probe
• 22 to 25 gauge, 2- to 3-inch needle

Common Injectates
• L ocal anesthetics for diagnostics or for muscle trigger
point or QL blocks
• Orthobiologics (PRP, platelet poor plasma, bone marrow
concentrate, etc.)

Injectate Volume
• 0.5 to 1 mL per tendon area

Technique
• Fig. 14.26Ultrasound-Guided Long-Axis Interspinous Ligament Out-
Patient Position
of-Plane Setup. • P
 rone with a pillow under the lower abdomen/pelvis
to allow lumbar spine to be in a flattened or rounded
kyphotic position.

Clinician Position
• S tanding at the side of the patient with the ultrasound
screen on the opposite side.

Transducer Position
• L ong axis to spine and QL (Fig. 14.28).
• Can rotate to visualize more medial or lateral fibers.
• Identify the posterior medial superior border of the iliac
crest.
• Scan up to 5 to 7 cm laterally from the medial border.

Needle Position
• I n-plane, proximal to distal approach (Fig. 14.29).
• May use two to four different needle entry sites to target
• Fig. 14.27 Ultrasound-Guided Interspinous Ligament Out-of-Plane
multiple areas of the tendons.
Injection.

Target
• Th
 ere is great variability to its locations and can have • T endon fibers at and proximal to the iliac crest.
interwoven fibers of the different intrinsic spinal muscles • Hypoechoic fibers and the enthesopathy points.
• The iliohypogastric and ilioinguinal nerves course along
the ventral muscle fibers
• The QL lies posterior to the colon, kidneys, and dia- PEARLS AND PITFALLS
phragm and deep to the spinal erectors
• The anterior primary ramus of the 12th thoracic spinal • H
 eel toe maneuver with gel stand-off can be helpful to
visualize the needle better.
nerve runs in the abdominal wall inferior to the 12th rib,
known as the subcostal nerve   
198 SEC T I O N I I I Atlas

Pertinent Anatomy
• Th
 e intervertebral foramen is bordered by:
• Posterior: the inferior and superior articular processes
• Superior/Inferior: The pedicles superiorly and inferiorly
• Anterior: Vertebral body and intervertebral disc ante-
riorly from a lateral view
• The spinal canal (dural sac) lies medial from an anterior-
posterior perspective
• Would add anatomy of vascularization of the spinal cord
(Fig. 14.30)
• Pedicle (P)—Eye
• Pars interarticularis (PI)—Neck
• Superior articulating process (SAP)—Ear
• Transverse process—Nose
• Spinous process (SP)—Tail
• Fig. 14.28
Ultrasound-Guided Long-Axis Quadratus Lumborum In- • Lamina (L)—Body
Plane Setup. • Inferior articulating process (IAP)—Legs
Common Pathology
• L umbar disc herniation
• Facet arthrosis or synovial cyst with nerve root
impingement
• Disc osteophyte, resulting in subarticular narrowing
• Spinal stenosis with symptomatic neurogenic claudication
Equipment
• C -arm fluoroscope
• Extension tubing
• 22 to 25 gauge, 3.5- to 7-inch needle depending on body
habitus
• Contrast

Common Injectates
• Fig. 14.29Ultrasound-Guided Long Axis Quadratus Lumbar In-Plane • L ocal anesthetic and non-particulate corticosteroids
Injection. Arrows, needle. • Orthobiologics (platelet lysate)
• Avoid particulate steroids
Fluoroscopy-Guided Techniques
Injectate Volume
Lumbar Transforaminal Epidurals
• 2 to 5 mL, pending the degree of stenosis and patient
KEY POINTS tolerance
• Prior studies have shown that with an injectate volume of
• R eal-time live fluoroscopy is key for visualizing 2.8 mL, 95% of the lumbar transforaminal epidurals will
intravascular injection. Inject contrast slowly and carefully spread to the superior aspect of the superior interverte-
and assess the flow pattern. Do not rely on aspiration.
• Digital subtraction can be considered if there is a
bral disc and with 3.6 mL total volume, 95% with reach
question of aberrant flow pattern or difficulty with to the inferior aspect of the inferior intervertebral disc.45
visualization due to other factors such as contrast or
hardware obscuring the view with live fluoroscopy. Technique: Subpedicular Approach
• Particulate steroids are not recommended due the Patient Position
risk of catastrophic consequences thought to be from
• Prone with abdomen on a pillow to reduce lumbar lordosis.
particulate steroid embolization via the arterial supply to
the brain and spinal cord.40–43
• Particulate steroids have not been found to be C-Arm Position
consistently superior to soluble steroids (dexamethasone • C onfirm the level using the anteroposterior (AP) view
or betamethasone) in efficacy.43 and counting down from the 12th rib.
• Platelet lysate epidural injections for lumbar radicular pain • Line up the superior endplate corresponding to the cor-
have evidence that they can help pain and function.44
rect vertebrae by tilting the C-arm cephalad or caudal.
   This should “square off” the target segment.
 CHAPTER 14 Lumbar Injection Techniques 199

• O blique the C-arm ipsilateral to visualize the “Scotty potential osteophytes off the SAP or transverse
Dog.” process.
• The SAP of the level below will be below the 6 o’clock • Place the needle coaxial to the fluoroscopic beam using inter-
position of the pedicle above. mittent fluoroscopic guidance in the oblique view, guiding
• Obtain a non-obstructed view of the chin of the “Scotty the needle towards the 6 o’clock position of the pedicle.
Dog” or 6 o’clock position of the pedicle. • Do not advance too deep in the oblique view without
• If the iliac crest obstructs the trajectory to the L5-S1 checking an AP view.
foramen, a more cephalad tilt and a less oblique angle • Authors recommend in the oblique view to gently
may be required. touch os at the inferior aspect of the pedicle to ascer-
• It is recommended to have a more lateral rather than tain depth.
medial bias to decrease the risk of neural injury (6:30 if • Withdraw the needle slightly; then redirect just inferior
procedure is on the right side, or 5:30 if procedure is on to the pedicle.
the left side).46 • Obtain an AP view to ascertain depth and medial trajectory.
• Will use the AP view to triangulate the needle position. The needle tip should not pass the midpedicular line (6 o’
Optimal position in the AP view requires: clock of the pedicle) in the AP to avoid dural puncture.
• “Squaring” of superior and inferior endplate of the • Optional to obtain lateral view to ascertain depth.
target level using a cephalad or caudal tilt.
• The spinous process should be midline using an Target
oblique tilt. • Th
 e target point is also known as the “safe triangle”
• Optional to use “true” lateral view to ascertain depth. formed by the pedicle superiorly and the spinal nerve
Optimal position in the lateral view requires: that passes in a tangent inferomedially.47
• “Squaring” the superior and inferior endplate of the • By staying in the superior one-sixth of the “safe triangle”
target level using a wigwag. there is less risk of neural injury; however, vascular pen-
etration can still occur.48
Needle Position • In the AP view the needle should not pass the 6 o’clock
• S light bend in the needle can help with navigation. position of the pedicle.
• Start slightly inferior lateral to the final target as this • In the lateral view the needle should land close to the facet
starting point will make it easier to navigate around joint silhouette within the superior aspect of the foramen.

Nose or transverse process Ear or superior Tail or superior

articular process articular process
of contralateral
side

Eye or pedicle

Neck or pars Body or lamina

interarticularis and spinous
process

Rear leg or
Front leg or inferior articular
inferior articutar process on
process contralateral
side

• Fig. 14.30 Scotty dog fluoro image and anatomic sketch.

200 SEC T I O N I I I Atlas

• Th
 e anterior or ventral aspect of the foramen should be Technique: Infraneural Transforaminal
avoided due to increased risk of vascular injury or vascu- Epidural
lar injection as the radicular arteries and intervertebral Patient Position
veins typically lie dorsal to the vertebral body. • P
 rone with abdomen on a pillow to reduce lumbar
• Attach extension tubing, keeping the needle still. lordosis.
• Aspirate to ensure no vascular uptake; then inject a small
amount of contrast under live fluoroscopy. C-Arm Position
• In the AP view, contrast should flow epidurally along the • S quare off of vertebrae at injection level.
medial pedicle border with or without peripheral exten- • Identify the pedicle, pars interarticularis, transverse pro-
sion around the spinal nerve. cess, spinous process.
• In the lateral view, contrast should flow against the pos- • Ipsilateral oblique to rotate the SAP to approximately
terior margin of the vertebral body. one-half to one-third of the width of disc space.
PEARLS AND PITFALLS
Needle Position
• If the needle is adjusted in the lateral view, the AP view • Th
 e initial target is the lateral aspect of the SAP of the
should also be checked to confirm that the needle has inferior vertebral level.
not advanced past the mid-pedicular line (6 o’clock of • For example, when targeting the L4-5 foramen, one
the pedicle).
• If at any point, neuropathic pain is elicited, the needle should target the SAP of the L5 vertebrae.
should be withdrawn and repositioned. If the pain does • The needle is inserted just lateral to the SAP and advanced
not resolve, the procedure should be aborted. Pain in a coaxial position.
should not be used as an indicator of needle placement. • Once the needle contacts the SAP or is felt to be at the
• The injection of contrast should be done under live depth of the SAP, a lateral view should be obtained.
fluoroscopy.
• Extension tubing should be used for stability to avoid • Intermittent AP and lateral multiplanar views should be
inadvertent movements. utilized to assess depth in relation to the foramen.
• Ideal flow should outline the desired spinal nerve and • The needle can slowly be advanced past the SAP with
then flow medially into the epidural under the pedicle. care to note any changes in “feel” consistent with inad-
• Avoid intrathecal or subdural flow patterns. vertent disc access.
• Avoid all vascular flow patterns.
• Be aware of the characteristic downward “hairpin” turn
of the artery of Adamkiewicz (arteria radicularis magnus). Target
This vessel supplies the spinal cord from T8 to the conus • I n the AP view, the needle should not be advanced past
medullaris. It has a high degree of anatomic variation but the 6 o’ clock position of the superior pedicle to avoid
typically enters the canal between T12-L3 and is more intrathecal or subdural needle placement.
commonly found on the left side (Figs. 14.31–14.34).49–52
• In a true lateral view, the needle should be just anterior to
   the SAP in its final position.

SAP
SEP
SP PI P Target

LAM IC
IAP IAP
IEP

A B
• Fig. 14.31 (A) Fluoroscopic image of oblique “scotty dog” view with target below the chin of the Scotty
dog with pertinent anatomy labeled. (B) Artist’s rendition of the fluoroscopic image with pertinent anatomy
labeled similar to shown. IAP, Inferior articular process; IC, iliac crest; L, lamina; P, pedicle; SAP, superior
articular process; SP, spinal process; TP, transverse process. (From Furman MB. Atlas of Image-Guided
Spinal Procedures. 2nd ed. Elsevier; 2018.71)
 CHAPTER 14 Lumbar Injection Techniques 201

• A ttach extension tubing, keeping the needle still. Lumbar Interlaminar Epidural Injection
• Aspirate to ensure no vascular uptake; then inject a small
amount of contrast under live fluoroscopy. Confirm epi- KEY POINTS
dural flow in both AP and lateral views.
• A septic technique should be followed during the
performance of any epidural injection.
PEARLS AND PITFALLS • A fluoroscope should be used for routine performance
• M ultiplanar imaging is essential. of interlaminar epidural injections for the management
• If the needle is found too ventral on lateral view, the of painful conditions.
initially set up was likely not oblique enough. A less • A loss of resistance technique is commonly performed to
oblique trajectory results in a more ventral position access the epidural space from an interlaminar approach.
on lateral view and a less medial needle position • Contrast spread should cover the target of interest to
on AP. ensure appropriate injectate delivery.
• If the needle is found too medial on AP but has not   
reached the foramen on lateral, the initial trajectory
was likely too oblique, and readjustment is required to
make the trajectory less medial and more ventral. A
more oblique trajectory results in a more medial needle
position on AP and a less ventral position on lateral
view.
• Do not advance too deep in the oblique or lateral view
without checking an AP view.
• The needle tip should not pass the mid-pedicular line
(6 o’ clock of the pedicle) in the AP to avoid dural
puncture.
• Be aware of the characteristic downward “hairpin” turn
of the artery of Adamkiewicz.
• Beware of placing the needle too inferior and ventral to
avoid intradiscal puncture. This is more common with
an infraneural approach.
• Caution with needle advancement past the SAP
given proximity of the intervertebral disc. With proper
technique, Levi et al. reported intradiscal needle
placement 4.7% occurrence.53
• Pre-procedure MRI review is imperative to confirm
adequate epidural space for needle placement.
Dural ectasia or Tarlov cysts should be noted prior to
injection.
• Be aware of intrathecal, subdural, and vascular flow
patterns (Figs 14.35 and 14.36).
•Fig. 14.33 Lateral View with the Needle in Superior and Dorsal
   Aspect of the Foramen Epidural Space.

12
12
9 P3
9 P3 6
6

DS
SN

A B
• Fig. 14.32 (A) Anteroposterior view of a right L4-5 transforaminal epidural using the subpedicular
approach. Contrast flow shows nerve root medial flow to the pedicle into the epidural space. (B) Artist
rendition of the fluoroscopic image with pertinent anatomy labeled similar to shown. (From Furman MB.
Atlas of Image-Guided Spinal Procedures. 2nd ed. Elsevier; 2018.)
202 SEC T I O N I I I Atlas

Pertinent Anatomy • Th
 e lumbar epidural space contains fat, vasculature
• Th
 e lumbar interlaminar space is a semicircular or ellipsoid including Batson’s valveless venous plexus, and exiting
space, with the laminar convexity at the superior aspect of nerve roots (see Fig. 14.3).
the lamina. The lumbar interlaminar space is named by the Common Pathology
lamina of the level above and below (e.g., the L4-5 interlam-
inar space is bound by the L4 lamina superiorly and the L5 • N eural impingement can occur in a number of regions,
lamina inferiorly). The epidural space proper is just deep to including the subarticular zone (lateral recess), neural
the spinolaminar line and bound by the ligamentum flavum foramina, extraforaminal zone (far lateral), and central
posteriorly and the dura anteriorly (Figs. 14.37 and 14.38). canal.
• Impingement of the neural tissue may result from any
combination of disc herniation, ligamentum flavum
hypertrophy, facet arthropathy, disc-osteophyte complex
development, spondylolisthesis, or facet synovial cyst
formation.
• Epidural scarring postoperatively, can restrict neural
mobility and lead to chronic radiculopathy.

Equipment
• P erformed under sterile procedural conditions.
• Standard procedural kit, including sterile skin prepa-
ratory materials, hypodermic needle for skin anesthe-
sia, syringes, small-bore extension tubing, and sterile
gloves.
• Needles: Epidural loss of resistance needle (e.g., Tuohy,
Weiss, Hustead needles). Some clinicians prefer to per-
form without loss of resistance and place anatomically
with a standard spinal needle.
• Special equipment: Loss of resistance syringe, glass or
plastic, slip tip or luer lock, typically 8 mL volume.
• Fluoroscope.
• Radiation protection equipment, including lead apron,
• Fig. 14.34
Lateral View with Contrast Showing Flow Along the L4 leaded glasses (optional), and leaded gloves (optional).
Nerve Root and Epidural Space. • Radiolucent x-ray table.

VB
SAP
IC
IEP
IVD SEP

Target

A B
• Fig. 14.35 (A) Fluoroscopic image of oblique “scotty dog” view with target at the superior articular pro-
cess with pertinent anatomy labeled. (B) Artists rendition of the fluoroscopic image with pertinent anatomy
labeled similar to shown. IAP, Inferior articular process; IC, iliac crest; L, lamina; P, pedicle; SAP, superior
articular process; SP, spinal process; TP, transverse process. (From Furman MB. Atlas of Image-Guided
Spinal Procedures. 2nd ed. Elsevier; 2018.)
 CHAPTER 14 Lumbar Injection Techniques 203

A B

L4
Dura

SN
IVD L5 SEP

IEP

C D
• Fig. 14.36 (A) Lateral fluoroscopic image of needle placement with infraneural approach. Note needle
is advanced just anterior to the superior articular process. (B) Anteroposterior (AP) view of final needle
placement and contrast administration demonstrating epidural flow medial to pedicle and lobular flow pat-
tern. (C) Artist rendering of lateral view identifying vertebral body (VB), Superior and articular processes at
level of injection (SAP & IAP) and sacrum (S) with needle drawn in just past the SAP as in the fluoroscopic
image. (D) Artist rendering of AP view with final needle placement just under inferolateral to the pedicle
(labeled P) at the level of the disc space at l5-S1 past the lateral margin of the SAP as in the fluoroscopic
image. IAP, Inferior articular process; IEP, Inferior Endplate; IVD, intervertebral disc; SAP, superior articular
process; SEP, superior Endplate; SN, spinal nerve. (A–D, From Furman MB. Atlas of Image-Guided Spinal
Procedures. 2nd ed. Elsevier; 2018.)

Common Injectates stroke have been reported after transforaminal injection of

• P reservative-free saline, preservative-free local anesthetic, particulate steroids, though the interlaminar route has not
single-dose steroid, including betamethasone sodium been implicated in these side effects. It is recommended that
phosphate/sodium acetate mixture, methylprednisolone the proceduralist become familiar with the risks and ben-
acetate, and dexamethasone sodium phosphate. efits of using a particulate versus a non-particulate steroid
• Triamcinolone acetonide was a common steroid used in epi- for epidural injections.
dural injections until the Food and Drug Administration • Orthobiologics include 5% dextrose prolotherapy, plate-
(FDA) placed a black box warning stating “not for epi- let lysate, and PRP.
dural administration” in 2011. There is contention over the
safety of injecting particulate steroids in the epidural space. Volume
There have been a few case reports of adhesive arachnoiditis • S ufficient non-ionic contrast to visualize coverage of the
reported after interlaminar and transforaminal particulate desired structure, and ensure no vascular uptake, typi-
epidural steroid injection. Multiple cases of paraplegia and cally 0.5 to 2 mL (Figs. 14.39–14.41).
204 SEC T I O N I I I Atlas

SP
TP

L4
P

L5

• Fig. 14.37 Anteroposterior Fluoroscopic Image of the Lumbar Spine. • Fig. 14.39Fluoroscopic Image of Final Needle Position with Con-
IL, Interlaminar space; L4, fourth lumbar lamina; L5, fifth lumbar lamina; trast Flow Pattern in the Contralateral Oblique View for a Left Para-
P, pedicle; S, sacrum; SP, spinous process; TP, transverse process. median L4-5 Lumbar Interlaminar Epidural Steroid Injection.

SL

L4

L5

S1

•Fig. 14.38 Lateral Fluoroscopic Image of the Lumbar Spine. L4 • Fig. 14.40 Fluoroscopic Image of Final Needle Position with
VB, fourth lumbar vertebral body; L5 VB, fifth lumbar vertebral body; Contrast Flow Pattern in the Lateral View for a Left Paramedian L4-5
S1, S1 vertebral body; SL, spinolaminar line. Lumbar Interlaminar Epidural Steroid Injection.

• I njectate volume varies depending upon contrast flow pat-

tern and degree of patient stenosis. At least the volume Clinician Position
required to cover the target of interest should be used: 5 mL • S tanding to the side of the patient, most commonly
of injectate is common but varies from 2 mL to over 8 mL. opposite the side of the fluoroscope controls.

Technique Fluoroscope Position

Patient Position • Th
 e fluoroscope most commonly will enter from the side
• P
 rone with pillow under the abdomen to decrease lum- of the patient opposite the physician, with the level of
bar lordosis and accentuate the interlaminar space. interest centered in the beam (Fig. 14.42).
 CHAPTER 14 Lumbar Injection Techniques 205

Target
• V arious aspects of the epidural space can be targeted,
depending upon the site of pathology.
• Starting in the AP approach with the spinous process
centered between the pedicles, obtain a trajectory view
by caudally tilting until the interlaminar space appears
sufficiently wide (Fig. 14.43).
• Placing the needle in a paramedian approach in the AP
view, toward the side of pathology, will preferentially
cover that side unilaterally (Fig. 14.44).
• Midline approach can result in bilateral spread, though
contrast flow may be contained to the dorsal epidural
space.

Final Approach and Needle Position

• Th
 e safety view is either lateral or contralateral oblique
(CLO) to ensure needle placement is not too ventral into
the thecal sac.
• The CLO view will vary from 45 to 55 degrees, depend-
ing upon the laminar shape and distance the needle is
from midline.
• Fig. 14.41Fluoroscopic Image of Final Needle Position with Con-
trast Flow Pattern in the Anteroposterior View for a Left Paramedian • Upon engaging the ligamentum flavum at the ventral edge
L4-5 Lumbar Interlaminar Epidural Steroid Injection. of the lamina, the loss of resistance syringe is attached

A B
• Fig. 14.42Patient Positioned on Fluoroscopy Table with C-arm in Position and Clinician Standing on
the Left Side of the Patient. (A) anteroposterior view; (B) lateral view.
206 SEC T I O N I I I Atlas

to the needle hub and cautiously advanced slowly with

either intermittent or continuous gentle pressure on the
syringe plunger, until loss of resistance is obtained, which
is a sudden acceptance of the material in the loss of resis- SP
TP
tance syringe. Physician preference dictates which mate-
rial is used in the loss of resistance syringe: typically used
options are air, saline, or an air/saline mixture.
• Final needle position is within the dorsal epidural space, L
which appears just deep to the spinolaminar line in a P
view lateral to the laminar edge (Fig. 14.45). IL

L
PEARLS AND PITFALLS
• T he more laterally placed the needle, the more likely
to have injectate spread over the dorsal root
ganglion. L
• A very narrow interlaminar space can be made wider
by placing more pillows under the abdomen to give a
higher degree of lumbar flexion.
• If the interlaminar space is narrow, caudal tilt and
ipsilateral oblique rotation of the C-arm can help
present an opening for access.
• Do not perform an interlaminar epidural injection • Fig. 14.43 Trajectory View Anteroposterior Fluoroscopic Image for
through a laminectomy defect. The epidural space is an L4-5 Lumbar Interlaminar Epidural Steroid Injection. Note the
obliterated during laminectomy, and a dural puncture is wide appearance of the interlaminar space at the level of interest. IL,
highly likely to occur. Interlaminar space; L, lamina; P, pedicle; SP, spinous process; TP,
• The epidural space is a low-pressure system; thus transverse process.
there are no compressive forces to abate bleeding
and hemostasis in the epidural space; we rely purely
upon the intrinsic clotting function of the patient.
The risk of epidural hematoma, while low, is of
greater theoretical risk in this approach compared
to a transforaminal approach (apart from an S1
transforaminal), due to the needle tip violating the
epidural space during interlaminar placement.
Ensure that the physician has noted and held
for an appropriate duration any medications that
substantially affect hemostasis, such as aspirin and
warfarin.
• The injectate will follow the path of least resistance. If
attempting to target pathology above a level with high
resistance or no epidural space, such as above a level
of severe central stenosis, the injectate may not reach
the desired target and an alternate approach may need
to be considered.
• Reviewing the patient’s MRI or computed tomography
(CT) scans before the procedure can give the physician
insight into the size and shape of the epidural space to
plan the approach appropriately.
• Parallax occurs when the needle is not near the center
of the fluoroscope beam. It results in the angle and
position of the needle appearing different than it truly
is anatomically. The physician must accommodate for
this if working toward the edges of the field of view and • Fig. 14.44 Fluoroscopic Image of Needle Position in the Antero-
obtain a final view with the needle in the center of the posterior Trajectory View for a Left Paramedian L4-5 Lumbar Inter-
fluoroscope image. laminar Epidural Steroid Injection.
• Caution should be exercised if advancing more than
a short distance in the lateral or CLO views to avoid
inadvertently straying too far medially or laterally off Suboptimal Flow Patterns
trajectory. This can result in needle placement in
an unanticipated location, such as on the lamina or Retrodural Space of Okada (Figs. 14.46–14.50)
crossing over midline. • Th
 e retrodural space of Okada is a potential space deep
   to the lamina and superficial to the ligamentum flavum.
 CHAPTER 14 Lumbar Injection Techniques 207

SL

L4

L5

S1

• Fig. 14.45 Fluoroscopic Image of Final Needle Position in the • Fig. 14.47 Fluoroscopic Image of Contrast Flow Pattern Demon-
Lateral View for a Left Paramedian L4-5 Lumbar Interlaminar strating Filling of the Retrodural Space of Okada in the Lateral View
Epidural Steroid Injection. L4 VB, Fourth lumbar vertebral body; L5 During Performance of a Lumbar Interlaminar Epidural Steroid Injec-
VB, fifth lumbar vertebral body; LF, ligamentum flavum; S1, S1 verte- tion.
bral body; SL, spinolaminar line; TS, thecal sac.

• Fig. 14.48 Fluoroscopic Image of Contrast Flow Pattern Demonstrating

Filling of the Retrodural Space of Okada in the Anteroposterior View,
• Fig. 14.46 Fluoroscopic image of contrast flow pattern demonstrating with Further Advancement of the Needle to Obtain Epidural Flow
filling of the retrodural space of Okada during performance of a lumbar During Performance of a Lumbar Epidural Steroid Injection.
epidural steroid injection. Note the contrast flow into the bilateral facet
joints.
Intrathecal (Fig. 14.51)
It can communicate with the facet joints and the inter- • I f there is insufficient epidural space to accommodate the
spinous space to form an interspinous bursa. A false loss needle, or the needle is placed deep to the epidural space,
of resistance can occur, resulting in non-epidural place- intrathecal injection can occur. The contrast should layer
ment of injectate. Careful attention to contrast spread ventrally, and a hazy fluid–fluid interface may be appre-
can clue the clinician to an aberrant flow pattern and the ciated, as opposed to the crisp delineation expected with
need for correction prior to injectate delivery. epidural spread.
208 SEC T I O N I I I Atlas

• Fig. 14.49 Fluoroscopic Image of Contrast Flow Pattern Demonstrating • Fig. 14.51 Fluoroscopic Image of Contrast Flow Pattern Demonstrating
Filling of the Retrodural Space of Okada in the Lateral View, with Intrathecal Spread of Contrast During an Attempted Interlaminar
Further Advancement of the Needle to Obtain Epidural Flow During Epidural Steroid Injection. Note the hazy fluid–fluid interface of the con-
Performance of a Lumbar Interlaminar Epidural Steroid Injection. trast with the cerebrospinal fluid, and the ventral layering of the contrast.

• Fig. 14.50Axial T2-Weighted Magnetic Resonance Imaging Dem- • Fig. 14.52 Fluoroscopic Image of Contrast Flow Pattern Demon-
onstrating the Retrodural Space of Okada from the Preceding strating Intradiscal Contrast Flow During an Attempted Right Para-
Figures During Attempted Lumbar Interlaminar Epidural Steroid median Interlaminar Epidural Injection. The patient had a large disc
Injection. herniation that had extruded to the ventral aspect of the ligamentum
flavum.

Intradiscal (Fig. 14.52)

• I t should be extraordinarily rare during an interlaminar careful attention to technique and utilizing appropriate
epidural steroid injection to obtain intradiscal needle lateral or CLO views.
placement, as the needle is relatively posterior in the
epidural space. A large enough disc extrusion that has Subdural
migrated posteriorly and is contiguous with the parent • Th
 e subdural space is just deep to the epidural space
disc could be encountered. Placement of the needle ven- before piercing the arachnoid matter of the thecal sac.
trally into the disc would not be expected to occur with Subdural contrast spread will commonly demonstrate a
 CHAPTER 14 Lumbar Injection Techniques 209

railroad track pattern, showing circumferential spread of

the subdural space. Aspiration will often remove nearly
all of the injected contrast material.

Vascular
• V enous injection can occur in a posteriorly placed lum-
bar interlaminar epidural steroid injection, though it is
uncommon.
• A far laterally placed paramedian lumbar interlaminar
epidural steroid injection could theoretically encounter a
radiculomedullary artery if placed ventrally into the peri-
foraminal region.

Medial Branch Block

KEY POINTS
• T he lumbar medial branch block is solely diagnostic.
It is used to determine whether axial back pain is
facet-mediated.
• Lumbar medial branch radiofrequency ablation is
performed if patients receive substantial benefit from • Fig. 14.53 Left contralateral oblique view demonstrating needle
medial branch bocks. placement for medial branch block at L3-4, L4-5, and L5-S1 with
optimal placement at the junction of the superior articulating pro-
   cess and transverse process (i.e. the eye of the scotty dog).

• O
 blique the C-arm to the ipsilateral side until the “Scotty
Pertinent Anatomy
dog” is clearly visualized.
• F acet joints have dual innervation from a pair of medial
branches from the dorsal primary rami. The joint is Needle Position
innervated by the branch at the same level and the above. • I nsert the needle coaxially, targeting the “eye” of the
For example, the L5-S1 joint is innervated by the L4 and Scotty dog.
L5 medial branch.
• The medial branch branches off of the dorsal primary Target
ramus, run across the neck of the SAP, and then wraps • Th
 e “eye” of the Scotty dog, which is at the articulation
around the transverse process one level below at the junc- of the SAP and the transverse process (Fig. 14.53).
tion of the SAP; for example, the L4 medial branch lies
on the transverse process of L5. Injectate Volume
• L1-L4 medial branch pass under the mamillo-acces- • U se of contrast is optional. If the practitioner elects to
sory ligament, which some time can be an obstacle; use contrast, 0.2 to 0.5 mL should be injected per level,
the medial branch is most accessible as it crosses the and contrast should spread along the lateral aspect of the
neck of the SAP. SAP. It can be useful to ensure there is no vascular or
• At the level of L5, the practitioner will target the primary epidural spread.
dorsal ramus itself. The L5 dorsal ramus is located at the • Injectate should consist of 0.5 mL volume of lido-
junction of the base of the S1 superior articulating pro- caine (1% or 2%), or bupivacaine (0.25%, 0.5%, or
cess and the sacral ala (see Fig. 14.4). 0.75%).
Technique
Patient Position PEARLS AND PITFALLS
• P
 rone with abdomen on a pillow to reduce lumbar • L umbar tilt may need to be adjusted at each level to
lordosis. optimize the needle trajectory to the target due to
lumbar lordosis and in patients with scoliosis.
C-Arm Position • The L5 dorsal ramus maybe access coaxial in AP view;
• C onfirm the appropriate level with an AP view. all other medial branches cannot be readily accessed if
the needle is coaxial in AP views.
• Tilt the C-arm cephalad or caudad to square off the supe-
rior endplate at the targeted level.   
210 SEC T I O N I I I Atlas

Radiofrequency Ablation
KEY POINTS
• R adiofrequency (RF) ablation uses a radiofrequency current
through an electrode tip needle to create a thermal lesion.
• Neurodestructive temperatures range from 65°C to 90°C.
• The RF electrode tip should be placed parallel to the
target medial branch.
  

Pertinent Anatomy
• M
 edial branch anatomy is described in the medial branch
section (see Figs. 14.1–13).

Technique
Patient Position
• Prone with abdomen on a pillow to reduce lumbar lordosis.

C-Arm Position
• C onfirm the appropriate level with an AP view.
• Tilt the C-arm cephalad or caudad to square off the supe- • Fig. 14.54 Right contralateral oblique view demonstrating lead
rior endplate at the targeted level. placement for radiofrequency ablation at L2-3, L3-4, and L4-5 with
• Oblique the C-arm to 20 degrees to the ipsilateral side. optimal placement at the junction of the superior articulating pro-
cess and transverse process (i.e. the eye of the scotty dog).
• Tilt the C-arm 45 degrees caudally.

Needle Position Zygapophyseal or Facet Joint Injections

• I nsert the needle coaxially, targeting the “eye” of the
Scotty dog. KEY POINTS
• The volume capacity of the facet joint is 1 to 1.5 mL.
Target
  
• Th
 e “eye” of the Scotty dog, which is at the articulation
of the SAP and the transverse process (Fig. 14.54).
Pertinent Anatomy
Injectate Volume • F acet joints are J-shaped joints that are composed of the
• 0 .5 to 1 mL of local anesthetic is typically injected after IAP and SAP of adjacent vertebral bodies.
stimulation and before the ablation to improve the • The joint is lined by articular cartilage and encapsulated
patient’s comfort. Practitioners may use lidocaine (1% or by synovial lining.
2%), or bupivacaine (0.25%, 0.5%, or 0.75%). • The obliquity of the joint increases as we go down from
L1 to L5.
PEARLS AND PITFALLS • The capsule of the lumbar facet joint attaches tight to the
articulating cartilage, but at superior and inferior ends of
• E nsure that the needle is placed at an angle so that
there is parallel placement of the tip along the nerve;
the joint, the capsule relaxes, creating the superior and infe-
hence, the suggestion to oblique the C-arm 20 degrees rior subarticular recess when the joint is in neutral position.
and tilt 45 degrees. • There are also small foramen at either end of the capsule that
• Before the ablation, motor and sensory stimulation may allow contrast material to leak out during the injection.
should be performed to ensure there are no radicular • Subfascial channel communicates between the joint on
symptoms or signs of muscle movement.
• 0.5 to 1 mL of local anesthetic is typically injected after
one side and the opposite side; contrast material may
stimulation and before the ablation to improve the flow to the opposite side.
patient’s comfort.
• Practitioners vary in their ablation settings; it can be 70 Technique
to 85 degrees for up to 90 seconds. Some practitioners Patient Position
may do two or three rounds of the ablation.
• For monopolar RF, the temperature reading will not stay
• P
 rone with abdomen on a pillow to reduce lumbar
exactly at the preset temperature but will go over and lordosis.
under, typically within half a degree. This is due to the
probe itself causing the surrounding tissue to oscillate to C-Arm Position
create heat. The probe then reads the tissue temperature • C onfirm the appropriate level with an AP view.
and adjusts to keep the temperature constant. • Square up the top endplate of the lower vertebrae (for
• This also limits the size of the “zone of coagulation.”
example, square up L5 superior endplate for an L4-L5
   facet injection).
 CHAPTER 14 Lumbar Injection Techniques 211

• O blique the fluoroscope ipsilaterally until the joint can Pertinent Anatomy
be clearly identified. • Th
 e “Scotty dog” sign represents the normal appearance
• Due to the J-shape, the ventromedial segment may be of the posterior elements of the lumbar vertebra on the
mistaken for the dorsal opening. oblique radiograph.54 The transverse process is the nose,
• Next, it may be useful to decrease the tilt by 5 degrees the superior facet is the ear, the inferior facet is the front
from that position to facilitate entry into the joint from leg, the pars interarticularis reflects the neck or collar,
a medial to lateral trajectory. and the pedicle forms the eye.54
• IAP and SAP should be clearly identified. • A gap through the dog’s neck/collar indicates spondy-
• Lateral images should be obtained to verify needle lolysis, a fractured pars interarticularis or a congenital
depth; the needle should land close to the facet joint pars defect, originally described by LaChapelle (Fig.
silhouette. 14.58).54
Needle Position Common Pathology
•  e needle should be inserted coaxially.
Th • C ongenital pars defect.
• Advance needle until the joint capsule is penetrated. • Traumatic pars fracture can lead to non-union fracture.
• “Purchase” should be achieved. If an acute pars fracture is suspected, then MRI or a CT
• Needle entry may be difficult due to most injections scan.54a and the initial x-ray is equivocal.55
being on advanced arthritic joints. • An x-ray is usually the imaging modality of choice
and may assist in the confirmation of the diagnosis
Target in 80% of cases. In cases with a high clinical suspi-
• Facet joint. cion and a negative x-ray, a CT-scan or MRI may be
recommended.54a
Injectate Volume • Trauma fracture: usually occurs with loaded hyperexten-
• 0 .2 to 0.5 of contrast should be injected to confirm intra- sion such that occurs in sports like soccer, basketball,
articular positioning. football, gymnastics, wrestling, etc.56
• Common injectates: Depo-Medrol (methylpredniso- • Conservative management includes a thoracic lum-
lone) or dexamethasone with lidocaine or bupivacaine: bar sacral orthotic (TLSO) brace, activity modifica-
1 mL total volume. tion, physical therapy, and bone growth stimulation.
PEARLS AND PITFALLS
A review article showed the average time to return to
sports was 3.7 months, and good clinical outcomes
• C ephalad or caudad tilt may be required to optimize were achieved in 84% to 91% of patients and were not
entry into the joint, especially in scoliotic patients. dependent on resolution or healing of the fracture.56
• When performing a facet injection at L5-S1, cephalad
tilt can be used to create a clear needle trajectory if the
• If conservative measures fail or the resulting non-
iliac crest is superimposed. union is symptomatic despite conservative care, sur-
• When there is significant facet arthropathy and gery may be an option.56
overgrowth, it will be easier to enter the joint if the • A non-surgical alternative may include the injection
medial border of the joint is targeted. This is because of mesenchymal stem cells from bone marrow. There
overgrowth tends to occur on the SAP, which
corresponds with the lateral aspect of the joint.
is some published literature on utilizing bone mar-
• Optimal contrast spread can be seen encircling the joint row aspirate concentrate (BMAC) for the treatment
capsule and filling the joint line. Try to minimize volume of non-union fractures; however, there is no literature
of contrast used as the total volume capacity of the published on treating non-union of pars interarticu-
joint is only 1 to 1.5 mL. laris fractures.57
• An ideal intra-articular spread may be shaped like an
apple core or dumbbell.
• PRP, BMAC, and demineralized bone matrix (DBM)
• Needle placement superior to the joint in AP and all have evidence for osteoinductivity.58
oblique views or too ventral to the facet joint silhouette • Degenerative spondylolysis.
on lateral views can increase risk of injuring the exiting
spinal nerve (Figs 14.55 and 14.56). Equipment
   • C -arm fluoroscopy.
• 22 to 25 gauge, 3- to 5-inch spinal needle used for diagnos-
Pars Interarticularis Defect tics, degenerative spondylosis, and for injury with no callus.
• or 15 gauge, 3.5-inch trochar for defect with callus
KEY POINTS formation.
• Contrast medium.
• T he pars can be injected for diagnostic purposes.
• Orthobioligics may play a role in treating symptomatic
non-union pars fractures that have failed conservative
Common Injectates
management, but at the time of writing there are no • L ocal anesthetic for diagnostics
studies published on this technique. • Orthobiologics (PRP, bone marrow concentrate, etc.)
   • Demineralized bone matrix
212 SEC T I O N I I I Atlas

C D
• Fig. 14.55
Intra-articular facet needle position without contrast in the oblique view (A) and anteroposterior view (B). With contrast in the oblique
view (C) and lateral view (D).

Injectate Volume • L ateral images should be obtained to verify needle depth.

• 0..5 to 2 mL • Use the AP view to confirm needle position and to inject
contrast.
Technique Needle Position
Patient Position • Th
 e needle should start directly over the pars or neck of
• P
 rone with abdomen on a pillow to reduce lumbar the “Scotty dog”.
lordosis. • The needle should be inserted coaxially.

C-Arm Position Target

• C onfirm the appropriate level with an AP view. • T ouch down on os right at the neck of the scotty dog/
• Square off the top endplate of the lower vertebrae (for pars area.
example, square off L5 superior endplate for an L4-L5 • Confirm needle placement in the AP view, where it
injection). should be just inferior and medial to the pedicle 5 o’clock
• Oblique the C-arm to the ipsilateral side until the “Scotty position on the left side, 7 o’clock position on the right
dog” is clearly visualized. side.
 CHAPTER 14 Lumbar Injection Techniques 213

• I ntervertebral disc (IVD)-related pain can be caused by

structural abnormalities, such as disc degeneration or
disc herniation.
• Biochemical effects, such as inflammation, and neuro-
biologic processes may play a role.
• Nerve growth factor (NGF) may play an important role
in discogenic back pain.60,61

Pertinent Anatomy
• I ntervertebral disks constitute 25% of the height of the
spine, which decrease with aging.59,62
• Disc nutrition is supported through lymphatics and
extracellular fluid osmosis.
• Discs have three major components: nucleus pulposus,
annulus fibrosus, and cartilaginous endplates.
• Nucleus pulposus: ovoid, yellowish, gelatinous paracen-
trally located and made of mucoprotein.
• Annulus fibrosus: firm concentric, meshwork of collag-
enous fibers called the annulus fibrosus.
• Disc innervation: receive innervation to outer third of
• Fig. 14.56 Optimal Contrast Spread. annulus anteriorly, posteriorly, and laterally.
• Posteriorly, the annulus receives innervation from the
• C onfirm depth in the lateral to ensure it is not in the fora- sinovertebral nerves; laterally from the exiting spinal
men. It should be below the facet joint (for example, if inject- nerve roots; and anteriorly, fibers from the sympathetic
ing the L4 pars, the needle will be below the L3-4 facet joint). chain (see Fig. 14.2).59,62,63
• Inject a small amount of contrast to confirm contrast
spread in the pars defect in both views. Indication
PEARLS AND PITFALLS • P rovocative discography for diagnostic purposes
• Intradiscal placement of device or therapeutic
• If there is a symptomatic non-union with bony callus, a 15 medication
gauge, 3.5-inch trocar will be needed to get into the defect.
• Manually drill the trocar if possible. If not, and a power
drill is utilized, then advance the trocar in the lateral Contraindication
view and proceed slowly and cautiously to prevent • A bsolute
advancing the trocar into the foramen.
• If there is a large defect, there may be less bony
• Unable or unwilling to consent
resistance, and there is a chance the needle can go • Untreated localized infection in the procedural field
through the defect into the foramen. Also, if using a trocar, • Systemic or local infection
it is easier to advance too deep. Observe the needle in the • Pregnancy
lateral view to confirm trocar and needle depth. • Known bleeding diathesis
• In the AP view, do not travel too far medially past the
lamina into the central canal.
• Anticoagulants
• Relative contraindication
   • Anatomic derangements; congenital and acquired
• Allergy to contrast medium, local anesthetic or
Intradiscal Injection antibiotics
KEY POINTS
Equipment
• A ll lumbar intradiscal injections should be done utilizing • A 22 or 25 gauge, 3.5- or 5-inch spinal needle
fluoroscopy or CT guidance.
• Intradiscal injections can be done for diagnostic and
• An 18 or 20 gauge, 3.5- or 5-inch spinal needle as an
therapeutic purposes. outer needle for two-needle technique
• Local anesthetic
  
• Connecting tubing
• Prophylactic intravenous antibiotics
Introduction • Consider diluted gentamicin
• Th
 e prevalence of pain due to internal disc disruption, in • Water-soluble, nonionic contrast dye
patients with chronic low back pain, is 39%.59 • Manometer for diagnostic discography
214 SEC T I O N I I I Atlas

• Fig 14.57 X-ray oblique view with scotty dog correlate. (From Ridley LJ, Han J, Ridley WE, Xiang H.
Scotty dog: normal anatomy—pars interarticularis. J Med Imaging Radiat Oncol. 2018;62[Suppl 1]:152.
https://doi.org/10.1111/1754-9485.26_12786.)

• Fig. 14.58 L5 Injection in Anteroposterior with Contrast.

• Fig. 14.59 L5 Defect Injection Lateral View with Contrast.

Technique small triangle created by the iliac crest, the L5 vertebral

Patient Position body, and the body of S1.
• P
 rone position on the fluoroscopy table with the pillow • “Square off” the target disc by squaring off the vertebral
under the abdomen to reduce lumbar lordosis. endplate above or below the disc (Fig. 14.60).

C-Arm Position Needle Position

• C onfirm the appropriate level with an AP view. • Th
 e needle should be inserted coaxially.
• Tilt: cephalic enough to open disc space at affected level; • Target the SAP at the midpoint of width of the disc.
substantially tilt at L5-S1. • On a longitudinal plane navigate the needle lateral to the
• Rotate toward affected side to create an acute oblique SAP of the same segment as the target disc; stay sufficiently
image. At L5-S1 you will visualize the entry point as a lateral to SAP to avoid snagging the periosteum of SAP.
 CHAPTER 14 Lumbar Injection Techniques 215

Lumbar Ligaments: Supraspinous, Interspinous,

Ligamentum Flavum, Iliolumbar, Intertransverse

KEY POINTS
• T he lumbar ligaments are important structures to
consider when patients have low back or lumbar
radicular pain, especially in the presence of scoliosis,
spondylolisthesis, loss of disc height, after trauma, or in
patients with a hypermobility syndrome.
• Spine ligament injuries are often not seen or diagnosed
on x-rays or MRI.64
• Flexion extension x-rays can show subtle movements in
the vertebral bodies in different positions.
• Damaged ligaments may or may not be primary pain
generators but should be considered as part of the
spinal functional unit (adjacent vertebrae, intervertebral
disc, ligaments, and facet joints) in which injury to any
part can cause biomechanical alterations leading to
degeneration and pain.64,65
  

Pertinent Anatomy
• Th
 e supraspinous (SS) ligaments course between and just
over the spinous processes.66
• The interspinous (IS) ligaments course between the spi-
nous processes.66
• Fig. 14.60 Patient Positioning for Lumbar Discography. • The ligamentum flavum extends from the second cervical
vertebra to the first sacral vertebra connecting the adja-
• A two-needle technique can be used for an added precau- cent laminae.65
tion against infection and to facilitate the passage of a • The intertransverse (IT) ligaments course between and
very fine needle through the back muscles. just anterior to the transverse processes.66
• The depth of insertion should be checked periodically • The iliolumbar ligament can have several anatomic varia-
by briefly reverting to an AP and lateral view (Figs 14.61 tions but mostly courses between the transverse processes
and 14.62). of the lowest lumbar vertebra (typically L5) and the iliac
crest.
Complications • The iliolumbar ligament restricts lateral, rotational, and
• D iscitis; most common severe complication after flexion movement of the lumbosacral junction and helps
discography to stabilize the superior SI joint.
• Subdural abscess • There are two inferior bands off of the lowest (typically
• Epidural and prevertebral abscess L5 transverse process):
• Spinal cord injury • The transverse (transverse process to the superior pos-
• Vascular injury terior medial aspect of the posterior iliac crest).
• Direct trauma to nerve roots • The inferior (which connects lower and medially on
the posterior iliac crest and can have some connec-
PEARLS AND PITFALLS tions to the superior SI joint capsule). This can have
both ventral and dorsal components.
• A ny needle tip should not be touched or handled by the
• Sometimes a third band, the superior band can con-
glove hands. Always use sterile gauze or instrument.
• Obtain CT of lumbar spine following diagnostic nect from the superior medial aspect of the posterior
discography within 2 to 4 hours. iliac crest to the lateral aspect of the second lowest
• Consider a post-injection MRI if any worsening or transverse process (typically L4) and have some con-
prolonged lower back pain to rule out discitis. nections to the L5 spinous process, blending with the
   L4-5 IT ligament).
216 SEC T I O N I I I Atlas

• Fig. 14.61 Needle positioning at L5-S1 in the anteroposterior and lateral views.

• B uckling and hypertrophy of the ligamentum flavum has

been associated with degenerative disc disease segmental
motion abnormalities, spondylosis, and contributes to
spinal stenosis.67
• Iliolumbar syndrome has been described as unilateral low
back pain at the posterior iliac crest, reproduced by hip flex-
ion and the Patrick test. One small study showed that 25%
dextrose solution helped pain in six of seven patients.69
Equipment
• C -arm fluoroscopy
• 22 to 25 gauge, 3- to 3.5-inch spinal needle
• Optional: contrast

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.)
• Avoid intraligamentous corticosteroids

Injectate Volume
• 0.5 to 1 mL per area/ligament
• Fig. 14.62 Anteroposterior Contrast View Shows Normal Disc
Appearance at L3-L4, L4-L5. and “Degenerative Appearing Disc
at L5-S1.”
Technique: SS/IS Mid Ligamentum Flavum
Patient Position
• S ame as for other lumbar procedures.
• M
 uscle fibers of the erector spinae, iliacus quadratus • Prone with pillow under the waist to decrease lordosis.
lumborum, and the thoracodorsal fascia attach to dif-
ferent parts of the IL ligament.67,68 Clinician Position
• Standing opposite of the C-arm.
Common Pathology
• T raumatic injury. C-Arm Position Fluoroscopy
• Lumbar ligament injuries are common after MVAs or • True lateral view.
traumas.
• Lumbar spondylosis, degenerative disease, and loss of Needle Position
lordosis can cause lumbar ligament laxity and vice versa. • P alpate the spinous processes to ascertain midline; option
• Scoliosis: for a lateral curve, the intertransverse ligaments to mark the skin.
are stretched. with increased laxity at the convexity of the • Insert needle aiming for spinous process at desired level
segmental curve, and are the targets for injection. to ensure midline placement.
 CHAPTER 14 Lumbar Injection Techniques 217

Needle Position
• F or the iliolumbar ligament:
• The needle starts over the inferior lateral border of the
lowest lumbar transverse process.
• Guide the needle coaxially to touch down on the peri-
osteum of the lateral aspect of the transverse process.
• For the intertransverse ligaments:
• The needle starts over the lateral border of the targeted
transverse process.
• For instance, if targeting the L3-4 IT ligament, start
one needle over the L3 TP and redirect inferiorly. A
second needle will start over the L4 transverse process
and redirect superiorly.

Target
• I liolumbar ligament:
• To target the iliolumbar inferior band, redirect the
needle inferiorly off of the periosteum and deep/ven-
tral no more than 1 to 2 mm.
• Inject a small amount of contrast to show vertical flow
• Fig. 14.63 Supraspinous (SS) Injection and Interspinous (IS) extending inferiorly to the posterior iliac crest and
Injection Lateral Fluoroscopy Needle in Mid IS Ligament. superior sacroiliac joint.
• To target the transverse band, redirect the needle
Target slightly laterally off of the periosteum and deep/ven-
• G ently touch down on the spinous process and inject the tral no more than 1 to 2mm.
SSL. • Inject a small amount of contrast to show linear flow
• Redirect the needle superior between the spinous pro- horizontally going toward the posterior iliac crest.
cesses to inject the ISLs. • To target the superior band, redirect the needle
• Cautiously advance the needle towards the mid-portion superiorly and lateral to the lowest transverse pro-
of the ligamentum flavum. Stay posterior to the spinal cess and go slightly deep/ventral no more than 1
laminar line. to 2 mm
• Option to inject contrast for the deeper structure to • Inject a small amount of contrast to show flow going
ensure no epidural flow. toward the L4 spinous process and toward the poste-
rior iliac crest.
PEARLS AND PITFALLS • Transverse ligaments:
• U se smallest needle possible.
• The needle should be advanced to the lateral aspect of
• Use two hands when injecting the deeper ligaments to the transverse process until touching down on the perios-
ensure adequate control of the needle, which will also teum. Redirect the needle either superior and deep/ante-
limit accidental advancement of the needle too deep rior or inferior and deep/anterior to target the desired
(Figs 14.63 and 14.64). superior or inferior band no more than 1 to 2 mm.
   • Inject a small amount of contrast that should show
vertical flow along the ligament superiorly or inferi-
Technique for Iliolumbar, Intertransverse orly, depending on the target.
Ligaments • Inject both the superior and inferior aspects of the
ligament.
Patient Position
• S ame as for other lumbar procedures. PEARLS AND PITFALLS
• Prone with pillow under the waist to decrease lordosis.
• T he iliolumbar ligament is an important stabilizer for the
L5-S1 segment and for the superior sacroiliac (SI) joint.70
Clinician Position • Always start over and touch down on is to ascertain
depth and for safety.
• Standing opposite of the C-arm. • If the patient is awake, injecting the iliolumbar ligament can
reproduce some typical pain and may provide diagnostic
C-Arm Position Fluoroscopy information on if the IL ligament is a pain generator.
• T rue AP view, so the spinous process of the desired level • The authors recommend using contrast to confirm
is centered between the vertebral bodies. ligamentous spread. Also, it can serve as a diagnostic
injection using an anesthetic agent (Figs 14.65-14.67).
• “Square off” endplate of the desired level.
• Center the transverse process.   
218 SEC T I O N I I I Atlas

A B
• Fig. 14.64 (A) Mid-portion ligamentum flavum (LF) injection lateral fluoroscopy with contrast showing supra-
spinous injection and LF flow and no epidural flow. (B) LF mid-portion anteroposterior fluoroscopic view.

A B
• Fig. 14.65 (A) Iliolumbar ligament anteroposterior fluoroscopy with contrast inferior band showing con-
nection to superior supraspinous injection (SI) joint capsule. (B) Iliolumbar ligament inferior and transverse
bands with contrast also showing flow along the anterior inferior band connecting to anterior SI capsule.

Technique for Lateral Aspect of the Ligamentum Clinician Position

Flavum • Standing opposite of the C-arm.
Patient Position C-Arm Position Fluoroscopy
• S ame as for other lumbar procedures. • T
 rue AP view, so the spinous process of the desired level
• Prone with pillow under the waist to decrease lordosis. is centered between the vertebral bodies.
 CHAPTER 14 Lumbar Injection Techniques 219

• “ Square off” endplate of the desired level. Needle Position

• Make sure the lamina are clearly visualized. • Identify the lamina just below the targeted area.
• Use CLO view around 40 degrees or what rotation For example, for the L3-4 ligamentum flavum, identify the
visualizes the lamina best in order to gauge needle L4 lamina.
depth. • Start the needle just lateral to the spinous process and
• Can also use true lateral to gauge needle depth. mid-portion of the lamina superior to inferior.
• Guide the needle anterior and slightly superior to touch
the superior aspect of the lamina.

Target
• T arget the ligament flavum by redirecting the needle just
superior to the lamina.
• Stop and check the needle depth in the contralateral
oblique view or utilize a true lateral view.
• Advance the needle to the spinal laminar line.
• Inject a small amount of contrast to show flow along the
ligament in the CLO view or lateral and to make sure no
epidural flow. Can confirm in the AP as well.

PEARLS AND PITFALLS

• T he starting needle position should always be over
the periosteal surface of the lamina and always touch
down on the lamina to ascertain depth and for safety
prior to advancing the needle into the interlaminar
space.
• Theoretically, tightening the ligamentum flavum with
prolotherapy or orthobiologics may decrease buckling
and hypertrophy, thus widening the epidural space
and potentially providing symptomatic relief in patients
with central canal stenosis and ligamentum flavum
hypertrophy (Figs 14.68 and 14.69).
• Fig. 14.66 Iliolumbar Ligament Anteroposterior Fluoroscopy with Con-
trast Needle at Superior Band Also Showing Inferior Band Flow.   

A B
• Fig. 14.67 (A) Anteroposterior (AP) view of scoliotic patient with needle at the left L1-2 intertransverse
ligament (IT) with contrast highlighting the injected IT ligaments. (B) AP view of needle at the L3-4 IT liga-
ment with contrast highlighting the injected IT ligaments.
220 SEC T I O N I I I Atlas

A B
• Fig. 14.68 (A) Contralateral oblique view of needle at the ligamentum flavum with contrast highlighting.
(B) Lateral view of needles at the ligamentum flavum.

A B
• Fig. 14.69 (A) Anteroposterior (AP) view of needle at left L3-4 ligamentum flavum with contrast highlight-
ing. (B) AP view of needles at bilateral L3-4, l4-5 ligamentum flavum with contrast highlighting.

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017-0113-5. ment. Bone Rep. 2020;12:100249. https://doi.org/10.1016/j.
45. Furman MB, et al. Injectate volumes needed to reach specific bonr.2020.100249.
landmarks in lumbar transforaminal epidural injections. Reeves 59. Lundon K, Bolton K. Structure and function of the lumbar
RS PM R. 2010;2(7):625–635. intervertebral disk in health, aging, and pathologic conditions.
46. Bogduk N, ed. Practice Guidelines for Spinal Diagnostic and J Orthop Sports Phys Ther. 2001;31(6):291–306. https://doi.
Treatment Procedures. International Spine Intervention Society; org/10.2519/jospt.2001.31.6.291.
2013. Artery of Adam. 60. Aoki Y, Nakajima A, Ohtori S, et al. Increase of nerve growth
47. B ogduk N, Aprill CN, Derby R. Epidural steroid injec- factor levels in the human herniated intervertebral disc: can
tions. In: White AH, Schofferman JA, eds. Spine Care: annular rupture trigger discogenic back pain? Arthritis Res Ther.
Diagnosis and Treatment. St. Louis: Mosby Year Book. 1995: 2014;16(4):R159. https://doi.org/10.1186/ar4674.
322–342. 61. Ohtori S, Miyagi M, Inoue G. Sensory nerve ingrowth, cyto-
48. Simon Jeremy I, et al. Intravascular penetration following lum- kines, and instability of discogenic low back pain: a review. Spine
bar transforaminal epidural injections using the infraneural Surg Relat Res. 2018;2(1):11–17. https://doi.org/10.22603/
technique. Pain Med. 2015;16(8):1647–1649. ssrr.2016-0018.
49. Sayre PA, Burr Ridge IL, Glaser Scott E. Root cause analysis of 62. Waxenbaum JA, Reddy V, Futterman B. Anatomy, back, interver-
paraplegia following transforaminal epidural steroid injections: tebral discs. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
the “unsafe” triangle. Pain Phy. 2010;13:237–244. Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/­
50. Kroszczynski AC, et al. Intraforaminal location of thoracolum- books/NBK470583/.
bar anterior medullary arteries. Pain Med. 2013;14(6):808– 63. Mirza SK, White 3rd AA. Anatomy of intervertebral disc
812. and pathophysiology of herniated disc disease. J Clin Laser
51. Yoshioka K, et al. MR angiography and CT angiography of Med Surg. 1995;13(3):131–142. https://doi.org/10.1089/
the artery of Adamkiewicz: noninvasive preoperative assess- clm.1995.13.131.
ment of thoracoabdominal aortic aneurysm. Radiographics. 64. Panjabi MM. A hypothesis of chronic back pain: ligament sub-
2003;23(5):1215–1225. failure injuries lead to muscle control dysfunction. Eur Spine J.
52. Bogduk N, et al. Complications of spinal diagnostic and treat- 2006;15(5):668–676. https://doi.org/10.1007/s00586-005-
ment procedures. Pain Med. 2008;9(suppl 1):S11–S34. 0925-3.
53. Levi D, Horn S, Corcoran S. The incidence of intradiscal, intra- 65. Kushchayev SV, Glushko T, Jarraya M, et al. ABCs of the degen-
thecal, and intravascular flow during the performance of retro- erative spine. Insights Imaging. 2018;9(2):253–274. https://doi.
discal (infraneural) approach for lumbar transforaminal epidural org/10.1007/s13244-017-0584-z.
steroid injections. Pain Med. 2016;17(8):1416–1422. https:// 66. Behrsin JF, Briggs CA. Ligaments of the lumbar spine: a
doi.org/10.1093/pm/pnv067. review. Surg Radiol Anat. 1988;10(3):211–219. https://doi.
54. Ridley LJ, Han J, Ridley WE, Xiang H. Scotty dog: nor- org/10.1007/BF02115239.
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Oncol. 2018;62(suppl 1):152. https://doi.org/10.1111/1754- bar ligament. Clin Orthop Relat Res. 2000;380:167–172. https://
9485.26_12786. doi.org/10.1097/00003086-200011000-00022.
 CHAPTER 14 Lumbar Injection Techniques 223

68. R ucco V, Basadonna PT, Gasparini D. Anatomy of the iliolum- 70. P

 ool-Goudzwaard AL, Kleinrensink GJ, Snijders CJ, Entius
bar ligament: a review of its anatomy and a magnetic resonance C, Stoeckart R. The sacroiliac part of the iliolumbar ligament.
study. Am J Phys Med Rehabil. 1996;75(6):451–455. https://doi. J Anat. 2001;199(Pt 4):457–463. https://doi.org/10.1046/
org/10.1097/00002060-199611000-00010. j.1469-7580.2001.19940457.x.
69. Naeim F, Froetscher L, Hirschberg GG. Treatment of the
chronic iliolumbar syndrome by infiltration of the iliolumbar
ligament. West J Med. 1982;136(4):372–374.
15
Sacrococcygeal Injection
Techniques
JOANNE BORG-STEIN, CATHERINE MILLS, CAROLYN
BLACK, OLUSEUN OLUFADE, AND GIORGIO A. NEGRON

Ultrasound Guided Procedures

Sacroiliac Joint

KEY POINTS
• U
 ltrasound-guided intra-articular injections can provide Equipment
both pain relief and diagnostic information in sacroiliac
• N eedle size: 25–22 gauge and 2 to 3.5-inch needle
(SI) joint pain
• Low frequency curvilinear ultrasound transducer
Pertinent Anatomy Common Injectates
• T he SI joint is stabilized by the anterior SI ligament, the • L ocal anesthetics for diagnostics, corticosteroids
interosseous ligament, and the short and long posterior • Prolotherapy, Orthobiologics (PRP, bone marrow
SI ligaments. Secondary stabilizers are the sacrospinous concentrate, etc.)
and sacrotuberous ligaments (Fig. 15.1).
Injectate Volume
• The cranial third of the joint is a fibrous joint, the middle
• 0.8–2.5 mL8
third of the joint is fibrocartilaginous and resembles a
symphysis, while the caudal third is synovia.1,2 Technique
• The anterior joint capsule is contiguous resulting in a
“true synovial joint”, while the posterior joint capsule Patient Position
is thin and non-contiguous, made up of a series of • P rone with a pillow under the abdomen to flatten the
ligaments, allowing for diffusion of larger volumes of lumbar curvature.
injectate around the posterior ligaments and soft tissue • Lower extremities should be internally rotated while feet
structures.1,2 are inverted to help flatten the gluteal region.
Clinician Position
Common Pathology • Sitting or standing by the patient’s side
• T he SI joint (SIJ) is a common source of axial low back
pain, with a prevalence of 25%.3 Transducer Position
• The pathophysiology of SI joint pain is highly debated. • T ransverse orientation to identify the sacral hiatus
Pain generation may be the result of abnormal movement • Move the transducer laterally to identify the lateral edge
of the SI joint (either laxity or immobility), malalignment of of the sacrum
the SI joint, and osteoarthritis of the SI joint. • Keeping the transducer in the transverse orientation, move
• Sacroiliitis may be an early symptom of cephalad until the contour of the ilium is identified (Fig. 15.2A)
seronegative spondyloarthropathies. Seronegative • Transducer should end over the caudal third of the SI joint.9,10
spondyloarthropathy should be suspected in younger Needle Position
(<45 years) male patients presenting with SI joint or • In-plane with the transducer, medial to lateral approach with
low back pain of insidious onset that improves with approximately 45–65 degrees of angulation (see Fig. 15.2B)
activity.4,5
• Increased Doppler signal surrounding the SI joint is seen Target
in sacroiliitis.6 • T he caudal third of the SI joint is targeted advancing the
• In addition to axial pain, pathology of the SIJ can produce needle past the posterior SI ligament (see Fig. 15.2).9,10
variable referred pain patterns, including pain referred into • Alternatively, the middle third or the cranial third of the SI
the buttock, the lower lumbar area, and the thigh.7 joint can be targeted with comparable pain reduction.11–13
  

224
 CHAPTER 15 Sacrococcygeal Injection Techniques 225

Dorsal
Sacroiliac Ligament

Sacrospinous
Labrum
Ligament

Iliofemoral
Capsule Ligament

Ischiofemoral
Ligament

Transverse
Ligamentum Acetabular
Sacrotuberous Sacrococcygeal
Teres Ligament
Ligament Ligament
• Fig. 15.1 Posterior pelvic and sacral ligaments.

Lateral

Ilium *
Sacrum

A B
• Fig. 15.2 Ultrasound guided sacroiliac joint injection (A) Set-up. The posterior superior iliac spine, superior
border of the sacrum, and lateral borders of the sacrum are marked on the model for reference during the
procedure. (B) A transverse ultrasonic view of the SI joint with the ilium to the left of the screen and sacrum
to the right. The needle approach shown from medial to lateral into the boat-shaped SI joint (arrow). Dorsal
sacral foramina (*).

PEARLS AND PITFALLS

• A 2%–2.5% rate of vascular uptake in US guided SI joint • In cadaveric studies, >50% of injections at the caudal
injection has been reported.14,15 third of the SI joint had extra-articular spread.16 For this
• The posterior sacral foramen should be visualized on reason, it may be worthwhile to consider targeting the
ultrasound along with the SI joint to confirm injection cranial third or middle third of the SI joint, as the approach
location lateral to the S2 foramen, and avoid foraminal may be technically less challenging with the wider joint
injection. space in this area.13
  
226 SEC T I O N I I I Atlas

The Sacrococcygeal Joint

KEY POINTS
• U
 ltrasound can be a useful adjunct to fluoroscopy to Technique
locate the sacrococcygeal joint (SCJ) for joint injection or Patient Position
set-up for ganglion impar block. Fluoroscopy is required • P rone, with a pillow under the abdomen to flatten the
to confirm needle depth and position. lumbar curve.
• Lower extremities should be internally rotated while feet
Pertinent Anatomy are inverted to help flatten the gluteal region.
• T he SCJ contains the sacrococcygeal disc, which may
ossify with age and obscure the SCJ on fluoroscopy. Clinician Position
• The ganglion impar is located ventral to the deep • Seated or standing next to the patient
sacrococcygeal ligament and can be accessed through Transducer Position
the SCJ. • S tart with the transducer transverse across the midline
and locate the sacral hiatus.
Common Pathology • Identify the sacral cornua.
• P ain can be traumatic or non-traumatic • The sacrococcygeal ligament can be identified overlying
• Coccydynia more frequently affects women. Compared the sacral hiatus, which is superficial to the base of the
to males, the female coccyx tends to be shorter, sacrum.
straighter, and more prone to retroversion.17 • Rotate longitudinally over the SCJ and sacral hiatus, so
the proximal part of the transducer rests between the two
Equipment cornua, and the first cleft caudal to the sacral hiatus is
• N eedle size: 25–22 gauge and 2 to 3-inch needle. the SCJ (Fig. 15.3A).
• High-frequency linear ultrasound transducer
Needle position
Common Injectates • In plane with the transducer Fig. 15.3B
• L ocal anesthetics for diagnostics, corticosteroids
Target
• Prolotherapy, Orthobiologics (PRP, bone marrow
• T
 he cleft of the SCJ (the first cleft caudal to the sacral
concentrate, etc.)
hiatus is the SCJ) (see Fig. 15.3B)
Injectate volume
• 1–3 mL
  

PEARLS AND PITFALLS

• T he tip of the needle can be difficult to visualize in the joint • T
 he same approach is used for ganglion impar block,
space using ultrasound. passing through the joint to reach the ganglion anterior to
• Fluoroscopy is preferred to confirm needle depth and the ventral sacrococcygeal ligament with fluoroscopy to
position. confirm needle placement.
  

Prox
S5 *
Coccyx

A B
• Fig. 15.3
Ultrasound guided injection of the sacrococcygeal joint. (A) Set up. (B) Ultrasound view of the
sacrum (proximal, left), coccyx (distal, right), and sacrococcygeal joint (*), with needle path (arrow).
 CHAPTER 15 Sacrococcygeal Injection Techniques 227

Short and Long Dorsal Sacroiliac Ligaments

KEY POINTS
• T
 he short and long dorsal SI ligaments are able to be Injectate Volume
visualized superficial to the SI joint using ultrasound • 1–3 mL
guidance and targeted for injection.18,19
Technique
Pertinent Anatomy Patient Position
• T he SI joint is located in the bony cleft between the • P rone, with a pillow under the abdomen to flatten the
sacrum and the contour of the ilium. lumbar curvature.
• The dorsal ligaments lie within this bony cleft lateral to the • Lower extremities should be internally rotated while feet
sacrum at the S1–S2 level. are inverted to help flatten the gluteal region.
• The short dorsal ligament is oriented perpendicular to the
joint, while the long ligament runs oblique to it. Clinician Position
• S
 itting or standing next to the patient opposite the side to
Common Pathology be injected (for a medial to lateral approach).
• D
 isruption or laxity of the ligamentous structures leading to Transducer Position
altered joint mechanics is a potential cause of SIJ pain.20 • T ransverse to the SI joint, long-axis to the short ligament
• Obliquely paralleling the lateral border of the sacrum and
Equipment long-axis to the long ligament
• N eedle size: 25–22 gauge and 2 to 3.5-inch needle. Needle Position
• High-frequency linear ultrasound transducer • In-plane to the transducer, medial to lateral approach
Common Injectates with needle oriented 45 to 65 degrees.
• L ocal anesthetics for diagnostics Target
• Prolotherapy, Orthobiologics (PRP, bone marrow • Anechoic or hypoechoic signal within the ligaments.
concentrate, etc.)
• Avoid intra-ligamentous corticosteroid injections.
  

PEARLS AND PITFALLS

• Marking the posterior superior iliac spine on the skin for reference allows for better transducer positioning during the procedure.
  

Superficial Posterior Sacrococcygeal Ligament

KEY POINTS
• In 90% of cases, coccydynia responds to conservative mechanism of coccydynia (the second intercoccygeal
treatment.21 joint is typically fused).22
• In refractory cases, interventional procedures such as
injections have been shown to be effective. Equipment
• N eedle size: 27–25 gauge and 1.5 to 3-inch needle.
Pertinent Anatomy • High-frequency linear ultrasound transducer
• T
 he superficial posterior sacrococcygeal ligament runs
posteriorly, spanning from the sacral hiatus and inserting Common Injectates
distally to the first inter-coccygeal joint. • L ocal anesthetics for diagnostics
• Prolotherapy, orthobiologics (PRP, bone marrow
Common Pathology concentrate, etc)
• Avoid intraligamentous corticosteroid injections.
• P ain can be traumatic or non-traumatic
• In non-traumatic cases, ligamentous laxity with excessive Injectate Volume
motion of the 1st intercoccygeal joint is one proposed • 1–3 mL

Continued
228 SEC T I O N I I I Atlas

KEY POINTS—cont’d
Technique Transducer Position
Patient Position • L
 ong-axis to the sacrococcygeal ligament
• P rone with a pillow under the abdomen to flatten the (Fig. 15.4A).
lumbar curvature. Needle Position
• Lower extremities should be internally rotated while feet • L
 ong-axis to the ligament and in plane to the transducer.
are inverted to help flatten the gluteal region. A proximal to distal or distal to proximal approach can be
Clinician Position used (see Fig. 15.4B).
• Seated or standing directly next to the patient Target
• A
 nechoic or hypoechoic signal within the ligament (see
Fig. 15.4B).
  

PEARLS AND PITFALLS

• Interstitial tearing of the ligament can be challenging to during skin preparation from the antiseptic cleansing
identify with imaging. A diagnostic lidocaine injection agents.
into the ligament can be used to confirm the ligament as • Ultrasound allows for direct visualization of the
a source of pain, which can guide further workup and superficial fibers of the sacrococcygeal ligament,
treatment decisions. but acoustic shadowing from the bone prevents
• Occult interstitial tearing can sometimes be identified visualization of the deep sacrococcygeal ligament.
during the injection when small aliquots of the If there is suspected involvement of the deep
injectate are placed in the ligament as the needle is sacrococcygeal ligaments (SCL), fluoroscopy guidance
advanced. should be used to access the superficial and deep
• Gauze should be placed in the inter-gluteal or natal fibers23.
cleft just proximal to the rectum to protect the mucosa
  

PROX

Co2

PSCL

Co1

S5

A B
• Fig. 15.4Ultrasound guided injection of the sacrococcygeal ligament. (A) Setup. (B) Ultrasound view with
proximal to the left. The sacrum (S5), first and second bones of the coccyx (cox1, cox2), posterior sacro-
coccygeal ligament (PSCL), and needle approach (arrowheads) are shown.
 CHAPTER 15 Sacrococcygeal Injection Techniques 229

Sacrotuberous and Sacrospinous Ligaments

KEY POINTS
• T
 he sacrotuberous ligament is a key point of attachment • Low frequency curvilinear ultrasound transducer
for the hamstrings and gluteal musculature.
Common Injectates
Pertinent Anatomy • L ocal anesthetics for diagnostics
• Prolotherapy, Orthobiologics (PRP, bone marrow
• T he sacrotuberous and sacrospinous ligaments have concentrate, etc.)
a conjoint origin, with interwoven fibers that attach • Avoid intraligamentous corticosteroid injections.
proximally to the posterior superior iliac spine, the long
posterior SI ligament, the lateral sacrum, and the coccyx Injectate Volume
proximally. Fibers of the proximal sacrotuberous ligament • 1–3 mL
serve as attachment sites for the gluteus maximus and
piriformis.24 Technique
• The sacrotuberous ligament narrows and spirals along Patient Position
its length, then broadens toward its distal attachment on • P rone with a pillow under the abdomen to flatten the
the ischial tuberosity. Fibers of the distal sacrotuberous lumbar curvature.
ligament are contiguous with the conjoined tendon of the • Lower extremities should be internally rotated while feet
biceps femoris and semitendinosus.24,25 are inverted to help flatten the gluteal region.
• The sacrospinous ligament attaches distally on the ischial
spine. Clinician Position
• Seated or standing directly next to the patient
Common Pathology
Transducer Position
• E ntrapment between the sacrotuberous and • S tart with one end of the transducer positioned along the
sacrospinous ligaments is a common cause of pudendal lateral border of the sacrum and the other pointed toward
neuralgia.26 the greater trochanter over the piriformis, the probe is
• The sacrotuberous and sacrospinous ligaments are then rotated toward the ischial spine (lateral edge greater
important pelvic stabilizers, and may be injured due to sciatic notch).
high-energy trau-ma (i.e., motor vehicle collisions, falls, • The sacrospinous ligament is visualized as a hyperechoic
pedestrians struck by a vehicle) with anterior-posterior line extending medially from the ischial spine.
compression forces across the pelvis. • The sacrotuberous ligament can be seen as a
• Irritation of the sacrotuberous ligament with localized light hyperechoic line parallel and superficial to the
pain, swelling, and reduced echogenicity may be seen at sacrospinous ligament.26,27
its junction with the conjoined tendon. Fibers of the distal • The transducer may need to be rotated clockwise/
ligament are contiguous with the conjoined tendon of the counterclockwise to improve visualization of the ligament.
long head of the biceps femoris and semitendinosus, and
they are disrupted in full hamstring tear.25 Needle Position
• In-plane with the transducer
Equipment
Target
• Needle size: 25–22 gauge and 2 to 3.5-inch needle. • Anechoic or hypoechoic signal within the ligament.
  

PEARLS AND PITFALLS

• P atient body habitus is a key factor influencing success sacrotuberous ligament can be followed to its attachment
visualizing the sacrotuberous and sacrospinous ligaments on the ischial tuberosity.
under ultrasound. • The pudendal nerve is difficult to reliably visualize due
• Resistance can be felt as the needle advances through to its small size and anatomic variability. One, two, or
the sacrotuberous ligament, typically with a loss of three nerve trunks may be identified at this level. Doppler
resistance as the needle “punches through” the ligament ultrasound visualizing the pudendal artery can be a useful
to the soft tissues underneath. guide, although it should be noted that the artery course
• The sacrotuberous ligament may be confused with is highly variable. The pudendal artery may be located
the sciatic nerve at the level the sciatic notch. The medial to the nerve, lateral to the nerve, or with two
sciatic nerve can be traced down into the posterior branches on either side of the nerve.27
thigh, passing lateral to the ischial spine, while the
  
230 SEC T I O N I I I Atlas

Caudal Epidural PEARLS AND PITFALLS

KEY POINTS • G auze should be placed in the inter-gluteal or natal
cleft just proximal to the rectum to protect the mucosa
• U
 ltrasound greatly enhances the accuracy of caudal during skin preparation from the antiseptic cleansing
epidural injection compared to palpation alone, and agents.
treatment outcome in ultrasound-guided injection is • There should not be much resistance during injection.
comparable to fluoroscopy.28,29 • The needle is no longer visualized once it enters the
sacral hiatus. In the majority of patients, the hiatus
Pertinent Anatomy is located at the S4 level (65%–68% of patients).
• T he sacral hiatus is the open caudal termination of the However, in a minority of patients it may be located
sacral canal. It is most commonly located at the S4 level30. further cranially (S3 level: 15% of patients, S1 to
• The sacral cornua border the sacral hiatus laterally and S2: 3%–5% of patients). A cranial hiatus is located
are frequently palpable. closer to the dural sac, and care must be taken
• The dural sac typically terminates between S1 and S2. to avoid accidental dural puncture. Don’t advance
more than 0.5 mm into the hiatus to avoid dural
Common Pathology penetration as shortest distance to the dural can be
• C audal approach is frequently preferred in the setting 6 mm.30,32
of lumbar stenosis or history of lumbar surgery with • Avoid injecting air, as there have been reports of portal
altered anatomy. vein air embolism.33
• Also can be used for: • Ultrasound guided caudal injection technique
• Lumbosacral radiculitis has been shown to have 96.9%–100% accuracy,
• post-laminectomy or post-fusion syndromes however patients with a closed or small sacral hiatus
• epidural fibrosis are poor candidates and may have a higher failure
• Nerve block required for posterior hip and lower rate.34,35 Unidirectional flow within the sacral hiatus
extremity procedures may be visualized on Doppler to confirm successful
injection.28,29
Equipment   
• N eedle size: 25–22 gauge and 2 to 3.5-inch needle
• High-frequency linear ultrasound transducer
Common Injectates
• A nesthetics for lower extremity/sacral nerve block
• Corticosteroids
• Orthobiologics (platelet lysate, PRP).31
Injectate Volume
• 10–20 mL

Technique
Patient Position
• P rone, with a pillow under the abdomen to flatten the
lumbar curve.
• Lower extremities should be internally rotated while feet
are inverted to help flatten the gluteal region.
Clinician Position
• Seated or standing next to the patient
Transducer Position
• S tart with the transducer transverse across the midline
and locate the sacral hiatus, sacral cornua, and
sacrococcygeal ligament superficial to the base of the
sacrum (Fig. 15.5A and B)
• Rotate longitudinally over the sacral hiatus so the
transducer rests between the two cornua. A
Needle Position
• In plane to the transducer distal to proximal approach
(Fig. 15.6).
Target
• T he needle pierces the SCL into sacral hiatus and SC SC
advance 0.5 cm deep (Fig. 15.7A)
• Inject under color flow to show epidural flow (see Fig. 15.7B)
SH
B
  
• Fig. 15.5 (A) Sacral cornua view transducer set up. (B) Sacral cor-
nua ultrasound view. SC, sacral cornua; SH, Sacral hiatus; Downward
white arrows, sacrococcygeal ligament.
 CHAPTER 15 Sacrococcygeal Injection Techniques 231

SCL

SH
SB
A Cephalad

SH
SB
B
• Fig. 15.7 (A) Caudal epidural injection under ultrasound needle into
sacral hiatus. (B) Injecting under color flow Doppler to ensure epidural
flow. SH, sacral hiatus; SB, sacral base; SCL, sacrococcygeal liga-
ment; White arrows, needle path.
• Fig. 15.6 Caudal epidural injection under ultrasound needle trajectory.

Fluoroscopic Procedures
S1 transforaminal epidural using the subpedicular approach.

KEY POINTS
• T
 he objective of transforaminal injection is to deliver Injectate Volume
injectate around the spinal nerve and its nerve root • 2–5 mL
sleeve. It must not be delivered into the thecal sac.
Technique
Pertinent Anatomy Patient Position
• E ach lumbar intervertebral foramen is formed between • Prone position on a fluoroscopy table
two consecutive vertebrae with the most inferior lumbar
articular facet joining with S1 superior articular process. Clinician Position
• The sacrum is made up of five fused vertebrae (S1–S5) • Lateral to the patient
with four pairs of ventral and dorsal sacral foramina (left Fluoroscopic
and right). • “ Square off” the superior endplate of the sacrum using a
• S1 foramen is bounded superiorly by L5 pedicles, cephalad tilt in the AP view
inferiorly by sacral base, anteriorly by the sacral • The target dorsal S1 foramen can be difficult to visualize
intervertebral disc (L5–S1) and posterior longitudinal and can be mistaken for the larger, more obvious ventral
ligament, and posteriorly by the ligamentum flavum. S1 foramen.
• The dorsal S1 foramen is a more ovoid shape, smaller
Common Pathology and located superiomedial to the ventral S1 foramen and
•  5–S1 Degenerative disk disease
L inferior to the S1 pedicle at 6 o’clock.
• Lumbosacral radiculopathy • First, visualize the S1 pedicle and look just inferior to the
• Failed back surgery syndrome 6 o’clock position.
• Epidural fibrosis • Visualize “Charlie’s line,” named after Charlie Aprill, which
runs along the medial aspect of the S1 pedicle (Fig.
Equipment 15.8). This can also help localize the dorsal S1 foramen.
• 2 5–22 gauge and 3 to 3.5-inch spinal needle • If the dorsal S1 foramen cannot be visualized in the AP
• Connecting tube view, then oblique the C arm slightly ipsilateral, 5 to 10
• Water soluble, non-ionic radiographic contrast medium degrees.
(Isovue 300/370 or omnipaque) Needle Position
Common Injectates • P
 lace the needle coaxial to the fluoroscopic beam aiming
• L ocal anesthetics for diagnostics, corticosteroids to be in the superolateral aspect of the foramen. This
• Neuroprolotherapy, Orthobiologics (platelet lysate) avoids the nerve, which runs inferolaterally.
Continued
232 SEC T I O N I I I Atlas

KEY POINTS—cont’d
• D
 epth can be gauged by touching down on the lateral • O nce the target site is achieved, inject a small amount of
wall of the foramen and then “walking” off the periosteum contrast already primed and attached to the extension
tubing (Fig. 15.10).
Target • The injection should be done under live fluoroscopy to
• S uperior lateral aspect of the foramen in the AP view better identify a vascular filling pattern (Fig. 15.11).
• In the lateral view (Fig. 15.9), the tip of the needle should • Ideal flow should outline the S1 nerve and flow medially
lie about 5 mm short of the floor of the sacral canal (SIS) into the epidural space to the S1 pedicle.
and should lie just short of the floor of the sacral canal.
  

PEARLS AND PITFALLS

• F
 irst contact the posterior sacral bone prior to “walking” • D
 o not advance past the iliopectineal line to avoid visceral
off the periosteum and entering the S1 foramen injuries
  

• Fig. 15.8 Precontrast L S1 transforaminal epidural. Note: Charlie’s line.

• Fig. 15.10 Post contrast with S1 nerve root flow and epidural flow.

• Fig. 15.11 Intra-arterial contrast flow during an S1 transforaminal epi-

• Fig. 15.9 Lateral view of S1 TFESI. Note iliopectineal line. dural injection showing tortuous filling of the vasculature.
 CHAPTER 15 Sacrococcygeal Injection Techniques 233

Caudal Epidural Injection

KEY POINTS Needle Position

• P alpate the sacral cornuae and start 0.5–1 inch below
• L
 andmark guided caudal epidural results in incorrect • Use the lateral fluoroscopic view to identify needle
needle placement as high as 38% of procedures.36 trajectory. Insert the needle into the skin caudal to
cephalad heading towards the sacral hiatus (Fig. 15.13)
Pertinent Anatomy • Ensure the needle is in the midline
• T he sacrum is a triangular bone dorsally convex, that
consists of fused 5 sacral vertebra Target
• Sacral hiatus is an opening in the spinal canal in the • S acral epidural space via the sacral hiatus
lower part of the sacrum formed by the incomplete • Advance the needle past opening and not higher than
midline fusion of the lamina at S4 or S5. the S3 level to avoid dura sac puncture
• The sacral hiatus is a U-shaped space with the lateral • Contrast is injected to confirm epidural flow (Figs. 15.14
margins formed by the sacral cornu and covered by the to 15.16).
sacrococcyeal ligament. • One can visualize how far cephalad the contrast flows
• The sacral canal contains terminal part of the dural sac after adding an injectate (see Fig. 15.14)
which generally ends at the S2 but may terminate at the   
S1 or S3 level

Common Pathology PEARLS AND PITFALLS

•  umbar radiculopathy
L
• Lumbar stenosis with and without axial low back pain • M ajor complications related to procedure may include
• Post-laminectomy syndrome infection, hematoma/abscess formation, subarachnoid
• Epidural fibrosis and subdural injection
• Avoid advancing too ventral and puncturing the bowel.
Equipment:
  
• 2 5–22 gauge and 2 to 3.5-inch spinal needle
• Extension tubing
• Contrast
Common Injectates
• L ocal anesthetic and non particulate corticosteroids
• Orthobiologics (platelet lysate)
• Avoid particulate steroids
Injectate Volume
• 5–15 mL pending patient tolerance

Technique
Patient Position
• P
 rone with abdomen on a pillow to reduce lumbar
lordosis
Clinician Position
• Lateral to the patient
Fluoroscope Position
• S tart in the lateral view to identify the sacral hiatus
• AP view is used to keep the needle midline and avoid
advancing too cephalad (Fig. 15.12).

• Fig. 15.12 AP view of the C-arm at the needle’s point of entry into
the skin.
234 SEC T I O N I I I Atlas

A B
• Fig. 15.13 Lateral view of the C-arm as the needle approaches the S3 foramen.

• Fig. 15.14
AP and lateral view of a caudal epidural injection with and • Fig. 15.15
AP and lateral view of a caudal epidural injection with and
without contrast injection without contrast injection
 CHAPTER 15 Sacrococcygeal Injection Techniques 235

A B
• Fig. 15.16 Fluoroscopic view during caudal epidural injection with and without contrast.

Sacroiliac Joint

KEY POINTS
• T he inferior approach is the author’s preferred approach. Technique (Inferior Approach)
• The superior approach is an alternative if the inferior Patient Position
approach is unsuccessful. • Prone position
• One can use the superior approach to inject the superior
SI joint dorsal ligaments. Clinician Position
• Lateral to the patient
Pertinent Anatomy
Fluoroscope Position
• S I joint is an auricular-shaped di-arthrodial joint with joint • T ilt the fluoroscope cephalad, approximately 10–15
capsule and synovial fluid. It has hyaline cartilage on the degrees to visualize the lower SI joint effectively
sacral side and fibrocartilage on the iliac side. • Under live fluoroscopy, oblique the C-arm to obtain the
• Multiple ligaments support the SIJ joint; namely the best view of the dorsal caudal joint opening. Author
anterior, short, lateral and interosseous ligament. found that ipsilateral oblique is more common, but the
• The sacrotuberous and sacrospinous ligament stabilize best view may be contralateral oblique as well.
the pelvis. • Watch for the hyperlucency region at the caudal portion
• The posterior aspect of the joint is innervated by the of the SIJ.
posterior rami of L4–S3.
Needle position
Common Pathology • S tart just caudal and medial to the Joint
• S IJ dysfunction • Guide the needle to the caudal and medial wall of the
• SIJ arthropathy joint, and then “walk off” cephalad and laterally to enter
the joint.
Equipment • As the needle contacts firm tissues on the posterior aspect
of the joint, it should be redirected if needed and advanced
• C arm fluoroscopy
through the ligaments and capsule into the joint.
• 25–22 gauge and 3 to 3.5-inch spinal needle
• Contrast Target
• T he target is the medial aspect of the SIJ 1–2 cm
Common Injectates cephalad to the caudal aspect of the joint (Fig. 15.17).
• L ocal anesthetic for diagnostics: Corticosteroids • Contrast in injected with ideal flow visualized outlining the
• Prolotherapy and orthobiologics (PRP, bone marrow medial and lateral aspect of the joint (Fig. 15.18).
concentrate, etc.) • If resistance is felt, withdraw or advance the needle and
injection contrast again. A tactile sensation of a “giving
Injectate Volume away” or loss of resistance can often be felt.
• 1–2 mL • If desired, one can inject just overlying the joint to target
the inferior dorsal SI ligaments (Fig. 15.19).
  
236 SEC T I O N I I I Atlas

PEARLS AND PITFALLS

• C
 are should be taken not to advance the needle beyond • T
 he AP view is used to show the needle advancing lateral
the ventral joint capsule and caudal to the joint.

Technique (Superior Approach) Needle Position

• S tart the needle medial and cephalad to the joint.
Patient Position • The tip of the needle should be advanced laterally and caudally
• Prone position • Touch on the medial wall of the joint (i.e., sacrum), and then
Clinician Position walk off laterally into the joint (see Fig. 15.20B and C).
• Lateral to the patient Target
Fluoroscope Position • C ephalad aspect of the SIJ
• T ilt the fluoroscope cephalad approximately 10–20 • Inject a small amount of contrast to confirm intra-articular
degrees to improve the target flow (see Fig. 15.20 D and E).
• Move the C-arm to 40–50 degrees contralateral oblique to • If desired, one can inject just overlying the joint to target
visualize the joint opening (Fig. 15.20A). the superior dorsal SI ligaments (see Fig. 15.20F).

  

• Fig. 15.17 Posterior and lateral fluoroscopy view during a left sacro-
iliac joint injection.
• Fig. 15.19
Optional figure showing sacrospinous and part of sacrotu-
berous ligament off inferior SI joint approach.

• Fig. 15.18 Contrast was injected to ensure the joint has been accessed.
 CHAPTER 15 Sacrococcygeal Injection Techniques 237

A B C

D E F
• Fig. 15.20 Superior approach of SIJ injection showing access to the joint by using (A) contralateral oblique view. The C-arm was positioned at 40–50
degrees (42 degrees in this view) in contralateral oblique view to demonstrate the wedge shape formed by the medial iliac ala and the lateral border
of the sacrum (white arrow). (B) Contralateral oblique view. After positioning a guide needle, a 26-gauge curved needle was inserted into the wedge
shape and then advanced laterally and inferiorly into the sacroiliac joint. (C) Antero-posterior view showing the needle advanced further laterally and
inferiorly into the joint. (D) Antero-posterior view showing an arthrogram of the sacroiliac joint after injecting contrast material. (E) SI joint arthrogram
in ipsilateral oblique view. (F) The periarticular injection was performed using the same needle. After withdrawing the needle cranially, needle position
was confirmed by contrast injection.

PEARLS AND PITFALLS

• C
 are should be taken not to advance the needle beyond • T
 hough less common, the success rate of the superior
the ventral joint capsule.13 approach has been found to be 90%.37
  

Sacroiliac Joint Radiofrequency Ablation

KEY POINTS
• T hermal or conventional radiofrequency (RF) neurotomy • C
 ooled RF sends RF current through cooled electrodes,
produces a RF current through an electrode creating and has a larger lesion size than traditional RF. It relies
thermal energy and lesions or destroys the targeted on keeping the impedance low and allowing alternate
nerve by denaturing its constituent proteins. It develops current to heat tissues longer. Cooled RF can be
between 60 and 80 °C at interval of 60–90 seconds per delivered for two and a half minutes to achieve target
lesion. electrode temperature of 60°C38,39.
• Pulsed RF is similar to thermal ablation; however, it uses
a higher voltage dissipating heat easily and generating Pertinent Anatomy
less heat. This can be achieved with a single probe • T
 he SIJ is innervated by the dorsal rami of L5–S3, dorsal
electrode and grounding pad (monopolar) or two parallel rami and ventral rami of L4–5.
probe electrodes (bipolar).
Continued
238 SEC T I O N I I I Atlas

KEY POINTS—cont’d
Common Pathology Fluoroscope Position
• S IJ dysfunction • L 5 dorsal rami is identified by obtaining an AP view to
• SIJ arthropathy visualize the notch between the ala and the superior
articular process of the sacrum.
Equipment • Using a lateral view, the needle is confirmed to be no
deeper than the AP midline of the superior articular
• C -arm fluoroscopy
process.
• Generator that produces a high-frequency, alternating,
• Using the AP view, the S1, S2 and S3 foramen are
electric current
identified.
• A ground plate that delivers the current
• A lateral view is taken to ensure that the probe is not in
• A needle like electrode whose shaft is insulated but
the sacral canal.
whose tip is exposed, which receives current
Needle Position
Common Injectates • T
 he introducer is inserted lateral and inferior to the target
• Local anesthetic until bony contact is made.
Target
Injectate Volume
• F or the L5 dorsal rami, aim for the notch between the
• 1–2 mL sacral ala and the superior articular process
• Aim just lateral to the sacral foramen (Figs. 15.21 and
Technique 15.22).
Patient Position • Before RFA, sensory and motor stimulation confirms
• Prone position correct needle position. Muscle contraction in the distal
lower extremities indicates the needle is in close proximity
Clinician Position to the spinal nerve and needs to be repositioned.
• Lateral to the patient
• Stylet of the introducer is removed and a small amount of
local anesthetic is administered to the target site.
• RFA is delivered
  

A B
• Fig. 15.21 Needle placement of the S1 and S2 lateral nerve.
 CHAPTER 15 Sacrococcygeal Injection Techniques 239

• Fig. 15.23 Lateral view of C-arm at the point of entry.

• Fig. 15.22Lateral view with the inferior needle at the target position
during an L5 dorsal rami RF ablation.

Common Injectates
• L ocal anesthetic plus or minus corticosteroids
PEARLS AND PITFALLS • Neuroprolotherapy, Orthobiologics (platelet lysate)
• P atients should be monitored for groin, anterior thigh,
Injectate Volume
lower leg and foot pain.
• Observational studies noted that success rates for • 3–5 mL
bipolar RFA was 38% compared to 82% for cooled
RFA.40 Technique
• When compared to monopolar RFA technique, Patient Position
bipolar lesions more reliably captured lateral branches • Prone position
with potential of a 100% capture rate on cadaveric
studies.40
Clinician Position
• Lateral to the patient
  
Fluoroscope Position
• U se a lateral view and place metallic mark to identify the
coccygeal cornu and SCJ
Ganglion Impar Injection • The C-arm is then brought to AP position to confirm
midline
• Use the lateral view to identify needle tip proximity to
KEY POINTS the anterior coccygeal line
Needle Position
Pertinent Anatomy • T
 he needle is inserted midline over the SCJ in the AP
view and then advance in the lateral view (Fig. 15.23).
• G anglion impar is the most inferior ganglia of the
sympathetic nervous system and is the terminal fusion Target
of the 2 sacral sympathetic chains. • N eedle advanced through the SCJ and disc
• It is located retroperitoneal at the level of the • The clinician may feel a subtle loss of resistance when
sacrococcygeal junction (SCJ) but can be located the needle passes through anterior longitudinal ligament
between the SCJ and lower segment of the first • Inject a small amount of contrast, which should form
coccyx. the “comma sign” in the retroperitoneal space on the
• The ganglion impar provides nociceptive and lateral view (Figs. 15.24 and 15.25).
sympathetic innervation to pelvic and perineal
structures.   

Common Pathology
•  occydynia
C
PEARLS AND PITFALLS
• Pelvic pain
• Rectal/perineal pain • A void bowel perforation by going too ventral
• Sympathetically mediated pain (i.e., complex regional • If the needle deviates too far from midline, it can block
pain syndrome) other pelvic nerves
• RF ablation of the ganglion impar can also be
Equipment performed which has been shown to improve chronic
• C -arm fluoroscopy intractable coccydynia through the transacrococcygeal
• 25–22 gauge and 3 to 5-inch spinal needle approach41
• Contrast
  
240 SEC T I O N I I I Atlas

7. Fortin J, Dwyer A, West S, Pier J. Sacroiliac joint: pain refer-

ral maps upon applying a new injection/arthrography tech-
nique. Part I: asymptomatic volunteers. Spine (Phila Pa 1976).
1994;19(13):1475–1482.
8. Zheng P, Schneider BJ, Yang A, McCormick ZL. Image-
guided sacroiliac joint injections: an evidence-based review
of best practices and clinical outcomes. Pharm Manag PM R.
2019;11(S1):S98–S104. https://doi.org/10.1002/pmrj.12191.
9. Chang WH, Lew HL, Chen CPC. Ultrasound-guided sacroiliac
joint injection technique. Am J Phys Med Rehabil. 2013;92(3):278–
279. https://doi.org/10.1097/PHM.0b013e318278d108.
10. Harmon D, O’Sullivan M. Ultrasound-guided sacroiliac joint
injection technique. Pain Physician. 2008;11(4):543–547.
11. Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S. Effect of
periarticular and intraarticular lidocaine injections for sacroiliac joint
pain: prospective comparative study. J Orthop Sci. 2007;12(3):274–
280. https://doi.org/10.1007/s00776-007-1126-1.
• Fig. 15.24 Lateral view of the C-arm around contrast is injected. 12. Nacey NC, Patrie JT, Fox MG. Fluoroscopically guided sacro-
iliac joint injections: comparison of the effects of intraarticular
and periarticular injections on immediate and short-term pain
relief. Am J Roentgenol. 2016;207(5):1055–1061. https://doi.
org/10.2214/AJR.15.15779.
13. Park J, Park HJ, Moon DE, Sa GJ, Kim YH. Radiologic analy-
sis and clinical study of the upper one-third joint technique for
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14. De Luigi AJ. Ultrasound guided sacroiliac joint injections.
Acad Med. 2019 September. https://doi.org/10.1097/PHM.
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15. De Luigi AJ, Saini V, Mathur R, Saini A, Yokel N. Assessing
the accuracy of ultrasound-guided needle placement in sacroiliac
joint injections. Am J Phys Med Rehabil. 2019;98(8):666–670.
https://doi.org/10.1097/PHM.0000000000001167.
16. Perry JM, Colberg RE, Dault SL, Beason DP, Tresgallo RA. A
cadaveric study assessing the accuracy of ultrasound-guided sac-
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• Fig. 15.25 AP view of the C-arm around contrast is injected. 17. Woon JTK, Perumal V, Maigne JY, Stringer MD. CT morphol-
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25. Bierry G, Simeone FJ, Borg-Stein JP, Clavert P, Palmer WE. Sacro- study. Clin Anat. 2009;22(6):730–737. https://doi.org/10.1002/
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16
Shoulder Injection
Techniques
JASON MARKLE AND CLEO D STAFFORD II

Ultrasound Guidance • C orticosteroids, hyaluronic acid, prolotherapy, orthobio-

logics (platelet-rich plasma [PRP], bone marrow concen-
Glenohumeral Joint: Intra-Articular trate, micronized adipose tissue, etc.)
• For capsular distention: High-volume mix of anesthetics,
saline (corticosteroids, or orthobiologics: PRP, platelet
KEY POINTS lysate, platelet-poor plasma)
• Intra-articular ultrasound-guided injections can be done
using the anterior rotator interval approach or posterior
Injectate Volume
approach. The posterior technique avoids accidental • 2 to 8 mL
neurovasculature injury and has lower extra-articular • 20 to 60 mL for capsular distention (40 to 50 mL most
extravasation rates of the injectate compared to the
common per authors’ experience). Inject maximum vol-
anterior approach.1
ume as tolerated by pain or stop when getting back flow
   into the syringe to avoid capsular rupture.5
Pertinent Anatomy Technique: Glenohumeral Intra-Articular Posterior
See Fig. 16.1. Approach
• The shoulder joint (glenohumeral joint) is a ball and Patient Position
socket synovial joint between the scapula and the See Fig.16.2.
humerus. • Lateral recumbent with elbow flexed 90 degrees and
• The joint is the major joint connecting the upper limb to shoulder internally rotated (authors’ preferred).
the trunk. • Can also have patient in the seated position with the
• The joint is one of the most mobile joints in the human shoulder internally rotated and hand resting in the
body, at the cost of joint stability.2 patient’s lap or contralateral shoulder to open to poste-
rior joint space.
Common Pathology
• I ntra-articular pathology can present with a joint Clinician Position
effusion, and distention of the joint can be seen pos- • Posterior to the patient
terior joint line or inferior axillary recess on magnetic
resonance imaging (MRI).3 Transducer Position
• Patient presents with stiffness, loss of range of motion, • L ong axis to infraspinatus tendon, starting with probe
and pain described as deep-seated anterior or posterior. parallel and just inferior to the spine of the scapula
Osteoarthritis can result in chronic instability from • Visualize the posterior glenohumeral joint line deep to
chronic ligament or tendon pathology.4 the muscle belly (infraspinatus)

Equipment Needle Position

• L inear array ultrasound transducer • I n-plane: needle visualization from lateral to medial with
• 25 to 22 gauge 2 to 3.5 inch needle target between the posterior glenoid labrum and humeral
head.
Common Injectates • Out-of-plane: visualize the needle tip as it contacts the
• Local anesthetics for diagnostics humeral head lateral to the posterior labrum

242
 CHAPTER 16 Shoulder Injection Techniques 243

Levator
scapula Supraspinatus

Deltoid (cut)

Rhomboids

Infraspinatus

Teres minor

A
Coracoacrominal
ligament
Acromion Supraspinatus muscle

Rotator cuff Clavic

le
interval
Coracoid process
Transverse
ligament

Short head of
biceps tendon Subscapularis muscle

Deltoid

Scapula

Long head of
biceps tendon
Shoulder Anatomy
B
(Anterior)

Shoulder Anatomy
(Lateral)
Trapezius

Deltoid

Subdeltoid bursa

Supraspinatus Subscapularis
muscle muscle

Infraspinatus
muscle Pectoralis major
muscle

Teres minor
muscle
Triceps brachii Bicep muscle
muscle

Latissimus dorsi Brachialis muscle

C
• Fig. 16.1 Shoulder Anatomy. (A) Rotator cuff musculature, posterior view. (B) Rotator cuff musculature,
anterior view. (C) Shoulder girdle musculature, lateral view.
244 SEC T I O N I I I Atlas

Needle
Trajectory
Infraspinatus Articular Surface
Muscle Belly

Posterior
Labrum
Humeral
Head
Posterior 4.4 cm

B Glenoid 2D: G: 50
Res DR: 0
C
• Fig. 16.2 (A) Patient positioning and probe position. (B) Ultrasound image and target. (C) Injection.

Target Clinician Position

• G lenohumeral joint space, avoiding the posterior • Side of the affected shoulder
labrum.
• Should visualize injectate flowing over the humeral head Transducer Position
without extravagating superficial to the joint line. • Th
 e transducer is placed over the anterior shoulder
• Can use power Doppler imaging to ensure intra-articular with a transverse view of the rotator interval. The
flow and no pooling outside of the joint. long head of biceps tendon at the center of image and
supraspinatus (SS) and subscapularis to either side is
obtained.
PEARLS AND PITFALLS • The coracohumeral ligament (CHL) is seen draped supe-
riorly over the biceps tendon.
• F or posterior approach the needle angle can be steep,
so sometimes gel stand-off can help.
• Keep needle closer to humeral head to avoid labral injury. Needle Position
• With larger body habitus patient, curved linear probe • I n-plane: The needle is introduced into the rotator inter-
may be needed. val using a lateral to medial approach.
• With capsular dilations, common to have resistance
initially given the thickened capsule but with continued Target
pressure and injectate volume into joint, flow becomes
less restrictive. • Th
 e needle tip is imaged in real time, and the target is the
biceps tendon sheath between the CHL above and biceps
  
tendon below.
• Can use power Doppler imaging to ensure intra-articular
flow and no pooling outside of the joint.
Technique: Glenohumeral Intra-Articular Anterior
Approach Via Rotator Interval PEARLS AND PITFALLS
Patient Position
See Fig. 16.3. • F
 or frozen shoulders, anterior capsular distention via
rotator interval has been shown to be superior to other
• The patient lies supine or semi-supine with the affected techniques.6,7
shoulder slightly extended, externally rotated with elbow
flexed or extended for patient comfort.   
 CHAPTER 16 Shoulder Injection Techniques 245

Needle
Trajectory

CH-L SSp

BT
SGHL
SSc

B C
• Fig. 16.3 (A) Patient positioning and probe position. (B) Ultrasound image and target (asterisks). (C)
Injection. BT, biceps tendon; CH-L, Coracohumeral ligament; SGHL, superior glenohumeral ligament;
SSc, subscapularis; SSp, supraspinatus.

Subacromial Injection Equipment

• L inear array ultrasound transducer
KEY POINTS • 25 to 22 gauge 1.5 to 2 inch needle.
• Impingement syndrome and rotator cuff pathology are a
common diagnosis in patients with shoulder pain.8 Common Injectates
• Ultrasound-guided subacromial bursa injections allow • L ocal anesthetics for diagnostics
for higher degree of accuracy when compared to
• Corticosteroids, hyaluronic acid, prolotherapy, orthobio-
landmark-guided injections.9
• For adhesive capsulitis, both subacromial and intra- logics (PRP, platelet-poor plasma).
articular glenohumeral corticosteroids have been both
shown to be effective.10 Injectate Volume
   • 1 to 5 mL
Technique for Subacromial Bursa: Lateral Approach
Pertinent Anatomy Patient Position
 e subacromial bursa is the largest bursa in the body11
• Th See Fig. 16.4.
and lies between the acromion (superiorly) and SS ten- • Seated upright with the shoulder fully adducted and the
don (inferiorly). hand in neutral position with the elbow full extended
• Can extend laterally towards the greater tuberosity and (author preferred), or the shoulder in a Crass or modi-
medially towards the acromion-clavicular joint.11 fied Crass position for better visualization of the SS
• Bursa are synovial line potential space that reduces friction tendon.
at the tendon-tendon and tendon-bone interface, and there • Can also have patient in the lateral decubitus position with
are five potential bursa in the shoulder (subacromial/sub- the shoulder fully adducted and the hand in neutral posi-
deltoid bursa, subscapularis recess/bursa, subcoracoid bursa, tion with the elbow full extended or flexed to 90 degrees.
coracoclavicular (CC) bursa, and supra-acromial bursa).11 • Additionally, can place the patient in supine position
with the shoulder fully adducted and the hand in neutral
Common Pathology or prone position with the elbow full extended.
• S ubacromial impingement and rotator cuff tendinosis
• Subacromial and subdeltoid bursitis Clinician Position
• Adhesive capsulitis • Standing or seated adjacent to the affected shoulder
246 SEC T I O N I I I Atlas

A C

Deltoid
Muscle Belly
Needle
Trajectory

* * * SSp*
A

B
• Fig. 16.4 Subacrominal Bursa Injection (A) Ultrasound probe and patient positioning (B) Injection (C)
Ultrasound image of injection. A, acromium; SSp supraspinatus tendon; asterisks, subacromial bursa target.

Transducer Position • C
 onsider the supine or lateral decubitus position to
• Long axis to the SS tendon. avoid injury from a potential vasovagal episode.
  
Needle Position
• In-plane: needle visualization from lateral to medial Rotator Cuff Tendons
Target KEY POINTS
• S ubacromial bursa space with target between the under- • R otator cuff tears are common, and the most
surface of the deltoid muscle and superior to the SS commonly affected tendon is the supraspinatus (SS).12
tendon. • Full-thickness rotator cuff tears are present in 25%
individuals over 60% and 50% of individuals over 80.13
• Asymptomatic full-thickness tears are common, but 50%
PEARLS AND PITFALLS will become symptomatic over a 2- to 3-year period.13
• The size of the tear increases in 12% to 25% of patients
• E nsure you visualize a separation between the SS at 18 months,14 but in 50% of patients who become
tendon and undersurface of the deltoid muscle when symptomatic, there is evidence of tear progression.13
injecting, and your needle tip is not the SS tendon • Symptomatic full-thickness tears progress in 50% of
(particularly with corticosteroid injections). 6 cases over a 2-year period.13
• Consider using a longer needle (2 inches to 2.5 inches) • Long-head biceps tendinopathy can have similar
with patients with a larger body habitus to ensure you presentation to SS pathology.15
are not injecting into the deltoid muscle.
  
 CHAPTER 16 Shoulder Injection Techniques 247

A C

Deltoid
Muscle Belly

Needle
SSp
Trajectory

B Humeral Head

• Fig. 16.5
(A) Patient positioning and probe position. (B) Ultrasound image and target (asterisk): supraspi-
natus (SSp) tendon. (C) Injection.

Common injectates:
Pertinent Anatomy
• L ocal anesthetics for diagnostics
• Th
 e footprint of the SS on the greater tuberos- • Prolotherapy, orthobiologics (PRP, bone marrow con-
ity is much smaller compared to the footprint of the centrate, micronized adipose tissue, etc.)
infraspinatus.16 • Avoid intratendinous corticosteroid injections.
• Footprint of the SS is triangular in shape, with an
average maximum medial-to-lateral length of 6.9 mm Injectate Volume
and an average maximum anteroposterior width of • 1 to 5 mL
12.6 mm.16
• The infraspinatus had a long tendinous portion in the Technique: Supraspinatus Tendon
superior half of the muscle, which curved anteriorly and
Patient Position
extended to the middle facet of the greater tubercle of the
See Fig. 16.5.
humerus.16
• Seated, supine or lateral recumbent with arm in Crass
Common Pathology or modified Crass position (shoulder extended and
• T endinosis internally rotated, with the hand on the posterior lat-
• Partial-thickness tears eral hip)
• Can be interstitial, articular or bursal-sided
• Full-thickness tears Clinician Position
• Can be incomplete or complete • O
 n the side of the affected shoulder, behind or in front
• Complete retracted or complete non-retracted of patient (depending on dexterity and comfort)
• Calcific tendinopathy
Transducer Position
Equipment • L ong axis to the SS.
• L inear array ultrasound transducer • Keeping this orientation, scan the tendon from ante-
• 27 to 22 gauge 1.5 to 2 inch needle rior to posterior to identify locations of pathology. The
248 SEC T I O N I I I Atlas

Needle
Trajectory
ISp

Humeral Head
B C
• Fig. 16.6 (A) Patient positioning and probe position. (B) Ultrasound image and target (asterisk).
(C) Injection. ISp, Infraspinatus tendon.

tendon should also be scanned in transverse to obtain

orthogonal views for an accurate assessment. Needle Position
• I n-plane, distal to proximal (lateral to medial) approach
or proximal to distal approach
Needle Position
• I n-plane, distal to proximal fibers (lateral to medial) or, Target
alternatively, can inject proximal to distal fibers. • Pathologic aspect of infraspinatus or teres minor
• Can redirect the needle to get more anterior to poste-
rior fibers. Technique: Subscapularis Tendon via Ultrasound
• Can also inject in the transverse view; can inject in-plane Guidance
posterior to anterior across the SS fibers. Patient Position
See Fig.16.7.
Target • Lateral decubitus or supine with shoulder externally
• Pathologic aspect of SS tendon rotated (instruct patient to turn palm to ceiling)
• Sometimes easier to have patient flex elbow to 90
Technique: Infraspinatus/Teres Minor Tendons via degrees and have assistant bedside passively externally
Ultrasound Guidance rotate shoulder.
Patient Position
See Fig. 16.6. Clinician Position
• Seated or lateral recumbent with elbow flexed 90 degrees • On the side of the affected shoulder
and shoulder internally rotated
Transducer Position
Clinician Position • L ong axis to the tendon, scan superior-inferior to iden-
• On the side of the affected shoulder, behind patient tify pathology
• The tendon should also be scanned in transverse to
Transducer Position obtain orthogonal views for an accurate assessment.
• L ong axis to the tendon, scan anterior-posterior/supe-
rior-inferior to identify pathology. Needle Position
• Continue scanning inferiorly, and you will come to the • In-plane, distal to proximal (lateral to medial) approach
small footprint of teres minor. The tendon should also be
scanned in transverse to obtain orthogonal views for an Target
accurate assessment. • Pathologic aspect of subscapularis
 CHAPTER 16 Shoulder Injection Techniques 249

e
er at
Needle

ld ot
ou ly r
SSc trajectory

sh nal
r
te
Ex
BT

Hemural head
B C
• Fig. 16.7 (A) Patient positioning and probe position. (B) Ultrasound image and target (asterisks).
(C) Injection. BT, biceps tendon (long head); SSc, Subscapularis tendon.

Glenohumeral Joint Capsule Ligaments

PEARLS AND PITFALLS
• U ltrasound evolution of the rotator cuff is susceptible KEY POINTS
to anisotropic artifact due to the curved course of the
• A nterior capsule can be difficult to visualize under
tendons, especially at the insertions, and should not be
ultrasound in patients with larger body habitus.
mistaken for tendinosis or partial-thickness rotator cuff tear.
• The capsular ligaments provide static stability across
• The posterior aspect of the SS overlaps with the
the glenohumeral joint.
infraspinatus. The infraspinatus tendon is centrally
positioned and surrounded by hypoechoic muscle that   
can be mistaken for a tendon tear if scanned obliquely.
• The subscapular tendon can have a varied appearance,
with hyperechoic tendon fibers interposed with
hypoechoic muscle fibers, and can be confused with Pertinent Anatomy
tendinosis or partial tear.
• Orthogonal views should be used to verify pathology. • A nterior capsule is composed of superior glenohumeral
• Full Crass position can be difficult for some patients ligament (SGHL), middle glenohumeral ligament
due to pain; modifying with slight shoulder extension (MGHL), and anterior band of the inferior glenohu-
and less internal rotation can still bring SS from under meral ligament (IGHL).
the acromion without placing excessive stress on
• The SGHL functions to resist inferior translation and
shoulder. If modifying for diagnostic purposes, modified
Crass position can result in overestimation of the size of external rotation of the humeral head in the adducted
rotator cuff tear.17 arm.19
• Injured areas of tendon may distend with injection • The MGHL functions primarily to resist external rota-
and small aliquots of anesthetic before a regenerative tion from 0 to 90 degrees and provides anterior stability
procedure can help localize occult or small tears.
to the moderately abducted shoulder.19
• Ultrasound-guided bone marrow concentrate combined
with platelet products are a safe and useful alternative • The anterior band of IGHL functions to resist antero­
to conservative exercise therapy of full thickness, less inferior translation.19
than 1 cm retracted SS tendons.18 • The superior glenohumeral and CHL were shown to be
• Utilizing a brachial plexus nerve block or suprascapular important stabilizers against inferior shoulder motion,
nerve block can help reduce the discomfort on part of
even though the CHL is much more robust.20
the patient when using bone marrow concentrate or
other orthobiologics. • The MGHL functions to resist external rotation from 0
• Patient positioning is best either supine or lateral to 90 degrees and provides anterior stability at 45 to 60
recumbent. Sitting position risks patient falling if degrees abduction.21
experiencing a vasovagal episode. • The IGHL complex is the most important stabilizer
   of the joint, resisting anterior and inferior shoulder
250 SEC T I O N I I I Atlas

translation. The anterior band prevents anterior dis- • A

 lternatively, can inject in long axis lateral to medial
location with the shoulder in abduction and exter- approach
nal rotation, and is injured in anterior shoulder
dislocations.22 Target
• I nject the CHL and SGHL around the LHBT
Common Pathology • See Fig. 16.8
• Th
 e majority (95%) of traumatic dislocation are
anterior.23 Technique: Middle Glenohumeral Ligament via
• Leads to chronic anterior capsular instability and, if left Ultrasound Guidance
untreated, eventually leads to need for athroplasty.24 Patient position
• Internal impingement of glenohumeral joint can be a See Fig 16.9.
result of deficiencies of glenohumeral capsular ligaments.25 • Supine or lateral recumbent with shoulder externally
• Excessive repetitive external rotation in throwing rotated (instruct patient to turn palm to ceiling)
athletes (example: baseball pitchers) increases ante- • Sometimes easier to have patient flex elbow to 90
rior capsule strain, leading to internal impingement degrees and have assistant bedside passively externally
syndrome.26–30 rotate shoulder.
• Tightness of the posterior capsule will result in gleno-
Clinician Position
humeral internal rotation deficiencies (GIRDs), lead-
ing to internal impingement syndrome.31 • Side of patient

Equipment Transducer Position

• S hort axis to LHBT in the bicipital groove
• L inear ultrasound transducer • As patient or assistant externally rotates the shoulder,
• Needle size: 25 to 22-gauge 2 to 3.5-inch needle slide transducer medial to the bicipital groove.
• 27 to 25 gauge 1.5 to 3 inch needle
Needle Position
Common injectates
• I n-plane needle visualization lateral to medial
• P rolotherapy, orthobiologics (PRP, bone marrow con- • Out-of-plane optional, visualize needle tip just above
centrate, etc.) humeral head.
• Avoid intraligamentous corticosteroids.
Target
Injectate Volume • I f possible, identify the anterior glenoid and correspond-
• 1 to 3 mL per ligament ing labrum.
• The MGHL will be just superficial to the labrum travel-
Technique: Superior Glenohumeral Ligament ing from glenoid to humeral head and deep to the sub-
and Coracohumeral Ligament via Ultrasound scapularis muscle.
Guidance • Inject diffusely along the MGHL
Patient Position
• Th
 e patient lies supine or lateral recumbent with the Technique: Inferior Glenohumeral Ligament via
affected shoulder closest to the physician. Ultrasound Guidance
• The shoulder is slightly extended. Patient position
See Figs. 16.10 and 16.11.
Clinician Position • The patient lies supine or lateral decubitus with the
• Side of affected shoulder affected shoulder closest to the physician.
• The shoulder is flexed and internally rotated.
Transducer Position • Dorsum of the affected side is just above the patient’s
• Th
 e transducer is placed over the anterosuperior head.
shoulder transverse view of the rotator interval, with • Goal is to flex and internally rotate the shoulder as
the long head biceps tendon (LHBT) at the center of much as possible to move neovascular structures out
image in short axis with SS and subscapularis to either of the needle trajectory.
side.
• The CHL is draped over the LHBT and SGHL deep to Clinician Position
the LHBT, forming a sling around the tendon as it enters • Side of affected shoulder
the glenohumeral joint.
Transducer Position
Needle Position • S tart distal on humeral shaft in short axis and then slide
• O
 ut-of-plane, identify needle tip and redirecting into proximally until the humeral shaft changes into the
each structure. humeral head (circular structure).
A

Needle
trajectory

CH-L
SSp
BT
SGHL

SSc

B C
• Fig. 16.8
(A) Patient and probe position. (B) Ultrasound image with targets (asterisks). (C) Injection. BT,
Biceps tendon; CH-L, corahumeral ligament, SGHL, superior glenohumeral ligament; SSc, subscapularis
tendon; SSp, supraspinatus tendon.

Needle
trajectory
te
SSc ta
ro
ll y er
na uld
MGHL er
Ext sho

Humeral head

B C
• Fig. 16.9 In-plane AC joint. (A) Patient and probe position. (B) Ultrasound image with target (asterisks).
(C) Injection. SSc, Subscapularis tendon; MGHL, middle glenohumeral ligament.
252 SEC T I O N I I I Atlas

Needle
trajectory

IGHL

Humeral head
B C
• Fig. 16.10 IGHL Transverse Approach. (A) Patient and probe position. (B) Ultrasound image with targets
(asterisks). (C) Injection. IGHL, inferior glenohumeral ligament.

Needle
IGHL
trajectory
ce
rfa
su

Humera head
lar
cu

Glenoid
ti

B C
Ar

• Fig. 16.11 IGHL Parallel Approach. (A) Patient and probe position. (B) Ultrasound image with target
(asterisks). (C) Injection. IGHL, inferior glenohumeral ligament.

• Th
 e IGHL appears as a hyperechoic thickening over the Needle Position
humeral head as you slide anterior to posterior. • P arallel to humerus view, inject in-plane: from either dis-
• Should view the ligament in orthogonal views: trans- tal to proximal or proximal to distal.
ducer parallel to humerus and transverse. • Choose the safest approach with regard to neovasculature.
• Observe adjacent neovascular structures and avoid • In the transverse view, in-plane needle approach from
them. posterior/lateral to anterior/medial.
 CHAPTER 16 Shoulder Injection Techniques 253

Target the labrum and biceps tendon compared to other phases

• I nject diffusely along the IGHL fibers surrounding the of throwing, resulting in repetitive trauma over time with
humeral head. eventual tissue failure.37
• Injured areas will easily distend. • Classification of SLAP lesions as types I–IV:
• Types I and II are classified more degenerative with
tearing
PEARLS AND PITFALLS
• Types III and IV are characterized by detachment off
• W hen treating the IGHL, utilize Doppler flow to identify the glenoid consistent with a bucket handle tear
and avoid the axillary vessels that run with the axillary • Types I and II are candidates for percutaneous treatment
nerve. with orthobiologics.
• After treating the IGHL in the axilla, ensure to discard
the needle before targeting other structures in the
• Bankart injuries are common in traumatic dislocations
shoulder and possibly sterilize the probe. and chronic shoulder instability patients; lesions are typi-
• P  ropionibacterium acnes mostly colonizes the cally located in the 3 to 6 o’clock position, where the
pilosebaceous follicles in the skin of the upper body, humeral head dislocates.
including the head, neck, shoulders, and especially • Identification of bony versus fibrous lesion is critical
the axilla.32
because bony Bankart lesions are treated with surgical
   management for best outcome.38 Common injury with
repetitive posterior resistive force such as weightlifters
Glenohumeral Joint Labrum (bench press), football players involved with blocking,
gymnasts, or swimmers.39
KEY POINTS • Posterior labral tears are often referred to as “reverse
Bankart” lesion, and can have concurrent concealed
• C ombination utilizing ultrasound guidance with avulsion fracture of the posteroinferior labrum.
fluoroscopic guidance is the preferred method for
isolating and treating a superior labral tear near or at the Equipment
biceps anchor.
• Anteroinferior labral injuries, or Bankart lesions, are • L inear ultrasound transducer
commonly associated with shoulder dislocations and/ • 25 gauge 3 to 3.5 inch needle (single or multi-needle
or chronic shoulder instability. When treating anterior technique)
inferior labrum, co-treating the anterior joint capsule is
needed.33
• C-arm fluoroscopy (optional)
• Labral tears that appear to be retracted (types III–IV • Contrast agent (optional)
SLAP tears) off glenoid or in conjunction with fractures
(bony Bankart lesion) are considered unstable and Common injectates
unlikely to improve with percutaneous injections, and, if • P rolotherapy, orthobiologics (PRP, bone marrow con-
symptomatic, should be managed surgically.34
centrate, etc.)
   • Avoid intralabral corticosteroids.

Pertinent Anatomy Injectate Volume

• Th
 e labrum is a fibrocartilaginous structure rim attached • 1 to 2 mL
around the margin of the glenoid cavity in the scapula.
• Labrum exists to give additional surface area to the gle- Technique: Superior Glenohumeral Labrum
noid articulating surface to help maintain stability.35 (Biceps Anchor)
• The long head of biceps brachii tendon (BT) attaches to Patient Position
the glenoid and labrum at the superior anterior aspect See Figs. 16.12 and 16.13.
(variable in each person) of the glenoid. • Supine
• The glenoid labrum runs in a circumferential orientation • Shoulder by patient side, externally rotated with
around the glenoid rim and contributes passive stability palm facing up (brings the BT anterior to allow easier
to the glenohumeral joint. visualization)
• Anteroinferior labrum is in connection with the
IGHL. Clinician Position
• Posterior inferior glenohumeral ligament (PIGHL) • Standing directly next to the shoulder being injected
attaches to the labrum.
• Circumferentially, the labrum deepens the glenohumeral MSK Ultrasound Transducer Position
socket by 50%.36 • S hort axis to longhead of the biceps
• Can be long axis to LHBT
Common Pathology • But ensure you have trajectory that allows to clear the
• S LAP tears (superior labral anterior-posterior tear) are humeral tuberosity with direct path to the glenoid.
common in throwing sport and/or overhead athletes. The • Follow the biceps in short-axis view proximally until lose
deceleration phase of throwing places increased stress on BT completely; then track distal until visualize again.
254 SEC T I O N I I I Atlas

Needle
trajectory

BT

A B

Needle
trajectory

LHBT

Humeral head

C D
• Fig. 16.12
(A and B) Short axis to LHBT starting approach. (C and D) Long axis to LHBT starting approach.
BT, Biceps tendon; LHBT, long head biceps tendon.

Superior – anterior labrum

12

9 3

A B
• Fig. 16.13 Superior-Anterior Labral Injection. (A) AP fluoroscopic image. Triangle, labrum. (B) Scapular-Y
view. Circle and numbers represent the clock face analogy for the labrum.

C-Arm Position (Biplanar Views) Needle Position

• A P with contralateral rotation of C-arm to align the • C an use MSK ultrasound to identify the BT and guide
anterior and posterior glenoid rim or “true AP”, under- the needle into the proximal LHBT and direct needle
standing that the shoulder joint is naturally rotated 10 towards the glenoid attachment.
to 30 degrees on the transverse plane (horizontal plane) • If available switch to fluoroscopic guidance and advance
• Evaluates superior/inferior position on glenoid. the needle to the glenoid.
• Scapular Y view • Once contacting the periosteum, add contrast and check
• Evaluates circumferential orientation on the glenoid biplanar views to evaluate location on glenoid and con-
(where you are in relation to the “clock face”). trast flow.
 CHAPTER 16 Shoulder Injection Techniques 255

C-Arm Position
• A
 P with contralateral rotation of C-arm to align the
anterior and posterior glenoid rim or “true AP,” under-
standing that the shoulder joint is naturally rotated
10 to 30 degrees on the transverse plane (horizontal
plane)

Needle Position
• I dentify the posterior labrum attached to posterior gle-
noid; guide needle lateral to medial, similar to posterior
intra-articular approach.
• Option to confirm with fluoroscopic guidance, true AP
• Fig. 16.14 Contrast into bicep tendon (white arrows), highlighting
attachment to glenoid anchor (white triangle).
view

Target
• I f achieved correct position and contrast flow, then inject • C ontrast flow should be triangular outlining the labrum.
and redirect to achieve full coverage of the labral tear. • Inject pathologic areas of the labrum based on MRI
findings.
Target • Redirect needle based on target location until covered.
• W ill be based on diagnostic imaging, preferably MRI- • Under ultrasound guidance, direct needle tip to the
arthrogram of shoulder to visualize the tear and extension. superficial layer of labrum (posterior capsule).
• Utilizing biplanar views (true AP and scapular Y), you • Redirect to achieve full coverage of the labral tear based
can triangulate location on glenoid to ensure covering on MRI findings.
necessary region of labrum and proximal LHBT. • Will be based on diagnostic imaging, preferably MRI-
• Example: 8 mm intrasubstance labral tear, extending arthrogram of shoulder to visualize the tear.
from 11 o’clock to 3 o’clock on the glenoid. Can be • Option to confirm with injection of a small amount of
confirmed with scapular Y views. contrast under AP fluoroscopy
See Fig. 16.14.

PEARLS AND PITFALLS

PEARLS AND PITFALLS
• W hen treating inferior posterior labrum, first identify and
• P rior to injections, brachial plexus nerve blocks at locate the axillary nerve and posterior circumflex artery.
interscalene or supraclavicular region are advisable for • Also identify suprascapular nerve and artery descending
patient comfort. from the spinoglenoid notch to avoid.
• Utilizing biplanar views based on MRI   
• Placing contrast into the long head of biceps tendon
proximally under ultrasound guidance will allow visualization
of the root attachment on the biceps to the glenoid and Biceps Tendon
effectively gives you a “target” for the labral anchor.
• If only ultrasound available, utilize the long axis of LHBT
approach and attempt to maintain trajectory within the KEY POINTS
LHBT tendon fibers until contact periosteum.
• T he biceps is a strong supinator of the forearm and
   serves as a weak elbow flexor.
• The proximal biceps brachii muscle has two heads,
a short and long head (LHBT). The LHBT is a well-
Technique: Posterior Labrum and Posterior recognized source of anterior shoulder pain.44
Capsule • The biceps tendon pathology can be divided into
three categories: inflammatory/degenerative (i.e.,
Patient Position tendinopathy/tenosynovitis, degenerative tear);
See Fig. 16.15. instability (subluxation or dislocation); and LHBT anchor
• Lateral recumbent abnormalities (SLAP lesions, rupture).
• Shoulder by patient side, elbow flexed to 90 degrees and • Shoulder impingement can affect the long head of the
biceps tendon, resulting in a spectrum of pathology
shoulder internally rotated from tendinosis, degenerative tears, and rupture.
Clinician position • Due to the impingement mechanism, there is a causal
• Standing posterior side of shoulder relationship between biceps tendon injures and rotator
cuff pathology,40 but biceps tendon pathology is often
Transducer Position overlooked. and partial tears are often missed on MRI
(73%).41
• S hort axis to posterior glenohumeral joint, visualizing
the posterior labrum   
256 SEC T I O N I I I Atlas

A C

B Glenoid Humeral head D

• Fig. 16.15 (A) Patient positioning. (B) Ultrasound Image: black asterisk, posterior capsule; white asterisk,
posterior labrum. (C) Needle approach. (D) Fluoroscopic image.

Pertinent Anatomy Common Injectates

• A pproximately 50% of the long head biceps brachii • L ocal anesthetics for diagnostics
(LHBT) originates from the supraglenoid tubercle and • Prolotherapy, orthobiologics (PRP, bone marrow con-
50% continuous with the superior portion of the glenoid centrate, etc.)
labrum. The short head originates from the tip of the • Avoid intratendinous corticosteroids.
coracoid process.42
• The LHBT exits the joint and passes through the rotator Injectate Volume
interval and over the anterior shoulder in the bicipital • 0.5 to 3 mL
groove. The biceps tendon has a synovial sheath, which is
an extension of the synovial lining of the glenohumeral Technique: Long Head of Biceps Tendon
joint. Patient Position
• The biceps serves to depress the humeral head and dimin- See Figs. 16.16 and 16.17.
ishes stress on the IGHL. Rupture or surgical detach- • Supine or lateral decubitus with shoulder externally
ment decreases the shoulder’s resistance to torsion and rotated (instruct patient to supinate the forearm)
places a greater strain on the IGHL, impacting anterior • Sometimes easier to have patient flex elbow to 90
shoulder stability,43 although some evidence refutes any degrees and have assistant bedside passively externally
major role of the biceps at the shoulder.44 rotate shoulder

Common Pathology Clinician Position

• T enosynovitis • Side of patient
• Partial- and full-thickness tears
• In many cases the MRI will miss a partial biceps ten- Transducer Position
don. Razmjou et al. showed that 73% of partial biceps • S hort axis to LHBT in the bicipital groove
tendon tears were missed on an MRI.41 • Can also visualize the biceps in long axis.
• Tendinosis • Find pathology in short axis then rotate about the ten-
• Biceps subluxation (transverse humeral ligament injury) don 90 degrees.

Equipment Needle Position

• L inear array ultrasound transducer • I f biceps visualized in short axis, in-plane lateral to medial
• 30 to 25 gauge 1 to 2 inch needle • If biceps visualized in long axis, in-plane distal to proximal.
 CHAPTER 16 Shoulder Injection Techniques 257

Needle
BT trajectory

Bicipital groove

B C
• Fig. 16.16 Short-Axis Approach. (A) Patient position, (B) ultrasound image, and (C) injection. Asterisk,
target; BT, Biceps tendon.

A C

Needle
BT
trajectory

B
• Fig. 16.17Long head of biceps tendon, long-axis approach. (A) Patient position. (B) ultrasound image
with target sites along biceps tendon (asterisks). (C) Injection. BT, Biceps Tendon.
258 SEC T I O N I I I Atlas

Target • S can distally to identify the myotendinous junction and

• P athologic aspect of LHBT then scan proximally until pathology has been identified.
• Scan distally to identify the myotendinous junction and
then scan proximally until pathology has been identified. Needle Position
• The LHBT is approximately 10 cm in length, and • T endon in short axis, in-plane, lateral to medial
pathology can occur proximal to the trochanteric • Tendon in long axis, in-plane, distal to proximal
groove, but visualization of the LBBT will be lost as it • Tendon in long axis, out-of-plane, with needle (shortest
dives deep into the joint.45 distance skin to target)
• If using corticosteroids, target sheath only.
Target
Technique: Short Head of Biceps Tendon (SHBT), • P
 athologic aspects of the tendon or myotendinous junc-
Coracobrachialis and Pectoralis Minor via tion of SHBT, pec minor, coracobrachialis.
Ultrasound Guidance
Patient Position
PEARLS AND PITFALLS
See Fig. 16.18.
• Supine or lateral decubitus with shoulder externally • If treating a large partial-thickness tear of LHBT, use the
rotated (instruct patient to turn palm to ceiling) smallest-gauge needle to ensure no additional damage
to tendon.
• Sometimes easier to have patient flex elbow to 90
• If the tear located close to proximal origin at labral
degrees and have assistant bedside passively externally anchor, utilizing a combination ultrasound and
rotate shoulder fluoroscopic approach is preferred.
• Pec minor: utilize Doppler flow to identify vasculature as
Clinician Position well as the medial and lateral pectoral nerve that supply
• Side of patient the muscle and the overlying pec major
• Pec minor: the best approach is out-of-plane because
Transducer Position in-plane (medial-lateral) becomes difficult to avoid
neuro-vascular structures.
• S hort or long axis to the tendon at the insertion on the
coracoid process   

Needle
Coracoid trajectory
process
SHBT

A C
• Fig. 16.18Short head of biceps tendon (SHBT) approach. (A) patient and probe position. (B) Ultrasound
image with target (asterisks) at the SHBT origin. (C) injection.
 CHAPTER 16 Shoulder Injection Techniques 259

Clavicle Needle
trajectory

Acromion

B C
• Fig. 16.19 In-Plane. (A) Patient and probe positioning, (B) ultrasound image, (C) injection and. Asterisk,
target.

Acromioclavicular Joint injuries)50 with disruption of the acromioclavicular

and/or CC ligaments.
KEY POINTS • Several classifications describe AC joint injuries, but
there continues to be substantial controversy about their
• A cromioclavicular (AC) joint pathology can be classified
into acute injuries or degenerative arthropathy.
management.51 More severe injuries may require surgery.
• The AC joint accounts for over 40% of all shoulder Coracoid and distal clavicle fracture can mimic CC liga-
injuries.46 ment and AC injury, respectively.
• Osteoarthritis of the AC joint with inferior osteophyte • AC osteoarthritis
lesions may narrow the subacromial space and • Chronic instability can progress to joint arthritis and
result in impingement and compression of nearby
structures.46,47
pain.52
   Equipment
• L inear array ultrasound transducer
• 30 to 25 gauge 1 to 1.5 inch needle
Pertinent Anatomy
• Th
 e articular surface of the AC joint is lined with fibro- Common injectates
cartilage and not hyaline cartilage. • L ocal anesthetics for diagnostics, corticosteroids
• The AC joint is supported by the joint capsule that • Prolotherapy, orthobiologics (PRP, bone marrow con-
extends circumferentially around the joint providing. centrate, etc.)
The superior and posterior AC ligaments are the stron- • Avoid intraligamentous corticosteroids
gest, and mainly provide horizontal stability.48
• The CC ligament complex consists of the conoid and Injectate Volume
trapezoid ligaments providing vertical stability.49 The • 0 .5 to 1.5 mL intra-articular
conoid and trapezoid ligament insert on the posterome- • 0.25 to 0.5 mL per joint capsule area
dial and anterolateral region of the undersurface of the • 0.5 to 1 mL per ligament
distal clavicle, respectively.
Technique: Acromioclavicular Joint Intra-Articular
Common Pathology Patient Position
• A
 C joint sprain and dislocations See Figs. 16.19 and 16.20.
• The AC joint is commonly injured in falls directly on • Lateral recumbent (affected shoulder up)
shoulder or falls on an outstretched arm (FOOSH • Alternatively, the patient can be supine or seated
260 SEC T I O N I I I Atlas

A C
Needle
trajectory

Acromion Clavicle

B
• Fig. 16.20 AC joint out-of-plane intra articular. (A) patient and probe position. (B) Ultrasound image with
target (asterix). (C) injection.

Clinician Position Transducer Position

• Posterior to patient • Transverse to the AC joint

Transducer Position Needle Position

• Transverse to the AC joint (visualize acromion and clavicle) • I n-plane, lateral to medial approach.
• Out-of-plane, joint line in the middle of the probe positioned
Needle Position so that you can visualize the inferior capsule of the joint.
• I n plane, from lateral to medial
• Out-of-plane Target
• I n-plane can only target superior aspects of the joint
Target capsule.
• A
 C joint space. As you inject, visualize the injectate • Out-of-plane can target all areas: superior, inferior, ante-
flowing into the joint space without extravagating into rior, and posterior components.
superficial tissue. Joint should distend slightly with • Taking a steep angle, visualize needle tip in the deep-
injection. est aspect of the joint into the inferior joint capsule.

Technique: Approach for Acromioclavicular Joint Technique: Conoid and Trapezoid Ligaments via
Capsule Ultrasound Guidance
Patient Position Patient Position
See Figs. 16.21 and 16.22. See Fig. 16.23.
• Lateral recumbent (affected shoulder up) or supine • Supine or lateral recumbent with affected shoulder up

Clinician Position Clinician Position

• At patient’s side • At side of patient
 CHAPTER 16 Shoulder Injection Techniques 261

Rotate
posterior for
post. AC-L

Sup. AC-L
Needle
trajectory
Rotate anterior
for ant. AC-L

B C
• Fig. 16.21
Superior, Anterior, and Posterior AC Capsule. (A) Patient and probe positioning, (B) ultrasound
image, and (C) injection. Asterisks, target; AC, Acromioclavicular; Sup. AC-L, superior AC joint ligament.

A C

Needle
trajectory

B Inf AC-L

• Fig. 16.22 Inferior AC Capsule. Inferior AC capsule ligament. (A) patient and probe position.
(B) Ultrasound image, and (C) injection. Asterisks, target; inf AC-L, inferior AC ligament. (C) injection.
262 SEC T I O N I I I Atlas

C-L
Rotate lateral to
Tr-L

C-L
Out-of-plane Rotate lateral to
Tr-L
CL

Needle
CP trajectory

C-L
B C
• Fig. 16.23
(A) Patient and probe positioning, (B) ultrasound image, and (C) injection. Asterisks, target;
C-L, Conoid ligament; CL, clavicle; CP, coracoid process; Tr-L, trapezoid ligament.

Transducer Position Suprascapular Nerve

• I dentify coracoid process, medial to the biceps tendon.
• Rotate probe so that the clavicle and the coracoid process KEY POINTS
are visualized in the same field of view.
• E ntrapment may present as SS and infraspinatus
• For trapezoid, keeping the focal point on the coracoid weakness and pain, and can mimic rotator cuff pain.53
process, rotate the clavicular end laterally. • Commonly used nerve for procedural and
• For conoid, keeping the focal point on the coracoid pro- postprocedural shoulder pain control.54
cess, rotate medially. • Ultrasound-guided nerve sheath injections can be a
useful diagnostic technique.
Needle Position   
• O
 ut-of-plane, placing the space between clavicle and
coracoid process in the middle Pertinent Anatomy
• Can also be done via in-plane • P rovides motor function to the SS and infraspinatus
muscles, and sensory innervation to the posterior capsule
Target and subacromial space.55
• A dvancing needle tip until reaching the anechoic ligaments. • Arises from the upper trunk of the brachial plexus (C5,
• Target the insertion and origins of the conoid and trap- C6) in the majority of patients; however, some have con-
ezoid ligaments. tribution from the C4 nerve root.56
• If no vasculature impeding injection, can also target the • The nerve courses laterally through posterior cervical
mid portion of the ligaments. triangle, then across the superior border of the scap-
ula into the suprascapular notch, where it is accom-
PEARLS AND PITFALLS ACROMIOCLAVICULAR
JOINT panied by the suprascapular artery and vein.57
• Shortly after passing through the suprascapular notch
• C an also target the anterior and inferior AC joint capsule (underneath the transverse scapular ligament) the nerve
from the same injection point, rotating around the AC
innervates the SS muscle. It then courses through the
joint, allowing visualization of origin, and insertion of
capsule on clavicle and acromion, respectfully. spinoglenoid notch underneath the spinoglenoid liga-
• There can be small vascular bundles overriding the ment, where it innervates the infraspinatus muscle.56
conoid and trapezoid ligaments; using Doppler prior to
injecting can help avoid these during injections. Common Pathology
   • Suprascapular nerve entrapment and neuropathy
 CHAPTER 16 Shoulder Injection Techniques 263

A C

traps

Needle
trajectory
Infraspinatus

Suprascapular notch

B Scapula

• Fig. 16.24 In-plane Suprascapular Notch. (A) Patient and probe positioning, (B) ultrasound image, and
(C) injection.

Equipment Clinician Position

• L inear array ultrasound transducer • Posterior to the patient
• 25 gauge 1.5 to 2 inch needle.
Transducer Position
Common Injectates • S tart with the probe in long axis over the scapular spine;
• L ocal anesthetics for diagnostics or preprocedural block move in a lateral and cephalad path until the suprascapu-
• Corticosteroids, prolotherapy, orthobiologics (PRP). lar notch is identified.
• Identify artery with color flow Doppler prior to injection
Injectate Volume to avoid.
• 1 to 5 mL
Needle Position
Technique: Superior Approach for Suprascapular • I n-plane, lateral to medial or medial to lateral
Nerve Injection • Alternatively, can inject out-of-plane.
Patient Position
See Fig. 16.24. Target
• Best if lateral recumbent, seated or prone (can be done • J ust superior to the suprascapular nerve and medial to
seated) the suprascapular artery.
264 SEC T I O N I I I Atlas

PEARLS AND PITFALLS

Clinician Position
• Side of patient
• E nsure your needle tip is superior to the nerve, and you
are able to visualize anechoic halo of fluid around the Transducer Position
nerve to ensure the injectate is properly placed.
• Ensure your needle tip is medial to the suprascapular
• L ong axis to humeral shaft, mid humeral shaft, and slide
vasculature.6 superiorly until the muscle belly of the teres minor is
• Consider using a longer needle (2 to 2.5 inches) with identified.
patients with a larger body habitus • Then slide medially off the humeral head.
• Ensure you maintain needle visualization to avoid pleural • Utilize Doppler flow to identify posterior humeral cir-
injury.
• Use color Doppler to identify the suprascapular
cumflex artery adjacent to the axillary nerve that will be
vascular, and the nerve should lie just medially to it. in short axis.
  
Needle Position
• N
 erve in short axis, in-plane approach, inferior to supe-
rior or superior to inferior
Axillary Nerve at Quadrilateral Space
Target
KEY POINTS
• Infiltrating QS
• Q
 uadrilateral space is defined by teres minor superiorly,
humeral shaft lateral, long head triceps medial, and
teres major inferiorly (see Fig. 16.8) PEARLS AND PITFALLS
   • Caution: to avoid vascular injury, utilize Doppler.
  

Pertinent Anatomy
• Th
 e axillary nerve has fibers from C5 and C6 cervical
Fluoroscopic Guidance
nerve roots. Glenohumeral Joint: Intra-Articular
• Axillary nerve arises from the upper trunk, posterior divi-
sion, and posterior cord of the brachial plexus. KEY POINTS
• Travels along humeral head with circumflex artery
• Intra-articular injections with the use of fluoroscopic
guidance can be done using the anterior approach.
Common Pathology
  
• Q uadrilateral space (QS) syndrome (QSS) is a relatively
rare condition in which the axillary nerve and the pos-
terior humeral circumflex artery are compressed within Pertinent Anatomy
the QS.58 • See Ultrasound section
• Due to the low specificity of physical examination maneu-
vers and lack of a good diagnostic study, local anesthetic Common Pathology
blocks often remain as the diagnostic “gold standard.”59 • See Ultrasound section

Equipment Equipment
• Linear array ultrasound transducer • C -arm fluoroscopy
• Contrast
Common Injectates • 25 to 22 gauge 2 to 3.5 inch needle
• L ocal anesthetics for diagnostics
• Corticosteroids, anesthetics, orthobiologics (PRP). Common Injectates
• L ocal anesthetics for diagnostics
Injectate Volume • Corticosteroids, hyaluronic acid, prolotherapy, orthobio-
• 2 to 4 mL logics (PRP, bone marrow concentrate, micronized adi-
pose tissue, etc.)
Technique: Axillary Nerve Entrapment at • For capsular distention: High-volume mix of anesthetics,
Quadrilateral Space Hydrodissection saline (corticosteroids, or orthobiologics: PRP, platelet
Patient position lysate, platelet-poor plasma)
See Fig. 16.25.
• Prone Injectate Volume
• Shoulder internally rotated with palm facing up • 2 to 8 mL
 CHAPTER 16 Shoulder Injection Techniques 265

Needle
trajectory
TMn

Axillary nerve
B Humerus C
• Fig. 16.25 Axillary Nerve Hydrodissection. (A) Patient and probe positioning, (B) ultrasound image, and
(C) injection.

• 2 0 to 60 mL for capsular distention (40 to 50 mL most Needle Position

common per authors’ experience), Inject maximum vol- • S kin entry site over the superior third of humeral head
ume as tolerated by pain or can stop when getting back- and lateral to the joint line
flow into the syringe to avoid capsular rupture.5 • With a bent needle tip, off axis with needle tip medial
and hub lateral (trajectory lateral to medial)
Technique: Glenohumeral Intra-Articular Anterior
Approach Target
Patient Position • A dvance needle until contacting the humeral head just
See Fig. 16.26. lateral to joint line
• Supine • Once needle contacts periosteum of humeral head,
• Shoulder position 10 degrees abduction, externally pull back and advance medially until you feel sensa-
rotated with forearm supinate, palm facing up tion of needle sliding into the glenohumeral joint
• Inject a small amount of contrast to confirm intra-artic-
Clinician Position ular placement with arthrogram of glenohumeral joint
• Standing directly next to the shoulder being injected (Fig. 16.27)

C-Arm Position PEARLS AND PITFALLS

• A P with contralateral rotation of C-arm to align the • C aution: starting approach medially and inferior to joint
anterior and posterior glenoid rim or “true AP” line can risk damaging neurovascular structures.
• Understanding that the shoulder joint is naturally • Bent needle technique allows for increased
rotated 10 to 30 degrees contralateral on the transverse maneuverability in tissue.
plane (horizontal plane)   
266 SEC T I O N I I I Atlas

A C

B D
• Fig. 16.26Glenohumeral Joint Patient and C-Arm Positioning. (A and B) Fluoroscopic image—not true
AP to glenoid; (C and D) true AP to glenoid.

Equipment
•  -arm fluoroscopy
C
• Contrast
• Needle size: 25 to 22-gauge 2 to 3.5-inch needle.
• 27to 25 gauge 1.5 to 3 inch needle

Common injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
• Avoid intraligamentous corticosteroids.

Injectate Volume
• 1–3 mL per ligament
• Fig. 16.27 Arthrogram of Glenohumeral Joint.
Technique: Anterior Capsule Approach
Patient Position
Glenohumeral Joint Capsule Ligaments See Fig. 16.28.
• Supine
KEY POINTS • Shoulder position 10 degrees abduction, externally
rotated with palm facing up
• Y
 ou can use bony landmarks to inject the shoulder
capsular ligaments with fluoroscopy.
Clinician Position
  
• Standing directly next to the shoulder being injected

Pertinent Anatomy C-Arm Position

• See Ultrasound section • A
 P with contralateral rotation of C-arm to align the
anterior and posterior glenoid rim or “true AP,” under-
Common Pathology standing that the shoulder joint is naturally rotated 10 to
• See Ultrasound section 30 degrees on the transverse plane (horizontal plane)
 CHAPTER 16 Shoulder Injection Techniques 267

B C
• Fig. 16.28 (A) Target zone for each band, (B) patient position and C-arm, and (C) contrast spread high-
light contour of each ligament.

Needle Position • I GHL

• S kin entry site is midline on humeral head, lateral to the • Starting position mid-point on humeral head (do not
joint line. start inferior).
• With bent needle tip, off axis with needle tip medial and • Advance needle inferior medial until contact just lat-
hub lateral (trajectory lateral to medial) eral to joint line.
• Advance needle medial until contact on glenoid.
Target • Contrast flow should be horizontal from humeral
• S GHL head to glenoid, highlighting the inferior sling if the
• Starting position at superior aspect of humeral head. IGHL.
• Advance needle until contact superior humeral head
just lateral to joint line. PEARLS AND PITFALLS
• You can place contrast at humeral head attachment or
option to pull back and redirect and advance needle • C
 aution: Starting approach medially and inferior to joint
line can risk damaging neurovascular structures.
medial until contact glenoid at origin.
• Contrast flow should be horizontal from humeral   
head to glenoid.
• MGHL Glenohumeral Joint Labrum
• Staring position mid-point on humeral head.
• Advance needle until contact middle of humeral head KEY POINTS
just lateral to joint line.
• You can place contrast at humeral head attachment or • C
 ombination utilizing ultrasound guidance with
option to pull back and redirect and advance needle fluoroscopic guidance is the preferred method for
isolating and treating a superior labral tear near or at the
medial until contact glenoid at origin. biceps anchor, but fluoroscopy alone can be used to
• Contrast flow should be horizontal from humeral inject the labrum directly.
head to glenoid.
  
268 SEC T I O N I I I Atlas

Pertinent Anatomy • P
 ull the needle back slightly; then redirect posterior
• See Ultrasound section medial towards the superior glenoid.

Common Pathology Target

• See Ultrasound section • N eedle should touch down on the glenoid.
• Utilizing biplanar views (true AP and scapular Y) can tri-
Equipment angulate location on glenoid to ensure covering necessary
• 2 5 gauge 3 to 3.5 inch needle (single or multi-needle region of labrum.
technique) • Inject a small amount of contrast in the AP view to
• C-arm fluoroscopy ensure triangular labral flow.
• Contrast agent • You can sometimes see flow at along the proximal
LHBT.
Common Injectates • If only intra-articular flow, redirect the needle just supe-
• P rolotherapy, orthobiologics (PRP, bone marrow con- rior to the glenoid.
centrate, etc.).
• Avoid intralabral corticosteroids. Technique: Anterior-Inferior Labrum
Patient Position
Injectate Volume • S upine
• 1 to 2 mL • Shoulder position 10 degrees abduction, externally
rotated with palm facing up

PEARLS AND PITFALLS Clinician Position

• Standing directly next to the shoulder being injected
• B ent needle tip helps greatly to maneuver needle to the
target.
• Avoid the coracoid, which can sometimes affect needle
C-Arm Position (Biplanar Views)
trajectory. • A
 P with contralateral rotation of C-arm to align the
• Though not common or preferred, one can also inject anterior and posterior glenoid rim or “true AP,” under-
the posterior labrum with the patient in the lateral standing that the shoulder joint is naturally rotated 10 to
decubitus position. Use “true” AP C-arm view and
target the superior and middle glenoid/labrum in a
30 degrees on the transverse plane (horizontal plane)
similar fashion as described above.
Needle Position
  
• S kin entry site is lower third of the humeral head, lateral
to the joint line
Technique: Superior Labrum via Fluoroscopy Only • With bent needle tip, off axis with needle tip medial and
Patient Position hub lateral (trajectory lateral to medial)
• S upine
• Shoulder by patient side, externally rotated with palm fac- Target
ing up (brings the BT anterior to allow easier visualization) • A dvance needle inferior medial until contact just lateral
to joint line
Clinician Position • Advance needle medial until contact on glenoid
• Standing directly next to the shoulder being injected • Contrast flow pattern should be triangular shape at the
inferior aspect
C-Arm Position (Biplanar Views) • If too superficial, will get the IGHL flow pattern (Fig.
• A P with contralateral rotation of C-arm to align the 16.29)
anterior and posterior glenoid rim or “true AP,” under-
standing that the shoulder joint is naturally rotated 10 to
30 degrees on the transverse plane (horizontal plane) PEARLS AND PITFALLS
• Evaluates superior/inferior position on glenoid • V
 ery superficial joint: once you have placed the needle
• Scapular Y view into the skin, check fluoroscopic image to access depth.
• Evaluates circumferential orientation on the glenoid   
(where you are in relation to the “clock face”)

Needle Position Acromioclavicular Joint

• S tart needle over the superior humeral head lateral to the Technique: Acromioclavicular Joint Intra-Articular
joint line. Patient Position
• Advance the needle under intermittent fluoroscopy in • S upine
the AP view and touch down on the humerus. • Shoulder in neutral position
 CHAPTER 16 Shoulder Injection Techniques 269

A B

C D
• Fig. 16.29 Superior-Anterior to Posterior labral approach – SLAP. (A-B) AP fluoroscopic showing contrast
spread highlighting labrum. Anterior-Inferior labral approach. (C) AP fluoroscopic image with MRI image of
labral tear for reference. (D) Scapular-Y fluoroscopic image showing needle positioning.

Clinician Position
• Standing directly next to the shoulder being injected

C-Arm Position
• T rue AP view of the AC joint
• May have to rotate ipsilateral or contralateral to visualize
AC joint space opening

Needle Position
See Fig. 16.30.
• Palpate the superior aspect of the joint space and place
needle into joint • Fig. 16.30 Needle Trajectory; Arthrogram of AC Joint.
270 SEC T I O N I I I Atlas

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37. B akshi N, Freehill MT. The overhead athletes shoulder. Sports 48. C hang I-R, Varacallo M. Anatomy, shoulder and upper limb,
Med Arthrosc Rev. 2018;26(3):88–94. glenohumeral joint. In StatPearls. Treasure Island, FL: StatPearls
38. Ruiz Iban MA, et al. Instability severity index score values below Publishing, 2020.
7 do not predict recurrence after arthroscopic Bankart repair. 49. Hyland S, Varacallo M. Anatomy, shoulder and upper limb,
Knee Surg Sports Traumatol Arthrosc. 2019. clavicle. In StatPearls. Treasure Island, FL: StatPearls Publishing,
39. Escobedo EM, et al. Increased risk of posterior glenoid labrum 2019.
tears in football players. AJR Am J Roentgenol. 2007;188(1):193– 50. Bontempo NA. AD Mazzocca, Biomechanics and treatment of
197. acromioclavicular and sternoclavicular joint injuries. Br J Sports
40. Chen CH, et al. Incidence and severity of biceps long head ten- Med. 2010;44(5):361–369.
don lesion in patients with complete rotator cuff tears. J Trauma. 51. Johansen JA, et al. Acromioclavicular joint injuries: indications
2005;58(6):1189–1193. for treatment and treatment options. J Shoulder Elbow Surg.
41. Razmjou H, et al. Accuracy of magnetic resonance imaging in 2011;20(2 suppl):S70–S82.
detecting biceps pathology in patients with rotator cuff dis- 52. Merrigan B, Varacallo M. Acromioclavicular joint injection. In
orders: comparison with arthroscopy. J Shoulder Elbow Surg. StatPearls. Treasure Island, FL: StatPearls Publishing LLC; 2019.
2016;25(1):38–44. 53. Kostretzis L, et al. Suprascapular nerve pathology: a review of the
42. Vangsness Jr CT, et al. The origin of the long head of the biceps literature. Open Orthop J. 2017;11:140–153.
from the scapula and glenoid labrum. An anatomical study of 54. Auyong DB, et al. Comparison of anterior suprascapular, supra-
100 shoulders. J Bone Joint Surg Br. 1994;76(6):951–954. clavicular, and interscalene nerve block Approaches for major
43. Rodosky MW, Harner CD, Fu FH. The role of the long head of outpatient arthroscopic shoulder surgery: a randomized, double-
the biceps muscle and superior glenoid labrum in anterior stabil- blind, noninferiority trial. Anesthesiology. 2018;129(1):47–57.
ity of the shoulder. Ame J Sports Med. 1994;22(1):121–130. 55. Vorster W, et al. The sensory branch distribution of the supra-
44. Krupp RJ, et al. Long head of the biceps tendon pain: dif- scapular nerve: an anatomic study. J Shoulder Elbow Surg.
ferential diagnosis and treatment. J Orthop Sports Phys Ther. 2008;17(3):500–502.
2009;39(2):55–70. 56. Shin C, et al. Spinal root origins and innervations of the supra-
45. Denard PJ, et al. Anatomy of the biceps tendon: implica- scapular nerve. Surg Radiol Anat. 2010;32(3):235–238.
tions for restoring physiological length-tension relation during 57. Bigliani LU, et al. An anatomical study of the suprascapular nerve.
biceps tenodesis with interference screw fixation. Arthroscopy. Arthroscopy. 1990;6(4):301–305.
2012;28(10):1352–1358. 58. Flynn LS, Wright TW, King JJ. Quadrilateral space syndrome: a
46. Amirtharaj MJ, et al. Trends in the surgical management of acro- review. J Shoulder Elbow Surg. 2018;27(5):950–956.
mioclavicular joint arthritis among board-eligible US orthopae- 59. Chen H, Narvaez VR. Ultrasound-guided quadrilateral space
dic surgeons. Arthroscopy. 2018;34(6):1799–1805. block for the diagnosis of quadrilateral syndrome. Case Rep
47. Doyscher R, et al. Acute and overuse injuries of the shoulder in Orthop. 2015;2015:378627.
sports. Der Orthopade. 2014;43(3):202–208.
17
Elbow Injection Techniques
CHRIS WILLIAMS, WALTER I. SUSSMAN, AND JOHN PITTS

KEY POINTS Injectate Volume

• 2 to 3 mL
• M ost injections can be accomplished using a high-
frequency linear ultrasound transducer.
• Ultrasound allows evaluation of the three elbow
articulations (radiocapitellar, ulnotrochlear, and proximal Technique: Lateral Approach
radioulnar).
• Imaging of the posterior olecranon recess with the Patient Position
elbow in flexion is the most sensitive means to identify
pathologic fluid.
• S eated or supine.
• Elbow is flexed 40 degrees and the forearm is pronated
   with palm resting on the table (Fig. 17.2).

Ultrasound Guided Clinician Position

• S eated or standing directly next to the elbow being
Joint Injections
injected.
Pertinent Anatomy
• Th
 e elbow joint is a synovial hinged joint consisting of an Transducer Orientation
articulation between the humerus, radius, and ulna. • Long-axis to the radius over the radiocapitellar joint.
• The joint allows flexion at the elbow and forearm supina-
tion and pronation. Needle Orientation
• The joint can be accessed from a medial, lateral, anterior, • I n-plane to the transducer
or posterior approach (Fig. 17.1). • Or out-of-plane and short-axis to the transducer
Common Pathology Target
• Th
 ree primary patterns of arthritis can affect the elbow joint: • I n-plane: directed from distal to proximal into the radio-
rheumatoid (inflammatory), post-traumatic, and primary capitellar joint.
osteoarthritis. Intra-articular pathology can present with a • Short axis: start in center of probe and direct into joint
joint effusion, synovitis, and associated intra-articular bodies. directly below transducer.
• Stiffness, restriction of elbow extension, and painful
mechanical symptoms are common symptoms associated PEARLS AND PITFALLS
with arthritis. Pain is typically deep or diffuse, and may
• S
 ee the injectate expand the joint without soft tissue
present without any palpable tenderness. distention.
Equipment   
• N eedle size: 25- or 27-gauge 1- or 1.5-inch needle.
• High-frequency linear ultrasound transducer. Technique: Posterior Approach
Common Injectates Patient Position
• L ocal anesthetics for diagnostics, corticosteroids. • P rone position.
• Prolotherapy, orthobiologics (platelet-rich plasma [PRP] • Elbow is flexed approximately 90 degrees and the fore-
bone marrow concentrate, etc.). arm is hanging over the table (Fig. 17.3).

272
 CHAPTER 17 Elbow Injection Techniques 273

Arcade of Struthers
Biceps
Articular capsule tendon

Annular
ligament Triceps tendon

Cubital retinaculam

Radial
collateral Ulnar collateral
ligament ligament
Annular ligament

A B
• Fig. 17.1 (A and B) Illustration of pertinent bony and soft tissue anatomy anatomy of the elbow demon-
strating lateral and posterior views.

Proximal Distal

Capitellum of
Humerous
Radial
Head

A B
LOGIQ
pg
Proximal Distal

Lateral
Epicondoyle
Radial head

C
• Fig. 17.2 Intra-articular injection of the radiocapitellar joint using a 27-gauge needle. (A) Elbow position,
transducer position, and needle position for the in-plane approach. (B) Ultrasound shows the needle trajec-
tory (open arrow). (C) Elbow position, transducer position, and needle position for the out-of-plane approach
for entry into the lateral elbow joint. (D) Elbow position, transducer position, and needle position for the in-
plane approach for entry into the lateral elbow joint. (D) Ultrasound shows the needle out-of-plane in the joint
space (open arrow). Dashed circles indicate needle trajectory. Solid white arrow identify the needle trajectory.
274 SEC T I O N I I I Atlas

Lateral
Medial

Triceps

A B Olecranon fossa

• Fig. 17.3 Aspiration of the ulnar-olecranon joint using a 22-gauge needle in patient with triceps myo-
sitis and septic elbow joint. (A) Elbow position, transducer position, and needle position for the in-plane
approach. (B) Ultrasound shows the needle (open arrow) trajectory.

Clinician Position (ALCL); annular ligament; lateral radial collateral liga-

ment (LRCL); lateral ulnar collateral ligament (LUCL).
• Seated or standing directly next to the elbow being injected. • LCUL is the primary stabilizer to varus and external rota-
tion stress to the elbow.
Transducer Orientation
• Short-axis to the tendon over the olecranon fossa.
Common Pathology
Needle Orientation • S ubtle instability of the LCL complex is challenging to iden-
• S hort-axis to the triceps tendon and in-plane to the tify on examination, but associated ligament injuries have
transducer from a lateral to medial direction. been reported in up to 20% of cases of lateral epicondylitis.
Target There seems to be a correlation with the severity of the injury
to the common extension tendon and LUCL injury.2–3
• Directed underneath the triceps tendon and into the joint. • Associated with a traumatic elbow dislocation, significant
injury and instability is detected by conventional physical
PEARLS AND PITFALLS
examination and characterized by mechanical symptoms:
• T
 he ulnar nerve should be visualized at the medial that is, clicking or catching.
epicondyle before the injection to avoid nerve injury.
   Equipment
• N eedle size: 25- or 27-gauge 1- or 1.5-inch needle.
Ligament Injections
• High-frequency linear ultrasound transducer.
Lateral Collateral Ligament Complex
KEY POINTS Common Injectates
• M
 ost injections can be accomplished using a high- • P rolotherapy, orthobiologics (PRP, bone marrow con-
frequency linear ultrasound transducer. centrate, etc.).
   • Avoid intraligamentous corticosteroids.
Pertinent Anatomy
Injectate Volume
• L
 ateral collateral ligament (LCL) complex consists of
four ligaments: accessory lateral collateral ligament • 2 to 3 cc.
 CHAPTER 17 Elbow Injection Techniques 275

Technique Medial Ulnar Collateral Ligament

Patient Position
• S eated or supine position. KEY POINTS
• Elbow is flexed approximately 90 degrees and the fore-
arm is pronated. • M
 ost injections can be accomplished using a high-
frequency linear ultrasound transducer.
Clinician Position   
• Seated or standing directly next to the elbow being injected.
Transducer Position Pertinent Anatomy
• Long-axis or longitudinal to the ligaments.
• M edial ulnar collateral ligament (MUCL) is composed
Needle Position of three bands: anterior band, posterior band, and trans-
• F our ligaments comprise the LCL complex and the nee- verse ligament.
dle position should be adjusted to be in long-axis to the • Anterior band is the primary restraint to valgus
ligaments and in-plane to the transducer. stress with the elbow in 30–120 degrees of flexion,
• The LRCL and LUCL should be approached from a dis- coursing from the medial epicondyle to the sublime
tal to proximal orientation. tubercle.4
• The ALCL and annular ligament should be approached
from a lateral to medial orientation (Fig. 17.4). Common Pathology
Target • Th
 e MUCL is commonly injured in overhead throwing
• A reas of hypoechogenicity and cortical irregularities. athletes due to valgus stress on the elbow during the late
• Fenestration of tendon and mild excoriation at sites of corti- cocking and early acceleration phases.
cal irregularities until achieve change in the tissue texture.
• Regenerative injection (PRP, adipose-derived stromal cell
[ADSC], bone marrow aspirate concentrate [BMAC]) Equipment
should target areas of hypoechogenicity filling interstitial • N eedle size: 25- or 27-gauge 1- or 1.5-inch needle.
tears with injectate. • High-frequency linear ultrasound transducer
PEARLS AND PITFALLS
• F or the ALCL and annular ligament injections, visualize
Common Injectates
the radial nerve first to avoid injury. • P rolotherapy, orthobiologics (PRP, bone marrow con-
• Post-procedure pain medication should be offered and
the patient should be informed that pain in the elbow centrate, etc.),
region would likely be increased. • Avoid intraligamentous corticosteroids
• Extremes of range of movement (ROM) should be limited
in first 10–12 weeks after the procedure, especially
repetitive supination. Injectate Volume
   • 2 to 3 cc.

Proximal Distal Medial Lateral

Humerus Radial Radial Head

Head

A B
• Fig. 17.4 Intraligamentous injection of the lateral collateral ligament using a 25-gauge needle. Elbow
position, needle position, and transducer placement are similar to the common extensor tendon injection.
(A) Needle (open arrows) approaching lateral ulnar collateral ligament intraligamentous defect. (B) Needle
(open arrows) approaching intraligamentous defect in the annular ligament (arrowheads)
276 SEC T I O N I I I Atlas

Technique Pertinent Anatomy

Patient Position • Th
 e tendon originates from the lateral epicondyle of the
• S upine position. humerus.
• Elbow and shoulder are flexed to approximately 90 • Deep to the common flexor tendon, the radial collateral
degrees and the forearm is supinated. ligament occupies approximately 50% of the footprint at
the lateral epicondyle (Fig. 17.6).5
Clinician Position
• Seated or standing directly next to the elbow being injected. Common Pathology
Transducer Position • L ateral epicondylitis is the most common cause of lateral
• Long-axis or longitudinal to the ligaments. elbow pain.
• Typically an overuse syndrome.
Needle Position • Degenerative changes include tendon thickening, intra-
• Th
 e needle position should be positioned in long-axis to tendinous calcifications, or partial and complete tearing.
the UCL and in-plane to the transducer.
Target
• A reas of hypoechogenicity within the ligament.
• Regenerative injection (PRP, ADSC, BMAC) should tar- Pronator teres
get areas of hypoechogenicity filling interstitial tears with
Brachioradialis
injectate. Palmaris longus
Flexor carpi ulnaris
PEARLS AND PITFALLS
• P ost-procedure pain medication should be offered and Flexor carpi
the patient should be informed that pain in the elbow radialis
Flexor digitorum
region would likely be increased. superficialis
• Valgus stress should be limited in first 10–12 weeks
after the procedure. Overhead athletes should start a
progressive throwing program after the period of rest.
• The ulnar nerve should be visualized before the
procedure to avoid accidental nerve injury (Fig. 17.5).
  

Tendon Injections
Common Extensor Tendon
KEY POINTS
• M
 ost injections can be accomplished using a high- • Fig. 17.6
Pertinent muscular anatomy of the elbow demonstrating the
frequency linear ultrasound transducer. extensor muscles on the dorsal surface of the forearm and their attach-
ment on the lateral epicondyle of the humerus.
  

Proximal Distal

Com Flex

Med Epi
UCL

A B
• Fig. 17.5 Intraligamentous injection of the ulnar collateral ligament (UCL) using a 25-gauge needle.
(A) Elbow position, needle position, and transducer placement. (B) Needle (open arrow) approaching the UCL.
 CHAPTER 17 Elbow Injection Techniques 277

Equipment • R egenerative injection (PRP, ADSC, BMAC) should tar-

get areas of hypoechogenicity filling interstitial tears with
• N eedle size: 25- or 27-gauge 1- or 1.5-inch needle. injectate.
• High-frequency linear ultrasound transducer. • The needle should also be repositioned, moving in a medial
to lateral fashion for complete coverage of the enthesis and
Common Injectates targeting all areas of hypoechogenicity.

• L ocal anesthetic plus or minus corticosteroids peri­tendinous. PEARLS AND PITFALLS

• Orthobiologics (PRP, bone marrow concentrate, etc.). • E xamine for associated varus instability of lateral
• Avoid intratendinous corticosteroids. collateral complex as associated ligament injuries
have been reported in up to 20% of cases of lateral
epicondylitis.
Injectate Volume • Long-term studies have shown that corticosteroid
injections are no more beneficial than observation alone
• 2 to 3 cc. and may even have an inferior outcome with higher
recurrence rates at 1 year.6,7
Technique • Avoid intratendinous injection of local anesthetics,
Patient Position especially bupivacaine and lidocaine, as these
have been shown to have deleterious effects
• S eated or supine position. on progenitor cells. If intratendinous anesthesia
• Elbow is flexed approximately 90 degrees and the fore- is required, then a small amount of 0.125%
arm is prone (Fig. 17.7). ropivacaine is preferred.
  
Clinician Position
• Seated or standing directly next to the elbow being injected.
Common Flexor Tendon
Transducer Position
• Long-axis or longitudinal to the tendon. KEY POINTS
• M
 ost injections can be accomplished using a high-
Needle Position frequency linear ultrasound transducer.
• L
 ong-axis to the tendon and in-plane to the transducer   
from a distal to proximal orientation.

Target Pertinent Anatomy

• A reas of hypoechogenicity and cortical irregularities. • Th
 e tendon originates from the medial epicondyle of the
• Fenestration of tendon and mild excoriation at sites of cor- humerus and is shorter and broader than the lateral col-
tical irregularities until achieve change in the tissue texture. lateral ligament.

Proximal Distal

Lat Epi
Radial
head

A B
• Fig. 17.7Intratendinous injection of the common extensor tendon using a 25-gauge needle. (A) Elbow posi-
tion, needle position, and transducer placement. (B) Needle (open arrow) approaching intratendinous defect.
278 SEC T I O N I I I Atlas

Common Pathology Transducer Position

• T ypically an overuse syndrome. • Long-axis or longitudinal to the tendon.
• 7 to 10 times less common than lateral epicondylitis.8
• Degenerative changes include tendon thickening, intra- Needle Position
tendinous calcifications, or partial and complete tearing. • L
 ong-axis to the tendon and in-plane to the transducer
• Examine for associated valgus instability of UCL and from a distal to proximal orientation.
ulnar neuritis.
Target
Equipment • A reas of hypoechogenicity and cortical irregularities.
• Fenestration of tendon and mild excoriation at sites of
• N eedle size: 25- or 27-gauge 1- or 1.5-inch needle. cortical irregularities until achieve change in the tissue
• High-frequency linear ultrasound transducer. texture.
• Regenerative injection (PRP, ADSC, BMAC) should
Common Injectates target areas of hypoechogenicity, filling interstitial tears
with injectate.
• L ocal anesthetic plus or minus corticosteroids peritendinous. • The needle should also be repositioned, moving in a
• Orthobiologics (PRP, bone marrow concentrate, etc.). medial to lateral fashion for complete coverage of the
• Avoid intratendinous corticosteroids. enthesis and targeting all areas of hypoechogenicity.

Injectate Volume PEARLS AND PITFALLS

• 2 to 3 cc. • P ost-procedure pain medication should be offered and
the patient should be informed that pain in the elbow
Technique region would likely be increased.
Patient Position • The ulnar nerve should be visualized before the
procedure to avoid accidental nerve injury.
• S eated or supine position. • Avoid intratendinous injection of local anesthetics,
• Elbow is flexed approximately 90 degrees, shoulder especially bupivacaine and lidocaine as these
abducted to 60 to 90 degrees, and the forearm is supi- have been shown to have deleterious effects
nated (Fig. 17.8). on progenitor cells. If intratendinous anesthesia
is required, then a small amount of 0.125%
Clinician Position ropivacaine is preferred.

• Seated or standing directly next to the elbow being injected.   

Proximal Distal

CFT

ME
Ulna

A B
• Fig. 17.8 Intratendinous injection of the common flexor tendon using a 25-gauge needle. (A) Elbow
position, needle position, and transducer placement. (B) Needle (open arrow) approaching intratendinous
defect.
 CHAPTER 17 Elbow Injection Techniques 279

Distal Biceps Tendon Equipment

• N eedle size: 25- or 27-gauge 1.5-inch needle.
KEY POINTS • High-frequency linear ultrasound transducer.
• M
 ost injections can be accomplished using a high-
frequency linear ultrasound transducer. Common Injectates
  
• L ocal anesthetic plus or minus corticosteroids peritendinous.
• Orthobiologics (PRP, bone marrow concentrate, etc.).
Pertinent Anatomy • Avoid intratendinous corticosteroids.

• D istal biceps tendon inserts onto the radial tuberosity.

Injectate Volume
• Brachial artery runs superficial to the distal biceps myo-
tendinous junction. The median, radial, and lateral ante- • 2 to 3 cc.
brachial cutaneous nerves travel adjacent to the tendon.
Technique: Anterior Approach
Patient Position
Common Pathology
• S eated or supine position.
• D istal biceps tendinopathy often results from repetitive • Elbow is fully extended and the forearm is supinated
injuries with the elbow flexed and supinated. (Fig. 17.9).
• Bicipitoradial bursa and interosseous bursa can occur
due to friction irritation and may be more amenable to Clinician Position
aspiration and injection by alternative approaches. • Seated or standing directly next to the elbow being injected.

Proximal Distal

BT

Brachials

Proximal Distal

A
BT

Brachials

Radius

C
• Fig. 17.9 Intratendinous injection of the biceps tendon. (A) Elbow position, needle position, and trans-
ducer placement. (B) Anterior ultrasound of the biceps tendon demonstrating anisotropy of the tendon
limiting visualization of the insertion. (C) Oblique view showing biceps tendon to the insertion site on the
radial tuberosity (arrowhead).
280 SEC T I O N I I I Atlas

Transducer Position
Needle Position
• Long-axis to the tendon.
• Th
 e needle is advanced in-plane from a radial to ulnar
Needle Position direction deep to the supinator.
• L
 ong-axis to the tendon and in-plane to the transducer. A
distal to proximal or proximal to distal approach can be used. Target
Target • I ntratendinous regenerative injection (PRP, ADSC,
• Th
 e tendon insertion is difficult to visualize with this BMAC) should target areas of abnormalities (hypoechoic
approach, and an anterior approach is better suited to clefts) within the tendon with the injectate.
target the myotendinous junction. • Peritendinous injection/bicipitoradial bursa injection
• Target areas of hypoechogenicity with regenerative injec- of corticosteroids should target the peritendinous space
tions (PRP, ADSC, BMAC) filling interstitial tears with around the biceps tendon.
injectate.
PEARLS AND PITFALLS
PEARLS AND PITFALLS
• In one cadaveric intratendinous injectate had a proximal
• D oppler flow should be used to help identify the anterior flow of 3.4 cm (range, 3.0 to 4.0 cm). Proximal spread
elbow vasculature. An anterior approach may be may be enhanced by not maximally pronating the
precluded by the brachial artery in some patients. forearm which narrows the interosseous space.9
• There is a theoretical risk of tendon rupture after • Theoretical risk of tendon rupture after corticosteroid
corticosteroid injections. injection. Avoid intratendinous corticosteroids and
local anesthetics besides a small amount of 0.125%
   ropivacaine, if required.
• Position of the posterior interosseous nerve between
the superficial and deep head of the supinator should
Technique: Posterior Approach be identified before injection.
(Preferred Technique)   

Patient Position
Triceps Tendon
• S eated or supine position.
• Elbow is flexed to approximately 120 degrees and the KEY POINTS
forearm is pronated (Fig. 17.10).
• M
 ost injections can be accomplished using a high-
frequency linear ultrasound transducer.
Clinician Position
  
• Seated or standing directly next to the elbow being injected.
Pertinent Anatomy
Transducer Position
• T
 riceps brachii tendon is composed of a superficial layer
• Long-axis to the tendon on the dorsal (posterior) forearm. (lateral and long heads) and a deep layer (medial head)

Ulna

BT
Sup

A B Rad

• Fig. 17.10
Intralegamentous injection of the distal biceps tendon using a 25-gauge needle. (A) Elbow position,
needle position, and transducer placement. (B) Needle (open arrow) approaching biceps tendon (arrowheads).
 CHAPTER 17 Elbow Injection Techniques 281

that blends with the posterior capsule as it inserts on the • E

 lbow is flexed to 90 degrees and forearm resting on the
olecranon process. abdomen if patient is supine or hanging off the table if
patient is prone (Fig. 17.11).
Common Pathology
Clinician Position
• P
 athologic changes may include disruption of the tendon • S eated or standing directly next to the elbow being
fibers (as seen with a partial-thickness or full-thickness injected.
tear), or hypoechoic thickening of intact fibers (as seen
with tendinosis). Transducer Position
• Long-axis to the tendon.
Equipment
Needle Position
• N eedle size: 25- or 27-gauge 1.5-inch needle.
• High-frequency linear ultrasound transducer • L
 ong-axis to the tendon and in-plane to the transducer.
A distal to proximal or proximal to distal approach can
be used.
Common Injectates
• L ocal anesthetic plus or minus corticosteroids peritendinous. Target
• Orthobiologics (PRP bone marrow concentrate, etc.). • A reas of hypoechogenicity and cortical irregularities.
• Avoid intratendinous corticosteroids. • Fenestration of tendon and mild excoriation at sites of
cortical irregularities until achieve change in the tissue
Injectate Volume texture.
• Regenerative injection (PRP, ADSC, BMAC) should
• 2 to 3 cc. target areas of hypoechogenicity, filling interstitial tears
with injectate.
Technique: Anterior Approach • The needle should also be repositioned, moving in a medial
Patient Position to lateral fashion for complete coverage of the enthesis and
• Supine or prone position. targeting all areas of hypoechogenicity.

Proximal Distal

Triceps

Olecranon

A B
• Fig. 17.11
Intratendinous injection of the distal triceps tendon. (A) Elbow position, needle position, and
transducer placement. (B) Needle (open arrow) approaching intratendinous defect.
282 SEC T I O N I I I Atlas

PEARLS AND PITFALLS Proximal Distal

• If clinical suspicion exists, the posterior ultrasound
evaluation should include assessment of the olecranon
bursa superficial to the olecranon process.
• Local corticosteroid injections have been associated
with subsequent rupture of the triceps tendon. Avoid Bursa
intratendinous corticosteroids and local anesthetics
besides a small amount of 0.125% ropivacaine, if required.
  

Olecranon
Olecranon Bursa
KEY POINTS
• M
 ost injections can be accomplished using a high-
frequency linear ultrasound transducer. • Fig. 17.12 Aspiration of traumatic olecranon bursitis. Elbow position,
needle position, and transducer placement similar to triceps tendon
   injection (see Triceps Tendon Fig. 17.11 for positioning). Needle (open
arrow) in the bursa.

Pertinent Anatomy
• Th
 e olecranon bursa is an adventitious bursa that is Clinician Position
located over the olecranon process. The superficial loca- • S eated or standing directly next to the elbow being
tion of the bursae makes it vulnerable to injury and injected.
inflammation.
Transducer Position
Common Pathology • Long-axis to the tendon.

• Th
 e most common etiology is post-traumatic bursitis. Needle Position
Minor or repetitive trauma can provoke bursitis. • L
 ong-axis to the tendon and in-plane to the transducer.
• Olecranon bursitis is associated with diabetes, gout, rheuma- A distal to proximal or a proximal to distal approach can
toid arthritis, and human immunodeficiency virus (HIV). be used.
• Septic bursitis can also occur and Staphylococcus aureus is
the most common causative bacteria. Target
• A
 nechoic or hypoechoic collection superficial to the
Equipment olecranon process.

• N eedle size: 25- to 27-gauge 1.5- to 22-inch needle for PEARLS AND PITFALLS
anesthetic.
• S light compression can displace the bursa and the
• 18- or 22-gauge for aspiration of the bursa. ultrasound probe may need to be “floated” on gel and a
• High-frequency linear ultrasound transducer. gel standoff used during the procedure.
• If clinical suspicion exists, aspirate should be sent for
culture and sensitivity.
Common Injectates • Neoplastic pathology can mimic simple olecranon bursitis,
and rapidly expanding growth, failure of treatment, weight
• A spiration. loss, and prior history of neoplasia should prompt further
• Anesthetic and corticosteroid. work-up. Aspirate can be sent for cytology.
• Sclerosing agents can be used for recurrent bursitis.   

Injectate Volume
• 1 to 2 cc. Perineural Injections
Technique: Anterior Approach Deep Branch Radial Nerve
Patient Position KEY POINTS
• S upine or prone position.
• Elbow is flexed to 90 degrees and forearm resting on the • M
 ost injections can be accomplished using a high-
frequency linear ultrasound transducer.
abdomen if patient is supine, or hanging off the table if
patient is prone (Fig. 17.12).   
 CHAPTER 17 Elbow Injection Techniques 283

Pertinent Anatomy Transducer Position

• Th
 e radial nerve bifurcates into the deep branch of the • Short-axis to the nerve.
radial nerve and superficial radial sensory nerve at the
level of the radiocapitellar joint. Needle Position
• The deep branch of the radial nerve passes through the • Th
 e needle position should be positioned in-plane to the
arcade of Frohse (supinator arch), the tendinous edge transducer.
of the supinator, and fibrous entrance to the radial • Medial-to-lateral or distal-to-proximal approach.
tunnel.
• The nerve then passes between the superficial and deep
Target
layers of the supinator and becomes the posterior interos-
seus nerve once it exits the supinator. • Areas of focal flattening or proximal swelling.

PEARLS AND PITFALLS

Common Pathology
• P re-procedural scanning should be performed to
• Th
 e arcade of Frohse is thought to be the most fre- identify surrounding vasculature (recurrent radial artery)
quent site of entrapment, although this is controversial. and potential anatomic variants.
Entrapment may occur in or at the exit from the radial • The focal zone should be placed at the level of
tunnel (radial head to the inferior border of the supinator the nerve and gray-scale adjusted to provide
the greatest contrast between the nerve and
muscle). surrounding tissue.
• Focal or diffuse enlargement of the nerve can help local- • The needle should not be advanced if the tip is not visible.
ize site of entrapment. • Inject just before approaching the epineurium and
• Compression of the deep radial branch results in a advance while injecting slowly to push the nerve away,
deep aching pain only, without motor manifestations thus reducing the risk of intraneural injection.
• Creating a halo around the nerve will increase the
(although may have weakness due to pain). Symptoms definition of the nerve borders.
increase with forearm rotation and lifting activities.
  

Equipment
• N eedle size: 25- or 27-gauge 1.5-inch needle. Median Nerve at Pronator Teres
• High-frequency linear ultrasound transducer.
KEY POINTS
Common Injectates • M
 ost injections can be accomplished using a high-
frequency linear ultrasound transducer.
• F or nerve block: local anesthetic.
  
• For hydrodissection: mixture of normal saline and local
anesthetic solution or 5% dextrose solution, or platelet
lysate solution.
Pertinent Anatomy
Injectate Volume • Th
 e median nerve crosses the elbow and passes beneath
the bicipital aponeurosis (lacertus fibrosus) and then
• F or nerve block: 2 to 5 cc. between the radial and ulnar heads of the pronator teres.
• For hydrodissection: 5 to 10 cc.
Technique Common Pathology
Patient Position • P ronator tunnel syndrome is a rare compressive neu-
• S upine or seated position. ropathy of the median nerve at the elbow and involves
• Elbow is flexed approximately 90 degrees and the fore- entrapment at the level of the pronator teres.
arm resting on the table, with the thumb pointed upward • Neurologic symptoms in the median innervated forearm
(Fig. 17.13). muscles (flexor carpi radialis, palmaris longus, and flexor
digitorum superficialis) and numbness in median distri-
Clinician Position bution in the hand. Vague forearm pain with repetitive
• S eated or standing directly next to the elbow being pronation-supination.
injected. • Commonly associated with medial epicondylitis.
A C

Medial Lateral Proximal Distal

Sup Sup

Sup
Radius

Radius

B D

E
• Fig. 17.13 Perineural injection of the deep branch of the radial nerve (DBRN) (arrowheads). Elbow posi-
tion, needle position, and transducer placement for short-axis (A) and long-axis (B) to the nerve. (C) Needle
(open arrow) in-line to transducer approaching the DBRN in short-axis as it passes through the fascial
plane between the superficial and deep heads of the supinator muscle. (D) Long-axis approach to DBRN.
(E) Perineural injection of a thickened DBRN at the arcade of Frosch (arrowheads). Needle (arrow) is in-line
to the transducer and approaching the DBRN in short-axis.
 CHAPTER 17 Elbow Injection Techniques 285

Lateral Medial

Br

Ulna

Lateral Medial
BT

A
Br

Ulna

C
• Fig. 17.14
Perineural injection of the median nerve (arrowheads). (A) Elbow position, needle position, and
transducer placement. (B and C) Needle (open arrow) in-line to transducer approaching the median nerve
(arrowheads).

Equipment Injectate Volume

• N eedle size: 25- or 27-gauge 1.5-inch needle. • F or nerve block: 2 to 5 cc.
• High-frequency linear ultrasound transducer. • For hydrodissection: 5 to 10 cc.

Common Injectates Technique

• F or nerve block: local anesthetic. Patient Position
• For hydrodissection: mixture of normal saline and local • S upine or seated position.
anesthetic solution or 5% dextrose solution, or platelet • Elbow is extended, with forearm supinated and resting on
lysate solution. the table (Fig. 17.14).
286 SEC T I O N I I I Atlas

Clinician Position Equipment

• Seated or standing directly next to the elbow being injected. • N eedle size: 25- or 27-gauge 1.5-inch needle.
• High-frequency linear ultrasound transducer.
Transducer Position
• Short-axis to the nerve.
Common Injectates
Needle Position • F or nerve block: local anesthetic.
• Th
 e needle position should be positioned in-plane to the • For hydrodissection: mixture of normal saline and local
transducer. anesthetic solution or 5% dextrose solution, or platelet
• Medial-to-lateral or distal-to-proximal approach. lysate solution.

Target
Injectate Volume
• Areas of focal flattening or proximal swelling.
• F or nerve block: 2 to 5 cc.
• For hydrodissection: 5 to 10 cc.
PEARLS AND PITFALLS
• P re-procedural scanning should be performed to identify Technique
surrounding vasculature and potential anatomic variants.
Brachial artery is typically lateral to the nerve proximally, Patient Position
and the ulnar artery adjacent to the distal median nerve. • S upine or seated position.
• The focal zone should be placed at the level of the
nerve and the gray scale adjusted to provide the greatest
• Elbow is extended with forearm supinated and resting on
contrast between the nerve and surrounding tissue. the table (Fig. 17.15).
• The needle should not be advanced if the tip is not visible.
• Inject just before approaching the epineurium and Clinician Position
advance while injecting slowly to push the nerve away, • S eated or standing directly next to the elbow being
thus reducing the risk of intraneural injection.
• Creating a halo around the nerve will increase the
injected.
definition of the nerve borders.
Transducer Position
  
• Short-axis to the nerve.

Ulnar Nerve at the Cubital Tunnel Needle Position

• Th
 e needle position should be positioned in-plane to the
transducer.
KEY POINTS • Medial-to-lateral approach.
• M
 ost injections can be accomplished using a high- Target
frequency linear ultrasound transducer.
• A
 reas of focal flattening or proximal swelling of the ulnar
  
nerve.
Pertinent Anatomy
• Th
 e ulnar nerve crosses the elbow in the cubital tunnel PEARLS AND PITFALLS
posterior to the medial epicondyle.
• P re-procedural scanning should be performed to
identify surrounding vasculature and potential anatomic
Common Pathology variants.
• The focal zone should be placed at the level of
• U lnar neuropathy at the elbow is the second most com- the nerve and the gray scale adjusted to provide
mon entrapment in the upper extremity. the greatest contrast between the nerve and
• The most common site of entrapment is between the surrounding tissue.
• The needle should not be advanced if the tip is not visible.
radial and ulnar heads of the flexor carpi ulnaris (FCU). • Inject just before approaching the epineurium
Less common sites include between Osborne’s ligament and advance while injecting slowly to push the
and the MCL, medial head of the triceps, and anomalous nerve away, thus reducing the risk of intraneural
anconeus epitrochlearis. injection.
• Neurologic symptoms include paresthesias of the small • Creating a halo around the nerve will increase the
definition of the nerve borders.
finger and ulnar {½} of the ring finger and loss of strength
in the ulnar intrinsic muscles.   
 CHAPTER 17 Elbow Injection Techniques 287

FCUr
FCUu

Ulna

A B

FCUr

FCUu

Ulna

C
• Fig. 17.15 Perineural injection of the deep branch of the ulnar nerve. (A) Elbow position, needle position, and
transducer placement. (B) Needle (open arrow) in-line to transducer approaching the ulnar nerve (arrowheads)
in short-axis as it passes through the fascial plane between the two heads of the flexor carpi ulnaris . The nerve
is hydrodissected (C) above and below the nerve, creating an anechoic halo around the nerve.

Fluoroscopy Injections Equipment

Joint Injections • C-arm fluoroscopy.

KEY POINTS Common Injectates

• P
 atient position and C-arm position is key to minimize • L ocal anesthetics for diagnostics, corticosteroids.
radiation exposure and increase the likelihood of • Orthobiologics (PRP, bone marrow concentrate, etc.).
successful intra-articular needle placement.
  
Injectate Volume
Pertinent Anatomy • 2 to 3 cc.
• Th
 e elbow joint is a synovial hinged joint consisting of an
articulation between the humerus, radius, and ulna. Technique: Lateral Approach
• The joint allows flexion at the elbow and forearm supina- Patient Position
tion and pronation.
• Supine.
• The joint can be accessed from a medial, lateral, anterior,
or posterior approach.
288 SEC T I O N I I I Atlas

A B
• Fig. 17.16 Radiocapitellar joint lateral approach under fluoroscopy. (A) Needle directly in the joint space.
(B) Intra-articular injection from a lateral approach through the radiocapitellar joint using a 27-gauge needle.
Solid white arrow identifies the needle. Dashed line with circle indicates is showing the intra-articular con-
trast flow pattern.

• A rm is extended away from the body to allow Technique: Posterior Approach

C-arm positioning. Elbow is extended and forearm Patient Position
supinated.
• Elbow is flexed 40 degrees and the forearm is pronated, • P rone.
with palm resting on the table. • Shoulder is flexed and abducted. Elbow is flexed 90
degrees and the forearm is pronated with palm resting on
Clinician Position the table or arm rest (Fig. 17.17).
• S eated or standing directly next to the elbow being Clinician Position
injected.
• S eated or standing adjacent to the patient behind the
C-Arm Position elbow.
• L
 ateral view of the elbow with visualization of the C-arm Position
joint.
• L
 ateral view of the elbow, with humeral olecranon joint
Needle Position opened, medial, and lateral epicondyles aligned.
• E nter the skin laterally, directly over the joint line. Needle Position
• Advance the needle until the joint capsule is penetrated
(Fig. 17.16). • S tart at the skin posterior and superior to the joint.
• Angle and advance the needle under intermittent fluo-
Target roscopy toward the joint.
• Radiocapitellar joint. Target
• H umeral olecranon joint just into the posterior capsule.
• Inject contrast to demonstrate intra-articular flow.
PEARLS AND PITFALLS
• M ark sure the C-arm is aligned with the joint.
• Ensure contrast is circulating around the epicondyle PEARLS AND PITFALLS
without any contrast outside the joint.
• If desired, obtain an anteroposterior (AP) view to see • M ark sure the C-arm is aligned with the joint.
contrast flow lateral to medial. Reposition the arm so • Ensure contrast is circulating around the epicondyle
that the elbow is extended and supinated. without any contrast outside the joint.
• Use as little contrast as needed to confirm good flow. • Use as little contrast as needed to confirm good flow.
     
 CHAPTER 17 Elbow Injection Techniques 289

A B
• Fig. 17.17(A) Humeral olecranon joint injection fluoroscopy, posterior approach set up. (B) Humeral olec-
ranon joint injection under fluoroscopy, posterior approach using a 25-gauge needle. Arrow represents
needle trajectory. Black contrast fills joint space.

References 5. B
 ureau NJ, Destrempes F, Acid S, Lungu E, Moser T, Michaud J,
et al. Diagnostic accuracy of echo envelope statistical modeling
1. P otter HG, Hannafin JA, Morwessel RM, DiCarlo EF, O’Brien compared to B-mode and power Doppler ultrasound imaging
SJ, et al. Lateral epicondylitis: correlation of MR imaging, sur- in patients with clinically diagnosed lateral epicondylosis of the
gical, and histopathologic findings. Radiology. 1995;196(1): elbow. J Ultrasound Med. 2019;38(10):2631–2641.
43–46. 6. Smidt N, van der Windt DA, Assendelft WJ, et al. Corticosteroid in-
2. Bredella M, Tirman P, Fritz R, Feller J, Wischer T, Genant H. jections, physiotherapy, or a wait-and-see policy for lateral epicondyli-
MR imaging findings of lateral ulnar collateral ligament abnor- tis: a randomized controlled trial. Lancet. 2002;359(9307):657–662.
malities in patients with lateral epicondylitis. AJR Am J Roentgenol. 7. Bisset L, Beller E, Jull G, et al. Mobilisation with movement and
1999;173(5):1379–1382. exercise, corticosteroid injection, or wait and see for tennis elbow:
3. Qi L, Zhu Z-F, Li F, Wang R-F. MR imaging of patients with randomised trial. BMJ. 2006;333(7575):939.
lateral epicondylitis of the elbow: is the common extensor tendon 8. Leach RE, Miller JK. Lateral and medial epicondylitis of the el-
an isolated lesion? PloS One. 2013;8(11):e79498. bow. Clin Sports Med. 1987;6(2):259–272.
4. Labott JR, Aibinder WR, Dines JS, Camp CL. Understanding the 9. Sellon JL, Wempe MK, Smith J. Sonographically guided distal
medial ulnar collateral ligament of the elbow: review of native liga­ biceps tendon injections: techniques and validation. J Ultrasound
ment anatomy and function. World J Orthop. 2018;9(6):78–84. Med. 2014;33(8):1461–1474.
18
Wrist Injection Techniques
KEVIN CONLEY, YODITI TEFERA, MICHAEL ERICKSON,
ADAM M. POURCHO, PHILLIP HENNING, AND OLUSEUN
OLUFADE

Ultrasound-Guided Techniques Equipment

• I njections can be performed using a high-frequency lin-
KEY POINTS ear array transducer. If available, a hockey stick or shorter
footprint transducer may also be helpful.
• A hockey stick transducer or small linear/shorter
footprint transducer may be beneficial in areas about • 30 to 22 gauge, 1 to 2 inch needle.
the hand and wrist due to the nature of the smaller
anatomy. Common Injectates
• A gel standoff can be beneficial when doing • L ocal anesthetics for diagnostics, corticosteroids
procedures about the wrist to facilitate better needle
• Prolotherapy
visualization.
• As with any procedure, a knowledge of the at-risk • Orthobiologics (platelet-rich plasma [PRP], bone mar-
structures and common anatomic variants with row concentrate, etc.)
sonographic identification prior to any procedure is
recommended. Injectate Volume
   • 1 to 3 cc
Technique
Wrist Joint Injections Wrist Joint Injections (Radiocarpal, Midcarpal, and
Pertinent Anatomy Distal Radioulnar Joints)
• Th
 e wrist region is composed of three noncommuni- • P atient position
cating synovial joints: the radiocarpal joint, the mid- • A supine or seated position with the forearm fully
carpal joint, and the distal radioulnar joint (DRUJ) pronated and wrist in slight flexion (Fig. 18.2A).
(Fig. 18.1). • Place the wrist on a rolled-up towel; slight wrist flex-
• The triangular fibrocartilage complex (TFCC) is a con- ion opens up the dorsal joint recess.13,14
struct between the distal ulna and proximal carpal row. • Clinician position
The TFCC is composed of fibrocartilage (meniscal • Seated facing the wrist and ultrasound machine
homolog), flexor carpi ulnaris tendon sheath, and radio- monitor.
ulnar ligaments, which stabilize the DRUJ.1,2 • Transducer orientation
• Placing the transducer in the anatomic sagittal plane
Common Pathology optimizes visualization of most of the wrist joints, with
• I njuries to the wrist include dislocations, chronic insta- the exception of the DRUJ, which is best visualized in the
bility/ligamentous laxity, inflammatory arthritis, and anatomic axial plane due to its orientation (see Fig. 18.2).
osteoarthritis.3–8
• Prior scaphoid fractures, scapholunate or lunotriquetral
Radiocarpal Joint (Proximal Carpal Row)
ligament (LTL), and TFCC injuries may predispose to
post-traumatic arthritis.4,5,9 • T
 ransducer orientation: radiocarpal joint
• The anatomic variation of positive ulnar variance may • The anatomic axial plane over the dorsal radius at the
cause abutment of the cartilage and subsequent attri- level of Lister’s tubercle.
tional tearing/degeneration of the TFCC.10,11 • Center the transducer over Lister’s tubercle; then visu-
• Pathologic signs include osteophyte formation, cortical alize the radiocarpal joint by rotating the transducer
irregularities, articular space narrowing, joint effusions, 90 degrees to the anatomic sagittal plane on the longi-
or thickening of the synovium/synovitis.6,12 tudinal axis (see Fig. 18.2A).

290
 CHAPTER 18 Wrist Injection Techniques 291

Ulnotriquetral
ligament

Ulnolunate
ligament Triquetrum

Ulnar collateral
ligament

Meniscus
homolog
Lunate

Styloid band

Triangular
Carpal ligaments fibrocartilage
complex (TFCC)
Radius Ulna

Radioulnar Foveal band

ligament Triangular disk

• Fig. 18.1 Drawing of The Wrist Joint. Note the radiocarpal joint (green) between the radius and ulna
proximally and proximal carpal row distally. Mid carpal joint (blue) lies between the proximal and distal carpal
row. The distal radioulnar joint (yellow) is the articulation between the distal radius and ulna. The triangular
fibrocartilage complex is the fibroligamentous construct between the distal ulna and proximal carpal row.

* S
B DIST

R S
*
A C DIST
• Fig. 18.2Wrist Joint (Radiocarpal Joint [RC]). (A) Transducer placed along the anatomic sagittal plane
to optimize visualization of the RC and midcarpal joint. Black arrow represents the direction of needle
when using an in plane approach from a distal to proximal direction. White arrow represents path of needle
when performing an out of plane injection from ulnar to radial. (B) Needle (arrowheads) placed in plane
with transducer from distal to proximal direction (black arrow 2A). Asterisk denotes location of joint space.
(C) Needle is placed out of plane with transducer from radial to ulnar direction (white arrow 2A.), asterisk
denotes location of joint space. R, Radius, S, scaphoid.

• N
 eedle orientation • Th is can also be performed via an out-of-plane tech-
• A needle can then be inserted via an in-plane distal- nique with the transducer placed in the anatomic sag-
to-proximal trajectory toward the joint (see Fig. ittal plane centered over the radioscaphoid joint (see
18.2B). Fig. 18.2A and C).
• The transducer (Td) can be rotated and translated • Target
slightly to create a tendon-free region through which • Due to the paucity of overlying neurovascular
the needle will traverse (see Fig. 18.2B). structures and ease of access to the joint space, the
292 SEC T I O N I I I Atlas

radioscaphoid joint is the preferred target in an in-

plane approach.13,14
• Important to note that the articular hypoechoic
scaphoid cartilage may not be easily visualized given
the orientation.

Midcarpal Joint Injection

The technique is like the radiocarpal joint, with the excep-
tion being the target is the dorsal recess of the midcarpal
joint.

Distal Radioulnar Joint Injection

Transducer Orientation
• C
 entered over the DRUJ and overlying extensor ­digiti
minimi tendon in anatomic axial orientation (Fig. 18.3A).

Needle Orientation
In plane with ulnar-to-radial approach with the tip placed
in the dorsal recess of the joint (see Fig. 18.3B). A
• Alternatively, an out-of-plane technique can be used
when the needle is introduced from a distal-to-proximal
ERCB ERCL
direction into the joint (see Fig. 18.3A). EDM EPL
EDC

Target R
• J oint recess. U
• A slight oblique pathway of the needle may be needed
B RAD
to avoid placement of the needle through the overlying
extensor digiti minimi tendon or the posterior interosse-
ERCL
ous nerve (PIN) (see Fig. 18.3C). EDM ERCB
EDC
U
PEARLS AND PITFALLS R

• T he location of the PIN in the fourth dorsal compartment

should be identified and monitored during the injection.
• Joint aspiration may help to further delineate pathology
C RAD
and direct treatment for diseases such as inflammatory
and crystalline arthropathies.5,8 If one prefers to initially
• Fig. 18.3 Distal Radioulnar Joint (DRUJ) Injection. (A) Transducer is
placed along the anatomic axial plane to optimize visualization of the
aspirate the joint, a larger-gauge needle, such as an 18
DRUJ. (B) Ultrasound image with needle placed (arrowheads) in plane
gauge, would be recommended.
with transducer from ulnar to radial direction (black arrow [3A]) into the
• Reported accuracy rates of palpation-guided and
dorsal recess of the joint. (C) Ultrasound image with needle placed
ultrasound-guided injections for these regions range
(arrowhead) out of plane with transducer from distal to proximal (white
from 25% to 97% and 79% to 94%, respectively.15-19
arrow [3A]). ECRB, Extensor carpi radialis brevis; ECRL, extensor carpi
   radialis longus; EDC, extensor digitorum communis; EDM, extensor
digiti minimi; EPL, extensor pollicis longus; white oval encircles the
posterior interosseous nerve; R, radius; U, ulna.
Scapholunate Ligament, Lunotriquetral
Ligament, and TFCC Injections
Pertinent Anatomy • E
 asily visualized structures associated with the com-
• S capholunate ligament (SLL) and lunotriquetral liga- plex include the UCL and the overlying ECU tendon
ment LTL are both composed of 3 structurally distinct sheath.2,6,21
parts (volar, membranous, and dorsal). The dorsal SLL is
the strongest component, while the volar portion is the Common Pathology
strongest portion in the LTL.20 • Th
 ere are Twenty individual ligaments in the wrist, but
• The TFCC can be difficult to see in its entirety as the the SLL and TFCC are more prone to injury.
ulnar styloid process blocks the view. Adjacent structures • SLL and LTL injuries occur with a fall onto an outstretched
include wrist ulnar collateral ligament (UCL), extensor hand. This can lead to altered arthrokinematics and sub-
carpi ulnaris (ECU) tendon, and sheath. sequent development of arthritis.22 Total disruption of the
 CHAPTER 18 Wrist Injection Techniques 293

SLL and LTL can lead to instability and result in a scaph- Clinician Position
olunate advanced collapse of the wrist. Acute total SLL • S tanding or seated facing the wrist and ultrasound
injuries should be treated surgically. machine monitor.
• TFCC injuries may occur as a result of direct trauma
from falls or chronic attrition associated with ulnar abut- TFCC Injection
ment syndrome.1 • T ransducer orientation
• Anatomic axial plane over the distal ulna and
Equipment radius.
• I njections can be performed using a high-frequency lin- • Slide the transducer distally to view the ulnar attach-
ear array transducer. If available, a hockey stick or shorter ment of the TFCC. The transducer may need to be
footprint transducer may also be helpful. rotated clockwise/counterclockwise to improve visu-
• 30 to 22 gauge, 1 to 2 inch needle alization of the ligament (see Fig. 18.4A).
• Needle orientation
Common Injectates • Use an ulnar gel standoff
•  ocal anesthetics for diagnostics
L • In plane
• Prolotherapy • Ulnar-to-radial direction
• Orthobiologics (PRP, bone marrow concentrate, etc.) • Target
• Corticosteroids should not be injected directly into a • Dorsal aspect of the TFCC and UCL (see Fig. 18.4B)
ligament or tendon.
Scapholunate and Lunotriquetral Ligament
Injectate Volume Injection
• 1 to 3 cc • T
 ransducer Orientation
• The SLL is identified by placing the transducer in the
Technique anatomic axial plane over the distal radius and sliding
Patient Position the transducer distally (see Fig. 18.4A).
• S upine or seated with forearm pronated and resting on • The dorsal aspect of the LTL is identified by placing the
table with a towel under the wrist to induce slight wrist transducer in the anatomic axial plane over the distal
flexion (Fig. 18.4A). ulna and radius and sliding distally to view the LTL.

EDC
EDM
X3
S 1
L
U
B RAD

EDC
EDM

X3

L S
U
C RAD

EDC
EDM

T L
S
A D RAD

• Fig. 18.4 Dorsal Wrist Ligament and Triangular Fibrocartilage Complex (TFCC) Injection: (A) Transducer
orientation (black rectangle for SL and TFCC) (dashed rectangle for lunotriquetral ligament [LTL]) axial to
dorsal wrist. Black arrow, direction of needle placement from ulnar to radial. White arrow, out-of-plane
needle trajectory for LTL injection. (B) Needle (arrowheads) placed into the dorsal TFCC (open arrow).
(C) Needle (arrowheads) placed into the dorsal scapholunate ligament (curved arrow). Placement of the
forearm and wrist in preparation for the dorsal wrist joint injections. Hint: A rolled towel placed under the
distal forearm to cause slight wrist flexion aides in visualization of the target and needle. EDC, Extensor
digitorum communis; EDM, extensor digiti minimi; L, lunate; open oval, posterior interosseous nerve; S,
scaphoid; U, ulna.
294 SEC T I O N I I I Atlas

• N eedle Position • Th
 e radioscapholunate ligament (RSLL) (ligament of
• Using an ulnar gel standoff, the SLL injection is performed Testut and Kuenz) is located just ulnar to the LRLL
via an in-plane ulnar-to-radial direction with the goal of and radial to the SRLL.
placing the injectate in the ligament (see Fig. 18.4C).
• The LTL injection is performed using an out-of-plane Common Pathology
distal-to-proximal approach. • H yperextension of the wrist is a common mechanism.
• Caution should be taken to identify and avoid the • While the TFCC and SLL are the most commonly
PIN located on the radial side of the fourth dorsal injured structure, any of the 20 wrist ligaments can be
compartment (see Fig. 18.4C). injured.
• Target
• Hypoechoic or pathologic areas of the scapholunate Equipment
or LTL. • I njections can be performed using a high-frequency lin-
ear array transducer. If available, a hockey stick or shorter
PEARLS AND PITFALLS footprint transducer may also be helpful.
• 30 to 25 gauge, 1 to 2 inch needle.
• F
 ewer dorsal neurovascular structures are present
compared to the volar wrist, but the location of the PIN Common Injectates
on the radial side of the fourth dorsal compartment
should be noted prior to any procedure using the dorsal
•  ocal anesthetics for diagnostics
L
approach. • Prolotherapy
• Orthobiologics (PRP, bone marrow concentrate, etc.)
  
• Corticosteroids should not be injected directly into a
ligament or tendon.
Volar Ligaments: Radioscaphocapitate,
Long Radiotriquetral, Short Radiolunate, Injectate Volume
Radioscapholunate • 1 to 3 cc

KEY POINTS
Technique
Patient Position
• T his is an advanced injection that requires excellent • S upine, wrist supinated (Fig. 18.5A).
needle visualization skills.
• Must clearly identify and avoid the median nerve, radial,
• May have a small towel roll under the wrist for slight
and ulnar arteries. extension to "open" the space.
• One does not have to specifically identify each
individual ligament for injection. Clinician Position
   • Seated or standing on the side of the patient’s wrist.

Transducer Orientation
Pertinent Anatomy • S hort axis to the wrist and carpal tunnel structures.
• Th
 e wrist ligaments are generally grouped into the intrin- • Take care to angulate parallel or perpendicular to avoid
sic (ligaments between the carpal bones) and extrinsic anisotropy.
(connecting carpal bone to distal radius or ulna). The
volar ligaments can generally be called the palmar extrin- Needle Orientation
sic capsular wrist ligaments, and specific ligaments are • Th
 e radial and ulnar approaches are necessary to target
named for the bones they originate and insert onto.20,23 the desired ligaments.24
• Four ligaments originate from the distal radius and attach • Radial approach: the needle will enter medial to the radial
to the carpal bones. artery and radial to the median nerve (see Fig. 18.5B).
• The radioscaphocapitate ligament (RSCL) originates • Ulnar approach: the needle will enter radial to ulnar neu-
from the volar aspect of the radial styloid to approxi- rovascular structures and medially to the median nerve
mately the middle of the scaphoid fossa. (see Fig. 18.5C).
• The long radiotriquetral ligament (LRLL), which also
is known as the palmar radiolunotriquetral or the Target
radiotriquetral ligament, originates from the volar rim • T arget the bands overlying (extrinsic ligaments) and
of the distal radius, ulnar to the RSCL and spans the between (intrinsic ligaments) the carpal bones.
remaining part of the scaphoid fossa. • Redirect the needle as needed, targeting the ligaments
• The short radiolunate ligament (SRLL) originates with care to avoid the neurovascular bundle.
from the volar ulnar aspect of the distal radius across • Redirect proximal to target ligaments over the first proxi-
the entire width of the lunate fossa and attaches to the mal row and between the first carpal row and the distal
radial half of the palmar cortex of the lunate. radius and ulna as well.
 CHAPTER 18 Wrist Injection Techniques 295

FCR

FT

U R
B

FCR PL

R
A C U
• Fig. 18.5Sonographic Images of Volar Wrist Ligament Injections. (A) Transducer placement (black rect-
angle) along the volar wrist. (B) Needle placement along the volar wrist ligaments (blue rectangles), needle
(white arrows) traversing radial to ulnar. (C) Needle placement (white arrows) along the volar wrist ligaments,
needle traversing ulnar to radial. FCR, Flexor carpi radialis; PL, palmar ligament; R, radius; U, ulna.

PEARLS AND PITFALLS by the overlying extensor retinaculum (Fig. 18.6). The
compartments are numbered from lateral to medial, and
• B e sure to always visualize needle tips and avoid the contents include:
neurovascular structures. • First–abductor pollicis longus (APL) and extensor
• Variances in anatomy will determine how many of the
ligaments will be accessible
pollicis brevis (EPB)
• Second–extensor carpi radialis longus and brevis
  
(ECRL/ECRB)
• Third–extensor pollicis longus (EPL)
Dorsal Compartments of the Wrist (1 to 6) • Forth–extensor digitorum and extensor indices (lies
Injection deep to digitorum) (EDC, EIP)
• Fifth–extensor digiti minimi/quinti (EDM/EDQ)
KEY POINTS
• Sixth–extensor carpi ulnaris (ECU)
• T he first and sixth compartments are most commonly • The superficial radial nerve traverses over the first dor-
clinically involved.2 sal compartment and divides into the SR3 and SR2
• The first compartment tendons may have a separate branches just proximal to the extensor retinaculum
sheath that may require separate injections to
adequately resolve pain in this region.2 (Fig. 18.7A and B).7 The SR2 branch courses from
volar to dorsal over the first compartment, often just
  
proximal to the proximal edge of the retinaculum (see
Fig. 18.7A and B).25
Pertinent Anatomy • The cephalic vein has a branch that is typically located
• S ix compartments on the dorsal side of the wrist house over or slightly dorsal to the first dorsal compartment
the extensor tendons, and the tendons are held in place (see Fig. 18.7D).
296 SEC T I O N I I I Atlas

Transverse carpal
ligament

Ulnar nerve Median nerve Flexor carpi

Flexor digitorum radialis
superficialis Flexor pollicus longus

Flexor digitorum 1 Extensor pollicis brevis

profundus Abductor pollicis longus

6
Extensor carpi radialis brevis
Extensor carpi ulnaris 2
5 Extensor carpi radialis longus
3
Extensor digiti minimi 4 Extensor pollicis longus
Extensor digitorum
Extensor indicis

Dorsal compartments
A
Radial nerve superficial branch

Extensor retinaculum

Abductor pollicis longus

Extensor pollicis brevis

B Extensor pollicis longus
• Fig. 18.6 The Six Dorsal Compartments of the Wrist. (A) Transverse wrist.

V A
E

E B C VOL
A

E A

V
R
A D VOL

• Fig. 18.7 Anatomy of the First Dorsal Compartment. (A and B) Cadaveric dissection of the compart-
ment showing the abductor pollicis longus (A), extensor pollicis brevis (E), retinaculum (open star), the
bifurcation of the superficial radial nerve (curved arrow) and the SR2 (open arrow) and SR3 (white arrow)
branches. (C and D) Sonographic axial images of the first dorsal compartment. Note the SR2 (white oval)
and SR3 (yellow oval). R, Radius; V, adjacent cephalic vein.
 CHAPTER 18 Wrist Injection Techniques 297

• Th
 e first compartment can be divided into separate Equipment
synovial sheaths and compartments for the APL and • H igh-frequency linear array transducer.
EPB tendons by an intra-compartment septum in up to • Smaller footprint or hockey stick probes may be easier to
33% of patients. Implications include isolated tenosyn­ use.
ovitis of the EPB or APL and may be clinically signifi- • 30 to 25 gauge, 1 to 2 inch needle.
cant for the treatment of de Quervain’s syndrome7 (see
Fig. 18.7B and C). Common Injectates
• The APL tendon often has multiple slips, which can be • L ocal anesthetics for diagnostics, corticosteroids into
mistaken as longitudinal split tearing.12,26 tendon sheaths only
• Anatomic variations may also be seen in the second • Prolotherapy
dorsal compartment, such as the extensor carpi radialis • Orthobiologics (PRP, bone marrow concentrate,
intermedius, which should not be mistaken for a longi- etc.)
tudinal split tear.8
Injectate Volume
Common Pathology • 1 to 2 cc
• S tenosing tenosynovitis most commonly involves the first (de
Quervain’s syndrome) and sixth dorsal compartments.27,28 Technique
• The mechanism of action is believed to be repetitive Patient Position
microtrauma related to occupation or sporting activi- • F irst to second compartments: Seated or supine on
ties at the distal radial styloid, causing degeneration and the table with the forearm in neutral position (thumb
inflammation in the APL and EPB tendons.29,30 pointed upward) for (Fig. 18.8A and B).
• Tenosynovitis is seen more commonly in those with dia- • Third and fifth compartments: Seated or supine on the
betes mellitus or autoimmune conditions such as rheu- table with the forearm pronated (see Fig. 18.8C and D).
matoid arthritis.4,19,28 • Sixth compartment: Supine with the forearm pronated
• The first compartment crossing over the second (proxi- over a pillow on the chest (see Fig. 18.8E and F).
mal intersection syndrome) and the third compartment
crossing over the second (distal intersection syndrome) Clinician Position
can be other areas of pathology.31 • Seated or standing on the side of the patient’s wrist.

1 2 3
3 4 5
6

A C E

ECU
APL APB EPL EDC
E EM
A U
EPL U
R R

B DOR D ULN F VOL

• Fig. 18.8Transducer Placement and Sonographic Images of The Six Dorsal Compartments. (A and
B) Compartments 1–3, (C and D) Compartments 3–5, (E and F) 6th compartment. A, abductor pollicis
longus; E, extensor pollicis brevis; EM, extensor digiti minimi; ECU, extensor carpi ulnaris; EDC, Extensor
digitorum; EPL, extensor pollicis longus; R, radius.
298 SEC T I O N I I I Atlas

Transducer Orientation Needle Orientation

• Th
 e anatomic axial plane, short axis relative to the desired • Th
 e needle is introduced via an ulnar-to-radial, radial-to-
tendon (in-plane technique) (Fig. 18.9A and B). ulnar, or in the case of the ECU tendon volar-to-dorsal
• Alternative position: sagittal to the long axis of the dis- or dorsal-to volar direction.
tal forearm/tendon (in or out-of-plane technique) (see
Fig. 18.9A and C). Target
• T endon sheath of EPB/APL
• If using prolotherapy or orthobiologics, inject directly
into the tendon

PEARLS AND PITFALLS

• It is important to recognize anatomic variants of the first
and second dorsal compartment as they may affect
treatment outcomes or approaches.
• Note the presence of subcompartmentalization for
first dorsal compartment injections, with a septum
separating the APL and EPB. In cases with distinct
tendon sheaths, injecting only one sheath may be
associated with poor treatment outcomes.27,32-34
• The use of the gel standoff technique helps with the
accurate initial placement of the needle during an
in-plane approach.
• Tendon sheath distention during injection ensures
accurate placement of the injectate.
• The SR2 and SR3 branches of the superficial radial
nerve should be identified and avoided during first
compartment procedures.
• The use of particulate corticosteroids can increase the
risk of skin depigmentation, especially with superficial
injections.35
  

Ultrasound-Guided Ganglia Injection

A
KEY POINTS

E • G
 anglion cysts are often associated with joint, joint
A capsule, or tendon sheath injury. These underlying causes
V should be evaluated and treats as needed as well.
R   

B DOR
Pertinent Anatomy
• L ocation of ganglion cysts can be variable, with a major-
A
E
ity (up to 70%) occurring in the dorsal wrist.36
V
• The majority of cysts in the hand originate from the
scapholunate joint dorsally, while ventral cysts will origi-
R nate from the radiocarpal or scaphotrapezial joints (see
Fig. 18.11B and C).24
• Dorsal cysts arising from the scapholunate joint can
C DOR impinge on the PIN (see Fig. 18.11B and C).
• Fig. 18.9 Injection Technique for First Dorsal Compartment. (A) • On the volar side, the cyst most commonly arises from
Transducer placement (black rectangle); in-plane approach, black the radiocarpal joint, the radial artery and superficial
arrow, out-of-plane approach, white arrow. (B) Sonographic image radial nerve typically are superficial and radial to the cyst.
of in-plane injection, needle (arrowheads) placed deep to the abduc- The median nerve is typically ulnar to the cyst (see Fig.
tor pollicis longus (A) and extensor pollicis brevis (E) tendons. (C)
Sonographic image of out-of plane approach; note hyperechoic needle
18.10B and C). A volar cyst can also originate from other
tip (arrowhead) superficial to the tendons. Yellow oval, SR2; white oval, areas, such as between the pisiform and triquetrum, with
SR3; V, cephalic vein; I, radius. impingement of the ulnar neurovascular structures.
 CHAPTER 18 Wrist Injection Techniques 299

a
FCR
FT FT x
FPL

L
S

x
1
S
R

a
FCR

FPL FT FT
x
1
L
S

A D
• Fig. 18.10Volar Wrist Ganglion Cyst Aspiration/Injection. (A) Transducer placement: axial to wrist, solid
black rectangle, sagittal to wrist, dashed rectangle. (B and C) Sonographic appearance of ganglion cyst
(open star). (D) Needle (arrowhead) placement into the cyst. a, Radial artery; FCR, flexor carpi radialis;
FPL, flexor pollicis longus; FT, flexor tendon; L, lunate; R, radius; S, scaphoid; white oval, median nerve.

L
S
B ULN

S
C PROX

S
A D PROX

• Fig. 18.11 Dorsal Wrist Ganglion Cyst Aspiration/Injection. (A) Transducer placement: axial to wrist,
solid black rectangle, sagittal to wrist, dashed rectangle. (B and C) Sonographic appearance of ganglion
cyst (open star). (D) Needle (arrowhead) placement into the cyst. L, Lunate; R, radius; S, scaphoid; white
oval, posterior interosseous nerve.
300 SEC T I O N I I I Atlas

Common Pathology
PEARLS AND PITFALLS
• G anglion cysts can average 1 to 2 cm in diameter and
can be described as firm, nodular structures connected to • G el standoff may be helpful in maintaining contact over
the area of interest.
a nearby joint capsule or tendon sheath.37 These synovial • High-viscosity ganglion fluid can make aspiration
cysts are typically lined with a thin connective tissue layer difficult unless using a larger-gauge needle. (see Fig.
and filled with gelatinous mucoid material.9 18.11D).
• Common complaints from the patient include wrist pain • Cyst lavage may be necessary with local anesthetic or
aggravated by moving the wrist. Depending on the loca- sterile saline.39
tion, cysts can impinge on the neurovascular structures,   
causing either pain or paresthesia’s.38

Equipment Flexor Carpi Radialis Tendon and Sheath

• A nesthetic needle size: 25 or 27 gauge needle, 31.75 and
Injection
38 mm Pertinent Anatomy
• Cyst penetration and aspiration: 18 gauge, 38 mm • Th
 e flexor carpi radialis (FCR) is the most radial and
needle superficial of all the flexor tendons and does not pass
• High-frequency linear array ultrasound transducer through the carpal tunnel. The transverse carpal liga-
• Depending on the location of the cyst, a gel standoff ment (TCL) splits around the FCR, dividing into deep
may be used to help needle visualization and access to and superficial components that create a separate fibro-
the cyst osseous tunnel for the FCR tendon.40
• The radial artery is located just radial to the FCR tendon.
Common Injectates • The palmar cutaneous branch of the median nerve
• A spirate (PCN) is located between the FCR and, if present, the
• After aspiration: palmaris tendon.40
• Local anesthetics and corticosteroids • The FCR inserts into the base of the second and third
• Prolotherapy metacarpal and can be followed longitudinally to its
• Sclerosing agents insertion to confirm location.10
• Orthobiologics (PRP, bone marrow concentrate, etc.)
Common Pathology
Technique • A s the FCR passes over the scaphoid, it can develop
Patient Position attritional injuries in patients with radiocarpal, sca-
• Th
 e wrist may be pronated or supinated based on the photrapezial trapezoidal, and first carpometacarpal
location of the ganglion cyst (dorsal or volar, respec- osteoarthritis.12
tively) (Fig. 18.11A; see also Fig. 18.10A). • Pathology is commonly seen in tennis players and
golfers.12
Clinician Position
• Seated or standing facing the patient’s wrist and monitor. Equipment
• 2 7 to 25 gauge, 31.75 and 38 mm needle
Transducer Orientation • High-frequency linear array ultrasound transducer
• F or a volar ganglion cyst, the transducer is placed axial
or sagittal to the ganglion cyst, depending on the saf- Common Injectates
est anatomic window for approach (see Fig. 18.10A • L ocal anesthetics for diagnostics, corticosteroids in the
and C). sheath only
• For a dorsal ganglion cyst, the transducer is placed • Prolotherapy
axial or sagittal to the ganglion cyst, depending on the • Orthobiologics (PRP, etc.)
safest anatomic window for approach (see Fig. 18.11A
and C). Injectate Volume
• 1 and 2 cc
Needle Orientation
• D
 epending on the safest approach, an in-plane radial-to- Technique
ulnar or proximal-to-distal trajectory may be used (see Patient Position
Fig. 18.10D). • E
 lbow flexed, wrist supination with the patient sitting, or
lateral recumbent with arm forearm supinated.
Target
• Th
 e needle tip should be placed in the center of the cyst Clinician Position
(see Fig. 18.11A and D). • Seated or standing facing the wrist and monitor.
 CHAPTER 18 Wrist Injection Techniques 301

Transducer Orientation Target

• W
 ith the transducer placed in the anatomic axial plane • T endon sheath if diagnostics or steroids
short axis to the tendon. • Pathologic areas of the tendon if prolotherapy or ortho-
biologics are utilized
Needle Orientation
• I n-plane, radial-to-ulnar direction, deep to the FCR ten-
don at the level of the scaphoid (Fig. 18.12A–C). PEARLS AND PITFALLS
• H ave the patient flex the wrist against resistance, and
the tendon of the FCR will be visualized most proximal
to the thumb.41
• The palmar cutaneous nerve (PCN), radial artery,
and median nerve locations should be identified
for avoidance during procedures involving the FCR
tendon.
  

Flexor Carpi Ulnaris Tendon Lavage for Calcific

Tendonitis
Pertinent Anatomy
• Th
 e ulnar nerve and artery are adjacent and radial to the
flexor carpi ulnaris (FCU) tendon when followed from
the forearm distally.2
• The FCU is innervated by the ulnar nerve and functions
to flex, and ulnarly deviate the wrist.2
• The FCU does not have a tendon sheath and inserts dis-
tally into the pisiform, hamate, and fifth metacarpal.2

Common Pathology
• P
 athology in the region is relatively rare; however, there
A are case reports of tendinopathy as well as calcium
hydroxyapatite disease involving the FCU.42

Equipment
a
FCR FT • 3 0 and 25 gauge needle, 38 mm
FT FT P • High-frequency linear array ultrasound transducer
FPL
S
FT
• Several syringes of sterile, normal saline may be needed
to lavage the calcium deposit if present

B ULN
Common Injectates
L
• A nesthetize the skin and tendon with the anesthetic of
choice.
FCR • Corticosteroids can be deposited parallel/outside the ten-
FT
FT
don versus orthobiologics in the sheath or tendon, based
FT
FPL FT on provider preference.
S FT
Injectate Volume
L • 0.5 and 1 cc
C ULN Author’s Preferred Technique
• Fig. 18.12 Flexor Carpi Radialis (FCR) Tendon Sheath Injection. (A) Patient Position
Transducer placement (black rectangle); needle trajectory, black arrow. • A
 supine or lateral recumbent with the arm at the side
(B) Axial sonographic image of the volar wrist; note FCR tendon super- and forearm supinated.
ficial to the scaphoid (S). (C) Sonographic image of FCR tendon sheath
injection with needle in place (arrowhead). a, Ulnar artery; FPL, flexor
Clinician Position
pollicis longus; FT, flexor tendons; L, lunate; P, pisiform; white arrows,
transverse carpal ligament overlying carpal tunnel entrance. • Seated or standing facing the wrist and monitor.
302 SEC T I O N I I I Atlas

Transducer Orientation
• Th
 e transducer is placed in the anatomic axial plane, PEARLS AND PITFALLS
short axis to the FCU tendon proximal to the pisiform • C
 olor Doppler can be used to identify the at-risk ulnar
(Fig. 18.13A). neurovascular structures prior to the procedure.
  
Needle Orientation
• Th
 e needle is introduced via an in-plane ulnar-to-radial
direction. Carpal Tunnel Injection (i.e., Median Nerve
• A gel standoff is used ulnarly to better visualize the needle. Hydrodissection)
Pertinent Anatomy
Target • Th
 e carpal tunnel is bounded by the scaphoid and pisi-
• Th
 e pathologic areas of the tendon for the calcific lavage or form proximally and tubercle of the trapezium and hook
injection of the tendon itself (see Fig. 18.13A and B). of the hamate distally. The TCL overlies the tunnel.40
• Contents of the tunnel include the median nerve, flexor
pollicis longus, and the tendons of the flexor digitorum
superficialis and profundus (Fig. 18.14).40

Common Pathology
• C ompression of the median nerve can be related to thick-
ening of the TCL, ganglion cysts, tenosynovitis, amyloi-
dosis, joint effusions/synovitis, aneurysms, lipomatous
hamartomas, and accessory muscles.43,44
• It is the most common site of nerve compression in
the upper extremity, with an incidence of 3.5% and
6.2%.43,45
• There are many anatomic variants of the median nerve
that need to be taken into consideration when doing
injections about the carpal tunnel. The most common
anatomic variant is that of a persistent median artery
with a bifid median nerve.13,46
• There are also anatomic variants of the thenar motor
branch, which should be identified prior to procedures
about the median nerve.47
• For further information on anatomic variants, please see
Chapter 32.

Equipment
A • 3 0 to 25-gauge needle, 1 and 2 inch
• High-frequency linear array ultrasound transducer
V
a Common Injectates
FS
• L ocal anesthetics, corticosteroids
FP
• Neuroprolotherapy (5% dextrose)
• Orthobiologics (PRP, platelet lysate)
B U ULN
Injectate Volume
• 1 to 5 cc
FCU
P Technique
Patient Position
C • S eated with the elbow flexed and the wrist supinated,
PROX
with fingers relaxed.
• Fig. 18.13 Flexor Carpi Ulnaris Injection/Aspiration. (A) Transducer • An alternate position is lateral recumbent or supine with
placement (black rectangle) and needle trajectory (black arrow). the arm at the side, on the arm board.
Sonographic images of the needle (arrowhead) placed in plane (B) and
out of plane (C) within the flexor carpi ulnaris (FCU) tendon. a, Ulnar
artery; FP, flexor digitorum profundus; FS, flexor digitorum superficialis; Clinician Position
P, pisiform; U, ulna; yellow oval, ulnar nerve. • Seated or standing facing the patient’s wrist and monitor.
 CHAPTER 18 Wrist Injection Techniques 303

Median nerve

Fluid
Needle

Median nerve

• Fig. 18.14 Median Nerve Hydrodissection at The Wrist Under Ultrasound Guidance.

Transducer Orientation
• Th
 e transducer is placed in the anatomic axial plane,
Ulnar Nerve Hydrodissection
short axis to the median nerve, identifying the proximal Pertinent Anatomy
and distal carpal tunnel and any anatomic variants that • D istal to Guyon’s canal, the ulnar nerve splits into deep
would prohibit a safe injection (Fig. 18.15A–C). and superficial branches40 (Fig. 18.16B and see also Fig.
18.15C).
Needle Orientation • The ulnar artery travels with the ulnar nerve over the
• Th
 e needle is introduced via an in-plane, ulnar-to-radial ulnar aspect of the wrist. Color Doppler can be used to
approach. help identify neurovascular structures.
• Alternatively, an out-of-plane, distal-proximal or proxi- • Anatomic variation of the ulnar nerve is present in
mal-to-distal approach can be used with the transducer 1% to 3% of the population, where the nerve trav-
in the same position (see Fig. 18.15A and E). els in an osseo-fibrous canal distinct from Guyon’s
canal).40
Target • This is usually situated on the anteromedial portion
• P lace the needle both superficial and deep to the median of the TCL spanning 4 cm from the pisiform to the
nerve at the level of the proximal carpal tunnel (see Fig. hook of the hamate bifurcation, which may affect the
18.15B and D). Anesthetic and sterile saline is used to approach/technique.40
create a halo around the nerve for the hydrodissection.
• With the alternative out-of-plane approach, the goal is to Common Pathology
stay ulnar to the nerve. • Th
 e ulnar nerve at the wrist is subject to injuries related
to hamate fractures, ganglion cysts, arterial aneurysms,
nerve sheath tumors, repetitive compression, and gan-
PEARLS AND PITFALLS glion (see Fig. 18.15B and D).48,49
• C olor Doppler will help visualize the ulnar artery • Typically, entrapment of the ulnar nerve at the wrist
and ensure safe needle placement away from the within or near Guyon’s canal may have a positive Tinel
vasculature. sign over the ulnar nerve and decreased sensation over
• An ultrasound can be used for real-time visualization of ulnar nerve distribution in the palm. If motor fibers
injectate flow along the nerve by moving the transducer
along the length of the nerve.
are affected, there may be a positive Wartenberg’s
• A gel standoff is recommended during an in-plane sign.49
approach to avoid the ulnar artery and nerve.
• Identification of at-risk structures and understanding of Equipment
possible variant anatomy prior to injection is recommended. • 3 0 to 25 gauge needle, 1 and 2 inch
   • High-frequency linear array ultrasound transducer
304 SEC T I O N I I I Atlas

a
FCR FT
FT FT P
FPL
S

B L ULN

T FC
R H
FT FT

FP
FT

L
C C
ULN

FCR
a x

S FT

FP
FT

L
D ULN

a
FCR

T FT FT H
FT
FP
L

C
A E ULN
• Fig. 18.15 Ultrasound-Guided Carpal Tunnel Injection. (A) Transducer placement axial to wrist (dashed
rectangle), axial oblique placement of transducer (solid rectangle). Axial sonographic appearance of the
proximal (B) and distal (C) portions of the tunnel. (D) In-plane approach. (E) Out-of-plane approach. a, Ulnar
artery; arrowhead, needle; FCR, flexor carpi radialis; FPL, flexor pollicis longus; FT, flexor tendon; L, lunate;
H, hook of hamate; C, capitate; S, scaphoid; T, trapezium; white arrows, transverse carpal ligament; white
oval, median nerve; yellow ovals, ulnar nerve (dashed, deep motor branch of ulnar nerve).

Common Injectates Clinician Position

• L ocal anesthetics, corticosteroids • S eated or standing facing the patient’s wrist and
• Neuroprolotherapy (5% dextrose) monitor.
• Orthobiologics (PRP, platelet lysate)
Transducer Orientation
Injectate Volume • Th
 e transducer is placed in the anatomic axial plane, over
• 3 to 5 mL of total solution the ulnar nerve, under the flexor carpi ulnaris (FCU) ten-
don (see Fig. 18.17A).
Technique • Color Doppler can be used to identify the ulnar
Patient Position artery.
• S eated with the elbow flexed, wrist supinated with fin-
gers relaxed (Fig. 18.17A). Needle Orientation
• An alternate position is lateral recumbent or supine with • Th
 e needle is introduced via an in-plane ulnar-to-radial
the arm at the side, on the arm board. direction.
 CHAPTER 18 Wrist Injection Techniques 305

a x

ULN
A B 2.5

DIST
C D 2.5

a
x

H
ULN

E F 2.5
• Fig. 18.16Ganglion Cyst Guyon’s Canal. (A) Transducer placement, axial (solid rectangle) and sagittal
(dashed rectangle). (B) Ganglion cyst overlying distal canal (open star); note superficial (solid yellow oval)
and deep (dashed yellow oval) branches of the ulnar nerve overlying the hook of hamate (H). (C) Syringe
with aspirated synovial fluid (black curved arrow). (D) Sagittal sonographic image of the ganglion cyst
overlying the superficial branch of ulnar nerve (white arrows), (E) Note slight atrophy of the hypothenar
eminence. (F) Sonographic image of cyst aspiration\; needle, white arrowhead; a, ulnar artery.

Target Superficial Radial Nerve Hydrodissection/

• A
 dvance to the perineural space where injectate is
used to create a halo surrounding the nerve (see Fig.
Block
18.17A–C). Pertinent Anatomy
• Th
 e superficial radial nerve divides into the SR3 and SR2
PEARLS AND PITFALLS branches just proximal to the retinaculum of the first
dorsal compartment (Fig. 18.18A and B).7
• C olor Doppler will help visualize the ulnar artery
and ensure safe needle placement away from the
• The SR2 branch courses from volar to dorsal over the
vasculature. first compartment, often just proximal to the proximal
• As you are injecting, monitor the flow of solution along edge of the retinaculum (see Fig. 18.18A).25
the nerve by moving the transducer along the length of • At the wrist, the superficial radial nerve moves to a sub-
the nerve. cutaneous location and traverses between the brachiora-
   dialis and ECRL tendons.
306 SEC T I O N I I I Atlas

FCU

R
B ULN

FCU

A C R ULN

• Fig. 18.17 Ulnar Nerve Hydrodissection. (A) Axial placement of the transducer (black rectangle) along
volar distal forearm. (B) Needle (arrowhead) placement deep to the ulnar nerve (white oval) sitting just deep
to the flexor carpi ulnaris (FCU) tendon. (C) Note hypoechoic fluid margin/halo around the ulnar nerve post-
injection. a, Ulnar artery; R, radius; U, ulna,.

Common Pathology Needle Orientation

• Th
 e nerve is subject to compression as it moves between • Th
 e needle is introduced via a dorsal-to-volar or volar-to-
the brachioradialis and ECRL tendons or from external dorsal direction.
compression, such as handcuffs or ligatures.50
Target
Equipment • Th
 e needle is advanced to the perineural space with the
• 2 7 to 25 gauge needle, 31.75 to 38 mm goal of creating a halo of injectate around the nerve (see
• High-frequency linear array ultrasound transducer Fig. 18.18A and B).
Common Injectates
PEARLS AND PITFALLS
• L ocal anesthetics, corticosteroids
• Neuroprolotherapy (5% dextrose) • S uperficial injection of corticosteroids increases the risk
• Orthobiologics (PRP, platelet lysate) of skin depigmentation.
• As you are injecting, monitor the flow of solution along
the nerve by moving the transducer along the length of
Injectate Volume the nerve.
• 3 to 5 mL of total solution • Care should be taken to make sure that the injection
is performed proximal to bifurcation, thus getting both
Author’s Preferred Technique terminal branches of the nerve.
Patient Position   
• S upine with the forearm in a neutral position (see Fig.
18.18A).
Dorsal Radioulnar Joint Fluoroscopic-Guided
Clinician Position Injection
• Seated or standing on the side of the patient’s wrist.
KEY POINTS
Transducer Orientation
• Th
 e transducer is placed in the anatomic axial plane, • Ionizing radiation necessitates shielded protection of
the patient and staff.
short axis to the nerve proximal to the bifurcation into
the SR2 and SR3 branches (see Fig. 18.18A and B).   
 CHAPTER 18 Wrist Injection Techniques 307

Common Pathology
• T FCC tears are divided into traumatic or degenerative.53
• Traumatic tears usually involve a fall onto a pronated
hand.
• Degenerative tears are related to repetitive shearing of the
structure, and may be seen in conjunction when the ulna
is longer than the radius, referred to as positive ulnar
variance53

Equipment
• C -arm fluoroscopy
• 27 to 22 gauge, 1 and 2 inch needle

Common Injectates
• L ocal anesthetics for diagnostics, intra-articular cortico-
steroids only
• Prolotherapy
• Orthobiologics (PRP, bone marrow concentrate, etc.)

Injectate Volume
• 0.5 to 1.5 cc

Technique
A
Patient Position
• Th
 e patient will sit next to the table, with the arm
abducted, the elbow flexed, and the placement of the
prone wrist flat over a rolled towel.54

a Clinician Position
EPB • The clinician should be next to the affected hand.
APL
ECRL
Fluoroscope Position
ECRB • PA position centered on the DRUJ.
U

Needle Position
B • P alpate medial to the border of the ulna head on the dor-
sal aspect.
• Fig. 18.18 Superficial Radial Nerve Hydrodissection. (A) Transducer
placement axial to the distal forearm overlying the first dorsal compart-
• Mark the area with a needle tip.
ment and branches of the superficial radial nerve, black arrow shows • Slowly insert the needle into the joint (Fig. 18.19C).
trajectory of needle. (B) Needle (arrowhead) placement deep to the • Use a dorsal-to-volar approach.
superficial radial nerve (yellow oval). a, Radial artery; APL, abductor
pollicis longus; ECRB, extensor carpi radialis brevis; EPB, extensor pol- Target
licis brevis; ECRL, extensor carpi radialis longus.
• M edial border of the ulna head.
• If there is resistance, reposition the needle by advancing
or removing it slightly. Confirm intra-articular place-
ment with a small amount of contrast.
Pertinent Anatomy
• Th
 e complex joint between the distal radius and the ulna. PEARLS AND PITFALLS
• The TFC, volar and dorsal radioulnar ligaments, and
ulnotriquetral and lunate ligaments, along with the ten- • T o aid in stabilizing the joint, prolotherapy or
don subsheath of the ECU, stabilize the distal radioulnar orthobiologics can be used to target the volar and
dorsal radioulnar ligaments, lunotriquetral and
joint and provide shock absorption between the ulna and ulnolunate ligaments, and the TFC.
the carpus.51-53 • Distal placement of the needle may cause an
• Injury typically occurs after a fall on an outstretched inadvertent injection in the radiocarpal joint.
hand.51   
308 SEC T I O N I I I Atlas

• Fig. 18.19 Dorsal Fluoroscopic-Guided Injections of the Midcarpal

and Distal Radioulnar Joints. (A) Needle position for injection of the • Fig. 18.20 Distal carpal setup, PA view.
midcarpal joint via the scaphotrapezial joint. (B) Needle position along
with contrast distribution of the midcarpal joint when injected from • D orsal midcarpal instability is often due to a high-energy
the medial side of the joint. (C) Needle position and contrast flow of injury and can present as subluxation or "clunk." In cases
the distal radioulnar joint. Note contrast flow proximal to the triangular
of true subluxation, surgery may be necessary to main-
fibrocartilage complex (white arrow).
tain anatomic position.
Distal Carpal Rows Fluoroscopic-Guided Injection • Scaphoid-trapezium-trapezoid arthritis.

KEY POINT Equipment

• Ionizing radiation necessitates shielded protection of
• C arm fluoroscopy
the patient and staff. • 27 to 25 gauge, 1 and 2 inch needle
   Common Injectates
• L ocal anesthetics for diagnostics, intra-articular cortico-
Pertinent Anatomy steroids only
• Th
 e midcarpal joint is found between the proximal and • Prolotherapy
distal carpal bones. • Orthobiologics (PRP, bone marrow concentrate, etc.)
• It is responsible for 60% of wrist flexion and about two-
thirds of wrist extension.55 Injectate Volume
• The radioscaphoid column bridges the proximal and dis- • 0.5 to 1.5 cc
tal carpal rows on the radial side and articulates with the
scaphoid fossa of the distal radius, the lunate, the capi- Technique
tate, the trapezium, and the trapezoid. Patient Position
• The scaphoid distal pole transfers load from the thumb • A supine position with the elbow flexed, in a neutral
and radial side of the hand to the radioscaphoid and positioning, and the wrist in pronation.
scaphocapitate joints • The elbow is supported with the placement of towels.
• The midcarpal joint is stabilized by the scaphocapitate,
triquetrocapitatoscaphoid ligaments volarly, and the dor- Clinician position
sal intercarpal ligament dorsally.56 • The clinician stands next to the affected wrist.
Common Pathology Fluoroscope position
• Th
 e wrist is a relatively stable complex. Fracture or dislo- • P
 A position centered on the scaphoid trapezium joint
cation can lead to midcarpal joint instability. (Figs. 18.20 and 18.21).
 CHAPTER 18 Wrist Injection Techniques 309

Pertinent Anatomy
• Th
 e radiocarpal joint can be palpated just distal to
the distal radius in a depression near the scapholunate
articulation.
• The SLLT complex is composed of volar, interosseous,
and dorsal segments. Injury to the dorsal ligament can
lead to instability of the joint.60
• Complete disruption of these ligaments will cause the
scaphoid to flex relative to the lunate, known as a DISI
(dorsal intercalated segment instability) deformity.56
• The lunotriquetral joint is stabilized by volar, proximal,
and dorsal ligaments.60
• Complete injury to the lunotriquetral, ulnotriquetral,
and anterior midpalmar ligaments allows the lunate to
flex relative to the capitate, known as VISI (volar interca-
lated segment instability) deformity.56
• Radiographic clenched fist views demonstrating more
than 2 mm of separation between the scaphoid and
lunate signify the potential of a severe ligamentous
injury.61
• Prolonged instability of the joint(s) can lead to the devel-
opment of arthritis or scapholunate advanced collapse
(SLAC) wrist deformity.62

Common Pathology
• Fig. 18.21 Distal carpal setup, PA view.
• I ntercarpal ligament injury
Needle position • Wrist arthritis
• P alpate for the distal border of the scaphoid bone dorsal
aspect, and mark the area with a needle tip. Equipment
• Slowly insert the needle into the joint. • C -arm fluoroscopy
• 27 to 22 gauge, 1 and 2 inch needle
Target
• D orsal to the scaphoid trapezium joint space (see Fig. Common Injectates
18.19A). • L ocal anesthetics for diagnostics, intra-articular cortico-
• Alternatively, the dorsal joint recess between the trique- steroids only
trum and hamate allows for flow across the midcarpal • Prolotherapy
joint space (see Fig. 18.19B). • Orthobiologics (PRP, bone marrow concentrate, etc.)
• If there is resistance, reposition the needle by advancing
or removing it slightly. Confirm intra-articular place- Injectate Volume
ment with the injection of a small amount of contrast. • 0.5 to 1.5 cc
PEARLS AND PITFALLS
Technique
• M
 onitoring contrast flow while injecting is important to Patient Position
assess for aberrant flow. Normally, contrast will flow into • Th
 e patient should be in supine position with the
the carpometacarpal recesses of the index through the little
fingers.54,57,58 Contrast will also normally flow to the level of
elbow flexed, in a neutral positioning, and the wrist in
the proximal scapholunate and lunotriquetral joints.59 pronation.
• The elbow is supported with the placement of towels.
  

Proximal Carpal Rows Fluoroscopic-Guided Clinician Position

Injection • The clinician stands next to the affected wrist.
KEY POINTS
Fluoroscope Position
• Ionizing radiation necessitates shielded protection of • P
 A position centered on the scapholunate or triquetroha-
the patient and staff. mate or radiocarpal joint depending on the ligament or
• The radiocarpal joint is the articulation between the proximal
carpal row and the distal forearm construct: radius, ulnar,
joint target, respectively (Figs. 18.22 and 18.23).
and the intervening triangular fibrocartilage complex.
• This joint normally does not communicate with the Needle Position
distal radioulnar or midcarpal joints.58 • P
 alpate for the dorsal aspect of the scapholunate or tri-
   quetrohamate space, and mark the area with a needle tip.
310 SEC T I O N I I I Atlas

• Fig. 18.22 Proximal carpal setup, lateral view. • Fig. 18.24Fluoroscopic guided injections of the dorsal scapholunate
(A) and lunotriquetral ligaments (B).

Target
• D orsal scapholunate or triquetrohamate joint space.
• If there is resistance, reposition the needle by advancing
or removing it slightly. Confirm with an injection of a
small amount of contrast.

PEARLS AND PITFALLS

• T
 here is a good flow of contrast or medication to the
proximal carpal bones despite the site of entry.
  

References
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3. Gaston RG, Loeffler BJ. Sports-specific injuries of the hand and
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4. Geissler WB, Burkett JL. Ligamentous sports injuries of the hand
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• Dorsal scapholunate and LTLs can be injected by the first extensor compartment: a systematic review and comparison
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sound pictorial essay. Skeletal Radiol. 2014;43(6):745–760. novitis. J Ultrasound. 2012;15(1):20–28.
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1990;15(1):110–119. 44. Siegel DB, Kuzma G, Eakins D. Anatomic investigation of the
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Radiol Anat. 2017;39(4):451–454. Korompilias AV. Anatomic variations of the median nerve in car-
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vain disease: US identification of anatomic variations in the first 49. Duggal A, Anastakis D, Salonen D, Becker E. Compression of
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50. E hrlich W, Lee Dellon A, Mackinnon SE. Cheiralgia pares- 57. M anaster BJ. Digital wrist arthrography: precision in deter-
thetica (entrapment of the radial sensory nerve). J Hand Surg. mining the site of radiocarpal-midcarpal communication. Am J
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51. Thomas BP, Sreekanth R. Distal radioulnar joint injuries. Indian 58. Resnick D, Andre M, Kerr R, Pineda C, Guerra Jr J, Atkinson
J Orthop. 2012;46(5):494. D. Digital arthrography of the wrist: a radiographic-pathologic
52. Haugstvedt J, Langer M, Berger R. Distal radioulnar joint: func- investigation. Am J Roentgenol. 1984;142(6):1187–1190.
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2017;42(4):338–345. North Am. 1998;36(4):651–672.
53. Wu W-T, Chang K-V, Mezian K, et al. Ulnar wrist pain revis- 60. Bateni CP, Bartolotta RJ, Richardson ML, Mulcahy H, Allan
ited: ultrasound diagnosis and guided injection for triangular CH. Imaging key wrist ligaments: what the surgeon needs the
fibrocartilage complex injuries. J Clin Med. 2019;8(10):1540. radiologist to know. Am J Roentgenol. 2013;200(5):1089–1095.
54. Gilula LA, Hardy DC, Totty WG. Distal radioulnar joint 61. Jones W. Beware the sprained wrist. The incidence and diag-
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19
Hand Injection Techniques
YODIT TEFERA, KEVIN CONLEY, MICHAEL ERICKSON,
ADAM M. POURCHO, PHILLIP HENNING, AND OLUSEUN
OLUFADE

Ultrasound Guided Injection Techniques Equipment

Metacarpophalangeal, Interphalangeal, • H igh frequency linear array transducer
• Smaller footprint or hockey stick probes maybe easier
Proximal Interphalangeal, Distal to use over regions with noncompliant tissue.
Interphalangeal Joint Injections Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids intra-
KEY POINTS articular (IA) only
• Prolotherapy
• O ut-of-plane relative to transducer or short axis to the • Orthobiologics (PRP, bone marrow concentrate, etc.)
joint approaches maybe easier for these superficial joints • Corticosteroid should not be injected directly into
• A gel stand-off may improve joint and needle visualization capsular ligaments
• Understanding and identification of at-risk anatomy is
required prior to injection Injectate Volume
• A hockey stick transducer may improve ability to do • 0.5 to 1.5 mL
injections. Authors Preferred Injection Technique
• Joints often hold relatively small volumes of injectate;
therefore, practitioner will often have to limit anesthetic Patient Position
in favor of therapeutic injectate when performing the • S
 eated or supine on table with forearm pronated (Fig.
procedure. 19.3A)
• Use of particulate corticosteroids increases the risk of
Clinical Position
skin depigmentation, especially in the case of superficial
• Standing or seated ipsilateral side of the patient
injections1
Transducer Position
Pertinent Anatomy
• T he transducer is placed in the anatomic sagittal plane
• T he metacarpophalangeal (MCP), interphalangeal
with the desired target joint centered on the transducer,
(IP), proximal interphalangeal (PIP), and distal
for out-of-plane approach (see Fig. 19.3A).
interphalangeal (DIP) joints are small synovial joints that
• Alternatively, this can be done in the anatomic axial
allow for flexion and extension of the fingers and thumb.
plane for the in-plane approach.
• Neurovascular structures run along the relative volar
side of each digit (Figs. 19.1 and 19.2B). Needle Position
• Dorsal recess of the joints extends proximal to each • N
 eedle is introduced in short axis from an ulnar to radial
joint allowing for relatively easier access than volar to or radial to ulnar direction into the joint (see Fig. 19.3A and
joint (see Fig. 19.2C and D). B).
Common Pathology Targets
• O steoarthritis commonly effects the joints of the hand.1 • T he desired joint
• The MCP and IP joints are commonly affected by • Watch distention of the capsule or slight separation of
disorders of the hand, including dislocations, sprains, the bones with ultrasound during the injection.
fractures, and both osteoarthritis and inflammatory • Can also inject the overlying capsular ligaments (with
arthropathies.1 prolotherapy or orthobiologics) for each joint in the
• The PIP joint is a commonly injured finger joint, often same position with the needle in short axis or in long
resulting in fractures, collateral ligament injuries, axis (Fig. 19.4A and B)
palmar plate injuries, and subsequent post-traumatic
osteoarthritis.1   
• Inflammatory arthritis, such as rheumatoid arthritis, can
have a predilection for the joints of the hand1
• Common findings of joint space narrowing, osteophyte
formation, effusion, joint subluxation or deformity, and
erosive changes, in the case of inflammatory arthritis
can occur.1

313
 A1 Pulley Extensor
Hood

Dorsal
Digital
Pulley
Expansion
System

• Fig. 19.1 Hand Pulley System Anatomy. Note enlarged view of the A1 pully.

FS -1
x cm/
FP

B RAD
MC

PP
MC
D DIST

• Fig. 19.2 Transducer placement and sonographic appearance of volar and dorsal targets for hand injections. (A) Axial position of the transducer
(black rectangle) overlying the volar proximal hand with corresponding sonographic (B) sonographic appearance of the anatomy at this level. Note
the neurovascular structures (arrowheads) adjacent to the flexor digitorum superficialis (FS) and profundus (FP). (C and D) Sagittal position of the
transducer (black rectangle) overlying the dorsal metacarpal phalangeal joint with correlative sonographic image at this level. Note proximal extension
of the dorsal recess (open arrows). MC, Metacarpal; PP, proximal phalanx.
 CHAPTER 19 Hand Injection Techniques 315

PEARLS AND PITFALLS

• A dorsal approach to the joint effectively avoids the
neurovascular bundles, which are volar.
• Needle depth can also be confirmed by turning the
transducer 90 degrees to show an in-plane view of the
needle.
• When injecting the ulnar collateral ligament of the first
MCP joint, it may be helpful to have the patient hold
onto a rolled- up towel or other cylindrical object to help
position and stabilize the joint during the injection (see
A Fig. 19.4A).
  

x
Carpometacarpal and
MC
PP Scaphotrapeziotrapezoid Joints and
Carpometacarpal Capsular Ligaments
B DIST
KEY POINTS
• Fig. 19.3 Metacarpal or Interphalangeal Joint Injections. (A)
Transducer (black rectangle) placement along the dorsal recess of • W
 hen using orthobiologics it is recommended to
the target joint. Black arrow, trajectory of the needle. (B) Sonographic address the joint instability/mechanical symptoms in
image of the needle tip (arrowhead) within the dorsal joint recess. Note addition to the condition being treated.
reverberation artifact deep to the needle. MC, Metacarpal, PP, proximal
Pertinent Anatomy
phalanx.
• T he carpometacarpal (CMC) joint is a saddle shaped
synovial joint between the trapezium and first
metacarpal.
• The scaphotrapeziotrapezoid (STT) joint is a dome-
shaped articulation composed of scaphotrapezial and/
or scaphotrapezoidal articulation2
• The terminal SR2 and SR3 branches of the superficial
radial nerve border the volar and dorsal sides of the
STT and CMC joints.2
• Also just proximal to the STT and CMC joints the
radial artery branches into superficial and deep palmar
arteries (Fig. 19.5A and B).3
• The flexor carpi radialis (FCR) tendon is just palmar and
ulnar to the CMC and STT joints.
• The palmar cutaneous nerve usual resides between the
FCR tendon and the palmaris on the palmar side of the
wrist.4
Common Pathology
• O bserved in up to 15% of radiographic studies and
83.3% of cadaveric specimens, degenerative arthritis
A
of the CMC and STT joint are the first and second most
common cause of degenerative changes in the wrist.5
• Injuries to the scaphotrapezial ligament, the major
anatomic stabilizer of the STT joint, can lead to post-
traumatic arthritic changes.3
• Other theories for injury to the STT joint include
disruption of the scapholunate interosseous ligament
and cartilage erosion in the STT joint.5
• Common pathologic US findings include joint effusions,
synovitis, loss of articular space, cortical irregularities,
MC and osteophyte formation.6
MP
• STT and CMC arthropathy have been associated with
tendinopathy of the FCR tendon which lies anatomically
just palmar and ulnar to the STT joint.7-9
B PROX
Equipment
• Fig. 19.4 Metacarpal Phalangeal Joint and Ulnar Capsular • Injections can be performed using a high-frequency
Ligament Injection. (A) Transducer placement (black rectangle) for in linear array transducer. If available, a hockey stick or
plane technique with needle traversing from distal to proximal direction shorter foot-print transducer may also be helpful.
(black arrow). (B) Sonographic image of needle (arrowheads) injecting • 30 to 25-gauge 1 to 1.5 inch needle
along the ulnar capsular ligament, note joint distension (asterisk).
Continued
316 SEC T I O N I I I Atlas

KEY POINTS—cont’d PEARLS AND PITFALLS

Common Injectates • V olar and dorsal approaches can be used, these

• L ocal anesthetics for diagnostics, corticosteroids IA authors suggest a dorsal approach with needle as it
only tends to be less painful.
• Prolotherapy • In patients with severe osteoarthritis it may help to
• Orthobiologics (PRP, bone marrow concentrate, etc.) extend the wrist and ulnar or radially deviate the wrist
• Corticosteroid should not be injected directly into to open the joint. Also, it can help to pull the thumb to
capsular ligaments extend the joint opening.
• Toggling the transducer palmar or dorsal can be used
Injectate Volume of osteophytic formation blocks the desired path to the
• 1 to 2 mL joint.
• The terminal branches of the superficial radial nerve
Technique: CMC and STT Joints Intra-Articular
as well as the deep and superficial branches of the
Patient Position radial artery, should be identified and avoided during
• S upine (Fig. 19.5A) procedures involving the STT and CMC joints.
• For both joints, wrist supinated supported by towels • Color Doppler can be used to help identify the vascular
• For dorsal approach to the CMC joint, the wrist can be structures.
in neutral position.
Technique: CMC Capsule Ligaments: Palmer, Deep
Clinician Position Palmer, and Dorsal
• Standing or seated ipsilateral side of the patient
Patient Position
Transducer Position
• S upine
• Identify CMC joint in the transverse plane palmer
• Wrist supinated or neutral position supported by towels
aspect
for palmer ligaments (Fig. 19.6A)
• Transducer angled near parallel with the metacarpal
bone Clinician position
• Scaphotrapeziotrapezoid joint set up similar except the • Standing or seated ipsilateral side of the patient
transducer is positioned more proximal
Transducer position
Needle Position • P almer ligaments: place transducer over palmer CMC joint
• Short-axis injection in the transverse plane. Identify more radial (superficial)
and deep more medial aspect (see Fig. 19.6A).
Targets
• Transducer angled close to parallel with the metacarpal
• T he desired joint (see Fig. 19.5A, C and D)
bone
• Watch distention of the capsule or slight separation of
• Dorsal ligaments: identify radial artery to avoid then
the bones with ultrasound during the injection.
visualize the joint in the transverse plane over the dorsal
• Can also inject the overlying palmer capsular ligaments
aspect (see Fig. 19.6B)
for both joints in the same position
  

MC X

R
T
B S DIST

MC

R T

C S
DIST

T MC

A D DIST

• Fig. 19.5 Carpometacarpal (CMC) and/or Scaphotrapziotrapezoidal (STT) Joint Injection. (A) Visualization of the CMC or STT joint can be optimized
by placement of the transducer (black rectangle) sagittal to the hand along the dorsal surface. (B) Sonographic image showing the location of the radial
artery (open arrow) relative to the STT and CMC joints. (C and D) Sonographic images of the needle (arrowhead) within the STT and CMC joints respec-
tively. MC, metacarpal; R, radius; S, scaphoid; T, trapezium.
 CHAPTER 19 Hand Injection Techniques 317

PEARLS AND PITFALLS

• D eeper capsule is more difficult to inject in long axis
due to the anatomy
• Only inject 0.5 to 1 mL per ligament.
  

A1 Pulley Injection
KEY POINTS
• W
 hen injecting steroids it has been found to be more
clinically effective if you remain superficial to the pulley.10
Pertinent Anatomy
• F lexor tendon sheath contains the tendons of both the
flexor digitorum superficialis (FDS) and flexor digitorum
profundus (FDP).
• There are five fibro-osseous bands called annular
pulleys (A1-A5), that keep the FDS and FDP tendons
from bowstringing with finger flexion (Fig, 19.7).11
• The A-1 pulley is located just proximal to the MCP
A joint, superficial to the palmar plate, and can located by
surface anatomy using the distal palmar crease.11
• The neurovascular bundles, containing the digital
nerves, are located just radial and ulnar to the pulley on
the palmar side (see Fig. 19.2B).11
Common Pathology
• S tenosing tenosynovitis involves thickening/ stenosis
of the A1 pulley, with or without a Nodus nodule (Fig.
19.8A and B).12,13
• In some cases, there is tenosynovitis involving the
tendon and tendon sheath, with low flow color Doppler
T on ultrasound.12,13
• Common risk factors for development of stenosing
tenosynovitis include post-partum, diabetes, prior
transverse carpal ligament release, rheumatoid arthritis
S and gout.12-14
• Patients will often complain of “triggering” and catching
of their fingers.12,13
B PROX
Equipment
• Fig. 19.6 Carpometacarpal Capsular Ligament Injections. (A) • 2 5 to 30-gauge 1 to 2 inch needle
Transducer (black rectangle) and needle placement (black arrow) • Linear array transducer, hockey stick or short footprint
targeting the palmer ligaments. (B) Needle placement targeting the transducer maybe preferable if available
dorsal ligaments. Arrowhead, Needle location; asterisk, region of the
Common Injectates
ligaments.
• C orticosteroids with local anesthetics
• Orthobiologics (platelet lysate, etc.)
Injectate Volume
• 1 to 2 mL
PEARLS AND PITFALLS—cont’d
Technique
Needle Position
• S hort-axis injection for the superficial and deeper Patient Position
ligaments • S
 upine with forearm supinated and wrist placed in mild
• Long axis distal to proximal for the superficial ligaments. extension over towel (Fig. 19.9A)

Targets Clinician position

• C apsular ligament just overlying the joint distal and • Clinician should be lateral to the affected hand
proximal. Transducer position
• With short-axis injections redirect to inject the ligaments • T he pulley is first identified in its short axis by sliding the
direct over the joint and distal and proximal. transducer down the flexor tendons until the relative
   anechoic shadow of the pulley is visualized.
• Once the pulley is identified, the transducer can be
turned 90 degrees relative to the transducer to create
a short-axis view of the A1 pulley and long-axis view of
the flexor tendons beneath (see Fig. 19.9B).

Continued
318 SEC T I O N I I I Atlas

KEY POINTS—cont’d

5
• D
 ynamic flexion and extension of the finger can be
used prior to injection to identify the pulley superficial to
4 the flexor tendons.
3
2
1 Needle Position
• N
 eedle with slight bend in direction of the bevel, is
introduced from either distal-to-proximal or proximal-to-
distal direction toward the A1 pulley.
Target
• T arget the needle between the pulley and the FDS
• Fig. 19.7 Cadaveric Dissection of the Pulley System of the tendon (see Fig. 19.9A and B).
Finger. 1, A1, 2, A2, 3, A3, 4, A4, 5, A5. Arrowheads note the location • The transducer can be turned 90 degrees before
of the neurovascular structures relative to the pulley system. injection to confirm centralized placement of the needle
relative to the pulley (se Fig. 19.9B and C).
  

PEARLS AND PITFALLS

• T he digital nerves can be visualized both ulnar and
radial to the pulley in the anatomic axial view and
should be avoided during the injection.
• Dynamic motion, with flexion and extension of the finger,
prior to injection can help with the identification of the pulley.
  

A Digital Nerve Block

KEY POINTS
FS
X3 • G
 oal to anesthetize the digit prior to procedures such
FP
as fracture/joint reduction or laceration repair.
Pertinent Anatomy
MC • A
 t the distal palm, the proper digital nerves are found
PP on the ulnar and radial volar aspect of each digit (Fig.
B PROX 19.10A and B).

• Fig. 19.8 Sonographic Evaluation of the A1 Pulley. (A) Transducer Common Pathology
(black rectangle) placement sagittal to the involved digit. (B) Sonographic • T
 he nerve is subject to laceration from penetrating injury
image of the A1 pulley (white oval). Note the thickening in the tendon or compression from digital swelling of a finger with a
(arrowhead) distal to the pulley. FP, Flexor digitorum profundus; FS, flexor ligature or ring in place.15
digitorum superficialis; MC, metacarpal; PP, proximal phalanx.

FS

FP

PP MC
B PROX

x
FS
FP

A C MC RAD

• Fig. 19.9 Trigger Finger Injection. (A) Transducer placement for in plane (solid black rectangle) and out of plane (dashed black rectangle) tech-
niques, trajectory of needle (white arrow). (B) Needle (arrowhead) placement in plane with transducer adjacent to the A1 pulley. (C) Needle (arrow-
head) placed out of plane to transducer superficial to the tendons adjacent to the pulley. Open arrows, anisotropy of the sides of the A1 pulley, curved
arrows, neurovascular bundles, FP, flexor digitorum profundus; FS, flexor digitorum superficialis; MC, metacarpal; PP, proximal phalanx,.
 CHAPTER 19 Hand Injection Techniques 319

KEY POINTS—cont’d PEARLS AND PITFALLS

Equipment • It is recommended that epinephrine is avoided during
• 3 0 to 27-gauge needle, 1 to 1.5 inch these blocks to avoid end artery vasoconstriction to the
• High frequency linear array ultrasound transducer finger.
Common Injectates   
• Local anesthetics
Injectate Volume
• 0.5 to 1.5 mL
Technique: Palmar Proper Digital Nerve Block Fluoroscopy-Guided Injection Techniques
Patient position Thumb Carpometacarpal Joint Fluoroscopic
• Supine with forearm supinated
Guided Injection
Clinician position
• Standing or seated ipsilateral side of the patient
Transducer position
• T he transducer is placed in the anatomic axial plane, KEY POINTS
creating a short-axis view of the digital nerve (see Fig.
19.10A). • Ionizing radiation necessitates shielded protection of
• Color Doppler can be used to identify the neurovascular the patient and staff
bundle
Pertinent Anatomy
Needle Position • T
 his joint articulates the trapezium and the 1st
• T
 he needle is introduced via an in-plane approach from metacarpal bone
both an ulnar-to-radial and radial-to-ulnar direction (see
Fig. 19.10A and B). Common Pathology
• CMC synovitis/osteoarthritis
Targets
• T
 arget the nerves and create a halo of anesthetic is Equipment
created around each digital nerve to ensure complete • C -arm fluoroscopy
block. • 27 to 25-gauge 1 to 2 inch needle

   Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy
• Orthobiologics (PRP, bone marrow concentrate, etc.)
Injectate Volume
• 0.5 to 1.5 mL
Technique
Patient position
• P atient should be in supine position with the wrist
held in neural position between supination and
pronation
• The wrist is supported with towels
Clinician position
• Clinician should be seated next to the affected hand
A Fluoroscope position
• PA position centered on the CMC joint (Fig. 19.11A and B)
Needle position
• P lace needle or marker over the joint and confirm with
fluoroscopy
FS • Position the needle perpendicular to the skin with the
FP x 1 needle tip directed ulnarly toward the CMC joint
Target
• Intra-articular joint space. If there is resistance,
MC ULN reposition the needle by advancing or removing
B slightly
• Fig. 19.10 Digital Nerve Block. (A) Transducer (black rectangle) • Confirm intra-articular placement with a small amount
placement axial to proximal hand overlying the neurovascular struc- of contrast. The joint is small and want to make sure
tures, ulnar to radial needle course (white arrow), radial to ulnar needle contrast does not limit the ability to place the injectate,
course (black arrow). (B) Needle (arrowhead) placement adjacent to especially if using orthobiologics.
the common digital nerve (white oval). FP, Flexor digitorum profundus;   
FS, flexor digitorum superficialis; MC, metacarpal.
320 SEC T I O N I I I Atlas

B C
• Fig. 19.11
Fluoroscopic Guided Carpometacarpal Joint Injections. (A) Fluoroscopic image with needle in the CMC joint. (B) Fluoroscopic image
showing distension of the joint. (C) Needle.

PEARLS AND PITFALLS

Common Pathology
• T raction to the thumb can help make the joint space • M CP synovitis/osteoarthritis
more conspicuous to accommodate the injectate. • PIP joint osteoarthritis, gout, rheumatoid arthritis
• The thumb CMC joint can be approached on the • DIP joint osteoarthritis and gout
extensor side taking care to avoid the radial artery and Equipment
extensor pollicis tendons. • C arm fluoroscopic device
   • 30 to 25-gauge 1 to 2-inch needle
Common Injectates
Metacarpal, Proximal and Distal • L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy
Interphalangeal Fluoroscopic Guided Joint • Orthobiologics (PRP, bone marrow concentrate, etc.)
Injections
Injectate Volume
• 0.5 to 1.5 mL
KEY POINTS
Technique
• Ionizing radiation necessitates shielded protection of
the patient and staff Patient position
• P atient should be in supine position with the wrist held
Pertinent Anatomy in pronation and patient making a loose fist
• T he metacarpophalangeal joints are between the • The hand is supported with placement of towels
metacarpal bones and the proximal phalanges of the
fingers. Clinician position
• IP joint lines are best palpated with the digit in slight • Clinician should be seated next to the affected hand
flexion, just lateral to the midline extensor tendon.
• Passive flexion and extension of the joint during
palpation may facilitate identification.
 CHAPTER 19 Hand Injection Techniques 321

KEY POINTS—cont’d Target

• P oint of entry is over the MCP joint, just radial, or ulnar
Fluoroscope position to the extensor tendon
• PA position centered on the target joint • If there is resistance, reposition the needle by advancing
Needle position or removing slightly.
• P osition the needle perpendicular to the skin with the • Confirm intra-articular placement with a small amount
needle tip directed towards the desired joint (Fig. 19.12) of contrast. The joint is small and want to make sure
• Identify point of entry on the joint line on either contrast does not limit the ability to place the injectate,
side of the dorsal extensor tendon midline and the especially if using orthobiologics
neurovascular bundles   
• Direct the needle towards the middle of the IP joint (see
Fig. 19.12C)
• DIP joints may require a more vertical needle approach
(Fig. 19.13)
• Slowly insert needle into the joint

A B C
• Fig. 19.12 Fluoroscopic Guided Metacarpophalangeal (MCP) and Interphalangeal Joint Injections. (A) Note needle traversing from radial to ulnar
direction along the dorsal region of the joint space of the MCP joint. (B) Distal interphalangeal joint injection shown here, the proximal interphalangeal
joint (C) would be approached in a similar fashion.
322 SEC T I O N I I I Atlas

3. Coari AIG. Usefulness of high resolution US in the evaluation of

effusion in osteoarthritic first carpometacarpal joint. Scandina-
vian J Rheumatol. 2000;29(3):170–173.
4. DaSilva MF, Moore DC, Weiss AP, Akelman E, Sikirica M.
Anatomy of the palmar cutaneous branch of the median nerve:
clinical significance. J Hand Surg Am. 1996;21(4):639–643.
5. Hazani R, Engineer NJ, Cooney D, Wilhelmi BJ. Anatomic
landmarks for the first dorsal compartment. Eplasty. 2008;8:
e53–e53.
6. Bianchi S, Martinoli C. Ultrasound Musculoskeletal System.
Springer; 2007.
7. Chiavaras MM, Jacobson JA, Yablon CM, Brigido MK, Girish
G. Pitfalls in wrist and hand ultrasound. Am J Roentgenol.
2014;203(3):531–540.
8. Luong DH, Smith J, Bianchi S. Flexor carpi radialis tendon ultra-
sound pictorial essay. Skeletal Radiol. 2014;43(6):745–760.
9. Smith J, Kakar S. Combined flexor carpi radialis tear and flexor
carpi radialis brevis tendinopathy identified by ultrasound: a case
report. PM&R. 2014;6(10):956–959.
10. Taras JS, Raphael JS, Pan WT, Movagharnia F, Sotereanos DG.
Corticosteroid injections for trigger digits: is intrasheath injec-
tion necessary? J Hand Surg Am. 1998;23(4):717–722.
11. Fiorini HJ, Santos JBG, Hirakawa CK, Sato ES, Faloppa F,
Albertoni WM. Anatomical study of the A1 pulley: length and
location by means of cutaneous landmarks on the palmar surface.
J Hand Surg. 2011;36(3):464–468.
12. Fiorini HJ, Santos JB, Hirakawa CK, Sato ES, Faloppa F, Alber-
• Fig. 19.13Fluoroscopic image of distal interphalangeal joint injection. toni WM. Anatomical study of the A1 pulley: length and loca-
Note the needle traversing from radial to ulnar direction into the dorsal
tion by means of cutaneous landmarks on the palmar surface. J
recess of the joint.
Hand Surg Am. 2011;36(3):464–468.
13. Vuillemin V, Guerini H, Bard H, Morvan G. Stenosing tenosy-
PEARLS AND PITFALLS novitis. J Ultrasound. 2012;15(1):20–28.
14. Park I-J, Lee Y-M, Kim H-M, et al. Multiple etiologies of trigger
• A pproach the MCP joint dorsally but avoid placing the
needle through the extensor tendon or extensor hood. wrist. J Plastic Reconstruct Aesthetic Surg. 2016;69(3):335–340.
• The clinician’s non-injecting hand can be used to apply 15. Kay S, Werntz J, Wolff TW. Ring avulsion injuries: classification
traction to distract the joint and prognosis. J Hand Sur. 1989;14(2):204–213.
• Slight joint flexion can also facilitate opening of the joint
space
  

References
1. Leung GJ, Rainsford KD, Kean WF. Osteoarthritis of the hand
I: aetiology and pathogenesis, risk factors, investigation and diag-
nosis. J Pharmacy Pharmacol. 2014;66(3):339–346.
2. Swigart CR. Arthritis of the base of the thumb. Cur Rev Musculo-
skeletal Med. 2008;1(2):142–146.
20
Hip Injection Techniques
KEN MAUTNER, JOHN PITTS, OLUSEUN OLUFADE,
HEATHER LYNN SAFFEL, AND ADAM STREET

Ultrasound Guided • Th
 e lateral and medial circumflex arteries surround and
supply the femoral head. They arise from the deep femo-
Joint ral artery, a branch of the femoral artery. Hip joint inner-
Femoroacetabular vation comes from branches of the femoral, obturator,
and sciatic nerves (Figs. 20.2 and 20.3).

KEY POINTS Common Pathology

• H
 ip osteoarthritis, labral degeneration, labral tears,
• T
 he accuracy of ultrasound-guided intra-articular (IA) adhesive capsulitis, and can be a source for inflammatory
hip injections is 97%–100%1–3 in the literature.
arthropathies.
  
Equipment
• N eedle size: 22- to 25-gauge, 2.5- to 5.0-inch spinal needle
Pertinent Anatomy • Low-frequency curvilinear ultrasound transducer
• Th
 e hip joint is a ball and socket synovial joint formed by
the femoral head and acetabulum. Common Injectates
• It is surrounded by a thick articulate capsule that is • L ocal anesthetics for diagnostics, corticosteroids
made up of the iliofemoral, ischiofemoral (Y ligament of • Prolotherapy, hyaluronic acid, orthobiologics (platelet-
Bigelow), and pubofemoral ligaments that extend over rich plasma [PRP], bone marrow concentrate, micron-
the femoral head and neck. ized adipose tissue, etc.)
• The capsule extends from the acetabulum to the intertro- • For capsular distention. local anesthetic and normal
chanteric line. It folds back from this point on itself and saline +/− corticosteroid, and/or orthobiologics, such as
inserts on the femoral head-neck junction. Thus, from platelet-poor plasma, platelet lysate, etc.
the acetabulum to the femoral head-neck junction, the
capsule has one layer, and from the head-neck junction Injectate Volume
to the intertrochanteric line, the capsule is composed of • F or weight-bearing intra-articular (IA) injection: 2 to 5 mL.
two layers. • For capsular distention 10 to 20 mL. Stop when getting
• The synovial folds are referred to as the retinaculum of back flow into the syringe to avoid capsular rupture.
Weitbrecht (Fig. 20.1).4 Most hip capsules max out close to 16 mL, but some
• The acetabulum is surrounded circumferentially by the may tolerate close to 20 mL.
labrum, which is composed of fibrocartilage. The hyaline
cartilage on the femoral head articulates with the labrum. Technique: Anterior Approach
The labrum will appear hyperechoic and triangular on Patient Position
ultrasound. • S upine with a pillow under the knees for comfort and to
• The femoral neurovascular bundle descends medially relax the superficial structures around the joint
from the pelvis into the leg. It exits the pelvis through Clinician Position
the femoral triangle, which is lined laterally by the sarto- • Standing or sitting on affected side of patient
rius, medially by the adductor longus, and superiorly by Transducer Position
the inguinal ligament. The iliopsoas separates the bundle • Anteriorly in the oblique sagittal plane, parallel with the
from the hip joint. femoral neck (Fig. 20.4)

323
324 SEC T I O N I I I Atlas

Centeno/Schultz Hip Cadaver Dissection • A lternatively, anteriorly, slightly oblique with transducer
in plane to the femoral neck (Fig 20.5)
Needle Position
• In plane
• Caudolateral to cephalomedial
Target
• Anterior synovial recess, located at or just proximal to the
junction of the femoral head and neck (Fig 20.6).
• For IA biologics, optimal needle placement may be closer
to the weight-bearing portion of the joint at the junction
Retinaculum of
of the femoral head and the acetabulum (Fig. 20.7B).
Weitbrecht • It is helpful to tilt the transducer so that the needle is
parallel to the probe. Placing a gel standoff can eliminate
ultrasound dead space (see Fig. 20.7A). A slight bend
• Fig. 20.1 Retinaculum of Weitbrecht Dissection. (Courtesy to the needle tip can help for redirecting, with the goal
Christopher Centeno and John Schultz.)

Ilium

Lateral Femoral
Cutaneous Nerve

Femoral Artery Sacral Foramen

Pubic Symphysis Femur

Head

Obturator Nerve
Neck

Greater Trochanter
Circumflex Arteries
Lesser Trochanter

Ischium

• Fig. 20.2 Posterior Pelvic Large Neurovascular and Bony Anatomy.

Dorsal
Sacroiliac Ligament

Labrum Sacrospinous
Ligament
Iliofemoral
Capsule Ligament

Ischiofemoral
Ligament

Transverse
Ligamentum Acetabular Sacrotuberous Sacrococcygeal
Teres Ligament Ligament Ligament

• Fig. 20.3 Posterior View of Sacropelvic Ligaments.

 CHAPTER 20 Hip Injection Techniques 325

FH
FN

• Fig. 20.6 Anterior Sagittal Oblique Approach. Ultrasound image

with target being the anterior recess of the joint capsule at or just proxi-
mal to the femoral head-neck junction. Arrow indicates desired path of
needle into hip joint and head-neck junction. FH, Femoral head; FN,
femoral neck.

PEARLS AND PITFALLS

• U se lower-frequency probe for better visualization.
• Identify the location of the lateral circumflex femoral
artery, as it will often be in the projected trajectory of the
needle and the femoral neurovascular bundle medially.
• Needle visualization may be difficult in deeper
structures, especially if significant subcutaneous tissue
• Fig. 20.4 Anterior Sagittal Oblique Approach. Transducer in posi- is present, reducing the conspicuity of the target.
tion for in-plane approach to hip joint. • For injecting a collapsed joint recess, it is often helpful
to first inject local anesthetic to ensure accurate IA
needle placement before final injection.
  

Adhesive Capsulitis of the Hip

Adhesive capsulitis can occur in the hip similar to the shoulder
and can be associated with arthritis. It can be treated first
conservatively with physical therapy. Other interventions
include steroid injection, capsular dilation, manipulation under
anesthesia, and open or arthroscopic synovectomy, lysis of
adhesions, and capsular release.5–7
Capsular distention can help for adhesive capsulitis. There
are small reports in the literature.8
• Pitts-Williams A through D criteria for capsular
distention:
A. Utilize color flow to ensure that flow is confined to
the capsule and not flowing into the surrounding soft
tissue structures.
B. Inject 5 mL of 0.25% ropivacaine initially, followed by
an additional 5–15 mL of injectate connected to the
syringe with a T-connector.
C. Maximal distention volume is reached when there
is significant anterior thigh pressure reported by the
patient or observed backflow from the T-connector
once the syringe is removed. We recommend
checking for backflow while injecting in 2–3 mL
• Fig. 20.5 Anterior Transverse Approach. Transducer position for
increments.
alternate approach to hip joint.
D. Hip range-of-motion (ROM) techniques (i.e.,
proprioceptive neuromuscular facilitation, muscle
energy, muscle activation technique [MAT], etc.)
should be performed within 15 min of the distention
being to keep the needle closer to the femoral neck and while the joint is anesthetized. For optimal results,
avoid potential harm to the acetabular labrum. record a side-to-side comparison prior to the
• Having an assistant apply distal traction on the leg distention. Patients should be given a home
can help open the joint more to allow for easier flow stretching program to implement three times daily
of injectate and open more space to avoid labral until they can start physical therapy.
injection.   
326 SEC T I O N I I I Atlas

PEARLS AND PITFALLS

• P
 robe positioning and needle must be positioned to
clear the greater trochanter on the initial approach.
Often, the angle trajectory can be steep, making needle
visualization challenging.
  

Technique: Posterior Approach

Patient Position
• P rone
• Will likely need the hip internal rotated to move the
greater trochanter out of the needle trajectory. To achieve
this, bend the patient’s leg at the knee and rotate from
the lower leg outward (Fig. 20.8A)
• Alternatively, patient can be in the lateral decubitus posi-
A tion (see Fig. 20.8B)
Clinician Position
• Standing ipsilateral to the symptomatic hip
Transducer Position
• Posteriorly in the oblique sagittal plane, parallel with the
femoral neck
Needle Position
• In plane inferiolateral to superiomedial approach
Target
AC
• Posterior synovial recess, located at or just proximal
FH to the junction of the femoral head and neck (see Fig.
20.8C)

PEARLS AND PITFALLS

• T here is more acetabular coverage posterior, so this
approach is more difficult to obtain good weight-
B bearing flow. As such, this is not the preferred approach
for IA biologics.
• Fig. 20.7 (A) Hip intra-articular injection setup with heel toe maneu- • This is the preferred approach when there is a desire
ver and gel standoff. (B) Hip intra-articular injection femoral acetabular to distend posterior hip capsule due to tightness and
junction for weight-bearing flow. AC, Acetabulum; arrows, needle; FH, adhesions that limit hip internal rotation and hip flexion.
femoral head.
  

Technique: Lateral Approach Pubic Symphysis

Alternative approach for patients that have difficulty lying
supine KEY POINTS
Patient Position • C ommonly underdiagnosed area of pain or instability,
• Lateral decubitus with pillow between the knees and often associated with sacroiliac joint dysfunction
Clinician Position and instability.11,12
• Positioned behind the patient • The pubic symphysis is widest anteriorly.
Transducer Position • There will be some resistance while injecting the
fibrocartilage disc in the joint.
• Parallel with the femoral neck; often will need to angle
and rock the probe to keep the bony cortex parallel or   
near parallel to the probe
Needle Position Pertinent Anatomy
• In-plane, lateral-to-medial approach • Th
 e pubic symphysis is a non-synovial amphiarthrodial
Target joint connecting each pubis bone of the pelvis.
• Synovial recess at or just proximal to the junction of the • It consists of a fibrocartilaginous disc between the
femoral head and neck articular surfaces of the pubic bones. It resists tensile,
 CHAPTER 20 Hip Injection Techniques 327

AC
FH

C
• Fig. 20.8 (A) Posterior hip joint and capsule injection prone setup. (B) Posterior hip joint and capsule
lateral decubitus setup. (C) Posterior hip joint injection ultrasound view. AC, Acetabulum; arrow, needle tip
trajectory; FH, femoral head.

shearing, and compressive forces, and is capable of a • S econdary pubic symphysis disorder due to sacroiliac
small amount of movement under physiologic condi- joint dysfunction.17
tions in most adults (up to 2 mm shift and 1 degree
rotation).13 Equipment
• Four ligaments reinforce the joint: superior and inferior • N eedle size: 22- to 25-gauge, 1.5- to 2.5 inch needle
pubic ligaments, along with the anterior and posterior • High-frequency linear ultrasound transducer
pubic ligaments.14
• The anterior portion of the joint is 3 to 5 mm wider than Common Injectates
the posterior portion (see Fig. 20.3). • A nesthetics for diagnostics.
• Orthobiologics: (PRP, bone marrow concentrate, etc.)
Common Pathology and prolotherapy
• D egenerative of the pubic symphysis syndesmosis,
• Chronic anterior pelvic instability Injectate Volume
• Rare but underdiagnosed. Most common causes of • F or IA injection: 0.5 to 1 mL
instability include pregnancy and parturition, which • For ligamentous injection: 1 to 3 mL
often resolves but can persist. External causes of insta-
bility include direct trauma, insufficiency fractures, Technique
athletics, prior surgery, and osteitis pubis.15 Patient Position
• Osteitis pubis • S upine with a pillow under knees for comfort (if needed)
• Stress injury most commonly seen in athletes that par- and to relax the superficial structures around the joint
ticipate in sports involving quick changes of direction, Clinician Position
such as football, soccer, ice hockey, etc.16 • Standing to side of patient
328 SEC T I O N I I I Atlas

• Fig. 20.9 Patient supine, with transducer in the transverse plane

over the anterior aspect of the pubic symphysis for an out-of-plane
approach.

•Fig. 20.11 Pubic Symphysis Anterior Ligament Injection In-Plane

Setup.

PEARLS AND PITFALLS

• B
 ecause this joint is a non-synovial joint, it is important
to inject the fibrocartilage disc within the joint. There
will be some resistance while injecting the fibrocartilage
disc. A 25-gauge needle may be used to anesthetize
the soft tissue down to the joint; however, a 22-guage
needle is often needed to enter the joint.
• An anterosuperior to posteroinferior approach or
lateral in-plane approach is recommended to avoid
vascular structures of the genitalia that are inferior to
the joint.
• Be sure not to puncture posterior to the joint as
this may cause injury to the bladder. A distended
bladder can be positioned above the superior
margin of the joint and is susceptible to puncture
there, as well.
• Fig. 20.10 Patient supine, with transducer in the sagittal plane over
the anterior aspect of the pubic symphysis for an in-plane approach.   

Hip Capsular Ligaments

Transducer Position Hip Capsular Ligaments
• O ut-of-plane approach (Fig. 20.9), anatomic transverse
plane over the anterior aspect of the pubic symphysis, KEY POINTS
with the joint space midline on the monitor • Injection technique is very similar to IA injections except
• In-plane approach (Fig. 20.10), anatomic sagittal or just superficial to the joint, and the goal is to inject
transverse plane over the anterior aspect of the pubic multiple sites along the ligaments/capsule.
symphysis • Prolotherapy and biologics can be used to stabilize
Needle Position a loose hip, especially in the presence of labral tears,
traumatic injuries, connective tissue disorders, and joint
• Out of plane, needle starting midline over the joint arthritis.
space
• In-plane, from lateral to medial (preferred approach to   
target the anterior ligaments) (Fig. 20.11)
Target (Fig. 20.12) Pertinent Anatomy
• Pubic symphysis fibrocartilaginous disc (Fig. 20.13) • A
 nterior ligaments include:
• Anterior ligaments • Pubofemoral: originates on iliopectineal eminence of
• Can inject along the ligament lateral to medial and the pubic rami and attaches triangularly to the femo-
fan out superiorly and inferiorly (Fig. 20.14) ral head, capsule, and ischiofemoral ligament, and
 CHAPTER 20 Hip Injection Techniques 329

orients more transverse. Limits excess external rota-

tion. Weakest hip ligament.
• Iliofemoral ligament (Y ligament of Bigelow): the
strongest ligament in the body. Inverted Y shape
originates vastly along the anterior femur and inserts
around the base of the anterior inferior iliac spine
(AIIS). Supports standing posture, which limits exces-
sive hip extension
• Lateral ligaments include:
• Iliofemoral ligament and ischiofemoral ligament
• Posterior ligaments include:
* * • Ischiofemoral runs mostly transverse from the ischial
acetabular margin to broadly at the base of the greater
trochanter. It prevents excessive extension and inter-
nal rotation (see Fig. 20.3)

Common Pathology
• Fig. 20.12 Short-Axis View of Pubic Symphysis Joint. Arrow indi-
 ip instability.18
• H
cates needle entry into the joint space. Note the absence of cortical • Causes include traumatic (post subluxation); iatro-
bone in the picture, as this indicates the best view of the pubic sym- genic, i.e., anterior dislocation after arthroscopy from
physis joint for this technique. Stars indicate joint space. traction or capsulotomy; developmental dysplasia of
the hip; connective tissue/hypermobility disorders;
and repetitive microtrauma

Equipment
• L ow-frequency curvilinear ultrasound transducer
• Typically, 25- or 22-gauge, 3.5-inch spinal needle is
sufficient.
• In larger or taller patient, a 25-gauge, 4.69-inch needle
or 22-gauge, 5-inch needle is required

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
PR PR centrate, etc.).
• Steroids should not be used as they can potentially injure
ligaments when injected directly.
• Fig. 20.13Long Axis View of Pubic Symphysis Joint. Dots repre-
sent walk-down technique into the joint space for out-of-plane injec- Injectate Volume
tion. PR, Pubic ramus.
• 2 to 4 mL

Technique: Anterior Approach

Patient Position
• S upine, leg extended, same as IA approach
Clinician Position
AL
• Standing on side of the affected hip
Transducer Position
• Anteriorly in the oblique sagittal plane, parallel with the
femoral neck
PR PR
Needle Position
• In plane, caudolateral to cephalomedial
Target
• Multiple areas along the capsule/iliofemoral and pubo-
femoral ligaments (Fig. 20.15)
• Fig. 20.14 Pubic Symphysis Anterior Ligaments In-Plane Injection. • Adjust transducer to inject multiple points along the
AL, Anterior ligament; arrows, needle; PR, pubic rami. joint capsule
330 SEC T I O N I I I Atlas

AC HC

FH PC
AC

FH

• Fig. 20.16 Posterior Hip Joint Capsular Ligament Injection. AC,

Acetabulum; arrows, needle trajectories; FH, femoral head; PC, pos-
• Fig. 20.15 Hip Anterior Capsule Injection. AC, Acetabulum; FH, terior capsule.
femoral head; HC, hip capsule. Arrows, needle trajectory.
Tendons and Bursae
Rectus Femoris/Sartorius Tendons
PEARLS AND PITFALLS KEY POINTS
• O bserve injectate flow to ensure injectate is within the • Potential site of anterior hip pain.
ligaments and not IA.
• Should have slightly more resistance than with IA   
injection, with resistance similar to tendons and other
ligaments. Pertinent Anatomy
   • Th
 e quadriceps muscle group is made up of the rectus
femoris, and three vastus muscles (medialis, lateralis, and
intermedius).
Technique: Posterior Approach • The rectus crosses two joints and, thus, allows for hip
Patient Position flexion and knee extension.
• P rone • The rectus femoris has two origins: a direct head, which
• Internally rotate the hip to move the greater trochanter originates from the AIIS; and an indirect, which origi-
out of the needle trajectory. To achieve this, bend the nates inferior and posterior to the AIIS from the superior
patient’s leg at the knee and rotate from the lower leg acetabular ridge.
outwards (see Fig. 20.8A) • The sartorius originates from the anterior superior iliac
Clinician Position spine (ASIS) of the pelvis.
• Standing ipsilateral to the affected hip
Common Pathology
Transducer Position
• Th
 e quadriceps can be injured by a muscle strain pattern
• Posteriorly in the oblique sagittal plane, parallel with the
during knee flexion and hip extension. The rectus femo-
femoral neck
ris is the most commonly injured,19,20 as it is the most
Needle Position
superficial and crosses two joints.
• In plane, inferolateral to superomedial approach
Target Equipment
• Multiple areas along the capsule/ischial femoral liga- • N eedle size: 22- to 25-gauge, 1.5- to 3.5-inch (depends
ments (Fig. 20.16). on body habitus)
• Adjust transducer to inject multiple points along the • High-frequency linear ultrasound transducer or low-fre-
joint capsule. quency curvilinear transducer

Common Injectates
• A nesthetics for diagnostics
PEARLS AND PITFALLS
• Prolotherapy, orthobiologics (PRP, bone marrow con-
• S
 imilar approach to intra-articular posterior approach, centrate, etc.)
but injection is into the ligaments. Should have slightly
more resistance than intra-articular injection. Injectate Volume
   • 2 to 4 mL in total
 CHAPTER 20 Hip Injection Techniques 331

IL S

• Fig. 20.19 Ultrasound image shows long axis of the sartorius for an
in-plane injection with path of needle directly to tendon pathology. I,
Iliopsoas complex; IL, anterior superior iliac spine of ilium; S, sartorius;
arrow, path of needle.

PEARLS AND PITFALLS

• S ince there is no tendon sheath in this area, avoid
corticosteroids, as they could have harmful effects on
the tendon.
• Fig. 20.17Patient and Needle Position. Anterior sagittal approach. • If performing fenestration, with or without biologic, be
Transducer position for in-plane approach to rectus femoris or sarto- sure to visualize and treat all damaged areas of the
rius tendons. tendon.
  

Adductor Tendons
KEY POINTS
 he adductor longus is the most commonly injured21
• T
adductor tendon.
  

Pertinent Anatomy
• Th
 e hip adductors are a powerful group of muscles that
consist of the adductor magnus/minimus, adductor lon-
R gus, adductor brevis, and the gracilis and pectineus mus-
I cle groups.
• Fig. 20.18 Ultrasound image in sagittal plane shows the direct head • The adductor longus, brevis, and magnus originate from
of the rectus femoris in long axis for an in-plane injection with path of the ischium and pubis of the pelvis.
needle directly to tendon pathology. I, Anterior inferior iliac spine; R, • The adductor longus shares a common aponeurosis
rectus femoris; arrow, path of needle.
with the rectus abdominus muscle on the pubis.
• Superficial and medial to the adductors, the gracilis origi-
Technique nates from the inferior pubic ramus (Fig. 20.20).
See Fig. 20.17.
Patient Position Common Pathology
• Supine with a pillow under knees for comfort (if needed) • R ectus abdominus-adductor longus aponeurotic plate injury
and to relax the superficial structures • Adductor tendon injury (acute or chronic)
Clinician Position • Acute injuries—change of direction, push-off, or
• Standing or sitting on affected side of patient stop-and-go movements (i.e., as in soccer, football,
Transducer Position hockey, lacrosse, basketball, tennis, etc.), and report a
• Long axis to the tendon “pop” or “pull” at the time of injury
Needle Position • Chronic overuse or repetitive movements, and ath-
• In plane, distal to proximal approach letes often complain of a dull ache with these injuries
Target but are often able to continue to play
• Pathologic tendon, usually at or just distal to attachment • Athletic pubalgia—spectrum of related pathology condi-
(Figs. 20.18 and 20.19) tions causing groin pain
332 SEC T I O N I I I Atlas

Equipment
Quadratus
• N eedle size: 22-to 25-gauge, 1.5 to 3-inch needle Lumborum Psoas
• High-frequency linear ultrasound transducer
Iliacus
Common Injectates
• A nesthetics for diagnostics
• Prolotherapy, orthobiologics (PRP, bone marrow con- Adductors
centrate, etc.)
Tensor
Femoral Nerve
Injectate Volume Fasciae
• 2 to 4 mL Gracilis
Rectus
Femoris Sartorius
Technique
Patient Position Quadratus
Saphenous
See Fig. 20.21. Nerve
• S upine, with the hip externally rotated and abducted Iliotibial Band
with the knee flexed. • Fig. 20.20 Hip Anterior Musculature Anatomy and Large
• Patient’s arms folded across the abdomen. Neuroanatomy.
Clinician Position
• Standing on affected side.
Transducer Position
See Fig 20.22.
• Long axis to the adductor longus tendon.
Needle Position
• In plane.
• Distal-to-proximal approach.
Target
• Adductor tendon where pathology is noted, most often
at insertion to pubic symphysis at the insertion of the
common aponeurosis of the rectus abdominus-adductor
longus (Fig. 20.23)

PEARLS AND PITFALLS

• M ust rotate the transducer to short axis during the
procedure to ensure that the entire width of diseased
tendon is treated.
• Identify the adductor longus tendon by palpation and
place the transducer over it in order to properly identify
the entire group of tendons.
• A distal-to-proximal approach for this injection decreases
the risk of intravascular injection, as the needle is moving
away from the major neurovascular bundle.
   • Fig. 20.21 Patient Position. The patient is supine with the hip
abducted, externally rotated and knee slightly flexed.
Iliopsoas Tendon and Bursa
lesser trochanter, with some fibers inserting on the proxi-
KEY POINTS
mal femur.
• D ynamic ultrasound evaluation for iliopsoas snapping • The psoas major originates from T12 to L5 transverse
should be considered. processes, vertebral bodies, and intervertebral discs.
• Injury to the iliopsoas in this location can occur with
• The iliacus originates from the iliac crest and the thora-
total hip arthroplasty or hip arthroscopy.
• Iliopsoas impingement has been associated with columbar spine, and joins the psoas muscles, forming the
anterior labral tears and should be targeted with the iliopsoas tendon.
same procedure. • The psoas minor (which is absent in approximately 40%
   of the population) attaches at T12 and L1 for its origin,
courses anterior to psoas major, and merges to form the
Pertinent Anatomy iliopsoas tendon.
• Th
 e iliopsoas musculotendinous unit is composed of the • The myotendinous junction occurs at the level of the
psoas major, iliacus, and psoas minor, and inserts on the superior pubic ramus.
 CHAPTER 20 Hip Injection Techniques 333

• L esser trochanter avulsion fracture

• Lesser trochanter avulsion in the adult should raise
concern for pathologic fracture
• Snapping iliopsoas tendon
• Seen with dynamic ultrasound when moving the hip
from flexion-external rotation or frog leg position to a
straightened position
• Iliopsoas bursitis
• Distention may coincide with iliopsoas tendinosis but
is more likely related to an IA hip pathologic process
due to continuous synovium between the joint and
iliopsoas bursa

Equipment
• N eedle size: 22-gauge, 2.5- to 3.5-inch needle
• Medium- to low-frequency linear ultrasound transducer,
depending on patient body habitus

Common Injectates
• A nesthetics for diagnostics
• Corticosteroids for bursa only; should not be injected
• Fig. 20.22 Patient and Needle Position. Long-axis, in-plane from intratendinous
distal-to-proximal approach for adductor longus tendon and sheath. • Prolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.)

0
Injectate Volume
• 2 to 4 mL
x • Technique iliopsoas bursa or tendon at the femoral
AL head
1
Patient Position
AB • Supine
• Hip in neutral position
2 Clinician Position
• Standing on affected side
Transducer Position
See Fig. 20.24.
3
• Oblique axial plane parallel to inguinal ligament
and iliopectineal eminence (just superior to femoral
ADD LAX head)
RT ANT HIP • Alternatively, sagittal plane in line with the iliopsoas ten-
• Fig. 20.23 Ultrasound image of adductor longus (AL) tendinosis don as it crosses the femoral head (Fig. 20.25A)
with cortical irregularities (small arrows) seen at insertion to the pubic Needle Position
ramus. Long arrow indicates needle angle and position for tenotomy • In-plane, lateral-to-medial approach
procedure with long-axis, in-plane approach. AB, Adductor brevis
muscle; P, pubic ramus.
Target
• Intratendinous pathology of the iliopsoas tendon, target-
ing areas of hypoechogenicity or occult tears
• Th
 e iliopsoas bursa is located between the anterior cap- • Target: Iliopsoas bursa if it is distended (Fig 20.26).
sule of the hip joint and the iliopsoas tendon. Otherwise, injection should be deep to the iliopsoas
tendon and superficial to the ilium at the iliopectineal
Common Pathology eminence
• I liopsoas tendinosis or, less commonly, tendon tear
• Iliopsoas tendon impingement in the setting of a hip Technique
replacement and the anterior aspect of the acetabular cup • A
 lternative approach distally and insertional iliopsoas
or femoral collar, causing impingement tendon
334 SEC T I O N I I I Atlas

V
V
IP V

*
IP
hip

LT

• Fig. 20.25 (A). Iliopsoas tendon at the femoral head in-plane injec-
tion setup. (B) Iliopsoas at femoral head long-axis, in-plane injection.
IP, Iliopsos at the femoral head long-axis, in-plane ultrasound injec-
tion. Hypoechoic interstitial tendon tear (asterisk); LT, lesser trochanter.
Needle (arrowheads).

• Fig. 20.24 Patient and Needle Position. Patient lies supine with the
hip in neutral position. Transducer in short axis to the iliopsoas tendon,
which is approximately parallel to the inguinal ligament. Needle is in Needle Position
plane to the transducer. • O ut-of-plane, lateral-to-medial approach (Fig 20.28A)
• Alternative: in-plane, proximal-to-distal approach
(see Fig. 20.28B)
Target
• Distal iliopsoas tendon, at or just proximal to the lesser
PEARLS AND PITFALLS
trochanter (see Fig. 20.28C and D)
• D ue to the curvilinear course of the iliopsoas tendon,
it is susceptible to anisotropy. Adjust the ultrasound
probe to eliminate anisotropy and improve visualization
of the tendon.
• Limited ultrasound evaluation of the hip prior to the PEARLS AND PITFALLS
procedure is essential to screen for snapping hip
• H ave to do pre-procedural scan to identify the femoral
syndrome and other causes for anterior hip pain, such
artery and avoid neurovascular injury.
as paralabral cyst.
• Proceduralist has to have good experience with out-of-
• Visualize the femoral neurovascular bundle in relation
plane approach as the target can be deep at close to
to the iliopsoas tendon before proceeding with the
the femoral artery that needs to be avoided.
injection to avoid injury.
• The iliopsoas tendon is a long tendon. Anesthetic
• The tendon can require several repositionings of the
injections into the tendon can help localize symptomatic
needle to target all pathologic areas.
pathology tendon at the iliopectineal eminence,
• Anesthetic can be used to anesthetize the tendon
superficial to the femoral or at the insertion, and guide
sheath and small aliquots can be used within the
future biologic injections.
tendon to assess for occult tears and plan where to
place the orthobiologic.   
  

Iliopsoas Bursa-Technique: Lateral Approach

Patient Position Patient Position
• S upine • S upine, hip in neutral position
• Knee flexed and hip externally rotated Clinician Position
Clinician Position • Seated or standing adjacent to the affected hip.
• Standing on affected side Transducer Position
Transducer Position See Fig. 20.29.
• Long axis to the tendon • Short axis to the iliopsoas tendon, oblique axial plane,
• Scan distal along the tendon to visualize the insertion on parallel to inguinal ligament and cephalad to femoral
the lesser trochanter head
 a a

bursa

I I

• Fig. 20.26 Short-axis ultrasound image to iliopsoas tendon (I) shows • Fig. 20.27
Short-axis ultrasound image to iliopsoas tendon (I) shows
hypoechoic iliopsoas bursal distention (short arrow). Long arrow indi- hypoechoic iliopsoas bursal distension (short arrow). Long arrow indi-
cates path of needle to iliopsoas bursa injection. The left side of image cates path of needle to iliopsoas tendon injection. The right side of
is lateral. a, Femoral artery. image is medial. a, Femoral artery.

A B

IP

IP LT

LT
C D
• Fig. 20.28 (A) Distal iliopsoas tendon out-of-plane injection setup. (B) Distal iliopsoas injection in-plane
setup. (C) Distal iliopsoas long-axis, out-of-plane injection. (D) Distal iliopsoas injection long-axis, in-plane
injection. Arrows, needle; IP, Iliopsoas; LT, lesser trochanter.
336 SEC T I O N I I I Atlas

flexion, internal rotation, abduction, and stabilization of

both the hip and knee.
• The iliotibial band (ITB) is a dense fibrous band of
connective tissue that runs laterally from the iliac crest
to the lateral knee.
• The ITB is a three-layer structure that originates, as
the fascia lata, from the iliac tubercle and superficial
to the TFL. As it traverses distally, at the site of the
greater trochanter, the fascia lata gains thickness (∼1.9
mm total) from a fibrous expansion of the gluteus
maximus (gluteal aponeurosis) and the TFL to form
the ITB.
• The ITB continues to run distally in the lateral portion
of the thigh, superficial to the vastus lateralis. The distal
insertion point is Gerdy’s tubercle, where it merges with
biceps femoris and vastus lateralis (see Fig. 20.20).

Common Pathology
• Th
 e TFL can become clinically significant in cases of
tightening and overuse at its origin, or through its attach-
ment to the ITB
• Fig. 20.29 Patient and Needle Position. Patient lies supine with the
• The TFL is a secondary hip abductor, and pathology may
hip in neutral position. Transducer in short axis to the iliopsoas tendon, be secondary to underlying gluteal medius weakness.
which is approximately parallel to the inguinal ligament. Needle is in • Strain injuries of the ITB (or, more specifically, the
plane to the transducer. fascia lata) at the iliac tubercle have been documented
and referred to as proximal iliotibial band syndrome.
Needle Position It is described as a strain injury to the ITB enthesis,
• I n-plane, lateral-to-medial approach where it attaches to the iliac tubercle.
Target • Abnormalities of the ITB at the level of the greater
• Iliopsoas bursa (see Fig. 20.26) trochanter are typically not considered part of proxi-
• If the bursa is not clearly distended, the injection mal iliotibial band syndrome.
should be deep to the iliopsoas tendon and superficial
to the ilium at the iliopectineal eminence. Equipment
• In post-arthroplasty patients, if the bursa is not clearly dis- • H igh-frequency linear transducer
tended, the target should be directly over the hip joint. • Needle size: 22-gauge, 1.5- to 2.5-inch needle

Common Injectates
PEARLS AND PITFALLS • A nesthetics for diagnostics and needle fenestration/
• W
 hen injecting deep to the iliopsoas tendon, the tenotomy
femoral head should not be in view. This will ensure that • Prolotherapy, orthobiologics (PRP, bone marrow con-
the injectate is located within the iliopsoas bursa and centrate, etc.)
not accidently injected into the hip joint
   Injectate Volume
• 2 to 4 mL in total
Tensor Fascia Lata Tendon and Proximal Iliotibial
Band Injections Technique
Patient Position
KEY POINTS • S ide-lying with affected side upwards, and hip/knee flexed
Clinician Position
• T
 he proximal tensor fascia lata (TFL) tendon and iliotibial • Seated or standing behind the patient
band are common sites of overuse injuries in runners Transducer Position (Fig. 20.30)
with pain at the ASIS attachment.
• Long axis to the origin of the TFL at the ASIS
   Needle Position
• In plane, distal to proximal
Pertinent Anatomy Target
• Th
 e Tensor fascia lata (TFL) originates from the ASIS • Site of pathology, often at origin of TFL on the anterior
and anterior aspect of the iliac crest, and assists with hip iliac crest to the ASIS (Fig. 20.31)
 CHAPTER 20 Hip Injection Techniques 337

A B
• Fig. 20.30 (A) Anterolateral sagittal approach. Patient is side-lying and the transducer is in the in-plane
sagittal approach, long axis to the tensor fascia lata, on the posterior aspect of the anterior superior iliac
spine. (B) Lateral coronal approach. Patient is side-lying and the transducer is long axis to the iliotibial band
in the lateral plane at the superior portion of the iliac crest with in-plane needle approach.

Proximal Hamstring Tendon and Ischiogluteal

Bursa Injections

KEY POINTS

I • T he hamstring tendons are deep and curved, making

them susceptible to anisotropy. Adjust the ultrasound
probe to eliminate anisotropy and improve visualization
of the tendon.
• The sciatic nerve should be localized during
prescanning, and injection approach should be medial
to the nerve.
• Fig. 20.31 Ultrasound image in long axis to the proximal tensor fascia • For ischial bursa injection, the ischial bursa is not
lata shows 20-gauge needle and needle tip (arrows) within tendon seg- always visible on ultrasound, and the approach for the
ment. I, Ilium. injection can be difficult, making patient positioning
important.
  

PEARLS AND PITFALLS

• P athology of the TFL is probably underdiagnosed, Pertinent Anatomy
especially in running athletes.22–24 • Th
 ere are four hamstring muscles. Three of the muscles
• Would consider needle fenestration with or without (semimembranosus, semitendinosus, and the long head
PRP injection into the tendon with ultrasound guidance.
The number of passes through the tendon during
of the biceps femoris) originate from the ischial tuberos-
fenestration should be enough until there is a change in ity and cross both the hip and knee joint to flex the knee
tissue resistance.25 and extend the hip. The fourth muscle is the short head
  
of the biceps femoris, and it originates from the linea
aspera and inserts with the long head on the proximal
   fibula.
• The long head of the biceps femoris and semitendinosus
• S uperior portion of the anterolateral iliac crest at the originate from a conjoint tendon.
attachment of the proximal ITB (fascia lata), or at the • The origin of the semimembranosus is deeper and more
site of defect or fascial injury lateral on the ischial tuberosity, and then runs deep and
338 SEC T I O N I I I Atlas

medial to the conjoint tendon. The proximal semimem-

branosus is mostly aponeurosis, and the muscle mass has
a more distal origin. The muscle belly runs medially to
the semitendinosus. The insertion is made of five tendi-
nous attachments to the medial tibial condyle, posterior
oblique ligament, and the posterior joint capsule.
• The majority of the semitendinosus muscle belly is proxi-
mal, with a long, thin tendon located superficial to the
semimembranosus that inserts with the sartorius and
gracilis tendons forming the pes anserine.
• The long head of the biceps femoris runs laterally and
attaches distally to the fibular head.
• The sciatic nerve is located slightly lateral to the conjoint
tendon and is critical to locate when performing proxi-
mal hamstring injections.
• The ischiogluteal bursa is located superficial to the ham-
string tendons and ischial tuberosity, and deep to the glu-
teus maximus.

Common Pathology
• Th
 e proximal hamstring is a common location for tendi-
nopathy. This is most common in distance runners and • Fig. 20.32 Patient is prone, for a long-axis, in-plane approach.
starts gradually. Acute injury can occur, particularly with
a violent motion of kicking.
• Sonography findings will typically demonstrate thick-
ened tendons, the loss of fibrillation architecture, and
hypoechoic areas within the tendon. Cortical irregu-
larities, hyperechoic areas, and tendon calcifications may
also be present.
• Ischiogluteal bursitis is often associated with an underly-
ing hamstring tendinopathy.

Equipment IT
• N eedle size: 22-gauge, 2.5- to 3.5-inch needle.
• High-frequency linear transducer or low-frequency cur-
vilinear transducer
• Fig. 20.33 Ultrasound image, with patient prone, long axis to the
Common Injectates proximal hamstring tendon origin on the ischial tuberosity. IT, Ischial
• A nesthetics for diagnostics tuberosity. Arrow, path of needle.
• Corticosteroids for bursa only, should not be injected
intratendinous
• Prolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.)
• Alternate technique to injectates: percutaneous needle
fenestration with an 18- to 20-gauge, 1.5- to 2-inch nee-
dle. The number of passes would depend on the size of
the defect and tactile feedback

Injectate Volume
• 2 to 5 mL

Technique
Patient Position
• P rone (Fig. 20.32): patient’s hips propped up with pillows
to reduce angle between buttock and upper leg (Fig. 20.33)
• Alternate (Fig. 20.34): side-lying with affected side up
and hip and knee flexed (Fig. 20.35) • Fig. 20.34 Patient is side-lying, for a long-axis, in-plane approach.
 CHAPTER 20 Hip Injection Techniques 339

IT

• Fig. 20.35 Ultrasound image, with patient side-lying, long axis to the
proximal hamstring tendon origin on the ischial tuberosity. Arrow, nee-
dle; IT, Ischial tuberosity.

Clinician Position
• S eated or standing on the side of the leg targeted for injec-
tion if prone. If side-lying position, in front of the patient.
Transducer Position
• Long axis to the hamstring tendon/conjoint tendon A
• Also, can visualize in transverse to inject across the width
of the tendon (Fig. 20.36A)
Needle Position
• If long axis to the hamstring, in plane to the transducer,
distal to-proximal approach HS
• If short axis (transverse) to the hamstring, in plane to the
transducer, lateral-to-medial approach (see Fig. 20.36B) IT
Target
• Hamstring tendon origin at site of defect or tendinopathy
• If injecting the bursa: peritendinous hamstring injection
at origin or ischial bursa if visible. (Long axis would be the B
alternate technique; see below for the preferred approach.) • Fig. 20.36(A) proximal hamstring transverse view setup. (B) Proximal
hamstring injection transverse view in-plane needle approach lateral
PEARLS AND PITFALLS to medial. HS, Hamstring in transverse; IT, ischial tuberosity. Arrows,
Needle.
• C are should be taken to avoid the sciatic nerve, which
is just lateral to the hamstring tendon insertion on the
ischial tuberosity.
• While performing the injection, the probe can be Pertinent Anatomy
changed to short axis (out of plane to the needle) to
visualize the medial-to-lateral location of the needle. • Th
 e gluteus maximus originates from the sacrum, poste-
• Peritendinous corticosteroid injections can provide rior sacroiliac ligaments, and a small portion of the ilium
short-term pain relief, but symptoms tend to recur and near the posterior superior iliac spine (PSIS). Some of its
can be more severe.29,30 Corticosteroids should not be fibers insert on the fascia lata and iliotibial tract, and oth-
injected into the tendon, but can be used to inject the ers insert on the proximal posterior femur on the gluteal
adjacent and superficial ischiogluteal bursa.
   tuberosity, which is located just distal to the trochanters
and the femoral head.
   • The gluteus medius originates from the superolateral sur-
face of the posterior iliac wing. The posterior portion of
Gluteal Attachments the muscular origin is covered by the gluteus maximus.
Gluteal Tendon Origin (Iliac Crest) Injections The anterior portion of the muscle inserts on the lateral
facet of the greater trochanter, while the posterior por-
KEY POINTS
tion inserts on the superoposterior facet.
• The gluteus minimus also originates on the lateral iliac
• T
 his is an underdiagnosed area for tendinopathy, wing, inferior to the gluteus medius, and runs deep to
especially in patients with low back pain and radiculitis. the gluteus medius, inserting on the anterior facet of the
   greater trochanter.
340 SEC T I O N I I I Atlas

Piriformis Cluneal Nerves

Gluteus
Medius

Gluteus
Minimus
Gluteus
Gluteal Nerves Maximus

Obturator Sciatic Nerve

Internus

Gemellus Semimembranosus
Inferior

Gemellus Superior
Quadratus Conjoint Tendon of
Femoris Pudental Nerve Hamstrings

Posterior Femoral
Cutaneous Nerves
Ischiogluteal Bursa ( Biceps Femoris )
Semitendinosus and

• Fig. 20.37 Posterior Pelvic/Hip Neuromuscular Anatomy.

• Th
 e gluteal aponeurotic fascia covers the gluteal medius
and a portion of the gluteus maximus, and serves at the
tendon of origin of the gluteus medius (Fig. 20.37).31

Common Pathology
• P athology at the origin of the gluteus maximus, glu-
teus medius, gluteus minimus, or TFL muscle appears
as hypoechoic abnormalities (interstitial tears, tendino-
pathic changes) or hyperechoic (enthesophytes, calcifica-
tions) abnormalities on sonographic evaluation.32
• Tearing and discontinuity of the gluteal aponeurotic fas-
cia has also been reported as a source of pain.31

Equipment
• N eedle size: 22- to 25-gauge, 2.5- to 3.5-inch needle
• Medium- to high-frequency linear transducer; if needed,
low-frequency curvilinear transducer

Common Injectates
• A nesthetics for diagnostics and needle fenestration/
tenotomy
• Prolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.)
• Fig. 20.38 Oblique Sagittal Approach. Short axis to the iliac crest,
starting at the posterior superior iliac spine with in-plane needle
Injectate Volume approach.
• 2 to 4 mL in total

Technique
Patient Position transducer in superior or inferior direction, maintaining
• P rone the crest in picture and in short axis
Clinician Position Needle Position
• Seated or standing directly next to the hip being treated • In plane to the transducer, and lateral-to-medial or dis-
Transducer Position tal-to-proximal approaches, depending on the muscle
See Fig. 20.38. being treated
• Short axis to the iliac crest, starting at the PSIS. To Target
change target on crest or orientation, operator will fan • Gluteal muscle origin site pathology
 CHAPTER 20 Hip Injection Techniques 341

PEARLS AND PITFALLS

• C
 are should be taken to avoid the needle slipping
superior or medial off the iliac crest.
  
From Atlas; Jacobson MSK US, Hollinshead’s9,33

  

Gluteus Tendon Insertion (Greater Trochanter)

and Trochanteric Bursal Injections

KEY POINTS
• R otation of hip during scanning identifies the plane
between the gluteus medius and gluteus maximus.
• Subgluteus maximus bursitis (trochanteric bursitis)
is much less common than gluteal tendon tears and
tendinosis.
  

Pertinent Anatomy
• Th
 e greater trochanter has four facets: anterior, lateral,
superoposterior, and posterior. • Fig. 20.39 Patient Side-Lying With the Hip in Neutral
• The gluteus medius originates from the iliac crest. The Position. Transducer is long axis to the targeted tendon for an in-
anterior portion inserts on the lateral facet, and the plane, distal-to-proximal approach.
posterior portion inserts on the superoposterior facet.
The gluteus minimus originates on the ilium, runs
deep to the gluteus medius, and inserts on the anterior Common Injectates
facet. • A nesthetics for diagnostics
• The trochanteric (or subgluteus maximus) bursa is • Corticosteroids for bursa only, should not be injected
located between the gluteus maximus/medius and ilio- intratendinous
tibial band, overlying much of the posterior facet. • Prolotherapy, orthobiologics (PRP, bone marrow con-
• The hip abductor muscles—the gluteus medius and glu- centrate, etc.)
teus minimus—support and level the pelvis during the
single leg stance of ambulation or running. Injectate Volume
• Sonographic evaluation may demonstrate intratendi- • 2 to 5 mL in total
nous calcification, hypoechoic or anechoic areas within
the tendon, cortical irregularities, tendon enlargement, Technique: Lateral Approach
or absence of visible tendon, indicating partial or full- Patient Position
thickness tears (see Fig. 20.37). • S ide-lying with affected hip up, pillows under head and
between legs
Common Pathology Clinician Position
• E xcessive friction between the tendon layers can cause • Seated or standing directly next to and posterior to hip
inflammation, thickening, and fluid accumulation in the being injected
subgluteus maximus bursa. This is commonly referred Transducer Position
to as trochanteric bursitis, and has fallen out of favor as • Long axis to the gluteal tendon, distal or proximal
a source of greater trochanteric pain as it is exceedingly approach (Fig. 20.39)
rare.34 • Short axis to the gluteus tendon, posterior-to-anterior
• The more common findings at the greater trochanter are approach
interstitial, partial-thickness, or full-thickness tears of the • For trochanteric bursa, superficial and slightly posterior
gluteus medius and minimus tendons. to the lateral facet, approximately 37 degrees posterior
• The most common location of these tears or tendinopa- rotation relative to the long axis of femur (Fig. 20.40)
thies is the anterior gluteus medius tendon. Needle Position
• In plane to the transducer
Equipment • Needle approach: distal to proximal, proximal to distal,
• N eedle size: 22- to 25-gauge, 2- to 3.5-inch needle or posterior to anterior
• Medium- to high-frequency linear transducer. If needed, Target
a low-frequency curvilinear transducer may be used due • Abnormal gluteus medius, gluteus minimus tendon, or
to body habitus adjacent bursa (Figs. 20.41 and 20.42)
342 SEC T I O N I I I Atlas

PEARLS AND PITFALLS

• If the subgluteus maximus bursa is not visible, its
location in the potential space between the gluteus
aponeurosis and gluteus medius tendon layer can be
better identified by external hip rotation.
• Corticosteroids for gluteal pain are controversial and
may have limited long-term benefits.35 Corticosteroids
may help with bursitis, but intratendinous injection
of corticosteroids into the gluteal tendons should be Gm
avoided. GT
• The trochanteric bursa is uncommonly distended and
rarely inflamed as an isolated cause of symptoms.
If bursitis is present, be extra careful scanning for
presence of gluteal tendon pathology, which is more • Fig. 20.41 Gluteus Medius Fenestration. Ultrasound image long
common.34 axis to the gluteus medius over the superoposterior facet of the greater
• Alternate technique to injectates: percutaneous needle trochanter shows needle within hypoechoic and thickened tendon
fenestration with 18- to 20-gauge needle. The number segment (left side of image is superior). arrows, needle; Gm, Gluteus
of passes would depend on the size of the defect and medius; GT, greater trochanter.
tactile feedback
  
From: Atlas, Jacobson MSK US.9,10

  

G. Max.

G. Med

• Fig. 20.42 Long-axis view of subgluteus maximus bursal fluid collec-

tion with needle directed at bursa (arrow).

Pertinent Anatomy
• Th
 e piriformis muscle is a relatively small muscle that lies
deep to the gluteus maximus muscle.
• Fig. 20.40In-plane approach, short axis and slightly oblique to the
• Its main function is to externally rotate the hip, although
tendon and slightly posterior to the lateral facet. it also abducts the hip when the hip is flexed.
• The sciatic nerve is normally found deep to the piriformis
External Rotators muscle, but anatomic variability exists and, occasionally,
Piriformis Muscle/Tendon the sciatic nerve may pierce or run superficial to the piri-
formis muscle.

KEY POINTS Common Pathology

• Th
 e piriformis muscle is a potential cause of myofascial
• T he sciatic nerve must be identified during pre-
procedure scanning and is most commonly deep to the
pain in patients presenting with gluteal pain.
piriformis muscle. • The diagnosis of piriformis syndrome is often a diagnosis
• The ascending branches of the inferior gluteal artery of exclusion.
should be identified prior to the procedure and are
located underneath the gluteus maximus muscle. Equipment
   • Needle size: 22-gauge, 3.5-inch needle
 CHAPTER 20 Hip Injection Techniques 343

MED

GM

PIR

ISCH

• Fig. 20.44 Long-Axis Ultrasound Image of Piriformis Muscle

Needle Placement. Arrows indicates needle. GM, Gluteus maximus
muscle; ISCH, ischium; MED, medial; PIR, piriformis muscle.

PEARLS AND PITFALLS

• T he sciatic nerve position relative to the piriformis
muscle should be identified during pre-procedure
scanning.
• Fig. 20.43 Patient prone, with transducer positioned from cephalo­ • The sciatic nerve will most often be found deep to the
medial to caudolateral for a lateral-to-medial, in-plane approach. ADD, piriformis muscle, but anatomic variations exist in which
transducer “long axis to piriformis” positioned. the nerve or its peroneal division passes through or is
superficial to the piriformis.
• Passive hip internal and external rotation may assist in
identifying the piriformis muscle because of the relative
• M
 edium-frequency linear transducer or low-frequency movement of the muscle compared to the overlying
curvilinear transducer, depending on body habitus and gluteus maximus muscle.
desired field of view   

Common Injectates
• A nesthetics for diagnostics or trigger points
Gemelli-Obturator Internus Complex and
• Corticosteroids for sheath only
Obturator Internus Bursa Injection
• Prolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.) KEY POINTS
• Botulinum toxin • C are should be taken to identify the sciatic nerve during
pre-procedure scanning, as it should lie just superficial
Injectate Volume to the obturator internus and gemellar muscles.
• 2 to 4 mL in total • It may be difficult to discern obturator and gemellar
muscles apart, as they may look like a single myotendinous
unit along with the obturator internus muscle.
Technique • The obturator internus can also be found superficial to
Patient Position the proximal ischium, as it “rotates” around the ischium
• P rone with internal and external rotation of the hip.
Clinician Position   
• Standing or sitting on affected side
Transducer Position
See Fig. 20.43. Pertinent Anatomy
• Long axis of piriformis muscle, axial oblique from cepha- • Th
 e gemelli muscles are a pair of muscles that bookend
lomedial to caudolateral over the piriformis muscle the obturator internus, inferiorly and superiorly, in a
Needle Position parallel fashion. The inferior gemellus originates on the
• In-plane, lateral-to-medial (or medial-to-lateral) approach superior aspect of the ischial tuberosity, coursing inferior
Target to the obturator internus and superior to the quadratus
• Piriformis muscle sheath and/or piriformis muscle (trig- femoris. The superior gemellus originates from the ischial
ger point) (Fig. 20.44) spine, and courses superior to the obturator internus and
• Precise location of injection has not been proven in the inferior to the piriformis muscle. Both of the gemelli
literature, but considerations include intramuscular, insert on the medial aspect of the greater trochanter with
deep, and superficial to the piriformis the obturator internus tendon.
344 SEC T I O N I I I Atlas

• Th
 e three muscles—inferior gemellus, obturator inter-
nus, and superior gemellus—are often viewed as a single
functional unit.9
• The sciatic nerve normally is found superficial to the lat-
eral part of the tendon.
• The obturator internus bursa is located between the obtu-
rator internus tendon and the surface of the ischium.

Common Pathology
• G
 emellar and obturator internus myofascial pain, ten-
dinitis, tendinosis, and bursitis have been reported to be
associated with gluteal and posterior hip pain. Symptoms
are often vague and poorly localized. The deep loca-
tion of the structures, small size, and close proximity
of the other external rotators makes diagnosis difficult.
Diagnostic injection of the muscle, tendon sheath, or
bursa may be helpful to localize the pain generator.36,37

Equipment
• N eedle size: 22-gauge, 2.5- to 3.5-inch needle
• Low-frequency curvilinear transducer or a medium-
frequency linear transducer, depending on body habitus • Fig. 20.45 Patient is prone, and transducer is placed in the transverse
plane, long axis to the obturator internus, quadratus femoris, and gemelli
Common Injectates muscles. They should be approached in plane from lateral to medial.
• A nesthetics for diagnostics or trigger points
• Corticosteroids for bursa or sheath only
• Prolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).

Injectate Volume 2 T
• 2 to 4 mL in total

Technique
Patient Position 4
• P rone
Clinician Position F
• Seated or standing on the side of the leg targeted for injec-
tion if prone. If side-lying position, in front of the patient.
• Fig. 20.46 Ultrasound image, with patient prone, long axis to the
Transducer Position gemelli muscles. Straight arrow shows in-plane path of the needle.
See Fig. 20.45. Curved arrow, Sciatic nerve; F, proximal femur; T, greater trochanter.
• Long axis to the gemelli in the transverse plane
Needle Position
• In-plane to the transducer, lateral to medial
Target
• Inferior or superior gemellus muscle, at its insertion on MED
1
femur or site of pathology (Figs. 20.46 and 20.47)
• Obturator internus bursa deep to the obturator internus
muscle on the ischium OI
2

PEARLS AND PITFALLS OI

ISCH
• T
 he sciatic nerve must be identified and avoided during
injection. The nerve will most commonly be found 3
superficial to the gemelli.
  
From: Atlas of US MSK Inj–Mautner, Fundamentals of MSK
• Fig. 20.47 Long-axis Ultrasound Image of Obturator Internus
US–Jacobson, Grays Anatomy9,10,38
Tendon Sheath Injection. Arrow indicates needle tip. ISCH, Ischium;
   MED, medial; OI, obturator internus tendon.
 CHAPTER 20 Hip Injection Techniques 345

Quadratus Femoris Injection

KEY POINTS
• T
 he sciatic nerve must be identified prior to injection; it
will always be just superficial to the quadratus femoris
2
muscle.
   F
I

Pertinent Anatomy 4

• Th
 e quadratus femoris is a muscle that sits in the poste-
rior pelvis between the lateral ischial tuberosity and the • Fig. 20.48 Ultrasound image, with patient prone, long axis to the
proximal femur at the quadrate tubercle of the posterior quadratus femoris running between the ischium and proximal femur.
intertrochanteric line. Needle in plane from lateral to medial. Arrow, Path of needle; F, proxi-
• Once the ischial tuberosity, at the level of the hamstring mal femur; I, Ischium.
origin, is visualized under ultrasound, the quadratus is
the first muscle lateral to the femur.
PEARLS AND PITFALLS
Common Pathology • Q uadratus femoris pathology is often due to
• Th
 e quadratus femoris muscle can become impinged ischiofemoral impingement.
• A small amount of local anesthetic into the quadratus
between the ischial tuberosity and lesser trochanter of
femoris can help to confirm the ischiofemoral
the femur, resulting in ischiofemoral impingement syn- impingement.
drome. Narrowing of the distance between the two bony • Care must be taken to avoid the sciatic nerve just
landmarks of the ischiofemoral space is a risk factor for superficial to the quadratus femoris muscle, but its
impingement. exact location can vary to some degree.
  
From: Atlas of US MSK Inj–Mautner; Fundamentals of MSK US–
Equipment Jacobson; American Journal of Roentgenology. 2011;197:1:170–174
(Issue publication date: July 2011) https://doi.org/10.2214/AJR.10.5898 40
• N eedle size: 22- to 25-gauge, 2- to 3.5-inch needle
• Low-frequency curvilinear transducer or a medium-   
frequency linear transducer, depending on body
habitus Labrum
Common Injectates KEY POINTS
• A nesthetics for diagnostics or trigger point
• T
 he injection technique is similar to IA, except you want
• Corticosteroids in sheath to target the labrum and the specific area of tear based
• Prolotherapy, orthobiologics (PRP, bone marrow con- on magnetic resonance imaging (MRI) findings.
centrate, etc.)   
• Botulinum toxin39

Injectate Volume Pertinent Anatomy

• 2 to 4 mL in total • Th
 e fibrocartilage labrum appears as a hyperechoic trian-
gular structure on ultrasound, extending from the mar-
Technique gins of the acetabulum.
Patient Position • An intact labrum and joint capsule function to seal the
• P rone joint-enhancing lubrication by maintaining a fluid layer
Clinician Position providing lubrication between the articular surfaces,
• Seated or standing on the side of the leg targeted for reducing friction and shear on the cartilage, and distrib-
injection if prone uting forces more evenly across the joint (see Fig. 20.3).
Transducer Position
• Long axis to the quadratus femoris muscle (Fig. 20.45) Common Pathology
Needle Position • L
 abral tears are classified as anterior, posterior, or supe-
• In plane to the transducer, lateral-to-medial approach rior-lateral, with the most common location being in the
Target anterior part of the labrum. Labral tears may be acute/
• Quadratus femoris muscle belly or site of pathology (Fig. traumatic or degenerative, and may be seen in conjunc-
20.48) tion with hip dysplasia, femoral-acetabular impingement,
346 SEC T I O N I I I Atlas

capsular laxity, and osteoarthritis. Labral tears can be

asymptomatic or result in symptoms of groin, buttock,
or lateral hip pain and clicking.
• Paralabral cysts occur in the presence of labral tears or
a weakened joint capsule and are caused by a leakage of
joint fluid through the tear. They can be asymptomatic
or present with nonspecific or nonfocal symptoms. In
some cases, the cysts can impinge on adjacent structures,
such as the iliopsoas tendon, causing internal snapping
hip, or the femoral or sciatic nerve.

Equipment
• N eedle size: 22- to 25-gauge, 2.5- to 3.5-inch spinal
needle
• Low-frequency curvilinear ultrasound transducer

Common Injectates
• A nesthetics for diagnostics.
• Prolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
• Steroids should not be used as they can potentially injure
cartilage/labrum when injected directly. • Fig. 20.49Anterior Sagittal Approach. Transducer in position for in-
plane approach to hip joint.
Injectate Volume
• 1 to 3 mL directly into the labrum. Extra can be placed
intra-articularly.

Technique Anterior (Indication: Anterior Tears)

Patient Position
• S upine with pillow under the head and appropriate drap-
ing to expose the inguinal region
Clinician Position
• Standing or sitting on affected side of patient
Transducer Position
• Aligned with the long axis of the thigh for an inferior
approach (Fig. 20.49), the femoral neck for an inferior-
oblique approach, or transverse to the thigh for a lateral L
approach
Needle Position AC FH
• In plane, inferior or inferior-lateral to superior or supe-
rior-medial approaches, depending on the target area
Target
• Cleft or defect most commonly visualized at the junction
• Fig 20.50 Ultrasound image with patient supine, transducer aligned
of the acetabulum and the hyperechoic labrum in the with long axis of thigh, and in-plane injection approach with path of
anterior portion of the joint (Fig. 20.50) needle directed at labrum. Needle (arrow), normal acetabulum (AC),
labrum (L) and femoral head (FH).
PEARLS AND PITFALLS
• In the setting of osteoarthritis (OA) of the hip, coexisting
“labral tears” are commonly asymptomatic and not the Clinician Position
cause of a patient’s pain. • I f lateral, standing behind the patient
  
Transducer Position
• Aligned with the long axis of the lateral greater trochanter
(Fig. 20.51A)
Technique Lateral (Indication: Superior Lateral and • For superior-lateral target, position the probe just ante-
Posterior Superior Tears) rior and superior to the greater trochanter
Patient Position • For posterior-superior target, position the probe just pos-
• Lateral decubitus with pillow between the knees terior and superior to the greater trochanter
 CHAPTER 20 Hip Injection Techniques 347

Needle Position
• I n plane, inferior lateral-to-superior medial approach
Target
• Cleft or defect most commonly visualized at the junction
of the acetabulum and the hyperechoic labrum in the
anterior-lateral or posterior-lateral portion of the joint
(see Fig. 20.51B)

A
PEARLS AND PITFALLS
• H
 aving the probe slightly anterior or posterior to the
greater trochanter will provide better needle clearance
to access the labrum.
  

Perineural
Sciatic Nerve

KEY POINTS
• S ciatic tunnel syndrome refers to entrapment and
L
neuralgia of the sciatic nerve in the gluteal triangle.
Sciatic tunnel may result in chronic neuralgic pain in the A
posterior thigh.
• Care should be taken to avoid intraneural or FH
intravascular injection.
• With expertise, circumferential hydrodissection could be B
attempted.
   • Fig. 20.51 (A) Lateral labrum ultrasound setup. (B) Lateral labrum
ultrasound injection in plane. Needle (arrow), normal acetabulum (A),
labrum (L), and femoral head (FH).

Pertinent Anatomy
• M
 edium-frequency linear transducer or low-frequency
• Th
 e sciatic nerve is formed from the anterior divisions of
curvilinear transducer, as appropriate for the individual’s
L4-S3.
body habitus
• The nerve exits through the greater sciatic foramen,
and traverses below (or sometimes through) the piri-
Common Injectates
formis and gluteus maximus muscles. It then courses
• F or nerve block: local anesthetic, plus or minus
superficial to the quadratic femoris, lateral to the ischial
corticosteroid
tuberosity.
• For hydrodissection: mixture of normal saline and local
• The sciatic nerve runs distally in the posterior thigh, ante-
anesthetic solution, 5% dextrose solution, or platelet
rior to the biceps femoris, prior to entering the popliteal
lysate solution
triangle, where the sciatic nerve divides into the common
fibular and tibial nerves branch apart (see Fig. 20.37).
Injectate Volume
• F or nerve block: 5 to 15 mL
Common Pathology
• For hydrodissection: 10 to 15 mL
• E ntrapment of the sciatic nerve in the gluteal triangle can
occur at the greater sciatic notch, ischial tunnel (between
Technique
the quadratus femoris and proximal hamstring), and
Patient Position   
at the level of the piriformis. Associated pathology at
• P rone (Fig. 20.52)
these sites of entrapment can diminish the sciatic nerve’s
• Alternate: side-lying with hip flexed, internally rotated
mobility, resulting in sciatic neuropathy.
and adducted
• Piriformis syndrome, ischiofemoral impingement, and
Clinician Position
hamstring pathology can cause symptoms related to sci-
• Seated or standing on the side of the intended injection
atic nerve entrapment.
Transducer Position
• Short axis to the sciatic nerve, at the subgluteal level.
Equipment
Nerve should be identified between the gluteus maximus
• Needle size: 22- to 25-gauge, 2- to 3.5-inch needle
and the quadratus femoris
348 SEC T I O N I I I Atlas

Needle Position PEARLS AND PITFALLS

• I n plane to the transducer, lateral-to-medial approach
Target • T he lateral recumbent position may allow improved
access to the nerve in individuals with larger body
• Sciatic nerve perineural sheath. Should see perineural
habitus.
spread surrounding the nerve circumferentially (Fig. • The sciatic nerve is located in the medial subgluteal
20.53) region with the inferior gluteal artery, and the lateral-
to-medial approach is less likely to have unintentional
intravascular injection.
• If needed, the sciatic nerve can also be approached
long axis to the nerve, in plane.
  

  

Lateral Femoral Cutaneous Nerve Block

KEY POINTS
• T
 he lateral femoral cutaneous nerve (LFCN) is a purely
sensory nerve, and entrapment or injury to the nerve
results in meralgia paresthetica.
  

Pertinent Anatomy
• Th
 e lateral femoral cutaneous nerve (LFCN) is a purely
sensory nerve formed by the L2–L3 nerve roots and
arises directly from the lumbar plexus.
• The nerve traverses along the lateral border of the ilio-
psoas muscle into the pelvis. It exits the pelvis under the
inguinal ligament, typically 1–4 cm medial to the ASIS.
• Fig. 20.52 Transverse Approach. Prone with transducer in position After exiting the pelvis, it enters the thigh, typically
for in-plane sciatic perineural injection. piercing the fascia lata.

G.max

QF
Sciatic N.

• Fig. 20.53 Short-axis ultrasound image of the sciatic nerve (Sciatic N), between the gluteus maximus
(G.Max.) and quadratus femoris (QF) muscles. Arrow demonstrates the needle path in plane for sciatic
nerve block.
 CHAPTER 20 Hip Injection Techniques 349

• T he LFCN can vary in its course, and, in some cases,

will cross the iliac crest lateral to the ASIS. The
LFCN typically divides into an anterior and poste-
rior branch distal to the inguinal ligament. However,
the nerve can be found to form branches proximal to
the ligament.
• After the nerve travels under the inguinal ligament, the
LFCN or the anterior branch will travel in the superficial
triangular space between the sartorius and TFL.
• The most common entrapment site is at the inguinal
ligament (see Fig. 20.2).

Common Pathology
• M eralgia paresthetica is a solely sensory mononeuropa-
thy of the LFCN. The nerve is commonly entrapped
as it exits the pelvis under the inguinal ligament.
Common symptoms include paresthesias, anesthesia,
or dysesthesias.
• Scanning from the lateral-to-medial direction in the
short axis can help locate the hyperechoic round or ellip-
tical nerve. It is typically best visualized between the sar-
torius and TFL, just lateral to the ASIS. • Fig. 20.54Patient is supine, transducer short axis to nerve, a few centi-
• This nerve can often be injured/compressed follow- meters distal to the ASIS, for in-plane lateral-to-medial LFCN nerve block.
ing anterior approach for a total hip replacement ASIS, Anterior superior iliac spine; LFCN, lateral femoral cutaneous nerve.
(THR).

Equipment
• N eedle size: 22- to 25-gauge, 1.5- to 3.5-inch needle
• Medium- to high-frequency linear transducer
Sar
Common Injectates
TFL
• F or nerve block: local anesthetic, plus or minus corticosteroid
• For hydrodissection: mixture of normal saline and local
anesthetic solution, 5% dextrose solution, or platelet
lysate solution

Injectate Volume
• F or nerve block: 2 to 5 mL
• For hydrodissection: 5 to 10 mL

Technique
Patient Position • Fig. 20.55 Ultrasound image, with patient supine, short axis to the
• S upine distal anterior superior iliac spine with needle in plane approaching lat-
Clinician Position eral femoral cutaneous nerve (LFCN; arrow). Arrowheads, needle; Sar,
• Seated or standing on the side of the intended injection sartorius muscle; TFL, tensor fascia lata.
Transducer Position
• Short axis to the LFCN, transverse to the body (Fig.
PEARLS AND PITFALLS
20.54). Alternation between short axis and long axis is
helpful to confirm needle tip location. • T he nerve is located just deep to the fascial plane,
Needle Position typically between the sartorius and TFL. Given the very
• In plane to the transducer, lateral-to-medial or distal-to- superficial nature or the course of the nerve, do not
look too deep when performing sonographic evaluation.
proximal approach • When performing the injection, care must be made to
Target not approach too steeply.
• Nerve sheath, may alternate between long and short axis   
From: Atlas, Furman41 Atlas, Jacobson.9,10
to confirm perineural spread during hydrodissection of
the nerve (Fig. 20.55)   
350 SEC T I O N I I I Atlas

Obturator Nerve Hydrodissection

KEY POINTS
Entrapment of the obturator nerve is an under-recognized
cause of groin, thigh, and knee pain.
  

Pertinent Anatomy
• Th
 e obturator nerve receives contribution from the L2 to
L4 nerve roots. It is both a sensory and motor nerve.
• The obturator nerve divides in the pelvis into the anterior
and posterior branches.
• The anterior branch traverses between the adductor
longus and adductor brevis muscles, and innervates the
gracilis, adductor longus, and adductor brevis.
• The posterior branch travels between the adductor longus • Fig. 20.56 Supine Position With Hip Externally Rotated and
and adductor magnus, and innervates the adductor magnus. Flexed. Transducer positioned in transverse plane for lateral-to-medial
in-plane approach.

Common Pathology
• Th
 e obturator nerve is susceptible to injury or entrap-
ment in the obturator foramen, particularly in the setting
of pelvic fracture. Large adductor strains can also result
in nerve injury or compression neuropraxia.
ALM 1
• Adductor spasticity often results from various neurologic
diseases, which can interfere with function, mobility, and
activities of daily living (ADLs). Neurolysis of the obtu-
rator nerve is often an effective treatment.
ObN Ant.Br.
Pectineus 2
Equipment
• N eedle size: 22-gauge, 2- to 3.5-inch needle ABM
• Medium- to high-frequency linear transducer. Low-
frequency curvilinear transducer, as appropriate for the
individual’s body habitus. 3

Common Injectates
• F or nerve block: local anesthetic, plus or minus ObN Post.Br. AMM
corticosteroid
4
• For hydrodissection: mixture of normal saline and local
anesthetic solution, or 5% dextrose solution or platelet • Fig. 20.57 Ultrasound image represents a short-axis view of the obtura-
tor nerve branches (ObN Ant.Br.) in the medial inguinal region: anterior and
lysate solution posterior branches. Long arrows demonstrate the in-plane path of needle
for a perineural injection of each nerve branch. ABM, Adductor brevis
Injectate Volume muscle; ALM, adductor longus muscle; AMM, adductor magnus muscle.
• F or nerve block: 2 to 5 mL
• For hydrodissection: 5 to 10 mL • N eedle approach: lateral to medial or medial to lateral
• Target: anterior and posterior branches of the obturator
Technique nerve. Should note perineural spread surrounding the
Patient Position nerve circumferentially in the planes between the mus-
Supine with hip externally rotated and flexed, with knee flexed, cles (Fig. 20.57).
as well
PEARLS AND PITFALLS
Clinician Position
• S eated or standing on the side of the intended injection • T he obturator artery must be identified and avoided
Transducer Position during the injection.
• Short axis to the obturator nerve and parallel to the • Nerve stimulation, in addition to ultrasound, can aid in
localization of the nerve, particularly in phenol neurolysis
inguinal ligament, making sure to stay medial to the for spasticity.
femoral vessels and nerve (Fig. 20.56) • Injections can be performed to the anterior branch,
Needle Position posterior branch, or both branches, as indicated.  
• In plane to the transducer   
 CHAPTER 20 Hip Injection Techniques 351

Posterior Femoral Cutaneous Nerve • L ateral-to-medial approach

Target
• Perineural to the posterior femoral cutaneous nerve (Fig.
KEY POINT 20.59)
• C
 ould be an overlooked cause of ischial or “sit-bone”
pain. PEARLS AND PITFALLS
  
• N erve can be injected with very small volume of
anesthetics for diagnostic confirmation.
• Nerve can be treated with larger-volume
Pertinent Anatomy hydrodissection.
• Th
 e posterior femoral cutaneous nerve is a small sensory
  
nerve that innervates the posterior thigh.
• The nerve is deep to the gluteus maximus muscle, and
superficial to the sciatic nerve and biceps femoris. The
nerve travels in close proximity and medial to the sciatic Pudendal Nerve Block
nerve. The nerve is seen departing from the sciatic nerve
and gradually surfacing up to the cutaneous layer when KEY POINTS
the transducer is relocated distally (see Fig. 20.37).
• Internal pudendal artery should be visualized prior to
Common Pathology the procedure; it is located lateral to the pudendal
nerve.
• Th
 e nerve will often have a normal appearance but could
be considered painful for those patients who have ischial   
(sit-bone), pain with or without associated proximal
hamstring pathology.

Equipment
• N eedle: 22-gauge, 2.5- to 3.5-inch
• Curvilinear or linear transducer, depending on body
habitus

Common Injectates
• F or nerve block: local anesthetic, plus or minus
corticosteroid
• For hydrodissection: mixture of normal saline and local
anesthetic solution, or 5% dextrose solution or platelet
lysate solution

Injectate Volume
• F or nerve block: 2 to 5 mL • Fig. 20.58 Prone or Side Lying Position. Transducer transverse to
• For hydrodissection: 5 to 10 mL gluteal crease at the level of the ischial tuberosity for in-plane approach.

Technique
Patient Position
• P rone with a pillow under the head and under the pelvis
(Fig. 20.58)
• Alternatively, side-lying on unaffected side, with hip flex-
ion to bring the structure more superficial and in better
view GM
Clinician Position
• Standing or seated on affected side of patient or behind 2
the patient if side-lying SN
Transducer Position IT
• Transverse near the gluteal crease at the level of the ischial
tuberosity, similar to proximal hamstring imaging (see
Fig. 20.58) • Fig. 20.59 Ultrasound in long axis showing long arrow as needle path
Needle Position of posterior femoral cutaneous nerve injection. GM, Gluteus maximus;
• In plane IT, ischial tuberosity; SN sciatic nerve.
352 SEC T I O N I I I Atlas

Pertinent Anatomy
• Th
 e nerve is deep to the gluteus maximus muscle and sacro-
tuberous ligament, and superficial to the sacrospinous liga-
ment. The ischial spine is found lateral to those structures.

Common Pathology
• E
 ntrapment of the pudendal nerve may cause pain and numb-
ness in the genital area. There are four subtypes of entrapment
based on possible sites of entrapment: (1) below the pirifor-
mis muscle as the pudendal nerve exits greater sciatic notch;
(2) between the sacrospinous and sacrotuberous ligaments
(this is the most common cause of nerve entrapment); (3)
inside Alcock’s canal; and (4) at the terminal branches.42

Equipment
• N eedle: 22-gauge, 2.3- to 3.5-inch needle
• Linear or curvilinear ultrasound transducer, depending
on the patient’s body habitus

Common Injectates
• F or nerve block: local anesthetic, plus or minus corticosteroid
• For hydrodissection: mixture of normal saline and local • Fig. 20.60 Patient is prone, for a short-axis, in-plane approach.
anesthetic solution or 5% dextrose solution, or platelet Transducer transverse to nerve at the level of the ischial spine.
lysate solution

Injectate Volume
• F or nerve block: 2 to 5 mL
• For hydrodissection: 5 to 10 mL
GM
Technique
Patient Position STL
• S ide-lying with the area to be blocked facing upwards a
and knees slightly flexed; pillows under the head and SSL
between the legs IS
• Prone with soft support under the pelvis (Fig. 20.60)
Clinician Position
• Fig. 20.61Ultrasound in long axis showing long arrow as needle path
• Standing or seated of pudendal nerve injection. The left side of the picture is medial. a,
Transducer Position Artery; GM, gluteus maximus; IS, ischial spine; SSL, sacrospinous liga-
• Transverse along the ischial spine ment; STL, sacrotuberous ligament.
Needle Position
• In-plane, medial-to-lateral approach or posterior/trans- Hip Injection Techniques
gluteal approach
Target Fluoroscopy Guided
• Space interposed by the sacrotuberous and sacrospinous Femorocetabular Joint
ligaments (most common site of entrapment) (Fig. 20.61)
KEY POINTS
• Alcock’s canal, also called pudendal canal (second most
common site of entrapment) • A uthors’ preferred approach is placing the needle using
• Anywhere along pudendal nerve at possible entrapment ultrasound guidance with the curvilinear transducer and
sites, beginning with pudendal nerve exiting from greater confirming with fluoroscopy.
• For osteoarthritis, ideally, you want to inject to obtain
sciatic notch to the terminal branches weight-bearing flow into the joint.
• For adhesive capsulitis, intra-articular capsular flow is
PEARLS AND PITFALLS preferred.
• Weight-bearing IA injection can be used for labral
• S ciatic nerve should be visualized prior to procedure; degeneration; however, for symptomatic labral tears,
it is located lateral to pudendal nerve. direct labral injection is preferred.
• Internal pudendal artery should be visualized prior to • Avoid placing injectate in the retinaculum of Weitbrecht
procedure; it is located lateral to the pudendal nerve. (see Fig. 20.1). Injecting here may limit weight-bearing
  
articular flow.
     
 CHAPTER 20 Hip Injection Techniques 353

Pertinent Anatomy and Common Pathology PEARLS AND PITFALLS

• Refer to ultrasound section
• F or weight-bearing placement, having a slight bend in
the needle can help with redirecting the needle.
Equipment
• Using 10–15 lb of inferior traction from an assistant
• C -arm fluoroscopy during needling guidance and injection can help expand
• Typically, 25- or 22-gauge, 3.5-inch spinal needle is the joint space and improve weight-bearing flow. This
sufficient can also improve patient comfort.
• In larger or taller patients, may require a 25-gauge, 4.69- • Loss of resistance once under the acetabulum can
be felt and a small amount of contrast can confirm IA
inch needle or 22-gauge, 5-inch needle
flow. If there is a significant amount of resistance during
• Contrast the injection or a soft tissue contrast dye pattern, then
advance the needle further and/or add slightly more
Common Injectates traction.
• L ocal anesthetics for diagnostics, corticosteroids • For capsular distention discussion, see anterior hip
capsule distention in ultrasound section.
• Prolotherapy, hyaluronic acid, orthobiologics (PRP,
bone marrow concentrate, micronized adipose tissue,   
etc.).
• For capsular distention. local anesthetic and normal
saline +/– corticosteroid, and/or orthobiologics such as
platelet-poor plasma, platelet lysate, etc. Technique: Lateral Approach
Patient Position
Injectate Volume • L ateral decubitus with pillow between the knees (Fig.
• F or weight-bearing IA injection: 2 to 5 mL. 20.63A)
• For capsular distention: 10 to 20 mL. Stop when getting • An alternative approach is to have the patient supine
backflow into the syringe to avoid capsular rupture. Most with the legs extended
hip capsules max out close to 16 mL, but some may tol- Clinician Position
erate close to 20 mL. • If lateral, standing behind the patient
• If supine, standing on ipsilateral side of the patient
Technique: Anterior Approach C-Arm Position Fluoroscopy Technique
Patient Position • AP projection visualizing the femoral acetabular joint,
• S upine leg extended (Fig. 20.62). the greater trochanter, and lateral soft tissue
Clinician Position • May use lateral projection to make sure needle is
• Standing on ipsilateral side of the patient maintained in central plane from anterior to poste-
C-Arm Position Fluoroscopy Technique rior. Option to align both the left and right joints
• Anteroposterior (AP) projection where the greater completely or offset them with rotation of the
trochanter, femoral head, and joint space are C-arm. If they are offset, then the smaller joint is the
visualized joint being injected due to its closer position to the
Needle Position transducer
• For diagnostic and therapeutic injections, can start Needle Position
over the lateral-inferior femoral head, needle in a • Start just anterior and superior to the greater trochanter,
direct anterior-to-posterior approach directed toward but below the lateral acetabular rim
the lateral-inferior femoral head or mid-femoral • Needle trajectory should be from inferior to superior
neck toward the lateral joint opening
• For weight-bearing flow: start anterior and slightly Target
medial to the greater trochanter (see Fig. 20.62B) • Touch the needle onto the bone cortex on the lateral
• Advance the needle with a superior, slightly medial femur just under the acetabulum. The needle should
trajectory be viewed directly lateral to the femur once the needle
Target touches down onto the periosteum surface
• For capsular flow (diagnostic and therapeutic intra- • Advance or “walk” the needle with the bevel pointed
articular injections), can aim at lateral-inferior femoral upward under the acetabulum, superior to the lateral
head or, for the superior, mid-femoral neck (see Fig. femoral head for IA flow on the weight-bearing surface
20.62D) of the joint (see Fig. 20.63B)
• For weight-bearing flow: advance the needle to the bone Technique: Posterior Approach
cortex on the inferior/central-lateral femoral head below Patient Position
the acetabulum. Then, “walk” the needle along the femur • Prone
superior to enter the joint under the acetabulum (see Fig. • Will likely need hip internal rotation to move the greater
20.62C). trochanter out of the needle trajectory. To achieve this,
354 SEC T I O N I I I Atlas

A B

C D
• Fig. 20.62 (A) Hip anterior fluoroscopy setup. (B) Hip anterior fluoroscopy needle start point. (C) Hip
anterior fluoroscopy weight-bearing target with contrast. (D). Hip anterior fluoroscopy target capsular
distention.

PEARLS AND PITFALLS

bend the patient’s leg at the knee and rotate from the
• F or weight-bearing placement, having a slight bend in lower leg outwards (Fig. 20.64A)
the needle can help with redirecting the needle.
• This is a great approach to get weight-bearing flow.
Clinician Position
Inferior traction here can help to open the joint, after which • Standing ipsilateral side of the patient
a small amount of contrast can be injected to confirm flow. Transducer Position or C-Arm Position Fluoroscopy
• Needle placement is key to ensure there is not much Technique
anterior or posterior advancement of the needle until it • AP projection where the greater trochanter, femoral
reaches the periosteum. Can use the lateral projection
of the joint with the C-arm to confirm the needle
head, and joint space are visualized
trajectory and adjust as needed. Needle Position
• Consider the use of ultrasound for the needle • Start posterior and slightly medial to the greater trochan-
placement; then make final adjustments with ter. Start a little more inferior than the anterior approach
fluoroscopy and confirm an IA flow pattern. (see Fig. 20.64B)
• This is not an ideal approach for hip capsular distention.
• Needle trajectory should be superior and slightly
   medial
 CHAPTER 20 Hip Injection Techniques 355

ant

post

B C
• Fig. 20.63 (A) Hip fluoroscopy lateral IA setup. (B) Hip fluoroscopy lateral IA target AP. (C) Hip fluoroscopy
lateral IA target lateral.

Target Pubic Symphysis

• F or IA flow: aim to touch the periosteum on the infe- Key Points and Pertinent Anatomy and Common Pathology
rior/central-lateral femoral head below the acetabulum. • Refer to ultrasound section
Then, advance or “walk” the needle along the femur
superior to enter the joint under the acetabulum (see Equipment
Fig. 20.64C). • C -arm fluoroscopy
• For capsular flow, aim for the superior femoral neck mid • 25- gauge, 2-inch spinal needle
portion from lateral to medial.
Common Injectates
• O
 rthobiologics (PRP, bone marrow concentrate) and
prolotherapy
PEARLS AND PITFALLS
• T here is more acetabular coverage posterior, so this Injectate Volume
approach is more difficult to obtain good weight- • F or IA injection: 0.5 to 1 mL
bearing flow. As such, this is not the preferred approach
• For ligamentous injection: 1 to 3 mL
for IA biologics.
• This is the preferred approach when there is a desire
to distend posterior hip capsule due to tightness and Technique
adhesions that limit hip internal rotation and hip flexion. Patient Position
• Having a slight bend in the needle can help with • S upine
redirecting the needle.
Clinician Position
   • Standing on either side of the patient
356 SEC T I O N I I I Atlas

A C

B
• Fig. 20.64 (A) Hip posterior fluoroscopy setup. (B) Hip posterior fluoroscopy needle start point. (C) Hip
posterior fluoroscopy weight-bearing target with contrast.

Transducer Position or C-Arm Position Fluoroscopy • S uperior and inferior pubic ligaments: Start at the far
Technique inferior or superior aspect of the joint. Advance the
• A P projection with the pubic symphysis centered needle to the superior or inferior edge of the joint.
Needle Position Can be advanced slightly deep to the joint, but not
• For IA or intradiscal injection, start directly over the joint more than a few millimeters (see Fig. 20.65C).
space in the middle from superior and anterior positions • Posterior pubic ligament: We do not recommend
(Fig. 20.65A). injecting for safety. A lateral fluoroscopic view would
• For the surrounding ligaments, you can use the same start- be required to ascertain depth but is difficult to
ing position and redirect the needle superior or inferior visualize.
down to the periosteum and ligamentous attachments.
Target PEARLS AND PITFALLS
• For intradiscal needle placement, guide the needle
• P ubic symphysis dysfunction is usually a problem of
directly into the center of the disc under intermittent stability; so targeting the ligaments in addition to IA
fluoroscopy. The depth can vary, but is typically less than injection alone is usually recommended.
2 cm. To confirm, inject a small amount of contrast to • Be sure to keep the needle over the joint capsule or
show IA flow. Should notice tissue resistance changes (see bony surfaces. If in the disc, do not advance the needle
Fig. 20.65B). more than 1–2 cm to avoid infiltrating the pelvis.
• Advancing through or past the joint can result in
• For ligament targets, touch down on the joint capsule as infiltration of the bladder. Ultrasound can be used for
described above. the initial needle placement to prevent injury to the
• Anterior pubic ligament: Inject the anterior surface of bladder.
the joint and “pepper” the area by moving superior, • Assess for associated sacroiliac pathology.
inferior, and lateral attachments on the pubic rami.   
 CHAPTER 20 Hip Injection Techniques 357

A B

C D
• Fig. 20.65(A) Pubic symphysis fluoroscopy needle start. (B) Pubic symphysis IA. (C) Pubic symphysis
fluoroscopy superior ligaments. (D) Anterior ligaments.

Ligamentum Teres and Transverse Acetabular Pertinent Anatomy

Ligament • Th
 e ligamentum teres is also known as the ligament of
the head of the femur or round ligament of the femur. It
KEY POINTS
is a pyramidal ligament that originates on the posteroin-
ferior acetabulum and the transverse ligament. It inserts
• T his is a highly advanced injection that requires on the central femoral head at the fovea. It has two bands
both ultrasound and fluoroscopy to inject safely and and is surrounded by a synovial sheath similar to the
accurately. Only the injectionist who has significant
experience with using both imaging modalities should
anterior cruciate ligament (ACL) in the knee.
attempt this injection. • The ligament acts as a secondary stabilizer of the hip, and
• This ligamentum teres origin is off the transverse prevents subluxation at extremes of motion, particularly
acetabular ligament, and both are often treated at the in mid-flexion, abduction/adduction, and rotation.
same time, as the injection techniques are similar. • Branches of the obturator artery enter inferomedial and
   penetrate the middle third of the ligament. The ligament
358 SEC T I O N I I I Atlas

does have proprioceptive and nociceptive free nerve end- Needle Position
ings throughout.54 • H aving a curve at the needle tip can help with redirecting
• The ligamentum teres origin is off the transverse acetabu- the needle.
lar ligament—a strong band of tissue at the inferior ace- • Start 2 to 3 cm lateral to the femoral nerve to pass deep
tabulum that is essentially an extension of the acetabular to the nerve and vessels when advanced to the trajectory
labrum and provides part of the load-bearing surface for (see Fig. 20.66C).
the femoral head (see Fig. 20.3).55 • Mark the trajectory by placing a needle on the skin or
using a surgical marker. Before piercing the skin, take an
Common Pathology AP image using the C-arm to ensure that the ultrasound
• I njury to the ligamentum teres and transverse acetabular image corresponds with the inferior half of the femur
ligament can be traumatic, iatrogenic, or associated with (see Fig. 20.66B).
hyperlaxity or acetabular morphology. • Ensure that the needle is staying in the transverse plane
• Trauma can be acute, such as a fall or motor vehicle acci- in relation to the hip. Check this relationship by taking
dent, or repetitive, and injury to the ligamentum teres an AP fluoroscopy picture periodically as you advance
has been associated with certain sports or activities such the needle under ultrasound guidance.
as ballet, figure skating, gymnastics, and martial arts. • Once the needle tip is in the joint as far as you can see
• Iatrogenic injury has been reported with hip arthroscopy, with ultrasound, go to the fluoroscopic view.
which requires a traction force on the hip and can cause • Keep the needle close to the femoral head, with the curve
ligamentum teres and other capsular ligamentous injury. going posterior to insure going deep into the joint while
• Hip dysplasia, in which the hip socket is shallower, also avoiding significant contact with the articular sur-
can cause more stress on the ligamentum teres. face to prevent damage to the cartilage.
• One study found that, in over 2000 hip arthroscopies for Target
femoral acetabular impingement, the ligamentum teres • Ligamentum teres: Under AP fluoroscopy, advance or
was found to be frayed or partially torn in 88% and com- “walk” the needle along the femoral head and aim at the
pletely torn in 1.5%, suggesting that ligamentum teres inferior aspect of the acetabular wall at the level of the
injury can be associated with labral tears.56 fovea on the femur or just slightly inferior. Once the nee-
dle is at the target against the acetabular wall, pull back
Equipment about 1 to 2 mm.
•  urvilinear ultrasound probe
C • Obtain a lateral view where the needle should be
• C-arm fluoroscopy about halfway across the femoral head.
• Typically, a 22-gauge, 5-inch spinal needle is sufficient. • A small amount of contrast should be injected showing
• Contrast media central flow along the ligament in lateral and AP views
without any IA contrast flow (see Fig. 20.66D and E).
Common Injectates • Transverse acetabular ligament: Aim at the inferior aspect
• L ocal anesthetics for diagnostics of the acetabular wall.
• Prolotherapy, orthobiologics (PRP, bone marrow con- • Obtain a lateral view in which the needle should be
centrate, etc.) in the central anterior third of the femoral head from
• Corticosteroids should not be injected directly into a anterior to posterior.
ligament • A small amount of contrast should be injected, showing
central flow along the ligament in lateral and AP views
Injectate Volume without any significant joint disbursement (Fig. 20.67B).
• 1 to 3 mL
PEARLS AND PITFALLS
Technique
Patient Position • T his is an advanced injection, so do not attempt unless
• S upine, leg extended, externally rotate the hip as much as you have good hip ultrasound and fluoroscopy-guided
needle experience.
the patient is able (Fig. 20.66A).
• It is much safer to use ultrasound to identify the
Clinician Position neurovascular structures.
• Standing on ipsilateral side of the patient. • The patient needs to have good external rotation of the
Transducer Position or C-Arm Position Fluoroscopy hip, and if unable to, position the hip (i.e., patients with
Technique severe hip arthritis, bone spurs, or lack of external rotation);
this injection can be difficult or impossible to perform.
• Set up the fluoroscopy image. Obtain a true AP projec-
• Make sure that the needle stays along the femoral head
tion with contralateral obliquity of the C-arm, in which to ensure that it does not travel into the joint space. The
the femoral head, acetabulum, and joint space are visual- curved needle helps to advance deep into the joint.
ized and the posterior and anterior rims of the acetabu- • When injecting into the ligament, patients will often have
lum are aligned (see Fig. 20.66A and B). reproduction of some of their typical pain if the ligament
is injured.
• With curvilinear ultrasound transducer, identify the infe-
rior aspect of the femoral acetabular joint. Identify the   
femoral artery, vein, and nerve.
 CHAPTER 20 Hip Injection Techniques 359

0
A N
1
B
2
AC
3

FH 4

C 6

E
• Fig. 20.66 (A) Ligamentum teres setup. (B) Ligamentum teres needle trajectory. (C) Ligamentum teres
ultrasound. (D) Ligamentum teres fluoroscopy target AP with contrast. (E) Ligamentum teres fluoroscopy
target lateral with contrast. AC, Acetabulum, FH, femoral head.
360 SEC T I O N I I I Atlas

A B
• Fig. 20.67 (A) Transverse acetabular ligament needle trajectory. (B) Transverse acetabular ligament target.

Hip Capsular Ligaments

KEY POINTS
• C an be used to manage ligament laxity, especially in the
presence of labral tears, traumatic injuries, connective
tissue disorders, and joint arthritis.
• Injection technique is very similar to IA injections, except
just superficial to the joint. The goal is to inject multiple
sites along the ligaments/capsule.
  

Pertinent Anatomy and Common Pathology

• Refer to ultrasound section

Equipment
• C -arm fluoroscopy
• Typically, 25- or 22-gauge, 3.5-inch spinal needle is suf-
ficient. In larger or taller patient, a 25-gauge, 4.69-inch
needle or 22-gauge, 5-inch needle is required
• Contrast dye
• Fig. 20.68 Anterior Capsule Target.
Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con- Clinician Position
centrate, etc.). • S tanding on ipsilateral side of the patient.
• Steroids should not be used as they can potentially injure Transducer Position or C-Arm Position Fluoroscopy
ligaments when injected directly. Technique
• AP projection in which the greater trochanter, femoral
Injectate Volume head, and joint space are visualized.
• 2 to 4 mL Needle Position
• Start anterior and slightly medial to the greater trochanter.
Technique: Anterior Approach Target
Patient Position • Femoral neck and inferior portion of femoral head (Fig.
• Supine, leg extended. 20.68).
 CHAPTER 20 Hip Injection Techniques 361

• A
 dvance needle to bone; then withdraw 1 mm and inject,
“peppering” a broad area of the capsule.

PEARLS AND PITFALLS

• B e sure to always keep the needle over the femoral
neck.
• Avoid injecting too far medially in order not to injure the
neurovascular structures.
• Can inject a small amount of contrast to make sure that
no vascular uptake is observed and to ensure that there
is no IA flow.
  

Technique: Lateral Approach

Patient Position
• L ateral decubitus, with pillow between the knees
• Alternative: supine, legs extended
Clinician Position
• If lateral decubitus, standing behind the patient
• If supine, standing on ipsilateral side of the patient
• Fig. 20.69 Lateral Capsule Target.
Transducer Position or C-Arm Position Fluoroscopy
Technique
• AP projection visualizing the femoral acetabular joint,
the greater trochanter, and the lateral soft tissue.
• May use lateral projection to make sure needle is main-
tained in central plane from anterior to posterior. Option to
align both acetabulum completely or offset them. If they are
offset, then smaller joint will be closest to the transducer.
Needle Position
• Start just anterior and superior to the greater trochanter,
but below the lateral acetabular rim. Needle trajectory
should be from superior to inferior toward the lateral
femoral neck.
Target
• Femoral neck and inferior portion of femoral head (Fig.
20.69).
• Advance needle to bone, then withdraw 1 mm and inject,
“peppering” a broad area of the capsule.

PEARLS AND PITFALLS

• B e sure to always keep the needle over bone.
• Can inject a small amount of contrast to make sure that
no vascular uptake is observed and to ensure that there
is no IA flow. • Fig. 20.70 Posterior Capsule Target.
  

Transducer Position or C-Arm Position Fluoroscopy

Technique: Posterior Approach Technique
Patient Position • A P projection in which the greater trochanter, femoral
• P rone head, and joint space are visualized
• Will likely need hip internal rotation to move the greater Needle Position
trochanter out of the needle trajectory. To achieve this, • Start posterior and slightly medial to the greater
bend the patient’s leg at the knee and rotate from the trochanter
lower leg outwards. Target
Clinician Position • Femoral neck and inferior portion of femoral head (Fig.
• Standing ipsilateral side of the patient 20.70).
362 SEC T I O N I I I Atlas

• A
 dvance needle to bone, then withdraw 1 mm and inject,
“peppering” a broad area of the capsule.

PEARLS AND PITFALLS

• B e sure to always keep the needle over the femoral neck.
• Avoid injecting too far medially in order not to injure the
neurovascular structures.
• Can inject a small amount of contrast to make sure that
no vascular uptake is observed and to ensure that there
is no IA flow.
  

Femoroacetabular Labrum
KEY POINTS
• A uthors’ preferred approach is placing the needle under
ultrasound guidance and confirming needle placement
with fluoroscopy.
• The injection technique is similar to IA, except you want A
to target the acetabulum and the specific area of tear
based on MRI findings.
• Will want to target the location of the labral tear (anterior,
superior, or posterior), depending on the location of the
labral tear on diagnostic MRI or ultrasound.
  

Pertinent Anatomy and Common Pathology

• Refer to ultrasound section

Equipment
• C -arm fluoroscopy
• Typically, 25- or 22-gauge, 3.5-inch spinal needle is suf-
ficient. In larger or taller patients, a 25-gauge, 4.69-inch
needle or 22-gauge, 5-inch needle is required
• Contrast dye

Common Injectates
• A nesthetics for diagnostics, prolotherapy, orthobiologics
B
(PRP, bone marrow concentrate, etc.).
• Steroids should not be used, as they can potentially injure • Fig. 20.71
(A) Hip fluoroscopy anterior superior labrum. (B) Hip fluo-
cartilage/labrum when injected directly. roscopy anterior lateral labrum.

Injectate Volume • A im to touch the needle on the bone cortex on the infe-
• 1 to 2 mL directly into the labrum rior femoral head and then “walk” the needle along the
Technique: Anterior Approach
femur superiorly to end at the acetabulum.
Patient Position
• Once the needle is touching the acetabulum, withdraw
• S upine leg extended. the needle 1 mm to inject the labrum.
Clinician Position • Confirm labral flow with a small amount of contrast.
• Standing on ipsilateral side of the patient.
Transducer Position or C-Arm Position Fluoroscopy
Technique PEARLS AND PITFALLS
• AP projection in which the greater trochanter, femoral • Injectionist can often feel more tissue resistance when
head, and joint space are visualized. injecting the labrum versus IA.
Needle Position • Inject a small amount of contrast to confirm desired flow.
• Start anterior and slightly medial to the greater trochanter. • There may be significant resistance and patient
discomfort when trying to inject more than 1–2 mL into
Target a labrum. Can place any extra injectate into the joint.
• Target the pathology in the superior anterior acetabulum
  
(Fig. 20.71).
 CHAPTER 20 Hip Injection Techniques 363

B C
• Fig. 20.72 (A) Hip fluoroscopy lateral labrum setup. (B) Hip fluoroscopy lateral labrum and superior cap-
sule target in AP. (C) Hip fluoroscopy lateral labrum and superior capsule target in the lateral position.

Technique: Lateral Approach for Superior and Posterior Needle Position

Lateral Labrum • I n the lateral view, ensure that the needle starting
Patient Position position is central, anterior, or posterior, depending
• L ateral decubitus, with pillow between the knees (Fig. on where the labral injury is from diagnostic MRI or
20.72A). ultrasound.
• Alternative is to have the patient supine, legs extended. • In the AP view, start just anterior and superior to the
Clinician Position greater trochanter, but below the lateral acetabular rim.
• If lateral, standing behind the patient. Needle trajectory should be from inferior to superior
• If supine, standing on ipsilateral side of the patient. toward the lateral joint opening. Having a slight curve in
Transducer Position or C-Arm Position Fluoroscopy the needle can help guide the needle.
Technique Target
• AP projection visualizing the femoral acetabular joint, • Superior lateral labrum.
the greater trochanter, and the lateral soft tissue. • Advance the needle down to the periosteum on the lat-
• May use lateral projection to make sure needle is main- eral acetabulum, just above the joint opening.
tained in central plane from anterior to posterior. Option • Inject a small amount of contrast to ensure accurate flow
to align both acetabulum completely or offset them. If (see Fig. 20.72B and C).
they are offset, then the smaller joint will be closest to the • Confirm accurate needle placement and contrast flow in
transducer. AP and lateral projections.
364 SEC T I O N I I I Atlas

PEARLS AND PITFALLS Sports Med. 2011;30(2):349–367. https://doi.org/10.1016/j.

csm.2010.12.008.
• See anterior approach. 19. Hughes 4th C, Hasselman CT, Best TM, Martinez S, Garrett Jr
  
WE. Am J Sports Med. 1995;23(4):500–506.
20. Cross TM, Gibbs N, Houang MT, et al. Acute quadriceps
muscle strains: magnetic resonance imaging features and
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s00276-018-2172-4. 25. Hung CY, Chang KV. Ultrasound-guided percutaneous needle
5. Looney CG, Raynor B, Lowe R. Adhesive capsulitis of the hip: tenotomy with platelet-rich plasma injection for an uncommon
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doi.org/10.5435/JAAOS-21-12-749. 2019;27(2):111–112.
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2214/AJR.10.5898 51. Topcu I, Aysel I. Ultrasound guided posterior femoral cutaneous
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Ultrasound-guided posterior femoral cutaneous nerve block: a
21
Knee Injection Techniques
JOSH HACKEL, TODD HAYANO, JOHN PITTS, AND
MAIRIN A. JEROME

Ultrasound Guided Common Injectates

•  ocal anesthetics for diagnostics, corticosteroids
L
Intra-Articular • Hyaluronic acid
• Prolotherapy
KEY POINTS • Orthobiologics (platelet-rich plasma [PRP], bone mar-
row concentrate, micronized adipose tissue, etc.)
• T
 he superolateral approach is preferred for intra-
articular knee injections, especially when an effusion is
present1,2
Injectate Volume
  
• 2 to 10 mL total

Technique for Suprapatellar Recess (Author

Pertinent Anatomy Preferred)
• Th
 e knee joint is an encapsulated hinge-type synovial Patient Position
joint • Supine or seated
• The knee joint is composed of four major bones: distal
femur, proximal tibia, proximal fibula, and patella (Fig. PEARLS AND PITFALLS
21.1) • If aspirating the knee, consider 1–3 mL of local
• The bones form three articulations: anesthetic with smaller-gauge needle (27 or 30 gauge)
• Femorotibial (medial and lateral compartments) for numbing the needle track.
• Patellofemoral • Directly target the hypoechoic space between the
prefemoral and suprapatellar fat pads. Start 1–3 cm
• Tibiofibular below the probe using the ultrasound to estimate depth
• Primarily function is to allow for knee flexion and of the suprapatellar recess and align needle to be as
extension close to parallel to the probe.
• The procedure becomes more difficult without an
Common Pathology effusion:
• Can have the patient contract the quad muscle to
• Th
 e knee is susceptible to several arthritides includ- bring forth any fluid or more easily see the bursa
ing osteoarthritis (most common), rheumatoid arthri- • Can push against medial soft tissue to visualize interval
tis, crystal arthropathies, and other inflammatory between prefemoral and suprapatellar fat pads
arthropathies. • Even in a dry knee joint, fluid can often be clearly
• It is also vulnerable to direct trauma, particularly in seen at the lateral midpatella gutter (between
the patella and lateral femoral condyle). The
sports-related injuries or motor vehicle accidents. joint capsule can be traced proximally as it
• Intra-articular pathology can present with a joint effu- communicates with the suprapatellar recess
sion or synovitis. • Float the transducer on gel, as downward pressure
can compress the recess and make it more difficult
Equipment to visualize.
• Avoid injecting into the quad tendon or fat pads.
•  igh-frequency linear array transducer
H • A midpatella lateral approach can also be used targeting
• 22 to 18 gauge 1.5 to 2 inch needle for aspiration the lateral midpatella gutter. This can create a sense
• 27 to 22 gauge 1.5 to 2 inch needle for injection only of fullness or pressure, and for some will be more
• For aspirations: uncomfortable than the suprapatella (see Fig. 21.2D). This
• 10 mL or 20 mL syringe—for small effusions approach is also less accurate than the superolateral.3
• 30 mL or 60 mL syringe—for large effusions   

366
 CHAPTER 21 Knee Injection Techniques 367

• F
 ind the patellar tendon in long axis; then maintain-
ing the same probe orientation, move laterally to visu-
alize the trochlear groove deep to the tendon.

Needle Position
• O
 ut of plane (similar to landmark-guided lateral infrapa-
Femur tellar knee injections) (see Fig. 21.3A).
Patella
Medial Target
epicondyle • D
 eep to the synovial membrane covering the medial or
Lateral
epicondyle Lateral and lateral femoral condyle. Care should be taken to visual-
medial intercondylar ize the needle tip deep to anterior (Hoffa’s) fat pad and
Patellar tubercles
surface confirm intra-articular fluid flow (see Fig. 21.3B)
Lateral Medial
condyle condyle PEARLS AND PITFALLS
Head of Tibial
• T here should not be any resistance when injecting. If
fibula tubercle
there is resistance the needle may be in the capsule or
Fibula
extra-articular. Pain may indicate the needle is within
the anterior fat pad.
Tibia • Use color Doppler when injecting to confirm intra-
Crest articular flow.
• Medial approach risks incidental injury to the saphenous
nerve.4
• The anterolateral approach may be less painful than the
superolateral approach.5,6
• This approach can also be performed with the
transducer oriented in short axis to the patellar tendon
and the needle in plane. The target can be just
• Fig. 21.1 Bony Landmarks of the Anterior Knee. (From Detterline superficial to the articular cartilage of the medial or
A, Babb J, Noyes FR, et al. Noyes’ Knee Disorders: Surgery, lateral trochlea depending on the anatomy and needle
Rehabilitation, Clinical Outcomes. 2017:2–22.) visualization.
• No significant difference in success rates between
• K
 nee flexed to 30 degrees with towel roll or bump under targeting the lateral or medial femoral condyle using the
lateral infrapatellar approach.7
the affected knee
  
Clinician Position
• Standing or seated on the side of the affected knee Technique for Medial or Lateral Directed Knee
Joint Injection
Transducer Position Patient Position
• Short axis to the quadriceps tendon (Fig. 21.2A) • S upine with the knee bent 60 to 90 degrees/hook-lying.
Can place booster pillow under the knee for support
Needle Position (Fig. 21.4A and B)
• I n-plane/long axis
• Lateral to medial approach Clinician Position
• Standing on either side of the patient.
Target
• Suprapatellar recess (see Fig. 21.2B and C) Transducer Position
• S agittal plane directly over the medial or lateral condyle
Technique for Anterolateral Approach (depending on target).
Patient Position • Find the patella; then maintaining the same probe ori-
• S eated or supine with the knee bent 60 to 90 degrees/ entation, move medially or laterally to the condyle and
hook-lying. Can place booster pillow under the knee for tibial plateau.
support (see Fig. 21.3A)
Needle Position
Clinician Position • L ong axis to the transducer proximal to distal (see Fig.
• Seated or standing on the side of the affected knee 21.4A and B).
• Needle will have a steep angle headed past the femoral
Transducer Position chondral surface towards the tibial in the anterior one-
• Sagittal plane directly over lateral condyle. third of the joint.
368 SEC T I O N I I I Atlas

Femur
B LATERAL

LATERAL
A C Femur

Patella

* * *
*
Lateral fem condyle

D
• Fig. 21.2(A) Suprapatellar bursa injection setup. (B) Suprapatellar bursa injection. (C) Suprapatellar bursa
aspiration. (D) Midpatella gutter.

PT
PAT

LTP
IPFP

A B DISTAL

• Fig. 21.3 (A) Anterolateral knee joint injection hook-lying setup. (B) Anterolateral knee joint injection out of plane.
 CHAPTER 21 Knee Injection Techniques 369

IPEP

LTP LFC

PROXIMAL
A B C
• Fig. 21.4 (A) Medial knee joint directed injection setup in plane. (B) Lateral knee joint directed setup in
plane. (C) Lateral knee joint directed injection in-plane ultrasound injection.

Target Needle Position

• B
 etween the femoral condyle and the tibial plateau just • L ong axis, distal to proximal approach (see Fig. 21.5A
superficial to the meniscus or the chondral surface (see and B).
Fig. 21.4C) • Can inject local anesthetic first from skin to just above
the joint capsule.
PEARLS AND PITFALLS • If the aiming for lateral condyle and patella is overlap-
ping, angle probe and needle medially to slide needle
• G ood approach if want to target specifically medial under the patella but still toward weight-bearing lateral
or lateral compartments but not a commonly used
technique, and it is a little more challenging.
chondral surface.
• Be careful not to scrape the needle along the chondral
surfaces. Visualize needle tip at all times. Target
• There should not be any resistance when injecting; if so. • M
 edial or lateral femoral condyle:
needle may be in the capsule or meniscus or cartilage. Pain • Aim for the anterior one-third of the chondral surface
may indicate the needle is within one of those structures.
• Use color Doppler when injecting to ensure intra-
with the bevel facing the surface (see Fig. 21.5C).
articular flow. • Gently touch chondral surface and inject. May have
to pull back very slightly to get flow intra-articularly.
  
Should see flow of injectate. Avoid injecting into the
capsule.
Technique for Weightbearing Trochlea Groove
Chondral Surfaces
Patient Position PEARLS AND PITFALLS
• S upine, hip and knee each flexed 90 degrees. Rest the leg • T his is not a common technique, but the authors’
on a block or bolster (Fig. 21.5A and B) preferred approach when using mesenchymal stem
cells (MSCs). The 90/90 position can allow for gravity-
Clinician Position dependent cell adhesion after 10 min.8 Inject very
• S tanding on left side of the patient for right-handed slowly over 3–5 min to allow for cell adhesion and to
avoid flushing the injectate off of the chondral surface.
injection, right side of patient for left-handed injection. • It is unknown if there is any advantage for this position
with other biologics besides MSCs.
Transducer Position • Use a smaller-gauge needle where possible to avoid
• P arallel to the leg/sagittal plane directly over desired con- damaging the cartilage. Guide the needle very slowly and
dyle medial or lateral. barely touch down on the chondral surface. Make sure
the bevel is facing the surface to decrease chances of
• Find the patella; then maintaining the same probe orien- cartilage injury and inject directly on chondral surface.
tation, move medially or laterally. • Aiming for the more anterior aspect of the condyle helps
• Scan slightly superior to visualize medial or lateral femo- achieve a more diffuse flow along the cartilage surface.
ral condyle. The patella can be partially covering the lat- • Only use 1–3 mL of injectate here. Any extra can be
eral femoral condyle so may have to scroll a little more placed intra-articular with above-described techniques.
laterally but stay over weight-bearing surface.   
370 SEC T I O N I I I Atlas

A B

MFC

DISTAL
C
• Fig. 21.5 (A) Medial femoral condyle intra-articular in-plane setup. (B) Lateral femoral condyle intra-artic-
ular in-plane setup. (C) Medial femoral condyle (MFC) in-plane injection.

Proximal Tibiofibular Joint Injection • V ascular supply: circumflex fibular artery wraps laterally
KEY POINTS
the head of the femur and anastomoses with the recur-
rent branch of the anterior tibial artery (inferomedial
• T he tibiofibular joint is an often overlooked cause of to the PTFJ),10 and the inferior lateral genicular artery
lateral knee pain. (superomedial to the PTFJ).13
• The posterolateral corner structures should be
evaluated when assessing this region.
• Nerves: the common peroneal nerve courses along the
• There is significant anatomic variability in the lateral aspect of the popliteal fossa and wraps laterally
angulation of the proximal tibiofibular joint (PTFJ), and anterior around the fibular head-neck junction.14
which may cause the transducer to be oriented
in an anatomic transverse oblique plane for best Common Pathology
visualization.
• The PTFJ is a small joint, and injectate volume is
• D egenerative osteoarthritis or direct traumatic injury
typically only 1–2 mL. • Ganglion cyst, which in some cases can compress the
common peroneal nerve
  
• Posterolateral (PL) corner injury with subsequent insta-
bility of the PTFJ (requires co-treatment of surrounding
Pertinent Anatomy injured/lax structures)
• Th
 e tibiofibular joint is a planar diarthrodial synovial
joint consisting of the fibular head facet and the articular Equipment
facet on the lateral tibial condyle. • H igh-frequency linear array transducer
• It is surrounded by a fibrous capsule, which is thicker • 25 to 30 gauge 1.5 to 2 inch needle
anteriorly, and stabilized by the tibiofibular ligaments.9,10
• In some patients (10% to 64% of cases)11 the proxi- Common Injectates
mal tibiofibular joint (PTFJ) is contiguous with the • L ocal anesthetics for diagnostics, corticosteroids
femorotibial joint, and can be considered a “4th” • Prolotherapy
compartment of the knee joint.9,12 • Orthobiologics (PRP, bone marrow concentrate, etc.).
 CHAPTER 21 Knee Injection Techniques 371

FH

DISTAL

A C

FH

B D PROX
• Fig. 21.6(A) Tibiofibular joint out-of-plane setup. (B) Tibiofibular joint in-plane setup. (C) Tibiofibular joint
out-of-plane injection. (D) Tibiofibular joint in-plane injection. FH, Fibular head.

Injectate Volume Popliteal/Baker’s Cyst Injections

• 1 to 3 mL total
KEY POINTS
Technique
• U sually result of underlying intra-articular pathology
Patient Position (i.e., osteoarthritis, inflammatory arthritis, meniscus
• S ide-lying with affected side facing toward the ceiling tear, chondral lesions) and increased synovial fluid
• Knee flexed 20 to 30 degrees with towel roll or bump to within the knee joint. Communication between the
place in between legs (Fig. 21.6A and B) joint and cyst behaves as a unidirectional or one-way
valve, with fluid leaking into and forming the synovial
cyst
Clinician Position • Intra-articular pathology should be addressed with the
• Seated facing the anterior PTFJ Baker’s cyst.
  
Transducer Position
• Transverse oblique plane over the anterior PTFJ
Pertinent Anatomy
Needle Position • B aker’s cyst, also known as popliteal cyst or gastrocne-
• O ut-of-plane anterior to posterior (see Fig. 21.6A) mius-semimembranosus bursa, is located15 between the
• Can touch down and the tibia and walk-down posterior medial head of the gastrocnemius and tendon of the
• Alternatively, in-plane proximal to distal approach (see semimembranosus
Fig. 21.6B) • Typically found posteromedially in the calf at or below
the joint line
Target
• Anterior superior PTFJ (see Fig. 21.6C and D) Common Pathology
• C an occur from blunt/direct trauma, repetitive micro-
PEARLS AND PITFALLS trauma, or inflammation
• Indicative of intra-articular pathology
• Identify the surrounding neurovascular structures such • Posterior medial meniscus tear can present with similar
as the common, superficial, and deep peroneal nerves symptoms as a Baker’s cyst without sonographic findings
prior to performing injection
of Baker’s cyst
  
372 SEC T I O N I I I Atlas

Equipment • A
 fter aspiration, can switch out syringe, keeping the
•  igh-frequency linear array transducer
H needle tip within the collapsed cyst, and inject (see Fig.
• 30 to 25 gauge 1 to 2 inch needle for local anesthetic 21.7C and D)
• 18 to 22 gauge 1.5 to 2 inch needle for aspiration
• For aspirations: Medial and Lateral Menisci
• 10 mL or 20 mL syringe—for small effusions
• 30 mL or 60 mL syringe—for large effusions KEY POINTS

Common Injectates • M
 usculoskeletal (MSK) ultrasound by an experienced
examiner has similar accuracy identifying medial and
• L ocal anesthetic for numbing track with a 25 to 27 gauge lateral meniscus injuries as compared to magnetic
2-inch needle resonance imaging (MRI),16–18 and easy to target and
• Aspiration inject peripheral tears of the menisci with ultrasound.
• Post-aspiration   
• Corticosteroids
• Prolotherapy (typically 25% dextrose solution)
• Sclerosing agents Pertinent Anatomy
• Orthobiologics (PRP, bone marrow concentrate, micro­ • Th
 e menisci are crescent-shaped fibrocartilage structures
nized adipose tissue, etc.) with a peripheral vascular border (red zone), middle inner
poorly vascular zone (red-white zone), and avascular zone
Injectate Volume (white zone).19,20
• 2 to 3 mL total post-aspiration • The thicker convex outer border is attached to the joint
capsule, tapering to a thin free-edged innermost border.
Technique • There are a number of meniscal ligaments, which can be
Patient Position variable amongst patients21:
• Prone • Coronary ligaments (meniscotibial),22 which act to
anchor the menisci to the tibia both anteriorly and
Clinician Position posteriorly.23,24
• At foot of patient or along affected side • Posterior meniscofemoral ligament (ligament of
Wrisberg) connects the posterior horn of the lateral
Transducer Position meniscus to the medial femoral condyle and the pos-
• Longitudinal/long axis to the bursa terior cruciate ligament (PCL).25
• Anterior meniscofemoral ligament (ligament of
Needle Position Humphry) connects posterior horn of lateral menis-
• I n-plane, long axis cus, but lies anterior to the PCL and inserts at the
• Distal to proximal approach (Fig. 21.7A) femoral PCL.25
• Anterior intermeniscal ligament, which connects the
Target anterior horns of the medial and lateral menisci (Fig.
• M iddle portion of largest area of the cavity (see Fig. 21.7B) 21.8).25
• Can redirect needle to aspirate into any septations or • Root attachments:
loculations • The medial meniscus posterior root attachment is
PL to the medial tibial eminence.
PEARLS AND PITFALLS • The lateral meniscus root attachment is posterior
• Identify all neurovascular structures in the popliteal and medial to the lateral tibial eminence.
fossa prior to aspiration/injection. • The medial meniscus anterior root attachment is
• If Baker’s cyst in an atypical location, must check anteromedial (AM) to the anterior cruciate ligament
Doppler to rule out tumor or vascular malformation. (ACL) tibial insertion and inserts into the anterior
Common mimics: intercondylar crest of the tibia.
• Myxoid liposarcoma
• Popliteal artery aneurysm • The lateral meniscus anterior root is anterolateral
• Peri-meniscal cysts to the ACL tibial insertion.26,27
• Recurrence is common in adults with underlying intra- • See Figs. 21.8 and 21.9.
articular pathology; consider identifying and addressing
primary contributor. Common Pathology
• The semimembranosus tendon may appear hypoechoic
from anisotropy; be aware to avoid injecting directly into • M
 eniscal tears can be traumatic and degenerative, with trau-
the tendon. matic injuries usually associated with an injury and sudden
• Ruptured cysts may mimic symptoms of a deep vein onset of pain, and a degenerative lesion without a history of
thrombosis. acute injury. Traumatic lesions can occur in isolation but are
   common in conjunction with ligament injuries.
 CHAPTER 21 Knee Injection Techniques 373

MFC

PROX
B

MFC

C D PROX

• Fig. 21.7(A) Baker’s cyst aspiration setup. (B) Bakers cyst in-plane injection. (C) Baker’s cyst aspira-
tion. (D) Baker’s cyst ultrasound view post-aspiration. MFC, Medial femoral condyle.

Posterior cruciate ligament • H  orizontal and oblique tears are more commonly asymp-
Ligament of Wrisberg tomatic. Vertical, complex, radial, and displaced tears
Ligament of Humphry have a stronger association with pain.29
Popliteal Medial • Medial meniscus posterior horn tears are commonly
tendon meniscus associated with ACL injury,23 as are lateral meniscus root
Fibular tears.27
collateral Deep
ligament Meniscal ramp tear may not affect the actual meniscus
medial
collateral tissue, and generally occur at the ligamentous connection
ligament between the posterior horn of the medial meniscus and
Popliteal
hiatus tibial plateau. Injury to the posterior medial meniscus cor-
(recess) onary ligament is associated with increased tibial internal
Lateral Superficial rotation.23
meniscus medial
collateral Equipment
ligament
Coronary Anterior • H igh-frequency linear array transducer
ligament Capsule Transverse cruciate
(meniscotibial) ligament • 22 to 27 gauge 1.5 to 2 inch needle
ligament
•Fig 21.8 Meniscal Ligaments. (From Rakel R. Textbook of Family Common Injectates
Medicine. 7th ed. Philadelphia: Saunders; 2007.)
• P rolotherapy
• Orthobiologics (PRP, bone marrow concentrate, micron-
• M
 edial meniscus tears should be characterized by the ized adipose tissue, etc).
location (e.g., anterior portion, body, posterior portion,
or root) and morphologies (e.g. radial, horizontal, verti- Injectate Volume
cal, flap, bucket handle, or complex)(Fig. 21.11).25,28 • 1 to 2 mL total
374 SEC T I O N I I I Atlas

Femoral Chondral
Surface
Lateral Meniscus

Lateral Posterior
Collateral Cruciate
Ligament (LCL) Ligament (PCL)

Medial Meniscus
Anterior Medial
Cruciate Collateral
Ligament (ACL) Ligament (MCL)

Transverse
Ligament

• Fig. 21.9 Knee Major Ligamentous Anatomy. Note close relation to the menisci.

Meniscofemoral
Ligament Plantaris

Posterior Arcuate
Cruciate Popliteal
Ligament
Popliteofibular
Ligament
Single longitudinal Double longitudinal
Popliteal

• Fig. 21.10 Knee Posterior Anatomy: Ligaments and Tendons.

Technique
Patient Position
• Supine with slight knee bend (Fig. 21.12A)

Clinician Position
• Seated or standing on affected side Flap Radial
• Fig. 21.11 Meniscus Tears. (From Detterline A, Babb J, Noyes FR,
Transducer Position et al. Noyes’ Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes.
• Short axis to the joint line 2017:2–22.)

Needle Position Target

• I n-plane, distal to proximal approach (see Fig. 21.12A) • A
 reas of hypoechogenicity within the medial or lateral
• Alternatively can inject out of plane with needle centered meniscus corresponding to tear of the meniscus (Fig.
over the meniscus (see Fig. 21.12B) 21.13C and D; see Fig. 21.12C and D).
 CHAPTER 21 Knee Injection Techniques 375

*
**
MTP
MFE

DISTAL
A C

**

MFE MTP

DISTAL
B D
• Fig. 21.12 (A) Medial meniscus and coronary ligaments in-plane setup. (B) Medial meniscus out-of-plane
setup. (C) Medial meniscus coronary ligament in-plane ultrasound injection. (D) Medial meniscus out-of-
plane injection.

• I f possible, you can redirect inferior or superior to Technique Alternate for Posterior Horn of the
inject more portions of the capsule. Menisci and Posterior Capsules
• You can adjust to inject along the meniscus to tar- Patient Position
get the length of the tear; this may require coming • Prone
out, repositioning the probe, and a second injec- Clinician Position
tion location. • Seated or standing on affected side
• Meniscal coronary ligament (see Fig. 21.12C). Transducer Position
• Short axis to the joint line
Needle Position
• I n-plane/long axis, distal to proximal approach (see Fig.
PEARLS AND PITFALLS
21.13A)
• Identify the surrounding neurovascular structures prior • Can redirect needle to aim for more medial or lateral aspects.
to injection/aspiration; in particular, the lateral geniculate • Alternatively, can inject out of plane, needle centered of
artery typically runs just superficial to the lateral meniscus. the meniscus (see Fig. 21.13B).
• The meniscal tissue is dense, and there can be quite
a bit of resistance to the injectate. There will be less • If possible, redirect inferior or superior to inject more
resistance in areas where the meniscus is. Slightly portions of the capsule.
adjust needle to torn parts if meeting more resistance. • Adjust out-of-plane angle to inject more medial or lateral
A slightly larger-gauge needle can help to inject. aspects.
• Perform stress ultrasound of the meniscus to see if the
meniscus is extruding with stress. This would suggest
possible coronary ligament injury, and the ligament Target
injected as well. • A reas of hypoechogenicity within the peripheral and
• This approach is best for tears that extend to the central aspects of the posterior horn of the medial or lat-
periphery where the tear can be visualized with eral meniscus (see Fig. 21.13C and D).
ultrasound guidance. • Meniscal root.
   • Posterior medial or lateral capsules.
376 SEC T I O N I I I Atlas

*
MFC

MTP

A C PROX

MFE

LTP
PROX
B D
• Fig. 21.13(A) Posterior medial meniscus and capsule in-plane setup. (B) Posterior lateral meniscus and
capsule out-of-plane setup. (C) Posterior medial capsule injection approaches. (D) Posterior lateral capsule
injection approaches. MFC, Medial femoral condyle.

PEARLS AND PITFALLS

• M
 enisci are typically crescent-shaped structures that are
thicker peripherally and thinner centrally.
• Identify the surrounding neurovascular structures prior
to injection/aspiration. Common Pathology
• In particular, the lateral geniculate artery typically runs
just superficial to the lateral meniscus.
• M ost commonly, meniscal cysts are associated with hori-
• The meniscus is dense, so there can be quite a bit of zontal tears of the adjacent meniscus30 with communica-
resistance. Torn areas may be slightly less dense. Using tion of synovial fluid into the meniscocapsular complex
a slightly large needle gauge can help to inject. Slightly and adjacent soft tissues.
adjust needle to torn parts if meeting more resistance. • Three to 10 times 31 more commonly with lateral menis-
   cus tears than medial meniscus tears.

Parameniscal Cyst Aspiration/Injection Equipment

•  igh-frequency linear array transducer
H
KEY POINTS • 30 to 25 gauge 1 to 2 inch needle for local anesthetic
• P arameniscal cysts are typically associated with injuries • 18 to 22 gauge 1.5 to 2 inch needle for aspiration
to the adjacent meniscus. • For aspirations:
• Cysts can be multilobulated with viscous, gelatinous • 10 mL or 20 mL syringe—for small effusions
material extruded outside the meniscus. (Perimeniscal • 30 mL or 60 mL syringe—for large effusions
cysts are due to small lesions and fluid within the cyst.)
   Common Injectates
• L ocal anesthetic (25 to 27 gauge 1.5 to 2 inch needle)
prior to aspiration (18 gauge 1.5 inch needle)
Pertinent Anatomy • Post-aspiration
• M
 edial and lateral menisci are made of fibrocartilage • Corticosteroids
located along the articular surface between the femoral • Prolotherapy, 25% dextrose solution
condyles and tibial plateaus. • Sclerosing agents
 CHAPTER 21 Knee Injection Techniques 377

MCL

MM

MFE
MTP

DISTAL
A B
• Fig. 21.14 (A) Medial meniscal cyst setup. (B) Medial meniscal cyst in-plane injection.

• O
 rthobiologics (PRP, bone marrow concentrate, micro­ Tendon Injections
nized adipose tissue, etc.).
Distal Quadriceps Tendon Injection/
Injectate Volume Tenotomy/Barbotage
• 2 to 3 mL total post-aspiration
KEY POINTS
Technique • F or percutaneous needle tenotomy, repetitive
Patient Position fenestration should be performed until the needle
• Supine or side-lying passes through all of the abnormal tissue with ease.
• We recommend 20- to 22-gauge needles for refractory
percutaneous needle tenotomy in quadriceps tendon.
Clinician Position • Since there is no tendon sheath in this area, we would
• Seated or standing on affected side not recommend corticosteroids as they could have
harmful effects on the tendon.
Transducer Position   
• Short axis to the joint line
Pertinent Anatomy
Needle Position
• Th
 e quadriceps tendon (Fig. 21.15) is a conjoined tendon of
• I n-plane/long axis
the rectus femoris, vastus medialis, vastus lateralis, and vas-
• Distal to proximal approach (Fig. 21.14A)
tus intermedius muscles, forming a trilaminar tendon that
inserts on the superior pole of the proximal of the patella.
Target
• As with most tendons, the quadriceps tendon is typically
• M
 iddle of largest portion of meniscal cyst (see Fig.
hypovascularized with a watershed35 zone just proximal
21.14B)
to its insertion.

Common Pathology
PEARLS AND PITFALLS • O veruse injuries and the continuum of tendon pathol-
ogy, include partial tearing
• Identify the surrounding neurovascular structures prior • Calcific tendinopathy of the quadriceps.
to injection/aspiration.
• Take care to avoid compressing the cyst with pressure
Complete tears (direct trauma or hyperflexion of the
from the transducer. In some cases compression can knee causing rupture of the extensor mechanism). Com-
decompress the fluid back through the meniscal tear plete tears require prompt diagnosis and surgical repair.
into the joint.32
• Cysts may be multilobulated and/or contain thick, Equipment
viscous, gelatinous material. If material cannot be
aspirated, can consider fenestration of cyst.
• H igh-frequency linear array transducer
• Meniscal cysts have been described in the absence of • 27 to 30 gauge 1.5 to 2 inch needle for anesthesia (stay
meniscal tears,33 but in the absence of an associated superficial outside of tendon/lesion)
meniscal tear, alternative diagnoses should be • 22 to 27 gauge 1.5 to 2 inch needle for injection
considered, including malignancy.34 • 18 to 22 gauge 1.5 to 2 inch needle and 10 mL syringe
   flushes for barbotage
378 SEC T I O N I I I Atlas

Common Injectates • A
 lternate position: in plane with probe (short axis to the
• L ocal anesthetics for diagnostics tendon), lateral to medial approach (see Fig. 21.16D)
• Prolotherapy
• Orthobiologics (PRP, bone marrow concentrate, etc.) Target
injections • P athologic tendon (hypoechoic area of tendinopathy or
• Saline for barbotage in calcific tendinopathy interstitial tear, calcification).
• For percutaneous needle tenotomy, repetitive fenestra-
Injectate Volume tion should be performed until the needle passes through
• 2 to 3 mL of regenerative agent or 10 mL saline (for all of the abnormal tissue with ease and can also target
barbotage) areas of cortical irregularity/enthesophytes at the supe-
rior pole of the patella.
Technique • Calcification for barbotage procedure (see Chapter—
Patient Position barbotage Chapter 24 )
• S upine with knee flexed to 30 degrees with towel roll or
bump to place under affected knee
Quadriceps
Clinician Position
• On side of affected knee
Quadriceps tendon
Transducer Position
Patella
• L
 ong or short axis to the quadriceps tendon (Fig. 21.16A
and B)
Fat pad Patellar tendon
Needle Position Fibula Pes anserine
• I n plane with probe (long axis to tendon), proximal to tendons
Tibia
distal approach (see Fig. 21.16C)
• Fig. 21.15 Anterior Knee Anatomy. Note knee extensor mechanism

PAT
QT

DISTAL
A C

LATERAL

B D
• Fig. 21.16 (A) Distal quad injection setup. (B) Distal quad long-axis in-plane injection. (C) Distal quad
transverse setup. (D) Distal quad transverse in-plan injection.
 CHAPTER 21 Knee Injection Techniques 379

PEARLS AND PITFALLS

Injectate Volume
• 1 to 3 mL of regenerative agent
• P roper visualization and planning prior to the procedure • 10 mL saline (for barbotage)
will allow for accuracy and efficiency of targeting of the
focal lesion and avoid normal tendon.
• Fenestrating or needling the enthesis for insertional
Technique
tendinosis is recommended to encourage angiogenesis Patient Position
from the periosteum. • S upine
   • Knee flexed to 30 degrees with towel roll or bump to
place under affected knee
Patellar Tendon Injection and Tenotomy/
Clinician Position
Barbotage • On side of affected leg

KEY POINTS Transducer Position

• P atellar tendon in long axis (Fig. 21.17A and B)
• F or percutaneous needle tenotomy, repetitive • Alternative approach with tendon in short axis
fenestration should be performed until the needle
passes through all of the abnormal tissue with ease.
• We recommend 18–22 gauge needles for percutaneous Needle Position
needle tenotomy in patella tendinosis refractory to • I n-plane/long axis
conservative treatment options. • Proximal to distal for distal lesions and enthesopathy;
• Corticosteroids are not recommended as they could distal to proximal approach for proximal lesions/myo-
have harmful effects on the tendon. tendinous junction (see Fig. 21.17C and D)
   • Alternate approach (probe short axis to the tendon): nee-
dle in plane, lateral to medial

Pertinent Anatomy
• Th
 e patellar tendon is a continuation of the deep fibers of Target
the rectus femoris of the quadriceps tendon, and techni- • P athologic tendon (hypoechoic area of tendinopathy or
cally is a ligament attaching the distal pole of the patella interstitial tear, calcification).
to the tibial tuberosity. • For percutaneous needle tenotomy, repetitive fenestra-
tion should be performed until the needle passes through
Common Pathology all of the abnormal tissue with ease and can also target
• O veruse injuries and the continuum of tendon pathology areas of cortical irregularity/enthesophytes at the supe-
include partial tearing. The most common location of pain rior pole of the patella.
and pathology is the proximal patellar tendon; however, • Calcification for barbotage procedure (see Chapter 24)
the distal insertion and mid tendon can also be affected.36
• Calcific tendinopathy of the patellar tendon. PEARLS AND PITFALLS
• Complete tears (direct trauma or hyperflexion of the knee
• P roper visualization and planning prior to the procedure
causing rupture of the extensor mechanism). Complete will allow for accuracy and efficiency of targeting of the
tears require prompt diagnosis and surgical repair. focal lesion and avoid normal tendon.
• Infrapatellar fat pad impingement can present similar to • Needling the enthesis for insertional tendinosis is
patellar tendinopathy. recommended to encourage angiogenesis from the
periosteum.
Equipment • Hoffa’s fat pad hydrodissection or high-volume injection
between the deep patellar fibers and Hoffa’s fat pad
• H igh-frequency linear array transducer may provide some therapeutic benefit. (See chapter
• 27 to 30 gauge 1.5 to 2 inch needle for numbing track 27.)
(stay superficial outside of tendon/lesion)   
• 22 to 27 gauge 1.5 to 2 inch needle for injection
• 18 to 22 gauge 1.5 to 2 inch needle and 10 mL syringes Prepatellar Bursal Injection
flushes for barbotage

Common Injectates KEY POINTS

• L ocal anesthetics for diagnostics • P

 repatellar bursitis are common. Up to one-third of
• Prolotherapy cases can be septic and two-thirds non-septic. In
cases of suspected septic bursitis, fluid should be sent
• Orthobiologics (PRP, bone marrow concentrate, etc.) for analysis.37
injections
  
• Saline for barbotage in calcific tendinopathy
380 SEC T I O N I I I Atlas

PAT

PROX

A C

TT

DISTAL

B D
• Fig. 21.17(A) Proximal patellar tendon setup. (B) Distal patellar tendon setup. (C) Proximal patellar tendon
long-axis in-plane injection. (D) Distal patellar tendon long-axis in-plane injection.

Pertinent Anatomy Injectate Volume

The prepatellar bursa is generally superficial and centered • 1 to 2 mL
over the patella but can have lateral and medial extension.
Technique
Common Pathology
Patient Position
• T ypically associated with chronic trauma from prolonged • S upine with knee flexed to 30 degrees with towel roll or
or repeated kneeling. Direct trauma or fall on the knee bump to place under affected knee
can result in a prepatellar bursa hematoma.
• Septic bursitis.
Clinician Position
• Rule out other potential etiologies such as patellar frac-
ture or Morel-Lavallée lesion. • On affected side of leg

Equipment Transducer Position

• H igh-frequency linear array transducer • O
 ver the patella bursa and patella in short or long axis
• 22 to 27 gauge 1.5 to 2 inch needle for injection (Fig. 21.18A and B)
• 18 to 22 gauge 1.5 to 2 inch needle for aspiration
Needle Position
Common Injectates • I n-plane (distal to proximal [Fig. 21.18C]; lateral to
•  ocal anesthetics for diagnostics
L medial approach [see Fig. 21.18D])
• Corticosteroids
• Sclerotherapy or prolotherapy Target
• Orthobiologics (PRP, bone marrow concentrate, etc.) • Prepatellar bursa
injections
 CHAPTER 21 Knee Injection Techniques 381

Patella PT

DISTAL
A C

PT
*

Femur

LATERAL

B D
• Fig. 21.18 (A) Prepatellar bursa long-axis setup. (B and C) Prepatellar bursa in-plane injection distal
aspect. (D) Prepatellar bursa in-plane injection proximal aspect.

PEARLS AND PITFALLS infrapatellar bursa is located between the posterior aspect
of the patellar tendon and the tibia.
• S eptic bursitis is common, and any cases of suspected
infectious bursitis should be aspirated and sent for • Fluid within the deep infrapatellar bursa can be physi-
analysis. ologic (present in up to 68% of knees), and should be
• Applying too much pressure with the transducer may distinguished from bursitis.39
decrease bursal fluid and make evaluation and needle • No communication exists between the deep infrapatellar
placement more difficult. bursa and the knee joint.
• Sclerotherapy with polidocanol has been reported, but
other sclerosing agents can be considered.38
Common Pathology
  
• T ypically associated with chronic trauma from prolonged
or repeated kneeling.
Infrapatellar Superficial/Deep Bursal Injection • May also be seen in gout, syphilis or association with
rheumatologic conditions.
KEY POINTS
• Superficial infrapatellar bursitis should be differentiated
• Infrapatellar bursa can be superficial or deep. from subcutaneous edema.
• Some fluid in the deep infrapatellar bursa is considered
physiologic. Equipment
   • H igh-frequency linear array transducer
• 27 to 22 gauge 1.5 to 2 inch needle for injection
• 22 to 18 gauge 1.5 to 2 inch needle for aspiration
Pertinent Anatomy
• Th
 e superficial infrapatellar bursa is located between Common Injectates
the tibial tubercle and the overlying skin. The deep • Local anesthetics for diagnostics
382 SEC T I O N I I I Atlas

TIBIAL TUBERCLE DISTAL

A B

PT

IPFP

TIBIAL PLATEAU

LATERAL
C D
• Fig. 21.19(A) Infrapatellar bursa long-axis setup proximal to distal. (B) Prepatellar bursa long-axis distal to
proximal approach in-plane injection. (C) Deep Infrapatellar bursa transverse view in-plane injection setup.
(D) Deep infrapatellar bursa transverse view in-plane ultrasound injection.

• C orticosteroids Target
• Sclerotherapy or prolotherapy • S uperficial infrapatellar bursa (see Fig. 21.19B)
• Orthobiologics (PRP, bone marrow concentrate, etc.) • Deep infrapatellar bursa (see Fig. 21.19D)
injections

Injectate Volume PEARLS AND PITFALLS

• 1 to 2 mL
• A pplying too much pressure on the transducer may
disperse bursal fluid and make evaluation and needle
Technique placement more difficult.
Patient Position • If infection is clinically suspected, the fluid should be
• S upine with knee flexed to 30 degrees with towel roll or aspirated and sent for analysis.
bump to place under affected knee   

Clinician Position Distal Iliotibial Band Bursa and Peritendinous

• O
 n affected side of leg with a lateral to medial
Injection
approach
KEY POINTS
Transducer Position
• I nfrapatellar region with the patellar tendon in short or • U se of corticosteroid injectate is only indicated for
long axis to the bursa bursal procedures.
• The iliotibial band comes in closest proximity to the
lateral femoral condyle at ≈30 degrees flexion of the
Needle Position knee, which causes friction/impingement.
• S uperficial infrapatellar: in plane, proximal to distal or • Be sure to identify and avoid the common peroneal
distal to proximal approach (Fig. 21.19A) nerve prior to any procedure due to its proximity to
• Deep infrapatellar bursa: in plane, lateral to medial these structures.
approach (see Fig. 21.19C)   
 CHAPTER 21 Knee Injection Techniques 383

GT

LFE PI
A B
• Fig. 21.20 (A) Distal iliotibial band (ITB) injection setup. (B) Distal ITB injection.

Pertinent Anatomy Needle Position

• Th
 e iliotibial band (ITB) is a dense, thick band of con- • L ong axis to the ITB: in plane to probe, proximal to the
nective tissue formed by the tensor fascia lata and gluteus distal (see Fig. 21.20B)
maximus proximally and runs distally over the vastus • Alternative approach (probe transverse to the ITB):
lateralis and lateral femoral condyle to attach to Gerdy’s in-line, posterior to anterior approach
tubercle on the lateral proximal tibia.
• At 30 degrees of knee flexion, the ITB is taut and moves over
the lateral femoral condyle, which can often be the cause of Target
friction and symptoms of bursitis/impingement syndrome. • Th
 ickened fascia at the level of the lateral femoral condyle
• Enthesopathy of the tendon at Gerdy’s tubercle
Common Pathology • Inflamed bursa adjacent to the ITB
• O
 ften susceptible to overuse/repetitive-type injuries, which
may include partial- or full-thickness tearing, inflammation
to the surrounding bursa or irritation to the adipose tissue. PEARLS AND PITFALLS
• Identify and avoid the common peroneal nerve and
Equipment lateral collateral ligament.
• H igh-frequency linear array transducer
  
• 27 to 30 gauge 1.5 to 2 inch needle for numbing track
• 22 to 27 gauge 1.5 to 2 inch needle for injection

Common Injectates Popliteus Tendon/Tendon Sheath Injection/

• L ocal anesthetics for diagnostics Tenotomy
• Prolotherapy
• Orthobiologics (PRP, bone marrow concentrate, etc.)
injections KEY POINTS

Injectate Volume • R ecommend 18–22 gauge needles for percutaneous

needle tenotomy in popliteus tendinosis refractory to
• 1 to 3 mL of corticosteroid or regenerative agent conservative treatment options.
• Be sure to identify and avoid the common peroneal
Technique nerve prior to any procedure due to its proximity to
Patient Position these structures.
• S ide-lying with knee flexed to 20 to 30 degrees with   
towel roll or bump in between the knees

Clinician Position
• Behind the patient Pertinent Anatomy
• Th
 e popliteus muscle originates from the posteromedial
Transducer Position tibia and courses obliquely and inserts proximally along
• L ong axis to the ITB (authors’ preferred approach for the PL femoral condyle.
percutaneous tenotomy [Fig. 21.20A]) • The action of the popliteus is to “unlock” the knee as it
• Alternative approach: transverse to the ITB goes from extension into flexion
384 SEC T I O N I I I Atlas

Common Pathology • F
 or percutaneous needle tenotomy, can also target cal-
• I solated injuries to the popliteus muscle are rare but can cific or tendinopathic lesions.
occur with hyperextension or twisting injuries.
• Susceptible to overuse/repetitive-type injuries which may
include partial- or full-thickness tearing or calcinosis of PEARLS AND PITFALLS
the tendon. • A void normal tissue if possible.
• Pathology of the popliteus tendon is often associated • Identify and avoid the common peroneal nerve and
with other PL corner injuries. lateral collateral ligament.
• For tenotomy, repetitive fenestration should be
Equipment performed until the needle passes through all of the
abnormal tissue with ease.
• H igh-frequency linear array transducer
• 27 to 30 gauge 1.5 to 2 inch needle for numbing track   
(stay superficial outside of tendon/lesion)
• 22 to 27 gauge 1.5 to 2 inch needle for injection Pes Tendon and Bursa Injection

Common Injectates
• L ocal anesthetics for diagnostics, corticosteorids for the KEY POINTS
sheath only • A
 void the inferior geniculate artery and nerve, which are
• Prolotherapy located in close proximity.
• Orthobiologics (PRP, bone marrow concentrate, etc.)
  
injections

Injectate Volume Pertinent Anatomy

• 1 to 3 mL • Th
 e pes anserine is a confluence of tendons which insert
Technique along the proximal AM tibia approximately 4 cm below
the tibial plateau.
Patient Position
• The pes anserine consists of the sartorius, gracilis, and
• S ide-lying with the knee flexed to 20 to 30 degrees with
semitendinosus tendons, and they run proximal to distal
towel roll or bump in between the knees
in a linear fashion.40
• Add slight internal rotation
• The tendons form the anserinus plate as the tendons
fuse with the fascia of the leg, with the superficial layer
Clinician Position
formed by the sartorius and the deep layer formed by the
• Behind or in front of the patient, depending on the approach
gracilis and semitendinosus.41
Transducer Position • These tendons can have individual insertion, but there
• O blique to the popliteus tendon can be significant variations of the tendons, with acces-
• Alternative position: long axis to the popliteus tendon, sory tendons and fascial bands arising from any of the
visualizing the tendon at the insertion at the popliteus tendons with separate insertions.
sulcus on the lateral femoral condyle • The pes anserinus bursa is situated between the pes anse-
rinus and the medial collateral ligament (MCL) and does
Needle Position not communicate with the knee joint.40
• I n plane (probe in oblique axis to the tendon) distal to
proximal (Fig. 21.21A and B)
Common Pathology
• Out of plane (probe in oblique axis to the tendon) (see • O ften associated with pain related to knee osteoarthritis,
Fig. 21.21C and D) the mean thickness of pes anserine tendons in knees with
• In plane (probe in long axis to the tendon) posterior to osteoarthritis have been shown to be significantly greater
anterior approach (see Fig. 21.21E and F) (preferred for than controls.42 This may be due to valgus knee defor-
needle tenotomy or if calcifications). mity often associated with knee osteoarthritis.43
• Alternatively, can inject anterior to posterior for muscu- • Medial meniscus protrusion and displacement of the
lotendinous junction pathology. MCL can result in localized inflammation.
• Overuse injuries can result in tendinopathy or pes anse-
Target rinus bursitis.
• W
 ithin the tendon sheath along the popliteal fossa over- • Injury from acute trauma and iatrogenic injury have
lying the lateral femoral condyle. been reported. Pes anserinus snapping syndrome can
• Can trace posteriorly and distally in an oblique angle occur when the semitendinosus or gracilis tendon
to follow the course of the popliteal tendon to assess snaps over the posteromedial knee during knee flexion/
defective areas. extension.
 CHAPTER 21 Knee Injection Techniques 385

LFC

DISTAL
A B

LTP LFC

PROX
C D

LFC

E F
• Fig. 21.21 (A) Popliteus in-plane setup lateral decubitus. (B) Popliteus out-of-plane setup. (C) Popliteus
short-axis in-plane ultrasound (US) injection. (D) Popliteus short-axis in-plane US injection. (E) Popliteus
long-axis in-plane injection. (F) Popliteus long-axis in-plane injection.

Equipment Clinician Position

• H igh-frequency linear array transducer • At the foot of the patient
• 22 to 27 gauge 1.5 to 2 inch needle for injection Transducer Position
Common Injectates • S hort axis to the pes anserine tendons
• Alternative approach: rotate probe to position-affected
• L ocal anesthetics for diagnostics tendon in long axis to tendon (preferred approach for
• Prolotherapy intratendinous orthobiologic injection).
• Orthobiologics (PRP, bone marrow concentrate, etc.)
injections Needle Position
• I n-plane (oblique to pes anserine tendon/bursa), distal to prox-
Injectate Volume imal or proximal to distal approaches (Fig. 21.22A and C)
• 1 to 2 mL • Alternative approach: in plane (long-axis to tendon)
Technique Target
Patient Position • P es anserine tendon sheath or bursa (between pes anser-
• S upine ine tendons and MCL) (Fig. 21.23).
• Knee flexed to 30 degrees with towel roll or bump to • For orthobiologics, target the thickened pes anserine
place under affected knee tendon. Interstitial tears will often be occult and open
• Can obtain better exposure with slight external rota- up with the intratendinous injection (see Fig. 21.22B
tion of the hip and D).
386 SEC T I O N I I I Atlas

MTP

DISTAL
A C

MT
PROX
B D
• Fig. 21.22(A) Pes tendon/bursa distal to proximal setup. (B) Pes tendon/bursa proximal to distal setup.
(C) Pes tendon distal to proximal in-plane injection (D) Pes tendon in plane proximal to distal injection.

PEARLS AND PITFALLS

• C olor flow Doppler should be used to identify and
avoid injecting the inferior geniculate artery and
nerve.
• Avoid injecting corticosteroids into the pes anserine
tendons or medial collateral ligament (MCL).
• Distinguish between the pes anserine tendons and
the semimembranosus tendon or MCL to ensure
MTP the correct target site. Sonopalpation and differential
lidocaine injections can help localize the source of
pain.
PROX
A   

Distal Biceps Femoris Injection/Tenotomy

KEY POINTS
• W e recommend 18–22 gauge needles for percutaneous
MTP
needle tenotomy in distal biceps femoris tendinosis
refractory to conservative treatment options.
• Use of corticosteroid injectate is not indicated for intra-
tendinous procedures.
• Be sure to identify and avoid the common peroneal
DISTAL nerve prior to any procedure due to its proximity to
B these structures.

• Fig. 21.23 (A) Pes anserine bursa in-plane proximal to distal ultra-   
sound injection. (B) Pes anserine bursa in-plane distal to proximal ultra-
sound injection.
 CHAPTER 21 Knee Injection Techniques 387

FH

PROX
A B
• Fig. 21.24 (A) Distal biceps in-plane setup. (B) Distal biceps long-axis in-plane injection.

Pertinent Anatomy • K
 nee slightly flexed to 10 degrees with towel roll or
• Th
 e distal biceps femoris tendon complex is composed of bump under the ankle or shins
the lateral hamstring muscle (the long and short head of
the biceps femoris). Clinician Position
• The tendon inserts in a fan-like fashion with multiple • Along the affected side of the patient
attachments, including attachments on the fibula and
tibia. Transducer Position
• The tendon bifurcates into superficial and deep portions • L
 ong axis to the biceps femoris tendon.
that encompass the lateral collateral ligament (LCL), • Be sure to visualize its insertion onto the proximal
otherwise known as the distal fibular collateral ligament. fibula to ensure correct structure, and clearly identify
• The fibular collateral ligament-biceps femoris bursa is a the fibular collateral ligament between the superficial
small bursa that exists between the superficial fibers and and deep fibers of the distal biceps tendon.
the LCL.
• The common peroneal nerve and posterior lateral geniculate Needle Position
artery run along the distal biceps femoris tendon complex. • I n-plane (long axis to biceps femoris tendon complex),
proximal to distal (Fig. 21.24A) or distal to proximal
Common Pathology approach
• S usceptible to overuse/repetitive-type injuries; pathology
includes partial- or full-thickness tearing or calcinosis of Target
the tendon. • D istal insertion of the biceps femoris at the proximal
• Fibular collateral ligament-biceps femoris bursitis. fibular head (see Fig. 21.24B)
• For percutaneous needle tenotomy, you can also target
Equipment calcific or tendinopathic lesions.
• H igh-frequency linear array transducer
• 27 to 30 gauge 1.5 to 2 inch needle for numbing track
PEARLS AND PITFALLS
(stay superficial outside of tendon/lesion)
• 22 to 27 gauge 1.5 to 2 inch needle for injection • A void normal tissue if possible. Caution should be used
when interpreting the anatomy in long-axis imaging as
Common Injectates the divergent superficial and deep heads of the biceps
femoris can simulate the appearance of tendinopathy
• L ocal anesthetics for diagnostics due to thickening and anisotropy. The biceps femoris
• Prolotherapy and fibular collateral ligament should be examined
• Orthobiologics (PRP, bone marrow concentrate, etc.) in multiple acoustic windows to help control for
injections anisotrophy.44
• Sonopalpation can be useful to help correlate potential
Injectate Volume pathologic findings with sonographic findings.
• Identify and avoid the common peroneal nerve and
• 1 to 3 mL fibular collateral ligament.
• For tenotomy, repetitive fenestration should be
Technique performed until the needle passes through all of the
Patient Position abnormal tissue with ease.
• Prone or side-lying   
388 SEC T I O N I I I Atlas

MTC PROX
A B
• Fig. 21.25 (A) Distal semimembranosus in-plane injection setup. (B) Distal semimembranosus long-axis
in-plane ultrasound injection.

Distal Semimembranosus Tendon Injection/ Common Injectates

Tenotomy • L ocal anesthetics for diagnostics
• Prolotherapy
KEY POINTS • Orthobiologics (PRP, bone marrow concentrate, etc.)
injections
• W e recommend 18–22 gauge needles for percutaneous
needle tenotomy in distal semimembranosus tendinosis Injectate Volume
refractory to conservative treatment options.
• Use of corticosteroid injectate is not indicated for intra- • 1 to 3 mL
tendinous procedures.
• Identify the pes anserine tendons, which are located Technique
anterior and distal to the semimembranosus tendon Patient Position
insertion. • P rone or side-lying
   • Knee fully extended

Clinician Position
Pertinent Anatomy • Along the affected side of the patient
• Th
 e distal semimembranosus tendon has five different
insertions along the medial knee.45,46 Transducer Position
• The main tendon inserts into the posterior medial tibial • L
 ong axis to the semimembranosus tendon.
condyle • Be sure to visualize its insertion onto the posterior
• The anterior arm (pars reflexa) inserts onto the tibia, runs medial tibial condyle to ensure correct structure.
deep to the MCL inserting distal to the medial joint line.
• There is some evidence of insertion onto the medial Alternate position
meniscus in some patients, which likely functions to pull • Short axis to the semimembranosus tendon
the meniscus posteriorly with deep knee flexion.47
Needle Position
Common Pathology • I n-plane (long axis to semimembranosus tendon), proxi-
• O veruse/repetitive-type injuries, which may include par- mal to distal approach (Fig. 21.25A)
tial- or full-thickness tearing or calcinosis of the tendon. • Alternate approach: short-axis approach
• Association between MCL pathology, knee osteoarthri-
tis, and semimembranosus tendon pathology46 Target
• Often injured from valgus stress to the knee causing • D
 istal insertion of the semimembranosus tendon at the
strains, tears, avulsions, and contusions. posterior medial tibial condyle (see Fig. 21.25B)

Equipment PEARLS AND PITFALLS

• H igh-frequency linear array transducer • A void normal tissue if possible.
• 27 to 30 gauge 1.5 to 2 inch needle for numbing track • Distinguish between the semimembranosus tendon and
(stay superficial outside of tendon/lesion) the medial collateral ligament or pes anserine tendons
to ensure the correct target.
• 22 to 27 gauge 1.5 to 2 inch needle for injection
  
 CHAPTER 21 Knee Injection Techniques 389

• F
 or percutaneous needle tenotomy, you can also target • S tart transducer in the sagittal plane over the patella
calcific or tendinopathic lesions. in long axis. Slide the transducer just medial to the
patella and orient oblique along the axis of the ACL.
This may be about 30 degrees but can vary.
Ligaments • The distal ACL seen in long axis ≈1 to 1.5 cm deep to
Anterior Cruciate Ligament Injection the anterior tibial cortex.
• ACL will often appear hypoechoic due to anisotropy.
KEY POINTS
Needle Position
• C an be difficult to visualize. Hyperflexion of the knee • I n-plane (long or oblique axis to ACL), distal/anterior to
can help, but may be limited due to ROM. proximal/posterior approach (Fig. 21.26A)
• Often used in treatment of distal partial ACL injuries, • Alternative position: can inject out of plane from medial
mostly for orthobiologic use.
• For more severe partial injuries or proximal injuries,
to lateral (see Fig. 21.26B)
fluoroscopy technique is required.
Target
  
• Th
 e ACL distal and mid substance (see Fig. 21.26C
and D)
Pertinent Anatomy
• Th
 e two bundles (AM and PL) of the ACL course from
lateral to medial, attaching the femur to the tibia to pre- PEARLS AND PITFALLS
vent excessive anterior translation of the tibia.
• Main stabilizer of anterior tibial translation. • F
 or in-plane injection, doing a gel stand-off can help
• Main arterial supply is the middle geniculate artery. clear the needle between the tibia and the transducer.
  
Common Pathology
• S usceptible to acute tear/rupture from a non-contact
injury or indirect contact resulting in valgus loading of Posterior Cruciate Ligament Injection
the knee. A direct contact blow to the lateral aspect of the
knee can also injure the ACL. KEY POINTS
• May be associated with other injuries such as medial or
• B e aware of proximity to the popliteal artery and tibial
lateral meniscus, PCL, LCL, or posterolateral corner nerve, which lie superficial to approach.
(PLC) injuries. • Often used in treatment of partial posterior cruciate
ligament (PCL) injuries, mostly for orthobiologic use, or
Equipment aspiration of PCL cysts.
• H igh-frequency linear array transducer   
• 22 to 25 gauge 2 to 3 inch needle for injection

Common Injectates Pertinent Anatomy

• P rolotherapy • Th
 e two bundles (anterolateral and posteromedial) PCL
• Orthobiologics (PRP, bone marrow concentrate) course from medial to lateral, attaching the femur to
the tibia to prevent excessive posterior translation of the
Injectate Volume tibia.
• 1 to 3 mL • Main stabilizer in posterior tibial translation (primarily
anterolateral bundle).
Technique • Main arterial supply is the middle geniculate artery.
Patient Position
• S upine Common Pathology
• Knee flexed to at least 90 degrees with tibia in slight • S usceptible to acute tear/rupture from a direct blow to a
internal rotation to further increase tension on ACL flexed knee (dashboard injury) or hyperextension injury.
• Can obtain better exposure with more hyperflexion of • May be associated with other injuries such as PLC, mul-
the knee tiligamentous, or knee dislocation injuries.
• PCL ganglion cysts are uncommon, and often inciden-
Clinician Position tal, but can mimic meniscal or chondral lesions.
• On affected side of patient knee
Equipment
Transducer Position • C urvilinear or high-frequency linear array transducer
• Long axis to the ACL • 22 to 25 gauge 2 to 3.5 inch needle for injection
390 SEC T I O N I I I Atlas

PT

PAT

PROX TP
A C

PT

PAT

TP

B D
• Fig. 21.26 (A) Anterior cruciate ligament (ACL) in-plane injection setup. (B) ACL out-of-plane injection
setup. (C) ACL in-plane ultrasound injection. (D) ACL out-of-plane ultrasound injection.

Common Injectates Needle Position

• P rolotherapy • I n-plane (long axis to PCL), distal/anterior to proximal/
• Orthobiologics (PRP, bone marrow concentrate, etc.) posterior approach (Fig. 21.27A)
• Alternative approach: out of plane from medial to lateral
Injectate Volume (see Fig. 21.27B)
• 1 to 2 mL
Target
Technique • PCL distal or mid substance (see Fig. 21.27C and D)
Patient Position
• P rone
• Knee in full extension with tibia in slight external rota-
tion to further increase tension on PCL PEARLS AND PITFALLS
Clinician Position • T he posterior cruciate ligament will often appear
• On affected side of patient knee hypoechoic due to anisotropy.
• Gel stand due to the anatomy of the popliteal fossa
can improve visualization of the needle under the
Transducer Position transducer.
• L
 ong axis to the PCL. • Be sure to identify the popliteal vessels and nerves,
• Rotate from coronal plane toward sagittal plane from and make sure the needle stays medial to those
medial to lateral direction until PCL seen in long axis structures.
deep to the posterior tibial cortex.   
 CHAPTER 21 Knee Injection Techniques 391

PROX PTP
A C

PTP F

PROX
B D
• Fig. 21.27(A) Posterior cruciate ligament (PCL) in-plane injection setup. (B) PCL out-of-plane injection
setup. (C) PCL long-axis in-plane injection. (D) PCL out-of-plane ultrasound injection.

Medial Collateral Ligament and Bursal • Th

 e middle layer includes semimembranosus, the
Injection superficial MCL, the medial patellofemoral ligament
(MPFL), and the posterior oblique ligament.
KEY POINTS • The deep layer includes the deep MCL, the pos-
terior medial capsule, and the meniscotibial
• T he bursa is located between the superficial and deep
ligament.
layers of the medial collateral ligament.
• Avoid the saphenous nerve or intra-articular joint, which • The MCL originates at the posterior aspect of the medial
may be inadvertently affected due to its proximity. femoral epicondyle and attaches distally to the medial
  
condyle of the tibia 5 to 7 cm below the joint line and
posterior to the pes anserinus insertion.48
• The MCL bursa, when present, is located between the
Pertinent Anatomy superficial and deep layers of the MCL.
• Th
 e MCL is part of the capsuloligamentous complex of the
medial knee and is a primary static stabilizer to valgus stress Common Pathology
and external rotation, particularly with the knee in flexion. • M CL injuries are common after valgus injury and classi-
• It has three layers: fied by the degree of injury.
• The superficial layer is composed of sartorius and the invest- • A subset of patients with incomplete MCL injuries may fail
ing fascia, which forms part of the patellar retinaculum. conservative management, with deep MCL often the source
392 SEC T I O N I I I Atlas

of ongoing symptoms. The meniscofemoral ligament is Lateral (Fibular) Collateral Ligament and Bursa
more commonly affected than the meniscotibial ligament.49 Injection
• MCL bursitis can be due to overuse/repetitive- or direct
trauma-type injuries, which may cause inflammation to
the bursa. KEY POINTS
• Calcification of the MCL and MCL bursa have both
been reported, and are distinct from the Pellegrini-Stieda • T he lateral collateral ligament courses longitudinally
process.50,51 across the knee joint.
• Avoid the common peroneal nerve, which may be
inadvertently affected due to its proximity.
Equipment
  
• H igh-frequency linear array transducer
• 22 to 27 gauge 1.5 to 2 inch needle for injection

Common Injectates Pertinent Anatomy

• P rolotherapy • Th
 e LCL is the primary restraint to varus stress with the
• Orthobiologics (PRP, bone marrow concentrate, etc.) knee in flexion, originating from the lateral femoral con-
dyle adjacent to the popliteus tendon, and inserting on
Injectate Volume the proximal fibular head.
• 1 to 3 mL • The LCL inserts on the fibular head between the superfi-
cial and deep heads of the biceps femoris.
Technique • The fibular collateral ligament-biceps femoris bursa is a
Patient Position small bursa that exists between the superficial fibers of
• S upine the biceps femoris and the LCL.
• Knee flexed to 30 degrees with towel roll or bump to
place under affected knee Common Pathology
• Can obtain better exposure with slight external rota- • Th
 e LCL is susceptible to varus injury to the knee.
tion of the hip • Isolated LCL injury is uncommon, and LCL injury is
more commonly associated with PL corner injury.52
Clinician Position • Calcification of the LCL and fibular collateral
• At the foot of the patient ligament-biceps femoris calcific bursitis have been
reported.53,54
Transducer Position
• Long axis to the MCL Equipment
• H igh-frequency linear array transducer
Needle Position • 22 to 27 gauge 1.5 to 2 inch needle for injection
• I n-plane, distal to proximal approach for proximal por-
tion of the MCL or MCL bursa, proximal to distal for Common Injectates
the distal portion of the MCL (Fig. 21.28A and B). • P rolotherapy
• Orthobiologics (PRP, bone marrow concentrate, etc.)
Target
• M CL: the affected areas of the MCL (proximal mid-por- Injectate Volume
tion deep fibers [see Fig. 21.28C and D]) • 1 to 2 mL
• MCL bursa: target between the superficial and deep
MCL fibers (Fig. 21.29B) Technique
Patient Position
PEARLS AND PITFALLS • L
 ateral decubitus position with knee flexed 30 degrees
• It is helpful to use color flow Doppler to identify small
OR supine with knee flexed to 30 degrees with towel roll
vessels to which the nerves travel adjacently in order to or bump to place under affected knee and hip in slight
avoid injecting branches of the saphenous nerve. internal rotation of the hip
• Chronic pathology of the medial collateral ligament
(MCL) more often will involve the deep fibers.49 Clinician Position
• The bursa can be small, and applying direct pressure
may disperse the bursal fluid, making evaluation and
• Standing on either side of the patient
needle placement difficult,
• Fluid extravasation from the bursa may anesthetize the Transducer Position
saphenous nerve due to its proximity. • Long axis to the LCL over area of pathology
• Calcification of the MCL and MCL bursa can be treated
with a percutaneous barbotage procedure.
  
 CHAPTER 21 Knee Injection Techniques 393

MFE

DISTAL
A C

MM

MTP
MFE

B D DISTAL

• Fig. 21.28 (A) Proximal medial collateral ligament (MCL) setup. (B) Distal MCL setup. (C) Proximal MCL
long-axis in-plane injection. (D) Distal MCL injection long-axis in-plane injection.

PEARLS AND PITFALLS

• A void normal tissue if possible. Caution should be used
when interpreting the anatomy in long-axis imaging as
V the divergent superficial and deep heads of the biceps
SMCL V femoris can simulate the appearance of tendinopathy
due to thickening and anisotropy. The biceps femoris

* dMCL
and fibular collateral ligament should be examined
in multiple acoustic windows to help control for
anisotrophy.44
• Sonopalpation can be useful to help correlate potential
MFE
pathologic findings with sonographic findings.
Tibia • Fluid extravasation external to the bursa may
anesthetize the common peroneal nerve due to its
proximity.
  
DISTAL

• Fig. 21.29 Medial Collateral Ligament Bursa In-Plane Ultrasound

It is helpful to use color flow Doppler to identify small
Injection. vessels to which the nerves travel adjacently in order to
avoid injecting branches of the geniculate nerves.

Anterolateral Ligament Injection

Needle Position
• I n-plane (long axis to LCL), distal to proximal for the prox-
KEY POINTS
imal portion of the LCL or proximal to distal approach for
the distal areas of the LCL (Fig. 21.30A and B) • T he anterolateral ligament is a thickening of the
anterolateral capsule, and has often been disregarded.
Target • Associated with anterior cruciate ligament (ACL) injuries.
• Pathologic areas of the LCL (see Fig. 21.30C and D)   
394 SEC T I O N I I I Atlas

FH

DISTAL
A C

LFE

DISTAL
B D
• Fig. 21.30 (A) Distal lateral collateral ligament (LCL) in long-axis setup. (B) Proximal LCL long-axis setup.
(C) Distal LCL long-axis in-plane injection. (D) Proximal LCL long-axis in-plane injection.

Pertinent Anatomy Technique

• Th
 e anterolateral ligament (ALL) is an important stabi- Patient Position
lizer against internal rotation, with the knee in greater • S upine with knee flexed to 30 degrees with towel roll or
than 35 degrees of flexion,55 and against anterior transla- bump to place under affected knee
tion of the tibia on the femur. • Can obtain better exposure with slight internal rota-
• Fanlike origin at the prominence of the lateral femoral tion of the hip
epicondyle anterior to the proximal LCL, and insertion
on the tibia between Gerdy’s tubercle and the tip of the Clinician Position
fibular head. The ALL takes an oblique course over the • At the foot of the patient
anterolateral knee, with firm attachments to the lateral
meniscus.56 Transducer Position
• L ong axis in oblique angle to the ALL (Fig. 21.31A).
Common Pathology • Find the ITB, which is easily identifiable; then scan to
• S usceptible to overuse/repetitve- or direct trauma (varus the LCL. The ALL are the thin bands between the two.
directed blow)-type injuries, which may cause partial tear
or rupture. Needle Position
• Similar mechanism to injury as ACL and ITB injuries.57 • In-plane, proximal to distal approach (see Fig. 21.31B)

Equipment Target
• H igh-frequency linear array transducer • The affected areas of the ALL fibers
• 22 to 27 gauge 1.5 to 2 inch needle for injection

Common Injectates
• P rolotherapy
PEARLS AND PITFALLS
• Orthobiologics (PRP, bone marrow concentrate, etc.)
• It is important to consider the anterolateral ligament
Injectate Volume for therapy in ACL injuries, lateral meniscus, and ITB
• 1 to 2 mL injuries.
  
 CHAPTER 21 Knee Injection Techniques 395

ALPT

PROX
A B
• Fig. 21.31 (A) Anterolateral ligament (ALL) long-axis setup. (B) Distal ALL long-axis in-plane injection.

Medial and Lateral Patellar Ligament Injection • L ateral patellofemoral ligament (LPFL)
• Origin is anterior and distal to the lateral epicondyle,
and inserts on the middle third of the lateral patella61
KEY POINTS
• T he medial patellofemoral ligament (MPFL) is the primary Common Pathology
medial patellar stabilizing ligament, and the medial • M PFL and MPML are typically injured in lateral patellar
patellotibial ligament (MPTL) and medial patellomeniscal dislocations, and rupture or injury of the ligament can
ligament (MPML) are secondary restraints.
• It is important to examine patellar stability in 20–30 vs. lead to patellofemoral joint instability58,60,62
5–10 degrees of knee flexion to distinguish between • Rupture of the MPFL has also been associated with ACL
MPFL vs. MPML or MPTL laxity. injury58
   • LPFL laxity, tearing or insufficiency:
• Medial patellofemoral joint instability (rare)61
• Prior aggressive lateral retinaculum surgical release61
Pertinent Anatomy
• Th
 e medial patellofemoral ligament (MPFL) and medial Equipment
patellomeniscal ligament (MPML) are important in • H igh-frequency linear array transducer
maintaining stability of the patellofemoral joint, particu- • 25 to 27 gauge 1.5 to 2 inch needle for injection
larly in the final phases of extension when they oppose
lateral traction of the quadriceps associated with recur- Common Injectates
rent lateral patellar dislocations • P rolotherapy
• The medial patellar retinaculcum is composed of three • Orthobiologics (PRP, bone marrow concentrate, etc.)
layers, the deepest of which contains three medial patel-
lar ligaments.58 Injectate Volume
1. MPFL58 • 0.5 to 1 mL per site
• Primary medial restraint against lateral subluxation
of patella58 Techniques
• Origin is between adductor tubercle and medial Patient Position
epicondyle59 and insertion at the superior border • S upine with knee flexed to 15 to 30 degrees with towel
of the medial patella. roll or bump to place under affected knee
• Lateral glide/translation is best assessed for laxity at
20 to 30 degrees of flexion60 Clinician Position
2. MPML58 • M PFL and MPML
• Secondary stabilizer • Standing at the contralateral side of the affected leg
• MPML origin at the medial meniscus anterior to the • LPFL
MCL and tibia through the coronary ligaments, and • Standing at the ipsilateral side of the affected leg
insertion at the inferomedial border of the patellar60
• Lateral glide/translation is best assessed for laxity at Transducer Position
5 to 10 degrees of flexion60 • M
 PFL (Fig. 21.32A): long axis to the ligament, posi-
3. Medial patellotibial ligament (MPTL)58 tion over the insertion at proximal medial patella at an
• Thinnest of the layers58 and not as clinically relevant oblique angle with fibers in view in the direction of the
• Lateral patellar retinaculum medial condyle.
396 SEC T I O N I I I Atlas

MEDIAL

PATELLA

MFC

MPFL
PATELLA

FEMUR
(MFC)

A C
• Fig. 21.32 (A) Setup for medial patellofemoral ligament (MPFL) injection. (B) Long-axis ultrasound-guided
injection of MPFL. (C) Illustration overlying ultrasound to highlight MPFL. MFC, Medial femoral condyle;
MPFL, medial patellofemoral ligament; stars indicate needle.

• M PML: reposition probe to the inferomedial patella. Perineural Injections

• LPFL (Fig. 21.33A): long axis the ligament, position
over insertion at middle third of the lateral patella at an Tibial Nerve Injection
oblique angle with fibers in view in the direction lateral
epicondyle.
KEY POINTS
Needle Position
• A n approach too far cephalad before bifurcation
• M PFL (Fig. 21.32B and C): in-plane, medial posterior targeting the sciatic nerve will affect the peroneal nerve
to lateral anterior approach fibers.
• LPFL (Fig. 21.33B and C): in-plane, lateral posterior to • Use a medial to lateral approach to avoid the peroneal
medial anterior approach nerve.
  
Target
• P
 athologic ligament (area of hypoechogenicity and
disorganization) Pertinent Anatomy
• Th
 e popliteal artery is located deep and medial to the
tibial nerve near the knee joint line.
PEARLS AND PITFALLS • The medial cutaneous sural nerve branches off of the
tibial nerve within the popliteal fossa to join with the
• V isualize the needle and target the ligaments and not lateral cutaneous sural nerve from the common pero-
the adjacent fat pad.
• It is important to localize and target the ligaments
neal nerve.
involved by examining for patellar instability in 20–30
vs. 5–10 degrees of knee flexion to distinguish Common Pathology
between medial patellofemoral ligament and medial • O
 ccasionally used to perform tibial nerve blocks for
patellomeniscal ligament involvement lower extremity procedures or for the treatment of com-
   plex regional pain syndrome of the lower extremity.
 CHAPTER 21 Knee Injection Techniques 397

MEDIAL

PATELLA

LFC

LFPL

PATELLA

LFC

A C
• Fig. 21.33 (A) Setup for lateral patellofemoral ligament (LPFL) injection. (B) Long-axis ultrasound-guided
injection of LPFL. (C) Illustration overlying ultrasound to highlight LPFL. LFC, Lateral femoral condyle;
LPFL, lateral patellofemoral ligament; stars indicate needle.

• T
 ypically, the popliteal fossa is not a site of entrapment, Transducer Position
but may develop entrapment from post-traumatic or • S hort axis to the tibial nerve at the middle of the popli-
post-procedural scar tissue formation. teal fossa
• Start transverse to the distal thigh and find the sciatic
Equipment nerve; then follow the sciatic nerve inferior until it
• H igh-frequency linear array transducer bifurcates into the tibial branch
• 25 to 22 gauge 2 to 3 inch needle
• Electromyography stimulator, if required for Needle Position
confirmation • In-plane, medial to lateral approach (Fig. 21.34A)

Common injectates Target

• L ocal anesthetics for diagnostics or nerve block • P
 erineural sheath, can target above and below the nerve
• For hydrodissection, anesthetics, corticosteroids, 5% to confirm adequate spread (see Fig. 21.34B).
dextrose solution, orthobiologics (platelet lysate, plate-
let-poor plasma, PRP, etc.) PEARLS AND PITFALLS

Injectate volume • T he needle should not be advanced if the tip is not visible.
• Avoid the neurovascular structures which lie deep to
• 5 to 20 mL and lateral to the tibial nerve in the popliteal fossa.
• A lateral approach may pose risk to peroneal nerve injury.
Technique • A tibial nerve block at this location may affect the motor
Patient Position function of the tibial nerve and should be anticipated
• Prone prior to the procedure.
• Inject as the needle is approaching the epineurium and
advance while injecting slowly to push the nerve away,
Clinician Position thus reducing the risk of intraneural injection.
• A
 long the opposite lower extremity of the patient or at • For hydrodissection, creating a halo around the nerve
the foot of the patient will increase the definition of the nerve borders.
  
398 SEC T I O N I I I Atlas

PV PA

MEDIAL
A B
• Fig. 21.34 (A) Tibial nerve block setup. (B) Tibial nerve block transverse in-plane injection.

Common Peroneal Nerve Injection Technique

Patient Position
KEY POINTS • S ide-lying with contralateral side closest to the table with
knee flexed to 30 degrees with pillow or towel roll or
• A
 pproaches to cephalad (prior to the bifurcation of the bump placed in between the knees
tibial nerve) or caudal (too distal after the bifurcation of
the lateral sural cutaneous nerve) may have undesired
effects on nerve function.
Clinician Position
• In front of the patient
  
Transducer Position
• S hort axis to the common peroneal nerve posterior to the
Pertinent Anatomy knee joint line and directed laterally towards the fibular head
• Th
 e common peroneal nerve is the lateral branch of the • Start transverse to the distal thigh and find the sciatic
sciatic nerve. While in the popliteal fossa, the common nerve; then follow the sciatic nerve inferior until it
peroneal nerve gives off the lateral genicular branches to bifurcates into the tibial and peroneal branches
the knee joint and the lateral cutaneous sural nerve prior
to coursing around the fibular head and dividing into the Needle Position
superficial and deep peroneal nerve. • In-plane, distal to proximal approach (Fig. 21.35A)
Common Pathology Target
• C an be a common site of entrapment between the fibular • P
 erineural sheath, can target above and below the nerve
head and external pressure from the tendinous origin of to confirm adequate spread (see Fig. 21.35B and C)
the peroneus longus.
• Injury associated with fracture of the proximal fibula,
post-traumatic or iatrogenic from positioning during a PEARLS AND PITFALLS
procedure compression.
• A void the neurovascular structures which lie posterior
Equipment and deep to the common peroneal nerve within the
popliteal fossa.
• H igh-frequency linear array transducer • An approach too far cephalad may affect the tibial
• 22 to 25 gauge 2 to 3 inch needle nerve prior to the bifurcation.
• Electromyography stimulator, if required for confirmation • A common peroneal nerve block at this location may
affect the motor function of the peroneal nerve and
Common Injectates should be anticipated prior to procedure.
• The needle should not be advanced if the tip is not
• L ocal anesthetics for diagnostics or nerve block visible.
• For hydrodissection, anesthetics, corticosteroids, neu- • Inject just before approaching the epineurium and
roprolotherapy, orthobiologics (platelet lysate, platelet- advance while injecting slowly to push the nerve away,
poor plasma, PRP, etc.) thus reducing the risk of intraneural injection.
• For hydrodissections, creating a halo around the nerve
Injectate Volume will increase the definition of the nerve borders.

• 5 to 20 mL   
 CHAPTER 21 Knee Injection Techniques 399

FH

FH POST
A C
• Fig 21.35 (A) Common peroneal nerve at fibular head setup. (B) Common peroneal nerve short-axis
in-plane injection. (C) Common peroneal nerve at the fibular head hydrodissection.

Saphenous Nerve Injection and Infrapatellar • I atrogenic injury may occur post-procedurally during
Branch of Saphenous Nerve Injection hamstring tendon harvest and total knee arthroplasty.63,64
Equipment
KEY POINTS • H igh-frequency linear array transducer
• 25 to 27 gauge 2 to 3 inch needle
• A
 nesthetize above and below the saphenous or • Electromyography stimulator, if required for confirmation
infrapatellar branch of the saphenous nerve within the
perineural sheath to ensure adequate effect. Common Injectates
   • L ocal anesthetics for diagnostics or nerve block
• For hydrodissection, anesthetics, corticosteroids, neu-
roprolotherapy, orthobiologics (platelet lysate, platelet-
Pertinent Anatomy
poor plasma, PRP, etc.)
• Th
 e saphenous nerve is a pure sensory branch of the fem-
oral nerve, which innervates the medial knee and foot. Injectate Volume
• The infrapatellar division can be a vulnerable to injury • 5 to 20 mL
due to its proximity to the prominence of the medial
femoral condyle, and the nerves superficially course Technique
through the sartorius muscle. Patient Position
• S upine with lower extremity externally rotated for better
Common Pathology exposure of the nerve
• A ssociated with direct trauma or associated muscle/ten-
don injury of the adductor and medial thigh. Clinician Position
• Vulnerable to entrapment, inflammation or injury any- • Along the affected side of the patient
where along its long course.
• Saphenous nerve syndrome refers to symptomatic Transducer Position
entrapment of the nerve as it courses through the • S aphenous nerve: short axis to the saphenous nerve just
adductor canal. inferior to the adductor canal
400 SEC T I O N I I I Atlas

SART

AL

FA

VM

A B F

• Fig. 21.36 (A) Saphenous nerve block just inferior to the adductor canal. (B) Saphenous nerve block in plane.

• I nfrapatellar branch: long axis to the infrapatellar branch Genicular Nerve Block
at the proximal tibia or short axis to the infrapatella adja-
cent to the metaphysis of the proximal tibia
KEY POINTS
Needle Position • T he nerves run adjacent to the corresponding genicular
• S aphenous nerve: in-plane, anterior lateral to posterior arteries, which should be identified and used as
medial approach (Fig. 21.36A) landmarks for injection. Utilize Doppler to identify
vasculature prior to injection.
• Infrapatellar branch: in-plane, anterior lateral to poste- • These nerves are typically blocked or ablated for
rior medial approach (Fig. 21.37A) knee pain, but also be injured or entrapped with knee
• Alternative: out-of-plane, anterior to posterior surgeries.
approach (see Fig. 21.37B)   

Target
• P
 erineural sheath, can target above and below the nerve Pertinent Anatomy
to confirm adequate spread • Th
 e knee is innervated by articular branches of several
• Saphenous (see Fig. 21.36B) nerves, including the femoral, obturator, saphenous,
• Infrapatellar branch (see Fig. 21.37C and D) common peroneal, and posterior tibial nerves.
• Superolateral genicular nerve (SLGN)
• Located at the junction of the lateral condyle and
femoral shaft65
PEARLS AND PITFALLS
• Superomedial genicular nerve (SMGN)
• H igh-frequency linear array or curvilinear transducer may • Located at the junction of the medial condyle and femo-
be used, depending on the patient’s body habitus. If it ral shaft.65 Lies beneath the adductor magnus tendon.66
is difficult to visualize the nerve, so you may consider • Inferomedial genicular nerve (IMGN)
injecting the fascial plane adjacent to the nerve.
• Femoral vessels and small vessels around the
• Located between the medial tibial condyle and the
infrapatellar saphenous nerve may serve as a landmark tibial insertion of the MCL.66
for a poorly visualized nerve. Use color flow Doppler to • Inferolateral genicular nerve (ILGN)
identify the vessels as the nerve often travels adjacent • Located superficial to the lateral tibial plateau and
to those. Avoid intravascular injection. superior and anterior to the fibular head.67
• The needle should not be advanced if the tip is not visible.
• Inject just before approaching the epineurium and
advance while injecting slowly to push the nerve away,
Common Pathology
thus reducing the risk of intraneural injection. • I njury to the genicular nerves is uncommon in the
• For hydrodissections, creating a halo around the nerve literature.
will increase the definition of the nerve borders. • Interventional procedures for the genicular nerves are pri-
   marily to treat intra-articular pathology, including knee
 CHAPTER 21 Knee Injection Techniques 401

MTP

LATERAL
A C

MM

MTP

B D DISTAL MFE

• Fig. 21.37(A) Infrapatellar branch of saphenous nerve injection in-plane setup. (B) Infrapatellar branch of
saphenous nerve out-of-plane setup. (C) Infrapatellar branch of saphenous nerve injection transverse in
plane ultrasound injection. (D) Infrapatellar branch of saphenous nerve transverse out-of-plane ultrasound
injection.

osteoarthritis66-68 postoperative pain following total or Transducer Position

partial knee replacement66,68 • S hort axis to the nerves. Confirm with color flow
Doppler. The nerves are adjacent to the arteries and may
Equipment be hard to visualize. To help identify each:
• H igh-frequency linear array transducer • SLGN (Fig. 21.38A)
• 25 to 27 gauge 1.5 to 2 inch needle for injection • Place the transducer in long axis to identify the quad-
riceps tendon.
Common Injectates • Slide the transducer laterally to the intersection of the
•  ocal anesthetics, plus or minus corticosteroids
L lateral femoral shaft and the lateral epicondyle.
• 5% dextrose (neuroprolotherapy) • Identify the superolateral genicular artery above the
• Platelet lysate periosteum.
• Radiofrequency ablation is also used but not discussed here • SMGN (Fig. 21.39A)
• Place the transducer in long axis to identify the quad-
Injectate Volume riceps tendon.
• 1 to 1.5 mL per site • Slide the transducer medially to the intersection of the
medial femoral shaft and the medial epicondyle.
Technique • Identify the superomedial genicular artery adja-
Patient Position cent to the periosteum, proximal to the adduc-
• S upine and knee flexed to 15 to 30 degrees with towel tor tubercle, and deep to the adductor magnus
roll or bump to place under the popliteal fossa of the tendon.
affected knee • IMGN (Fig. 21.40A)
• Place the transducer in long axis to identify the
Clinician Position intersection of the medial tibial shaft and the medial
• S LGN and ILGN epicondyle.
• Clinician ipsilateral to affected knee • Identify the inferomedial genicular artery adjacent to
• SMGN and IMGN the periosteum between the medial tibial epicondyle
• Clinician contralateral to affected knee and the tibial insertion of the MCL fibers.
402 SEC T I O N I I I Atlas

-4
cm/s

LAT FEM SHART DISTAL

B

LAT FEM SHART

A C
• Fig. 21.38 (A) Setup for superolateral genicular nerve (SLGN) injection. (B) Identification of superolateral
genicular artery. (C) Out-of-plane ultrasound-guided perineural injection of SLGN.

-4
cm/s

MFC

DISTAL
B

MFC

A C
• Fig. 21.39 (A) Setup for superomedial genicular nerve (SMGN) injection. (B) Identification of superomedial
genicular artery. (C) Out-of-plane ultrasound-guided perineural injection of SMGN.
 CHAPTER 21 Knee Injection Techniques 403

-4
cm/s

MTP
B
DISTAL

MTP
A C
• Fig. 21.40 (A) Setup for inferomedial genicular nerve (IMGN) injection. (B) Identification of inferomedial
genicular artery. (C) Out-of-plane ultrasound-guided perineural injection of IMGN.

• I LGN (Fig. 21.41A)

• Place the transducer in long axis to the knee, and PEARLS AND PITFALLS
identify the lateral meniscus and lateral tibial plateau. • B e sure to use Doppler to identify the genicular arteries.
• Slide the transducer distally, proximal to fibular • Use the quadriceps tendon as a landmark to identify
head, and anteriorly until the inferolateral genicu- the superomedial and superolateral nerves.
lar artery is identified, which may be at the lateral • For the inferolateral genicular nerve block, be sure to
border of the tibial plateau or superficial to the lat- identify and avoid the common peroneal nerve.
eral meniscus.   

Needle Position
• S LGN Knee Fluoroscopy Injection
• Out of-plane, lateral to medial approach (Fig. 21.38B Joints
and C)
• SMGN
Femorotibial Joint: Medial and Lateral
• Out of-plane, medial to lateral approach (Fig. 21.39B KEY POINTS
and C)
• IMGN • F luoroscopy can be used to confirm placement of
injectate in specific area of the knee joint.
• Out of-plane, medial to lateral approach (Fig. 21.40B • You can ensure flow directly along the specific chondral
and C) surface.
• ILGN • For accurate anterior, posterior, and lateral fluoroscopic
• Out of-plane, lateral to medial approach (Fig. 21.41B views, be sure to align femoral condyles and tibial plateaus.
and C)   
• Alternately, for all, inject inject in-plane, proximal to dis-
tal approach Pertinent Anatomy
See Ultrasound section.
Target
• A
 djacent to corresponding genicular artery or perineu- Common Pathology
rally, if nerve is visible. See Ultrasound section.
404 SEC T I O N I I I Atlas

LTP
B LFC

LTP

MTP
DISTAL
A C
• Fig. 21.41 (A) Setup for inferolateral genicular nerve (ILGN) injection. (B) Identification of inferolateral genic-
ular artery. (C). Out-of-plane ultrasound-guided perineural injection of ILGN.

Equipment
• C -arm fluoroscopy
• 18 to 27 gauge 1.5 or 3.5 inch needle depending on injec-
tate and body habitus. Micronized adipose tissue will
require 18 to 22 gauge needle. Bone marrow concentrate
or aspirate will require 22 to 25 gauge needle. Other thera-
peutic injectates usually performed with 25-gauge needle.
• Contrast dye

Common Injectates
• L
 ocal anesthetics for diagnostics, corticosteroids, hyal-
uronic acid, prolotherapy, orthobiologics (PRP, bone
marrow concentrate, micronized adipose tissue, etc.)
• Fig. 21.42 Knee Hook-Lying Position.
Injectate Volume
• 2 to 10 mL total Needle Position
• U se AP projection to identify mid portion of medial
Technique for Medial and Lateral Joint Compartments femoral condyle or lateral femoral condyle.
Patient Position • Then, in lateral position, start needle entry about 1 cm
• S upine hook-lying. Can place booster pillow under the above the tibial plateau.
knee for support (Fig. 21.42). • Under intermittent fluoroscopy, advance needle from
Clinician Position superior to inferior, anterior to posterior towards the
• Standing on ipsilateral side of the patient. middle of the tibial plateau.
C-Arm Position • Avoid hitting the femoral condyle articular cartilage.
• True anteroposterior (AP) projection, where anterior and Target
posterior femur and tibia are aligned. • Medial or lateral joint compartments
• Lateral projection, where medial and lateral femo- • Aim to gently touch down on the desired tibial pla-
ral condyles and medial and lateral tibial plateaus are teau or the meniscus in the middle third of the joint
aligned. from anterior to posterior (Fig. 21.43).
 CHAPTER 21 Knee Injection Techniques 405

PEARLS AND PITFALLS

• U se a smaller-gauge needle where possible and avoid
hitting the femoral surface to avoid cartilage injury.
• Needle trajectory should be slightly angled superior
to inferior instead of parallel to the tibial plateau. The
angled approach helps avoid damage to the meniscus
and tibial or femoral cartilage. Also, this can allow for
the needle to have adequate depth to get into the joint
if there is less joint space or osteophytes.
• Osteophytes can be seen on the x-ray and should be
avoided by a more lateral or medial starting point, or
angling the needle to avoid them.
• Use minimal contrast (⅛ to ¼ mL) to limit cytotoxic
effects.
• If contrast is pooling in the soft tissues rather than easily
flowing along the chondral surfaces, then placement is
likely extra-capsular within Hoffa’s fat pad. In this case,
advance the needle.
• If the injection is painful, the needle is likely not
intra-articular.
  

• Fig. 21.43 Knee lateral compartment intra-articular injection fluo-

roscopy AP view with contrast.

• Fig. 21.45
Knee medial compartment intra-articular injection fluo-
roscopy AP view with contrast.

• Fig. 21.44Knee medial compartment intra-articular injection fluo- Technique for Weightbearing Medial and Lateral
roscopy lateral view with contrast.
Femoral Chondral Surfaces
Patient Position
• C ontrast in lateral should spread anterior and pos- • S upine, hip, and knee each flexed 90 degrees. Rest the leg
terior above the tibial surface, perhaps making a on a block or bolster (Fig. 21.46)
“U” shape under the medial femoral condyle (Fig. Clinician Position
21.44). • Standing on the side of the patient
• In the AP view the contrast should be spread medial C-Arm Position
and lateral through the medial compartment (Fig. • Lateral projection with the femoral condyles and tibial
21.45). plateau aligned.
406 SEC T I O N I I I Atlas

Needle Position
• P alpate the patellar tendon. Move medial or lateral
depending on target to palpate the mid portion of the
desired femoral condyle.
• Start needle entry about 1 cm distal to the medial or lat-
eral aspect of the patella.
• Aim slightly proximally with bevel facing the chondral
surface.
Target
• Medial or lateral femoral condyle
• Aim for the one-third of the chondral surface with the
bevel facing the surface. Gently touch os.
• Inject a small amount of contrast. There should be
no resistance and easy flow if intra-articular. If not,
pull the needle back usually about 1 mm or less while
injecting until resistance is loss.
• In the lateral view, contrast should flow directly along
the desired chondral surface (Fig. 21.47).

PEARLS AND PITFALLS

• Fig. 21.46Knee setup for weightbearing femoral chondral surface
• T his is the preferred approach when using (90/90) position.
mesenchymal stem cells (MSCs). The 90/90 position
(hip and knee flexed 90 degrees each) can allow for
gravity-dependent cell adhesion after 10 min.8 Inject
very slowly over 3–5 min to allow for cell adhesion
and to avoid flushing the injectate off of the chondral
surface.
• It is unknown if there is any advantage for this position
(?approach) with other biologics besides MSCs.
• Use a smaller-gauge needle where possible to avoid
damaging the cartilage. Guide the needle very slowly
and barely touch down on the chondral surface. Make
sure bevel is facing the surface to decrease chances of
cartilage injury and inject directly on chondral surface.
• Contrast pool indicates extra-articular flow and the
needle may need to be redirected.
• Aiming for the more anterior aspect of the condyle
helps achieve a more diffuse flow along the cartilage
surface.
• If treating a femoral osteochondral defect or cartilage
defect using x-ray or previous diagnostic MRI, you can
specifically aim for the defect to inject.
• Only use 1–3 mL of injectate here. Any extra can be
placed intra-articular with traditional techniques.
  

Patellar Facets Intra-Articular: Medial and • Fig. 21.47Injection of weightbearing femoral chondral surface fluo-
Lateral roscopic lateral view.

KEY POINTS • Th
 e patella: it is composed of two main facets, medial
and lateral, separated by a vertical ridge.69 It is further
• D
 irect targeting of patellar facets is optimal for patients subdivided into seven facets: three medial and three lat-
with patellofemoral pain or chondral defects when
targeting with cellular therapy.
eral that articulate with the femoral groove and an odd
facet at the medial border that articulates with the medial
  
femoral condyle in deep knee flexion due to patellar rota-
tion in this position (Fig. 21.48A).70,71
Pertinent Anatomy • Vascular supply to the patella consists of the geniculate
• Th
 e patellofemoral joint: the cartilaginous articulation arteries: superolateral, inferolateral, superomedial, and
between the undersurface of the patella and the trochlea inferomedial (see Fig. 21.48B).
 CHAPTER 21 Knee Injection Techniques 407

Central
body
Medial Superior
extension tag
Medial
meniscopatellar
ligament Lateral
extension

Odd facet
Lateral
Medial facet
facet
Central
longitudinal
ridge
A

Superior
geniculate

Lateral superior
Medial
geniculate
superior
geniculate

Lateral inferior
geniculate

Medial
inferior
geniculate
Anterior tibial
recurrent
B
•Fig. 21.48 (A) Patella. (B) Patella vascular supply. (A, Detterline A, Babb J, Noyes FR, et al. Noyes’
Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes. 2017:2–22. B, From Miller. DeLee & Drez’s
Orthopaedic Sports Medicine. 5th ed.)

Common Pathology Injectate Volume

•  ocal patellofemoral chondral defects
F • 2 to 10 mL total
• Osteochondral defects
• Chondromalacia patellae Technique
• Patellofemoral osteoarthritis Patient Position
• P
 atient prone with pillows, block, or sheets placed under
Equipment the hip flexors and under the chin. The goal is to elevate
• C -arm fluoroscopy the knee a few inches above the bed/table (Fig. 21.49).
• 22 to 27 gauge 2 inch needle
• Contrast Clinician Position
• Standing on ipsilateral side of the patient.
Common Injectates
• L
 ocal anesthetics for diagnostics, corticosteroids, C-Arm Position
hyaluronic acid, prolotherapy, orthobiologics (PRP, • T
 rue lateral projection with femoral condyles aligned
bone marrow concentrate, micronized adipose tissue, and clear visualization of the patellofemoral space. The
etc.) C-arm will likely be angled rather than parallel to the
408 SEC T I O N I I I Atlas

floor, as elevating the knee as described will cause some • I n the AP view, the needle will be on the superior
external rotation of the leg. aspect of the medial patellar facet. Contrast will
• Anterior posterior view angling the beam to be parallel to spread in slightly circular fashion from the needle tip
posterior patellar surface.

Needle Position
• P alpate the superior lateral pole of the patella. Use your
hand to push from the medial aspect of the patella to
slide the patella laterally.
• Start needle about 1 cm posterior/above the superior
pole of the patella.
• Lateral patellar facet: A
• Needle will have steep trajectory aiming distal, medial,
and inferior toward the lateral facet.
• Medial patellar facet:
• Needle will have less steep trajectory. Aim just above
the middle ridge of the patella.

Target
• L ateral patellar facet:
• Target superior middle portion of the facet. In the lat-
eral view, the needle will be just above the cartilage
surface in the superior half of the patella.
• Contract will flow along the patella surface proximal
and distal with a linear appearance (Fig. 21.50).
• In the AP view, the needle will be on the lateral
patellar facet superior aspect. Contrast will spread in
a slightly circular fashion from the needle tip (Fig.
21.51).
• Medial patellar facet:
• Same approach as lateral but needle will continue to
over superior middle portion of the medial facet. The B
middle ridge of the patella can block needle entry, and
if contact is felt, redirect slightly above the ridge and • Fig. 21.49 (A) Patient positioning and lateral fluoroscopic setup. (B)
Patient positioning and AP fluoroscopic setup.
then reangle back to the target.

A B
• Fig. 21.50 Lateral patellar facet injection lateral fluoroscopic view with contrast.
 CHAPTER 21 Knee Injection Techniques 409

• Fig. 21.52 Tibiofibular joint injection. AP fluoroscopy with contrast.

• Fig. 21.51 Lateral patellar facet injection. AP fluoroscopic view with
contrast.
Equipment
• C -arm fluoroscopy
PEARLS AND PITFALLS • 25 or 27 gauge 2 inch or 1.5 inch needle
• Contrast
• P roceduralist should pull the patella laterally; it can help
to open the patellofemoral space to allow for ease of Common Injectates
needle entry.
• The medial patellar facet injections are deeper, so • L
 ocal anesthetics for diagnostics, corticosteroids, prolo-
the needle angle is different and usually less steep. therapy, orthobiologics (PRP, bone marrow concentrate,
Sometimes starting a little more superior to the patella etc.).
will help avoid the middle ridge.
• Inject slowly to allow for possible adhesion of Injectate Volume
mesenchymal stem cells,
• 2 to 10 mL total
  
Technique
Tibiofibular Joint Patient Position
• Supine with the knee in hook-lying (see Fig. 21.42)
KEY POINTS
Clinician Position
• A n often overlooked cause of lateral knee pain.
• Entire posterolateral corner needs evaluation when • Standing on ipsilateral side of the patient
assessing for pain in this region.
• There is significant anatomic variability in the angulation C-Arm Position
of the proximal tibiofibular joint. • A nterior posterior projection with slight lateral oblique
   to open the joint
• Lateral view

Pertinent Anatomy Needle Position

See Ultrasound section. • P alpate the fibular head. Start needle entry just superior
and anterior to the fibular head.
Common Pathology • Aim posteriorly and slightly inferiorly.
• D egenerative osteoarthritis or direct traumatic injury
• Ganglion cyst, which may or may not compress the com- Target
mon peroneal nerve • I n the AP view, needle should be a third to halfway in the
• PL corner injury with subsequent instability (requires co- joint space. Contrast should show medial and inferior
treatment of surrounding injured/lax structures) flow inside the joint (Fig. 21.52).
410 SEC T I O N I I I Atlas

• O rigin on the lateral trochlea posterior relative

to PL band with the knee in flexion and anterior
when in extension in the majority of patients75
• Function: controls AP translation (anterior drawer
test/Lachman test)
• Biomechanics: tight in 45 to 60 degrees of knee flexion
• Connects with medial meniscal root
2. PL bundle:
• Insertion on the medial tibial spine lateral and pos-
terior to the AM bundle
• Origin on the lateral trochlea slightly posterior and
proximal relative to the AM band when the knee is
in extension and anterior and slightly distal when
in flexion in many patients.75 In the lateral fluoro-
scopic view, it is located posterior and distal to the
marrow shadow of the femur (see Fig. 21.54D)
• Function: controls AP translation (anterior drawer/
• Fig. 21.53 Tibiofibular joint injection. Lateral fluoroscopy with contrast.
Lachman test) and tibial rotation (pivot shift test,
ACL dial)
• Biomechanics: tight in extension
• I n the lateral view, the needle should be halfway in the • ACL sheath: The ACL is surrounded by a synovial sheath
joint from anterior to posterior. Contrast should show a shown to provide a protective role, and damage to which
coin-shaped flow in the joint (Fig. 21.53). is associated with ACL degeneration.76 The sheath pre-
vents direct contact of synovial fluid with the ligament
PEARLS AND PITFALLS (Fig. 21.55).77 The ACL, therefore, lies within the joint
capsule, but separated from the synovial membrane.78
• E nter just anterior and superior of the joint to avoid
neovasculature. Common Pathology
• Check lateral view to avoid advancing too far posteriorly
and to avoid peroneal nerve. • A CL laxity, partial tear, non-retracted full tear, or full tear
• If contrast is pooling, then adjust the needle to obtain that is approximated and retracted less than 1 cm.
better intra-articular flow. • Acute ACL tears are more common in women, are asso-
• It is a small joint, so don’t advance the needle more ciated with cutting sports and valgus stress or hyperex-
than halfway into the joint to prevent cartilage injury. tension injury, and are associated with biomechanical
   imbalance secondary to quadriceps dominance.79

Anterior Cruciate Ligament Equipment

• C -arm fluoroscopy
KEY POINTS
• 25 gauge 3,5 inch needle
• T here is evidence that partial to complete, non- • Contrast
retracted ACL tears can be healed with bone marrow
concentrate.72,73 Common Injectates
• Fluoroscopically guided ACL injection is the preferred
technique for partial to complete non-retracted ACL
• P
 rolotherapy, orthobiologics (PRP, bone marrow con-
tears.72,73 It is necessary to treat both bundles, centrate, etc.).
insertion, and origin, as well as mid substance tears if
present. Injectate Volume
• Ultrasound-guided ACL injections have been shown to • 1 to 2 mL total
reach the insertion, mid substance, and ACL origin74;
however, fluoroscopy is the preferred method to confirm
spread in real time and to readjust needle to achieve full
Technique
coverage when tears are present. Patient Position
  
• Supine hook lying (see Fig. 21.42)

Clinician Position
Pertinent Anatomy • Ipsilateral to the side of the patient
• T
 wo bands of the ACL (Fig. 21.54A to D):
1. AM bundle: C-Arm Position
• Insertion on medial tibial spine medial and ante- • T
 rue anterior posterior projection where anterior and
rior to the PL bundle posterior femur and tibia are aligned.
 CHAPTER 21 Knee Injection Techniques 411

• L
 ateral projection where medial and lateral femoral con- • I n true AP fluoroscopic view, needle should be cen-
dyles and medial and lateral tibial plateaus are aligned. tered between the tibial spines.
• In AP view, advance needle about 1 cm, aiming poste-
Needle Position rior and inferior, making sure needle is staying in the
• I n true AP fluoroscopic view, needle should be centered middle of the tibial spines.
between the tibial spines. • Angle should be fairly steep relative to the knee.
• Needle will travel through the patella tendon, Hoffa’s fat • Advance further in the lateral view to the insertional
pad, and the anterior joint capsule into the ACL. target.
• Guide the needle to the tibial plateau just anterior to
Target/Injection Techniques the medial tibial eminence.
• T arget the ACL insertion, then move on to target origin, • Inject a small amount of contrast in the lateral view,
and possibly mid portion depending on contrast spread. which should show flow superior and posterior along
• ACL insertion, AM bundle: the distal to mid ACL fibers. Sometimes flow can go
• Palpate the patella. The needle will enter just below all the way to the proximal portion (Fig. 21.56).
the patella.

Posterolateral origin at Anteromedial origin at

A tibial spine, knee flexion tibial spine, knee flexion

Anterior transverse
Patellar tendon
ligament
ACL

Medial meniscus Lateral meniscus

Iliotibial tract
MCL

Popliteal tendon

Posterior oblique
ligament Arcuate ligament

PCL
Meniscofemoral ligaments
Oblique popliteal
Semimembranosus ligament
B tendon
• Fig. 21.54Anterior Cruciate Ligament Anatomy. (A) ACL coronal. (B) ACL insertions transverse. ACL,
Anterior cruciate ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.
412 SEC T I O N I I I Atlas

Intercondylar fossa

Lateral condyle

Tibial spine

PL

AM

Flexion

Femur

Femur Femur
PL PL
AM
AM
PL AM

Tibia Tibia Tibia

D
•Fig. 21.54—cont’d (C) ACL bundles from AP with knee in flexion. (D) ACL bundles in extension and flex-
ion, sagittal view. AM, Anteromedial bundle, PL, posterolateral bundle. (B, From Tafur M, Bencardino JT,
et al. Insall & Scott Surgery of the Knee. 2018;133–160.e3.)

• I f contrast is pooling, then the needle is likely • W ith a curved needle tip, turn the needle slightly
anterior to the ligament, and the needle needs to medially but still just anterior to the tibial spine.
advance posteriorly. • Insertion point is slightly anterior and medial to
• If the contrast spreads diffusely in the joint, then PL bundle.
the needle is either lateral, medial, or posterior to • Contrast flow is at a shallower angle than the PL
the ACL. Recheck needle placement in AP. bundle.
• Confirm in the AP view as well to show con- • PL bundle insertion:
trast going superior and lateral (Fig. 21.57). • After injecting the AM bundle, turn the curved
Sometimes contrast will additionally flow into needle laterally and head slightly posterior (1 to 2
the medial > lateral meniscus via connection to mm) and inject the PL bundle.
the transverse ligament, which can be seen in the • Contrast flow is at a slightly steeper angle com-
AP view. pared to the AM bundle.
• Sometimes contrast flow will appear as one large • ACL lorigin:
single band; sometimes the bands clearly appear • Palpate the patella. This time the needle will enter
separate. about 1cm below the patella or midway between the
• AM bundle insertion: patella and the tibia.
 CHAPTER 21 Knee Injection Techniques 413

Epiligament
Periligament
Endoligament Synovial membrane
Intima
ACL Subintima
covered
by synovial
fold

Hoffa’s
fat pad

Synoviocytes
Patella
type A
A type B

Perivascular
stem cell niche
PCL

pl Synovial
LFC villus
MFC
am
ACL

Ligamentocyte

Collagen fibers
B T C
• Fig. 21.55 ACL Dissection, Sheath, and Blood Supply. (From Schulze-Tanzil G. Intra-articular ligament
degeneration is interrelated with cartilage and bone destruction in osteoarthritis. Cells. 2019;8:990 with
permission.)

• Fig. 21.56
Distal ACL Insertion Injection Lateral Fluoroscopy with • Fig. 21.57 Distal ACL Insertion Injection AP Fluoroscopy with Contrast.
Contrast Showing Double Bundle Flow.

• A ngle will be slightly upwards.

• I n true AP fluoroscopic view, needle should be cen- • Advance further in the lateral view gently towards the
tered between the tibial spines. mid lateral superior trochlear bone.
• In AP view, advance needle about 1 cm, aiming • The needle should touch down on bone in the anterior
toward the superolateral femoral trochlea. half of the medial wall of the lateral femoral condyle.
414 SEC T I O N I I I Atlas

• A dvance about 1 cm to make sure the needle is on this

trajectory.
• Should have a less steep angle than the insertion
technique.
• In the lateral view, advance posteriorly to the mid por-
tion of contrast from previous injections at the inser-
tion and origin.
• Inject a tiny amount of contrast to confirm flow in the
mid portion of the ACL in the lateral and confirm in
the AP view.
• Turn and redirect the needle 1 to 2 mm medial, lateral,
and superior inferior to make sure to pick up both bands.

PEARLS AND PITFALLS

• B e sure to visualize the patient’s ACL on MRI prior to the
procedure to notice any anatomic variations and get a
better idea of ACL insertion, origin, and mid substance
tear characteristics and help predict contrast flow.
• The ACL bundles run parallel to each other in full knee
extension where the anteromedial (AM) bundle is lax
and the posterolateral (PL) bundle is relatively taut.
•Fig. 21.58 Proximal ACL Injection Fluoroscopy Lateral View with However, these procedures are done with the knee in
Contrast Connecting to Distal ACL. 90–120 degrees of flexion. In flexion the mid sections
slightly cross as the AM bundle is taut, and the PL
bundle is relatively lax. This makes the PL origin appear
Then “walk” off the trochlea, aiming posterior to the more anterior and superior, and the AM origin appear
ACL origin at the posterior superior aspect of the lat- more posterior and inferior.
eral femoral trochlea. Use fluoroscopy to ensure the • A slight bend in the needle tip makes it easier to make
needle does not advance posterior to the femur. The slight adjustments and redirect the needle tip into
needle should be at or just 1 mm off the bone. multiple areas of the ligament.
• There is a great deal of variation in individual anatomy,75
• Inject a small amount of contrast in the lateral view, so use contrast flow to guide needle placement.
which should show flow inferior and anterior along • If you cannot get complete flow from the tibial insertion
the posterior to mid ACL fibers. The contrast should to femur, then you must also inject the femoral origins.
head toward or connect with contrast flow from inser- • Inject both AM and PL bundle for optimal treatment,
tional injection (Fig. 21.58). need to see two-directional flow, otherwise both
bundles were not reached.
• If contrast is pooling and not flowing along the • In some ACLs with partial healing prior to injection,
ACL fibers or flowing diffusely into the joint, then stump formation can occur. In these cases, needle
the needle is likely medial to the ligament, and the fenestration of the stump is recommended to encourage
needle needs to be adjusted laterally. fiber growth through the fibrous tissue of the stump.
• In the AP view, confirm contrast spread inferior, • Full remodeling of the ACL can take between 6 and
12 months (shorter time periods for younger patients).
medial, and connecting with contrast flow from inser- Repeat MRI at 3-month intervals can show progressing,
tional injection (Fig. 21.59). positive healing. Obtain ACL sagittal and/or coronal
• AM and PL bundles: oblique views to image better.
• In the flexed position, the AM bundle is taut, and • May need to also inject transverse ligament if there is
the origin appears more posterior and inferior on anterior meniscal root instability in association with ACL
injury.
the femur. To target, adjust the curved needle pos- • Often can get spread into anterior horns of the lateral
teriorly in the lateral view. and medial menisc; so if also targeting here, watch for
• In the flexed position, the PL bundle is lax, and the contrast flow to add additional injectate.
origin appears more anterior and superior on the   
femur. To target ,adjust curved needle and direct
anteriorly in the lateral view. Anterior Cruciate Graft
• ACL mid portion: target the mid portion of the ACL if there
is a specific tear hear on MRI, there is diffuse tearing through- KEY POINTS
out the ACL, or if contrast flows from the insertion and ori- • T reatment for partial tears only, not complete or
gin does not completely fill the mid portion of the ACL. retracted. Must have visible intact fibers.
• In the AP view, start needle entry in the middle of the • Similar approach to regular ACL, but look for the graft
ACL insertions and origin that should be filled with tunnels to guide needle placement.
contrast. • Try to angle inside the tunnel, if possible.
• Start the needle about ½ to 1 cm below the patella.   
 CHAPTER 21 Knee Injection Techniques 415

Needle Position
• H ave a slight bend in the needle tip to make it easier to
make slight adjustments injecting multiple areas of the
ligament and for redirection.
• Start with targeting the graft tunnel insertion; then target
the origin and possible mid portion.
• In true AP fluoroscopic view, needle should be centered
(medial/lateral) between the graft tunnel outline.
• Needle will travel through the patella tendon, Hoffa’s fat
pad, and the anterior joint capsule.

Target
• F ollow same step as the ACL with the below adjustments:
• ACL graft orientation, insertion, and origin sites will
vary between surgical technique used.
• However, graft tunnels can easily be seen on x-ray to be
used as landmarks.
• For the insertional and origin techniques, instead of
using set anatomic landmarks, aim directly for the graft
tunnel entries on the tibial and femur respectively.
• The majority of grafts are single bundle so no need to
• Fig. 21.59 Proximal ACL Origin Injection AP Fluoroscopy with Contrast.
consider double bundle techniques.
• Inject the graft thoroughly by redirecting the nee-
dle at each site (insertion, origin, mid portion) 1 to
2 mm as able to get full coverage of the graft (Figs.
Pertinent Anatomy 21.60–21.62).
• F emoral and tibial tunnels with screws to hold them in
place.
• Of note, ACL grafts are not contained within a synovial PEARLS AND PITFALLS
sheath, as is the case with native ACL.
• U se the surgical tunnels as guides for needle
Common Pathology placement.
• If possible, try to get needle into the tunnels.
• C
 omplete or incomplete tears of ACL graft. ACL graft • Redirect needle as much as possible to obtain
rupture rates range from approximately 2% to 10%.80 complete coverage.
  
Equipment
• C -arm fluoroscopy
• 25 gauge 3.5 inch needle
Posterior Cruciate Ligament
• Contrast
KEY POINTS
Common Injectates
• B iologic injections to treat posterior cruciate ligament
• P
 rolotherapy orthobiologics (PRP, bone marrow concen- (PCL) laxity or tear (partial or complete non-retracted).
trate, etc.) • If partial tearing of the PCL, be sure to at least inject
origin and insertion. Mid portion if tears there on MRI.
Injectate Volume
  
• 1 to 2 mL total

Technique
Patient Position Pertinent Anatomy
• Hook-lying position (see Fig. 21.42) • I nserts at posterior tibial plateau with the origin at the
anterior wall of the medial femoral trochlea.
Clinician Position • Ligament of Wrisberg (posterior meniscofemoral liga-
• Standing ipsilateral to the side of the patient ment) attaches to the posterior area of the lateral meniscus
and crosses superiorly and medially behind the posterior
Transducer Position or C-Arm Position Fluoro Technique cruciate ligament to attach to the medial condyle of the
• S tart with AP projection, transition between lateral and femur. This ligament is present in up to 90% of patients
AP as needed for needle guidance and can be confused with the PCL (Fig. 21.63).81
416 SEC T I O N I I I Atlas

Gastrocnemius,
Plantaris
medial head
Gastrocnemius,
Ligament lateral head
of Humphry
Anterior
Ligament cruciate
of Wrisberg ligament

Medial Popliteus
meniscus Lateral
Posterior meniscus
cruciate Lateral
ligament collateral
ligament
Semimembranosus
Biceps
Medial femoris
• Fig. 21.60 Distal ACL Graft Injection Lateral Fluoroscopic View with collateral
Contrast. ligament

• Fig 21.63PCL. (From Clarke HD, Kransdorf MJ, Conley, et al. Insall &
Scott Surgery of the Knee. 2018;2–49.e3.)

• T
 wo bundles: anterolateral bundle and posteromedial
bundle.82

Common Pathology
• L
 ax PCL due to:
• Trauma, via hyperextension mechanism in sports and
most commonly from motor vehicle accidents from
direct blow to the tibia with a bent knee.82
• Fig. 21.61
Proximal ACL Graft Injection Lateral Fluoroscopic View • Long-term weakness in the quadriceps with resultant
with Contrast. hyperextension to lock the knee.

Equipment
• C -arm fluoroscopy
• 25 gauge 3.5 inch needle
• Contrast

Common Injectates
• P
 rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).

Injectate Volume
• 1 to 2 mL total

Technique
Patient Position
• Supine hook-lying (120 degrees flexion) (see Fig. 21.42).

• Fig. 21.62 Proximal ACL Graft Injection AP Fluoroscopic View with Clinician Position
Contrast. • Standing ipsilateral to the side of the patient
 CHAPTER 21 Knee Injection Techniques 417

•Fig. 21.64 Distal PCL Injection Fluoroscopy Lateral View with

Contrast.

C-Arm Position
• AP to start and transition to lateral. • Fig. 21.65 Distal PCL Injection Fluoroscopy AP View with contrast.

Needle Position
• H ave a slight bend in the needle tip to make it easier to
make slight adjustments when injecting multiple areas of
the ligament and for redirection.
• Start with targeting the PCL origin at the posterior tibial
plateau; then target insertion on lateral wall of the femo-
ral condyle.
• In true AP fluoroscopic view, needle should be centered
between the tibial spines.
• Needle will travel through the patella tendon, Hoffa’s fat
pad, and the anterior joint capsule.

Target
• P
 CL origin at tibia:
• Palpate the patella. The needle will enter just below
the patella.
• In true AP fluoroscopic view, needle should be cen-
tered between the tibial spines.
• In AP view, advance needle about 1 cm, aiming poste-
rior and inferior, making sure needle is staying in the
middle of the tibial spines.
• Angle will be slightly inferior.
• Advance in the lateral view to the origin of the PCL • Fig. 21.66 PCL Injection Showing Double Bundle Contrast Flow.
at posterior tibia about ½ cm anterior to the posterior
tibial wall. Be sure not to advance past the femur. • R arely you can visualize two bundles in the PCL (Fig.
• Inject a small amount of contrast in the lateral view, 21.66).
which should show flow going superior and anterior • PCL insertion on the femur:
(Fig. 21.64). Often flow can go all the way to the • Palpate the patella. This time the needle will enter
proximal portion. about 1 cm below the patella or midway between the
• If the contrast spreads diffusely in the joint, then the patella and the tibia.
needle is either lateral, medial, or posterior. Recheck • In true AP fluoroscopic view, needle should be cen-
needle placement in AP. tered between the tibial spines.
• Confirm in the AP view to show contrast going supe- • In AP view, advance needle about 1 cm, aiming
rior and medial (Fig.21.65). toward the superior lateral femoral trochlea.
418 SEC T I O N I I I Atlas

•Fig. 21.67 Proximal PCL Injection Fluoroscopy Lateral View with

Contrast Connecting to Distal Portion.
• Fig. 21.68 Proximal PCL Injection Fluoroscopy AP View with
Contrast Connecting to Distal Portion.
• A ngle will be slightly upwards.
• Advance further in the lateral view slightly toward the
anterior, superior medial femur. PEARLS AND PITFALLS
• The needle should touch down on the bone in the • B
 e sure to start the needle trajectory at the true middle
anterior third of the lateral wall of the medial femoral of trochlea, not the center of the patella, since patellae
condyle. Then “walk” off the trochlea, aiming poste- are often deviated laterally.
rior to the PCL origin at the middle superior aspect   
of the medial femoral trochlea. Needle should be at or
just 1 mm off the bone. Meniscus
• Inject a small amount of contrast in the lateral view,
which should show flow going inferior and posterior
toward the posterior tibial plateau (Fig. 21.67). KEY POINTS
• If contrast is pooling and not flowing along the PCL • T here may be the advantage of going through less
fibers or flowing diffusely into the joint, then the nee- meniscal tissue and theoretically less risk of injury.
dle is likely anterior or medial to the ligament. • Contrast flow can confirm specific targets are injected
• Confirm in the AP view to show contrast going infe- accurately.
• It may be an easier route to inject micronized adipose
rior and lateral (Fig. 21.68). tissue to reduce trauma to the meniscus as usually a
• PCL mid portion: target the mid substance of the PCL if larger-gauge needle is required.
there is diffuse tearing throughout the PCL on MRI or if
  
contrast flow does not completely fill the mid substance
of the PCL.
• In the AP view, start needle entry in the middle of the Pertinent Anatomy
tibial spines. • M edial and lateral.
• Start the needle about 1 cm below the patella. • Anterior horn, body, and posterior horn.
• Advance about 1 cm to make sure the needle is on this • Red, red/white, white zones:
trajectory. • Red periphery zone rich in vasculature.
• Should have minimal angle on the needle. • Inner white zone with no blood supply, nutrition vis
• In the lateral view, advance posteriorly to the mid diffusion only.
height between the femur and the tibia. Target is pos- • Middle red/white zone: transition between vascular
terior one-third of the joint. Should be in mid portion and avascular areas.
of contrast flow from the origin and insertion. • Meniscal ligaments (can be variable within patients21):
• Inject a tiny amount of contrast to confirm flow in • Coronary ligaments (meniscotibial),22 which act to
the mid portion of the PCL in the lateral view and anchor the menisci to the tibia both anteriorly and
confirm in the AP view. posteriorly.23,24
 CHAPTER 21 Knee Injection Techniques 419

Posterior cruciate ligament • I njury to the posterior medial meniscus coronary ligament
Ligament of Wrisberg is associated with increased tibial internal rotation.23
Ligament of Humphry • Horizontal and oblique tears are more commonly asymp-
Medial
tomatic. Vertical, complex, radial, and displaced tears
Popliteal
tendon meniscus have a stronger association with pain and are generally
Fibular more clinically meaningful.29
collateral Deep
ligament medial Equipment
collateral
ligament • C -arm fluoroscopy
Popliteal • 23 to 18 gauge needle depending on injectate, 3 to 3.5
hiatus
(recess) inch length
Lateral Superficial
• Contrast
meniscus medial
collateral Common Injectates
ligament
Coronary Anterior • P
 rolotherapy orthobiologics (PRP, bone marrow concen-
ligament Capsule Transverse cruciate trate, micronized adipose tissue, etc.)
(meniscotibial) ligament ligament
• Fig. 21.69Meniscal Ligaments. (From Parvizi J, Kim GK, et al. High- Injectate Volume
Yield Orthopaedics. 2010;292–293.) • 1 to 2 mL total

• P osterior meniscofemoral ligament (ligament of Technique

Wrisberg) connects the posterior horn of the lateral Patient Position
meniscus to the medial femoral condyle and the • Supine hook-lying
PCL.25
• Anterior meniscofemoral ligament (ligament of Clinician Position
Humphry) connects posterior horn of lateral menis- • Standing on ipsilateral side of the patient.
cus, but lies anterior to the PCL and inserts at the
femoral PCL.25 Transducer Position or C-Arm Position Fluoro Technique
• Anterior intermeniscal ligament, which connects the • T rue AP projection, where anterior and posterior femur
anterior horns of the medial and lateral menisci (Fig. and tibia are aligned.
21.69)25 • Lateral projection, where medial and lateral femoral con-
• Deep MCLs (meniscofemoral and meniscotibial) are dyles and medial and lateral tibial plateaus are aligned.
deep to the MCL and are with the medial meniscus,
connecting it via longitudinal fibers to the femur and Needle Position
the tibia.83 • M RI imaging should help guide needle starting point.
• Root attachments: Needle should start over the peripheral edge of the
• The medial meniscus posterior root attachment is desired tibial plateau using AP projection to identify
PL to the medial tibial eminence. needle entry point in the sagittal plane.
• The lateral meniscus root attachment is posterior • Then, in lateral position, start needle entry about 1 cm
and medial to the lateral tibial eminence. above the tibial plateau.
• The medial meniscus anterior root attachment is • Under intermittent fluoroscopy, advance needle from
AM to the ACL tibial insertion and inserts into the superior to inferior, anterior to posterior toward the
anterior intercondylar crest of the tibia. desired area of the meniscus.
• The lateral meniscus anterior root is anterolateral • Avoid hitting the femoral condyle articular cartilage.
to the ACL tibial insertion.26,27
Target
Common Pathology • M
 edial meniscus
• M edial meniscus tears can occur in the anterior portion, • Anterior horn:
body, posterior portion, or root and can have the follow- • Aim to gently touch down on the medial menis-
ing types of morphologies: radial (associated with menis- cus just above the tibial plateau at the depth of the
cal extrusion), horizontal (parallel to tibial plateau), anterior tibial spine on the lateral view.
vertical (perpendicular to tibial plateau), flap (horizontal • Inject a tiny amount of contrast to confirm.
or oblique fissures with displacement), bucket handle, or • Contrast in lateral should spread anterior and
complex (combination).25,28 slightly posterior above the tibial surface.
• Medial meniscus posterior horn tears are commonly • In the AP view, be sure the needle is over the tibia
associated with ACL injury,23 as are lateral meniscus root and has not traveled too medial outside the joint or
tears.27 too lateral on the tibial plateau.
420 SEC T I O N I I I Atlas

•Fig. 21.70 Medial Meniscus Body Lateral Fluoroscopy View with

Contrast Showing Flow to the Anterior Horn Also.

• Fig. 21.71 Medial Meniscus Body AP Fluoroscopy View with

• C  ontrast in AP should be spread laterally across the Contrast.
anterior horn.
• Body:
• Aim to gently touch down on the medial meniscus
just above the tibial plateau at the depth of the mid
portion of the tibial spine on the lateral view.
• Contrast in lateral should spread slightly anterior
and posterior above the tibial surface (see Fig.
21.70).
• In the AP view, be sure the needle is over the tibia
and has not traveled too medially outside the joint
or too laterally on the tibial plateau.
• Contrast in AP should be just over periphery of the
tibia. There may be some faint spread to anterior or
posterior horn (see Fig. 21.71).
• Posterior horn:
• Aim to gently touch down on the medial menis-
cus just above the tibial plateau at the depth of
the posterior edge of the tibial spine on the lateral
view.
• You may need to start needle ½ cm lower to get
increased depth into the joint.
• Inject a tiny amount of contrast to confirm.
• Contrast in lateral should spread anterior and slightly
posterior above the tibial surface (Fig. 21.72).
• In the AP view, be sure the needle is over the tibia • Fig. 21.72 Posterior Medial Meniscus Lateral Fluoroscopy View
and has not traveled too medially outside the joint with Contrast.
or too laterally on the tibial plateau (Fig. 21.73).
• Contrast in AP should be spread laterally across the
posterior horn but look similar to anterior horn • A im to gently touch down on the medial meniscus
spread. root just above the tibial plateau at the depth just
• Root: posterior to the tibial spine on the lateral view.
• Instead of starting over the medial aspect of the • You may need to start needle ½ cm lower to get
tibial wall, start just medial to the medial tibial increased depth into the joint.
spine in the AP view. • Inject a tiny amount of contrast to confirm.
 CHAPTER 21 Knee Injection Techniques 421

• C  ontrast in AP should be just over periphery of the

tibia. There may be some faint spread to anterior or
posterior horn.
• Posterior horn:
• Aim to gently touch down on the lateral meniscus
just above the tibial plateau at the depth of the pos-
terior edge tibial spine on the lateral view.
• May need to start needle ½ cm lower to get
increased depth into the joint.
• Inject a tiny amount of contrast to confirm.
• Contrast in lateral should spread anterior and
slightly posterior above the tibial surface.
• In the AP view, be sure the needle is over the tibia
and has not traveled too laterally outside the joint
or too medially on the tibial plateau.
• Contrast in AP should be spread medially across
the posterior horn but look similar to anterior horn
spread.
• Root:
• Instead of starting over the lateral aspect of the tib-
•Fig. 21.73 Posterior Medial Meniscus AP Fluoroscopy View with
ial wall, start just lateral to the lateral tibial spine in
Contrast. the AP view.
• Aim to gently touch down on the lateral meniscus
root just above the tibial plateau at the depth just
• C ontrast in lateral should spread only slightly and posterior to the tibial spine on the lateral view.
stay mostly posteriorly above the tibial surface. Fig. • You may need to start needle ½ cm lower to get
21.74 increased depth into the joint.
• In the AP view, be sure the needle is just medial to • Inject a tiny amount of contrast to confirm.
the tibial spines. • Contrast in lateral should spread only slightly and
• Contrast in AP should be spread laterally across the stay mostly posterior above the tibial surface.
posterior horn and root but look similar to anterior • In the AP view, be sure the needle is just lateral to
horn spread (Figure 21.74). the lateral tibial spine.
• Lateral meniscus • Contrast in AP should be spread medially across
• Anterior horn: the posterior horn and root but look similar to
• Aim to gently touch down on the lateral menis- anterior horn spread.
cus just above the tibial plateau at the depth of the
anterior tibial spine on the lateral view.
• Inject a tiny amount of contrast to confirm. PEARLS AND PITFALLS
• Contrast in lateral should spread anterior and • T he meniscus is dense; so there can be quite a bit of
slightly posterior above the tibial surface. resistance. Torn areas may be slightly less dense. Using
• In the AP view, be sure the needle is over the tibia a slightly large needle gauge can help to inject. Slightly
and has not traveled too laterally outside the joint pulling back on the needle while injecting can help the
or too medially on the tibial plateau. flow of injectate.
• Be conscious while advancing in the lateral fluoroscopic
• Contrast in AP should be spread medially across view that the needle trajectory is not veering medial or
the anterior horn. lateral to the joint.
• Body: • Be sure to check in both lateral and AP views to ensure
• Aim to gently touch down on the lateral menis- needle is in the meniscus and not out of the joint or just
cus just above the tibial plateau at the depth of over the tibial plateau.
• Be sure to avoid scraping the femoral chondral surface.
the mid portion of the tibial spine on the lateral
view.   
• Contrast in lateral should spread slightly anterior
and posterior above the tibial surface.
• In the AP view, be sure the needle is over the tibia Genicular Nerve Radiofrequency Ablation
and has not traveled too laterally outside the joint
or too medially on the tibial plateau. Radiofrequency Ablation
422 SEC T I O N I I I Atlas

KEY POINTS
• R adiofrequency (RF) ablation uses a RF current through
an electrode tip needle to create a thermal lesion.
• Neurodestructive temperatures range from 65°C to
90°C.
• Traditional monopolar RF ablation probes operate at
a constant temperature of 80°C, though temperature
reading will not stay perfectly constant at the preset
temperature but will go over and under, typically within
half a degree, during the ablation. This is due to the
probe itself causing the surrounding tissue to oscillate
to create heat. The probe then senses the tissue
temperature and adjusts to keep the temperature
constant. This also limits the size of the “zone of
coagulation.”
• Cooled RF ablation uses internally cooled RF probes
which are able to deliver more energy to surrounding
tissues. While internally cooled probes operate at a set
temperature of 60°C, temperatures in tissues beyond
the probe tip reach 80°C. As a result of the internal
cooling of the probe, larger lesions are created, which
can help compensate for physiologic variability of
nerve location and increase the likelihood of treatment •Fig. 21.74 Medial Meniscus Root Lateral Fluoroscopy View with
success. Contrast.
• The RF electrode tip should be placed parallel to the
target genicular nerve.
  

Pertinent Anatomy84
• Th
 e SMGN course is at the junction of the distal femoral
diaphysis and medial femoral epicondyle.
• The SLGN course is at the junction of the distal femoral
diaphysis and the lateral femoral epicondyle.
• The IMGN course is at the junction of the medial con-
dyle and diaphysis of the tibia.

Common Pathology
• U
 tilized for treatment of chronic knee pain due to
chronic osteoarthritis that is non-operative or chronic
knee pain after total knee arthroplasty.
Equipment
• C -arm fluoroscopy
• 18 to 20 gauge radiofrequency (RF) cannula with 10 mm
active tip • Fig. 21.75 Medial Meniscus Root AP Fluoroscopy View with
• RF generator capable of generating energy for thermal Contrast.
ablation, pulsed radiofrequency ablation, or cooled RF
ablation Technique
Patient Position
Common Injectates • S upine with a pillow underneath both knees to provide slight
• L idocaine (1%, 2%), bupivacaine (0.25%, 0.5%, flexion and improve comfort for patient during procedure
0.75%)
• Corticosteroids C-Arm Position
• C onfirm appropriate genicular nerve target zones with
Injectate Volume an AP view.
• 1 to 2 mL of local anesthetic is typically injected after • Tilt the C-arm slightly cephalad or caudad to square off
stimulation and before the ablation to improve the the tibial plateau.
patient’s comfort. Practitioners may use lidocaine (1% or • Oblique the C-arm 15 to 20 degrees toward medial
2%), or bupivacaine (0.25%, 0.5%, or 0.75%) with or aspect of joint to obtain a “down the barrel” view of
without corticosteroid in mixture superomedial and IMGN target zones (Fig. 21.76A).
 CHAPTER 21 Knee Injection Techniques 423

A B
• Fig. 21.76 (A) Genicular nerves RF C-arm set up. (B) Lateral flouroscopic view set up to ascertain
needle depth.

A B
• Fig. 21.77 Needle placement for SMGN and IMGN RF. (A) AP view; (B) Lateral view.

• O blique the C-arm 15 to 20 degrees toward lateral aspect course of each nerve on the shaft of each respective bone
of joint to obtain a “down the barrel” view of SLGN tar- (femur and tibia) (Fig. 21.77A and B).
get zone (see Fig. 21.76A).
• A lateral view of the C-arm should be obtained to check Targets
needle/trocar depth (see Fig. 21.76B). • F
 or the SMGN, needle placement should be at the junc-
tion of the distal femoral diaphysis and medial femoral
Needle Position epicondyle (Fig. 21.78A).
• I nsert the needle coaxially or slightly off plane in order to
obtain optimum parallel placement of probes along the
424 SEC T I O N I I I Atlas

A B C
• Fig. 21.78 RF probe placement for (A) SMGN; (B) SLGN; (C) IMGN.

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22
Ankle Region Injection
Techniques
ALLISON C. BEAN, ALLISON N. SCHROEDER,
M ATTHEW SHERRIER, ARTHUR JASON DE LUIGI, AND
KENTARO ONISHI

Joint Injections Equipment

• H igh-frequency, small footprint, linear ultrasound
Tibiotalar Joint Injection transducer.
• 30 to 25 gauge 1 to 2 inch needle.
KEY POINTS
Common Injectates
• U se of a high-frequency small footprint linear ultrasound
transducer, like the “hockey stick,” is recommended for • L ocal anesthetics for diagnostic injections.
all ankle region and joint injections. • Corticosteroids, hyaluronic acid, prolotherapy, orthobio-
• Various injection approaches exist, and the choice logics (platelet-rich plasma [PRP], bone marrow concen-
depends on individual anatomy.
trate, etc.).
  
Injectate Volume
• 2 to 4 mL
Pertinent Anatomy
• Th
 e ankle (also known as tibiocrural or tibiotalar) joint Patient Position
is a hinged synovial articulation between the distal tibia • S upine or seated on the exam table.
and fibula and the talus. • Knee flexed to approximately 90 degrees and ankle in
• The joint also allows primarily ankle plantarflexion and slight plantarflexion so that the plantar surface of the
dorsiflexion. foot is flat on the exam table.

Common Pathology Clinician Position

• A nkle joint pathology often presents with a joint effu- • S eated at the foot of the exam table facing the patient
sion, associated with deep and diffuse pain with restricted and ultrasound machine.
range of motion.
• Ankle joint injury can be acute or chronic. Etiologic Transducer Orientation
causes include arthritis, synovitis, fracture, chondral • P referred approach (Fig. 22.1A):
lesion, instability from chronic ligament or tendon • Begin with the transducer in long axis to the distal
pathology, or infection. tibia.
• On sonographic examination with the foot in slight • Translate the probe distally to identify the joint space.
plantarflexion and imaging the anterior joint recess, dis- • Identify the tibialis anterior tendon in long axis; then
tention of the joint with anechoic fluid is the most sensi- translate the probe medial to the tibialis anterior tendon.
tive location and position to identify an effusion.1 • Alternative approach #1:
• Of note, 1 to 2 mm of anechoic hyaline cartilage covers • The transducer is rotated 90 degrees from the position
the talar dome, and it is important not to mistake this for described above and is positioned in the transverse
intra-articular fluid. plane at the level of the joint.
• Tibiotalar intra-articular loose bodies are hyperechoic • Alternative approach #2:
and may migrate to the medial ankle tendon sheaths, as • The transducer is positioned as described in the pre-
these can communicate with the ankle joint.2 ferred approach and translated laterally with the distal

428
 CHAPTER 22 Ankle Region Injection Techniques 429

PEARLS AND PITFALLS

• T here is risk of perforating tendon or neurovascular
structures if they lie within the needle trajectory. The
preliminary scan is helpful to identify at-risk structures,
including the peroneal nerve branches, dorsalis pedis
vessels, and anterior ankle tendons.
• Needle contact with the chondral surface should
be avoided, since this can result in damage of the
cartilage.
  

Subtalar Joint Injection

KEY POINTS
• V arious injection approaches exist, and the choice
depends on individual anatomy.
• The posterolateral approach is the preferred method
by the authors due to less frequent anatomic variations
in this region.3 This targets the posterior subtalar joint
(PSTJ).
A • Alternate approaches (anterolateral via sinus tarsi and
posteromedial approaches) may be used; however,
these approaches require careful consideration to
avoid nearby tendons, nerves, and vessels and
account for more anatomic variations common to
these areas.
  
Tib
Pertinent Anatomy
Tal
• Th
 e subtalar joint (or talocalcaneal joint) is a multiarticu-
late joint where the talus articulates with the calcaneus
through three facets: anterior, middle, and posterior.
B • The joint primarily allows for ankle inversion and
ANT
eversion.
• Fig. 22.1 (A) Ultrasound-guided tibiotalar joint injection setup for an
in-plane, anterior to posterior approach. (B) Intra-articular tibiotalar Common Pathology
joint injection using an in-plane, anterior to posterior approach. Arrows
point to the needle. ANT, Anterior; Tal, talus; Tib, tibia. • I ntra-articular subtalar joint pathology often presents
with joint effusion.
• Pain is typically in the hindfoot and worse when walking
end and slightly rotated medially to view the anterior on uneven surfaces. Joint pain is the most common result
talofibular ligament (ATFL) in long axis. of post-traumatic arthritis.
• On sonographic examination of a subtalar joint effu-
Needle Position sion, anechoic intra-articular fluid can be visualized
• P referred approach: In-plane, anterior to posterior (Fig. when the talus and calcaneus are both in view with
22.1B). This can also be accomplished using an out-of- anterolateral, posterolateral, or posteromedial trans-
plane approach. ducer placement.3
• Alternative approach #1: In-plane, medial to lateral or
lateral to medial with the needle coursing deep to the Equipment
overlying tendons. • H igh-frequency, small footprint, linear ultrasound
• Alternative approach #2: In-plane, anterior/distal to pos- transducer.
terior/proximal, targeting both the tibiotalar joint and • 30 to 25 gauge 1 to 2 inch needle.
ATFL.
Common Injectates
Target • L ocal anesthetics for diagnostic injections.
• A
 nterior joint recess, deep to anterior fat pad, superficial • Corticosteroids, hyaluronic acid, prolotherapy, orthobio-
to talar dome cartilage. logics (PRP, bone marrow concentrate, etc.).
430 SEC T I O N I I I Atlas

Transducer Orientation
• P referred approach, posterolateral joint (Fig. 22.2A):
• Begin with a long-axis view of the Achilles tendon.
• Translate the transducer laterally while rotating the
distal end of the transducer farther laterally. The final
transducer position will be in the parasagittal plane.
• The angle of insonation of the ultrasound beam points
toward the medial malleolus and calcaneus.
• Both the talus and calcaneus should be in view.
• In case of severe arthritis or difficulty visualizing the
posterior joint recess, further anterior translation
around the “corner” of the posterolateral calcaneus
while maintaining the angle of insonation may allow
for improved visualization (with the peroneal tendons
in view superficial to the joint).
• Alternative approach, anterolateral through the sinus
tarsi. To find sinus tarsi:
• Begin at the third web space while visualizing third
and fourth metatarsal bones in short axis and translate
proximally.
A • The first opening you will encounter after the mid-
foot bones will be the sinus tarsi.

Needle Position
PT • P referred approach: In-plane, distal lateral to proximal
medial (Fig. 22.2B).
• Alternative approach: Out-of-plane, anterior to posterior.
Tal

Target
• P referred approach: PSTJ recess.
• Alternative approach: Anterior subtalar joint through the
B Calc sinus tarsi.
ANT
• Fig. 22.2 (A) Ultrasound-guided subtalar joint injection set-up,
for injection into the posterolateral joint. (B) Intra-articular subtalar PEARLS AND PITFALLS
joint injection using an in-plane, posterior distal to anterior proximal
approach. Arrows denote the needle. ANT, Anterior, Calc, calcaneus; • U se of gel stand-off technique over the posterolateral
PT, peroneal tendons; Tal, talus. edge of calcaneus will allow for improved needle
visualization during the injection.
• Given the steep angle of the needle in this approach,
needle localization software may also be helpful to
improve needle visualization.
• In the anterolateral approach through the sinus tarsi, the
Injectate Volume target is also deep and may require the use of a walk-
down technique.
• 1 to 3 mL
  
Technique
Patient Position Ligament Injections
• P rone with the foot hanging off the edge of the exam
table and ankle in dorsiflexion. Anterior Talofibular Ligament
• Alternative approach: Lateral decubitus with the lateral
ankle of the targeted side facing upward. KEY POINTS
• T he ATFL is the most commonly injured ligament in the
Clinician Position ankle (Figs. 22.3 and 22.4).4
• S eated or standing at the foot of the exam table facing the • There have not been any high-quality studies on
patient and ultrasound machine. the ideal injectate volume, type of injectate, or clinical
• Proceduralist knee or an assistant can be used to induce outcomes for ATFL injections.
ankle dorsiflexion of the patient.   
 CHAPTER 22 Ankle Region Injection Techniques 431

Pertinent Anatomy
• Th
 e ATFL extends from approximately the distal 10 mm
of the fibula to the neck of the talus, running 45 to 90
degrees anteriorly to the axis of tibia.5
Syndesmosis
• Anatomic variation exists. ATFL may be single-, double-,
or triple-bundled in morphology.6

Common Pathology
• I njury typically results from inversion of the ankle and
Anterior
talofibular should be suspected in patients with tenderness over the
ligament ATFL and a positive anterior drawer test.
Calcaneofibular (ATFL) • On sonographic examination of an injured ATFL,
ligament
Sinus the typically homogeneous hyperechoic ligament
tarsi that courses obliquely from the anterior distal fib-
ula to the talus will appear relatively hypoechoic or
disrupted.7
• It is important to note that the ATFL is prone to aniso­
trophy due to its nonlinear course and this should not be
misinterpreted as a tear.7
• Dynamic imaging while performing an anterior drawer
test can be helpful in equivocal cases.8

Equipment
• H igh-frequency, small footprint, linear ultrasound
transducer.
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
• Avoid intraligamentous corticosteroids.
• Fig. 22.3 Anterior Ankle Bony and Ligamentous Anatomy.

Anterior inferior
tibiofibular ligament
Posterior inferior
tibiofibular ligament

Posterior talofibular ligament

Anterior talofibular ligament

Calcaneofibular ligament
Superior peroneal
retinaculum Peroneal
brevis

Inferior
peroneal
retinaculum

• Fig. 22.4 Anatomy of the Lateral Ankle Ligaments.

432 SEC T I O N I I I Atlas

Injectate Volume
• 0.5 to 1 mL

Technique
Patient Position
• S upine or seated on the exam table.
• Knee flexed approximately to 90 degrees and ankle in
slight plantarflexion so that the plantar surface of the
foot is flat on the exam table.
• Alternatively, the patient can be place in the lateral decu-
bitus position with the lateral aspect of the targeted ankle
facing upward.

Clinician Position
• S eated or standing at the foot of the exam table, facing
the patient and ultrasound machine.

Transducer Orientation
• Th
 e ligament is identified by palpating the distal fibular
tip and placing the transducer in the transverse plane at A
the anterior aspect of the fibula (Fig. 22.5A).
• The medial end of the transducer is distally rotated.
• The ligament is identified in long axis, spanning from the
anterior distal fibula to the talus.

Needle Position
• P referred approach: In-plane, anterior to posterior
(Fig. 22.5B). * * * Fib

• Alternate approach: Out-of-plane, distal lateral to proxi-

mal medial. Talus

Target B PROX
• A
 reas of hypoechogenicity or interstitial tears in the
• Fig. 22.5 (A) Ultrasound-guided ATFL injection setup for an in-plane,
ATFL and cortical irregularities of the fibula and talus at anterior to posterior approach. (B) ATFL injection using an in-plane,
the ATFL origin and insertion. anterior to posterior approach. ATFL (asterisk) is imaged in long axis.
Arrows point to the needle. ATFL, Anterior talofibular ligament; Fib,
fibula; PROX, proximal.

PEARLS AND PITFALLS Calcaneofibular Ligament (CFL)

• A nterior ankle structures, such as the lateral tarsal
branch of the inferolateral malleolar artery and
KEY POINTS
intermediate dorsal cutaneous branch of the superficial
peroneal nerve, should be identified and avoided during • T
 he calcaneofibular ligament (CFL) is commonly injured
the injection. in combination with the ATFL.
• Often the anterior lateral malleolar artery travels
adjacent to the mid portion of the ligament. An injured   
ATFL may have increased vascularization superficial
to the ligament. Use color flow Doppler to identify Pertinent Anatomy
vasculature and avoid it.
• Use of a gentle gel stand-off technique may allow for • Th
 e CFL originates from the tip of the lateral malleolus
improved needle visualization during the injection. and inserts on the lateral side of the calcaneus (see Figs.
Aggressive stand-off will result in increased anisotropy 22.3 and 22.4).9
of the ATFL.
• The CFL restrains inversion of the calcaneus with respect
• The injection can be combined with physical therapy,
initially focusing on range of motion, then progressing to the fibula.10
to strengthening and proprioceptive training. A period
of plantarflexion limitation can be considered, as Common Pathology
dorsiflexion is the position of tension for ATFL. • Th
 e CFL is commonly injured with moderate to severe
   sprains of the ATFL with inversion injury.11
 CHAPTER 22 Ankle Region Injection Techniques 433

• I solated injuries can occur but are infrequent and occur

when the ligament is under maximum strain with the
foot in dorsiflexion.11

Equipment
• H igh-frequency, small footprint, linear ultrasound transducer.
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• O rthobiologics prolotherapy, orthobiologics (PRP, bone
marrow concentrate, etc.).
• Avoid intraligamentous corticosteroids.

Injectate Volume
• 0.5 to 1.5 mL A

Technique
Patient Position
PT
• L ateral decubitus position with the lateral aspect of the
targeted ankle facing upward.
• Dorsiflexion of the ankle.

Clinician Position CFL

• S eated or standing at the foot of the exam table, facing
the patient and ultrasound machine.
LM *
Transducer Orientation
Ca
• T ransducer in oblique coronal plane between the fibular
tip and the posterior heel.
• The CFL is visualized under the peroneal tendons (seen B
in short axis) and appears as a hammock (Fig. 22.6A).
• Long axis to the ligament. • Fig. 22.6
(A) Ultrasound-guided CFL out-of-plane injection setup.
(B) CFL out-of-plave injection. Asterisk, Needle tip; Ca, calcaneus;
CFL, calcaneofibular ligament; LM, lateral malleolus; PT, peroneal
Needle Position tendons.
• Out of plane in either direction (Fig. 22.6B).

Target
• Areas of hypoechogenicity or interstitial tears in the CFL. • Th
 e ligament resists posterior displacement of the talus
with respect to the fibula and tibia and is under most
PEARLS AND PITFALLS tension in dorsiflexion.14

• U
 se of gel stand-off technique may allow for improved Common Pathology
needle visualization during the injection.
• I solated PTFL injury is rare and is mostly associated with
   severe ankle inversion injury resulting in tearing of the
ATFL and CFL first.14
Posterior Talofibular Ligament
Equipment
KEY POINTS • H igh-frequency, small footprint, linear ultrasound
transducer.
• T
 he PTFL is the strongest and least commonly injured
lateral ligament in the ankle, at a rate of 5% to 10%.12 • 30 to 25 gauge 1 to 2 inch needle.
   Common Injectates
• O rthobiologics prolotherapy, orthobiologics (PRP, bone
Pertinent Anatomy marrow concentrate, etc.).
• Th
 e posterior talofibular ligament (PTFL) originates • Avoid intraligamentous corticosteroids.
from the malleolar fossa, located on the medial surface
of the lateral malleolus, coursing almost horizontally to Injectate Volume
insert in the posterolateral talus (see Fig. 22.4).13 • 0.5 to 1.5 mL
434 SEC T I O N I I I Atlas

Target
• A
 reas of hypoechogenicity or interstitial tears in the
PTFL and cortical irregularities of the fibula and talus at
the PTFL origin and insertion.

PEARLS AND PITFALLS

• U
 se of gel stand-off technique may allow for improved
needle visualization during the injection.
  

Inferior Tibiofibular Ligaments Injection

KEY POINTS
• T his injection can be performed using an in-plane or
out-of-plane technique.
• Deltoid ligament injury can be associated with the
same mechanism of anterior inferior tibiofibular
A
ligament (AITFL) injury as well, so often both need to be
evaluated and possibly treated.
  

Pertinent Anatomy
• Th
 e inferior tibiofibular joint is a syndesmotic articula-
tion between the distal tibia and fibula and is stabilized
by the AITFL and posterior inferior tibiofibular ligament
F
(PITFL) (see Fig. 22.4).
• The interosseous tibiofibular ligament provides additional
stabilization to the distal tibiofibular joint and extends
between the crest of the fibula medially and proximally to
PTFL the crest of the tibia, with its most distal portion approxi-
mately 1 cm proximal to the tibiotalar joint.15
• Variability exists in the number of bundles or fascicles
of the AITFL.16,17 The AITFL is a flat ligament that
B T courses superior and medial from the distal fibula to
• Fig. 22.7(A) Ultrasound-guided PTFL injection setup. (B) PTFL injec- the distal tibia. An accessory AITFL (Bassett’s ligament)
tion out-of-plane ultrasound injection. Asterisk, Needle tip; F, fibular may also be identified as a discrete bundle distal to the
head; PTFL, posterior talofibular ligament; T, talus. AITFL, spanning a greater distance between the tibia
and fibula in a slightly more horizontal orientation than
the AITFL.18
• The PITFL courses superior and medial from the pos-
Technique terior aspect of the distal fibula to the distal tibia and is
Patient Position analogous to AITFL. The deep portion of this ligament
• L
 ateral decubitus position with the lateral aspect of the is referred to as the inferior transverse ligament and is
targeted ankle facing upward. identifiable in 70% of ankles.19

Clinician Position Common Pathology

• S eated or standing at the foot of the exam table facing the • Th
 e AITFL and distal tibiofibular joint are commonly
patient and ultrasound machine. injured by forced external rotation and dorsiflexion at
the ankle.15
Transducer Orientation • Isolated injuries to the AITFL can lead to external rotary
• Long axis to the ligament (Fig. 22.7A). instability, even with an intact PITFL.20
• AITFL injuries can be evaluated with the dorsiflex-
Needle Position ion external rotation stress test, which causes joint
• Out of plane in either direction (Fig. 22.7B). widening.21
 CHAPTER 22 Ankle Region Injection Techniques 435

• O
 n sonographic examination of an injured AITFL, the
typical homogeneously hyperechoic structure spanning
between the anterior distal tibia and fibula will appear
disrupted. Dynamic imaging with dorsiflexion and exter-
nal rotation stress testing will show widening between
the distal tibia and fibula in a grade 3 AITFL tear.22
Equipment
• H igh-frequency, small footprint, linear ultrasound
transducer.
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
• Avoid intraligamentous corticosteroids.

Injectate Volume
• 0.5 to 1 mL

Technique A
Patient Position
• L
 ateral decubitus with the lateral ankle of the targeted
side facing upward.

Clinician Position
• S eated or standing at the foot of the exam table, facing
the posterior ankle and ultrasound machine.

Transducer Orientation
* * *
Fib
• Th
 e transducer is placed in short axis across the distal
tibia and fibula. Tib
• Identify the most distal aspect of the tibia. The lateral
aspect of the transducer is rotated inferiorly on the distal B LAT
fibula (anterior for AITFL or posterior for PITFL).
• The transducer will be long axis to the AITFL or PITFL • Fig. 22.8 (A) Ultrasound-guided AITFL injection setup for an in-plane,
(Figs. 22.8A and 22.9A) lateral to medial approach. (B) AITFL injection using an in-plane, lateral
to medial approach. AITFL (asterisks) is imaged in long axis. Arrows
point to the needle. AITFL, Anterior inferior tibiofibular ligament; Fib,
Needle Position fibula; LAT, lateral; Tib, tibia.
• I n-plane, lateral to medial (Fig. 22.8B).
• Alternatively, it can be out of plane in either direction
(Fig. 22.9B).
Deltoid Ligament Complex Injection
Target
• A
 reas of hypoechogenicity within the ligament and/or
area of maximum tenderness on sonopalpation.
KEY POINTS
PEARLS AND PITFALLS • T
 he deltoid ligament consists of up to six bands, each
• U se of a gel stand-off may allow for improved needle of which can be targeted for injection using a slightly
visualization during the injection. different transducer position and approach.
• The superficial peroneal nerve courses superficial to   
the AITFL and this should be avoided. Out-of-plane
injection risks injury to the peroneal nerve branches and
is not recommended. Pertinent Anatomy
• Injection can be combined with physical
therapy focused on range of motion and
• Th
 e deltoid ligament consists of superficial and deep
progressing to strengthening and proprioceptive components with up to six bands: (1) tibionavicular;
training. (2) tibiospring, also called the plantar calcaneonavicu-
   lar ligament; (3) tibiocalcaneal; (4) superficial posterior
436 SEC T I O N I I I Atlas

tibiotalar, (5) deep posterior tibiotalar; and (6) deep

anterior tibiotalar (Fig. 22.10).23
• It attaches the tibia to the talus, navicular, and calcaneus
and resists ankle eversion.23
• The spring ligament has two main components: super-
omedial calcaneonavicular ligament (SMCNL) and
inferior calcaneonavicular ligament (ICNL). Some ana-
tomic variants also have a third band, referred to as the
medioplantar oblique ligament. The SMCNL originates
from the anterior middle facet of the subtalar joint and
attaches medial side of the navicular articular margin.
The ICNL originates between the anterior and medial
subtalar facets and inserts on the lateral navicular break.
The third band can originate between the first two and
attaches to the navicular tuberosity.24
A • The SMCNL is intimately connected to the tibialis
posterior tendon and superficial component of the del-
toid ligament, adding medial stability for the ankle and
hindfoot.25
• The spring ligament helps to maintain arch height and
stability and resists forefoot abduction.25

Common Pathology
• I njuries to the deltoid ligament are less common than
lateral ankle injuries. They occur with forced ankle ever-
sion combined with external rotation.
F
• Injuries to the spring ligament accur most often in
the SMCNL and are mostly correlated with posterior
T tibialis injury. One study found that 92% of patients
B with posterior tibialis dysfunction had damage to the
SMCNL.26
• Fig. 22.9 (A) PITFL injection setup. (B) PITFL out-of-plane injection. • Isolated spring ligament injury is rare but has been
Asterisk, Needle tip in PITFL; F, fibular; posterior inferior tibiofibular liga- reported and is associated with loss of the foot arch.27
ment; T, tibia.

Tibiocalcaneal (Deltoid)
ligament
Posterior tibiotalar (Deltoid)
ligament Anterior tibiotalar (Deltoid) Plantar plate
ligament

Tibionavicular (Deltoid)
ligament
Calcaneal (Achilles)
Dorsal tarsometatarsal
tendon (cut)
ligament

Deep transverse ligament

Posterior talocalcaneal
ligament
Plantar fascia
Plantar calcaneonavicular (Spring)
ligament
Long plantar ligament
• Fig. 22.10 Anatomy of the Medial Ankle Ligaments.
 CHAPTER 22 Ankle Region Injection Techniques 437

• O
 n sonographic evaluation, injury may be identi-
fied by disruption of the normal fibrillar pattern, dif-
fuse hypoechoic enlargement, or discontinuity of the
ligament with possible hyperechoic avulsion fracture
fragments.22,28

Equipment
• H igh-frequency, small footprint, linear ultrasound
transducer.
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
• Avoid intraligamentous corticosteroids.

Injectate Volume
• 0.5 to 1.5 mL per ligament.

Technique
Patient Position A
• L
 ateral decubitus with the medial ankle of the targeted
side facing upward.

Clinician Position
• S eated or standing at the foot of the exam table, facing
the patient and ultrasound machine.
*
Transducer Orientation * Tib
• E ach component of the deltoid ligament (listed above)
can be visualized spanning between the respective bones
TP
*
it connects (Figs. 22.11A and 22.12A). *
• The transducer is oriented in long axis to the target liga-
ment component.
B PROX
Needle Position • Fig. 22.11(A) Ultrasound-guided deltoid ligament injection setup for
• I n-plane, distal to proximal (Fig. 22.11B). the deep anterior tibiotalar portion of the deltoid ligament. (B) Deltoid
• Alternatively, inject the ligaments out of plane (Fig. ligament injection using and in-plane, distal to proximal approach.
22.12B). Deep anterior tibiotalar portion of the deltoid ligament (asterisks) is
imaged in long axis deep to tibialis posterior (TP) tendon. Arrows point
to the needle. PROX, proximal; Tib, tibia.
Target
• A
 reas of hypoechogenicity within the ligament and/or Tendon Injections
area of greatest tenderness on sonopalpation.
Achilles Tendon or Paratenon Injection

PEARLS AND PITFALLS

KEY POINTS
• E valuate each component of the deltoid ligament and
pathologic-appearing bands. • Intratendinous or peritendinous injections may be
• Care should be taken to identify and avoid the tibialis performed.
posterior, extensor digitorum longus (EDL) tendons, and • Intratendinous injections are typically performed if there
tibial neurovascular bundle, as these structures course is a clear tendon defect, using an orthobiologic.
around the medial malleolus and run superficial to the • If tendinosis or pathologic thickening without obvious
posterior components of the deltoid ligament. tear is present for injection of orthobiologcs, needle
• Gel stand-off technique may allow for improved needle passages (needle tenotomy/fenestration) might be
visualization during the injection. needed in order to create space to inject.

     
438 SEC T I O N I I I Atlas

• P artial-thickness Achilles tendon tears may initially

appear as a more defined hypoechoic or anechoic area or
cleft within the tendon.33
• Tendinopathy associated with retrocalcaneal bursitis and
Haglund’s deformity may occur at the Achilles tendon
insertion.
• Haglund’s deformity is an enlargement of the posterior
superior aspect of the calcaneus and, when present, has a
more guarded prognosis in Achilles tendinopathy.34
• On sonographic evaluation, findings may include (1) a
hypoechoic region or thickened tendon size that may
represent general tendinopathy; (2) an anechoic region
within the tendon that may represent a tear; and/or (3)
hyperechoic region that is likely due to calcification;
finally, (4) calcaneal cortical irregularities representing
enthesophyte may be seen.
• Care must be taken to ensure that anisotropy is not mis-
taken for pathology.35

A Equipment
• H igh-frequency linear ultrasound transducer.
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
N
• Local anesthetic (diagnostic) or corticosteroid (therapeu-
tic) can be used in peritendinous injections.
Sp • Avoid intratendinous corticosteroids.

Injectate Volume
• 1 to 3 mL intratendinous, or as much as can be injected
C without significant resistance.
• 1 to 3 mL peritendinous.
B
Technique of Mid-Portion Achilles Tendon Injection
• Fig. 22.12 (A) Plantar calcaneal navicular ligament (spring ligament) Patient Position
setup. (B) Plantar calcaneal navicular ligament spring ligament ­injection.
Asterisk, Needle tip; C, calcaneus; N, navicular bone; Sp, spring ligament.
• P
 rone with the foot hanging off the edge of the exam
table and ankle positioned in slight passive dorsiflexion
applied by the clinician.
Pertinent Anatomy
• Th
 e Achilles tendon is the longest, thickest, and strongest Clinician Position
tendon in the body.29 • S eated at the foot of the exam table, facing the affected
• It connects the gastrocnemius and soleus muscles to the lateral ankle and ultrasound machine.
calcaneus.
Transducer Orientation
Common Pathology • Th
 e mid-portion Achilles tendon is easily palpable. The
• T endinopathy or rupture of the Achilles commonly Achilles tendon is visualized in short axis by placing the
occurs 2 to 6 cm proximal to its insertion at the calca- transducer in the anatomic transverse plane and in long
neus, as this region is relatively hypovascular.30 axis by placing the transducer in the anatomic longitudi-
• On sonographic evaluation, tendinosis appears as a nal plane (Fig. 22.13A).
hypoechoic fusiform enlargement of the Achilles tendon • The injection can be performed in short axis or long
without significant disruption of the tendon fibers. Increased axis to the tendon, whichever minimizes damage to sur-
neovascularity or hyperemia visualized on color or power rounding healthy tissues.
Doppler is suggestive of tendinopathy and has been found
to correlate with patient symptoms; vascularity should be Needle Position
evaluated with light transducer pressure and the foot in a • P referred approach: In-plane, lateral to medial (Fig. 22.13B).
neutral position so as to reduce the tissue tension.31,32 • Alternate approach: Out-of-plane, lateral to medial.
 CHAPTER 22 Ankle Region Injection Techniques 439

A A

AT
AT

Calc

B PROX

B LAT • Fig. 22.14 (A) Ultrasound-guided insertional Achilles tendon injection

setup for a distal to proximal approach. (B) Insertional Achilles tendon
• Fig. 22.13 (A) Ultrasound-guided mid-portion Achilles tendon injec- injection using an in-plane, distal to proximal approach. The Achilles
tion setup of an in-plane, lateral to medial approach targeting deep to tendon (AT) is visualized in long axis. Arrows point to the needle. Calc,
the Achilles tendon. (B) Mid-portion Achilles tendon injection using an Calcaneus; PROX, proximal.
in-plane lateral to medial approach. The Achilles tendon (AT) is visual-
ized in short axis. Arrows point to the needle. LAT, lateral. Technique of Insertional Achilles Tendon Injection
Patient Position
Target • P
 rone with the foot hanging off the edge of the exam
• I ntratendinous or peritendinous in regions of tendon table and ankle positioned in slightly passive dorsiflexion
hypoechogenicity, thickening, tears, hyperemia, or sono- applied by the clinician.
palpation tenderness.
Clinician Position
PEARLS AND PITFALLS • S eated at the foot of the exam table, facing the plantar
aspect of the foot and ultrasound machine.
• W hen approaching the tendon laterally, care must be
taken to avoid the sural nerve and small saphenous
vein, which lie lateral to the Achilles.36 Transducer Orientation
• Color Doppler can be used to identify areas of neovas- • Th
 e insertional Achilles tendon is visualized in the ana-
cularization, a surrogate marker for neonerves, which are tomic longitudinal view by placing the transducer over
thought to contribute to pain in Achilles tendinopathy. the posterior aspect of calcaneus (Fig. 22.14A).
• Orthobiologic injections can be combined with an ultrasound-
guided tendon scraping procedure which mechanically
• Can visualize some of the fibers in the transverse view as well.
separa­tes the deep surface of the Achilles tendon from
Kager’s fat pad (as described later in this chapter).37 Needle Position
• Procedures are often combined with an eccentric or • I n-plane, distal to proximal (Fig. 22.14B).
heavy slow resistance exercise protocol.38 • For the transverse view can also inject in-plane lateral to
   medial.
440 SEC T I O N I I I Atlas

Target
• A
 reas of tendon hypoechogenicity, calcification/enthe-
sopathy, and cortical irregularities. Peroneal
brevis Tibialis
muscle anterior
PEARLS AND PITFALLS muscle
Extensor
• E valuate for anisotropy, particularly at the calcaneal digitorum
insertion of the Achilles, to avoid misidentifying a tear. longus
• Target tendon enthesis as well and excoriate, if desired, muscle
if insertional tendinosis is present. Extensor
• Percutaneous needle tenotomy/fenestration can also be hallucis
performed until a change in tissue texture is achieved.78 longus
muscle
   Extensor
digitorum
brevis
Tibialis Anterior Tendon/Tendon Sheath muscle
Injection Extensor
hallucis
brevis
KEY POINTS muscle
• Injury to the tibialis anterior tendon is less common than
injury to other tendons about the ankle.39
  

Pertinent Anatomy
• Th
 e tibialis anterior originates from the upper two-thirds
of the lateral surface of the tibia. The tendinous portion
passes beneath the inferomedial band of the extensor
retinaculum to insert on the medial surface of the medial
cuneiform and the base of the first metatarsal (Fig. 22.15).
• The distal tibialis anterior tendon may have a longitudi- • Fig. 22.15 Anterior Ankle and Mid Foot Musculature.
nal split near its insertion, which is a normal variant.40

Common Pathology Technique

• I njuries most commonly occur within 3.5 cm of the Patient Position
insertion.40 • S upine or seated on the exam table.
• On sonographic evaluation, tendinopathy can be iden- • Knee flexed to approximately 90 degrees and ankle in
tified by loss of the typical hyperechoic and fibrillar slight plantarflexion so that the plantar surface of the
echotexture of the tibialis anterior tendon. Anechoic foot is flat on the exam table.
fluid may also be present within the tendon sheath.41
Clinician Position
Equipment • S eated or standing at the foot of the exam table, facing
• H igh-frequency, small footprint, linear ultrasound the affected medial ankle and ultrasound machine.
transducer.
• 30 to 25 gauge 1 to 2 inch needle. Transducer Orientation
• Th
 e tibialis anterior tendon is visualized in short axis as
Common Injectates the most medially located anterior ankle tendon when
• P rolotherapy, orthobiologics (PRP, bone marrow con- placing the transducer in the anatomic transverse plane
centrate, etc.). anterior to the ankle joint (Fig. 22.16A).
• Local anesthetic (diagnostic) or corticosteroid (therapeu-
tic) can be used in peritendinous injections. Needle Position
• Avoid intratendinous corticosteroids. • In-plane, medial to lateral (Fig. 22.16).
Injectate Volume Target
• 1 to 3 mL intratendinous, or as much as can be injected • T
 ibialis anterior tendon or tendon sheath at site of ten-
without significant resistance. don hypoechogenicity, enlargement, intra-sheath fluid,
• 1 to 3 cc peritendinous. or sonopalpation tenderness.
 CHAPTER 22 Ankle Region Injection Techniques 441

talocalcaneal ligament, and the inferior extensor retinac-

ulum and passes medially over the foot to insert on the
lateral side of the EDL on digits 2 to 4.

Common Pathology
• Th
 e extensor tendons may become irritated as they
course over the dorsal aspect of the foot.
• Tendinopathy of the EDL and EDB is commonly caused
by shoes tied too tightly, resulting in compression of the
tendons, or due to overuse, such as with running uphill
for prolonged periods.
• On sonographic evaluation, each slip of the EDL and EDB
can be visualized and evaluated for loss of the normal fibril-
lar tendon pattern or fluid within the tendon sheath.41
A
Equipment
• H igh-frequency, small footprint, linear ultrasound
transducer.
TA
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
• Local anesthetic (diagnostic) or corticosteroid (therapeu-
B Tal MED tic) can be used in peritendinous injections.
• Fig. 22.16 (A) Ultrasound-guided tibialis anterior peritendon injection • Avoid intratendinous corticosteroids.
setup for an in-plane, medial to lateral approach. (B) Tibialis anterior
injection using an in-plane, medial to lateral approach. The tibialis ante- Injectate Volume
rior (TA) is visualized in short axis, superficial to the talus (Tal). Arrows • 1 to 3 mL intratendinous, or as much as can be injected
point to the needle. MED, Medial.
without significant resistance.
• 1 to 3 mL peritendinous.
PEARLS AND PITFALLS
Technique
• Identify and avoid the dorsalis pedis artery and deep
fibular nerve which run laterally to the tendon. Patient Position
• A longitudinal split of the distal tendon may be a normal • S upine or seated on the exam table.
variant and should not be mistaken for a split tear.42 • Knee flexed approximately to 90 degrees and ankle in
   slight plantarflexion so that the plantar surface of the
foot is flat on the exam table.

Extensor Digitorum Tendon/Tendon Sheath Clinician Position

Injection • S eated or standing at the foot of the exam table, facing
the affected lateral ankle and ultrasound machine.
KEY POINTS
Transducer Orientation
• Injection can be performed anywhere along the tendon • Th
 e EDL tendon is visualized in short axis by placing the
from the ankle joint to the distal insertions at the transducer in the axial plane over the anterior ankle (Fig.
phalanges.
22.17A).
   • When visualized over the talus, it lies just lateral to the
tibialis anterior tendon.
• Identification of the EDL can be confirmed by following
Pertinent Anatomy it distally into the foot and visualizing its branches to the
• Th
 e EDL muscle originates on the anterior tibia, runs phalanges.
down the front of the tibia anterior to the ankle joint and • Injection is performed with the tendon visualized in
deep to the extensor retinaculum. It inserts on the mid- short axis.
dle and distal phalanges of digits 2 to 5 (see Fig. 22.15).
• The extensor digitorum brevis (EDB) muscle originates Needle Position
from the proximal lateral calcaneus, the interosseous • In-plane, lateral to medial (Fig. 22.17B).
442 SEC T I O N I I I Atlas

Retromalleolar Peroneus Brevis and/or Longus

Tendon/Tendon Sheath Injection
KEY POINTS
• N
 on-traumatic subluxation of the tendons in the
retromalleolar region can contribute to tendon
inflammation that can be targeted during injection.
  

Pertinent Anatomy
• Th
 e peroneus (fibularis) longus and brevis tendons course
posterior to the lateral malleolus with the peroneus brevis
lying medially in the supramalleolar region. The tendons
course through the osteofibrous tunnel formed by the bony
retromalleolar groove and the fibrous superior peroneal reti-
naculum. The superior peroneal retinaculum is a band of
deep fascia that extends from the posterior aspect of the lat-
eral malleolus to the lateral surface of the calcaneus.44
• The peroneus brevis tendon inserts on the base of the
A fifth metatarsal. The peroneus longus courses across the
plantar aspect of the foot and inserts on the first metatar-
sal and medial cuneiform.

EDL Common Pathology

• T endon injury may occur due to forceful contraction
of the peroneal muscles in attempts to correct for sud-
den abnormal plantarflexion and inversion, the typical
mechanism for a lateral ankle sprain.
• Non-traumatic subluxation or tendon irritation may
occur in individuals with ligamentous laxity, a shallow
retromalleolar groove, hypertrophied peroneal tubercle,
low-lying peroneus brevis muscle, or with disruption of
B Tal MED the superior peroneal retinaculum.
• On sonographic evaluation, tendinosis of the peroneus
• Fig. 22.17
(A) Ultrasound guided extensor digitorum longus (EDL) ten- longus or brevis will appear as hypoechoic enlargement
don sheath injection setup for an in-plane, lateral to medial approach.
(B) EDL tendon sheath injection using an in-plane, lateral to medial
without well-defined tendon defects, whereas a tear will
approach. EDL is visualized in short axis. Note the use of gel stand-off have a distinct cleft in the tendon. Visualization of two
technique. Arrows point to the needle. MED, Medial; Tal, talus. hemitendons is indicative of a longitudinal split tear.45
• Dynamic sonographic evaluation with dorsiflexion and
Target eversion of the ankle may be helpful for identifying sub-
• A
 reas of tendon hypoechogenicity, intra-sheath fluid, or luxation (Rankin type A = subluxation of tendons over
sonopalpation tenderness of the EDB or EDL tendon/ one another; Rankin type B = subluxation of the peroneus
tendon sheath. longus tendon through a longitudinal split tear in the per-
oneus brevis) or dislocation of the peroneal tendons.45-47
PEARLS AND PITFALLS • The superior peroneal retinaculum can also be evaluated
• E ach individual tendon of the EDL or EDB can be
sonographically and disruptions can be classified into
targeted at the location of sonopalpation tenderness. four anatomic types based on the Oden classification.48
• Identify and avoid the dorsalis pedis artery, common
digital arteries, deep peroneal nerve, and digital nerves Equipment
during injection. • H igh-frequency, small footprint, linear ultrasound
• A unilocular, anechoic, compressible fluid collection
identified deep to the EDL and superficial to the talus
transducer.
is the Gruberi bursa. This should be distinguished from • 30 to 25 gauge 1 to 2 inch needle.
anechoic fluid within the EDL tendon sheath or ganglion
cysts, which are typically non-compressible and Common Injectates
multilocular, and can be a target for injection.43 • P
 rolotherapy, orthobiologics (PRP, bone marrow con-
   centrate, etc.).
 CHAPTER 22 Ankle Region Injection Techniques 443

• L ocal anesthetic (diagnostic) or corticosteroid (therapeu-

tic) can be used in peritendinous injections.
• Avoid intratendinous corticosteroids.

Injectate Volume
• 1 to 3 mL intratendinous, or as much as can be injected
without significant resistance.
• 1 to 3 mL peritendinous.

Technique
Patient Position
• L
 ateral decubitus with the lateral ankle of the targeted
side facing upward. A towel roll may be placed under the
medial ankle to position the ankle in relative inversion
and plantarflexion.

Clinician Position
• S eated at the foot of the exam table, facing the affected
anterior ankle and ultrasound machine.

Transducer Orientation A
• P referred approach:
• The peroneal tendons are identified in the retromalleolar
groove by placing the transducer in the axial plane, just
posterior to the fibula. The peroneus brevis can be identi-
0.5
fied lying closer to the lateral malleolus (Fig. 22.18A).
• The tendons can be scanned in short axis by translat-
ing the transducer distally and proximally along the
course of the tendons. 1.0
• Alternate approach:
• For visualization of the tendons in long axis, the trans-
ducer is placed over the posterior aspect of the distal PL 1.5
fibula in the oblique-sagittal plane in the supramal-
PB
leolar region. This allows for visualization of the pero-
neus brevis and longus tendons in one imaging plane. B Fib CAUD
• Fig. 22.18 (A) Ultrasound-guided peroneus longus/brevis tendon
Needle Position sheath injection setup at the level of the lateral malleolus, using anterior
• P referred approach: In-plane, anterior to posterior (Fig. to posterior approach. (B) Peroneus longus/brevis tendon sheath injec-
22.18B). tion using an in-plane, anterior to posterior approach. Peroneus longus
• Alternate approach: In-plane, proximal to distal or distal (PL) and peroneus brevis (PB) are visualized in short axis. Arrows point
to the needle. Note the use of gel stand-off technique. CAUD, Caudal;
to proximal. Fib, fibula.

Target
• C
 ommon peroneal tendons/tendon sheath in the Insertional Peroneus Brevis Tendon/Tendon
retromalleolar groove. Sheath Injection
PEARLS AND PITFALLS
• D ynamic ultrasound evaluation with eversion and KEY POINTS
dorsiflexion or circumduction of the foot may reveal
tendon subluxation or superior retinaculum disruption. • W
 hen scanning with ultrasound, the peroneus “B”revis
• Fluid within the tendon sheath (tenosynovitis) should be is the tendon closest to the “B”one (lateral malleolus).
distinguished from extratendinous fluid related to injury of   
the calcaneofibular ligament located distally and deep to
the peroneus longus and brevis.
• A peroneus quartus is an anatomic variant (6%) that
should not be confused with a split tear of the peroneus Pertinent Anatomy
brevis.49 • Th
 e peroneus brevis tendon inserts on the base of the
   fifth metatarsal.
444 SEC T I O N I I I Atlas

Common Pathology
• I nsertional peroneus brevis tendinopathy is uncommon,
but may occur with repetitive eversion or in the setting
of a traumatic inversion injury as the muscle forcefully
contracts in response.50
• On sonographic evaluation, cortical irregularity at the
base of the fifth metatarsal with microcalcification and/
or a hypoechoic tendon structure may be visualized.51
Equipment
• H igh-frequency, small footprint, linear ultrasound transducer.
• 30 to 25 gauge 1 to 1.5 inch needle.

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
centrate, etc.).
• Local anesthetic (diagnostic) or corticosteroid (therapeu-
tic) can be used in peritendinous injections.
• Avoid intratendinous corticosteroids.

Injectate Volume A
• 1 to 3 mL intratendinous, or as much as can be injected
without significant resistance.
• 1 to 3 mL peritendinous.

* *
Technique
Patient Position
• L
 ateral decubitus with the lateral ankle of the targeted
side facing upward. 5th met
B PROX

Clinician Position • Fig. 22.19 (A) Ultrasound-guided peroneus brevis insertional ten-
• S eated or standing at the foot of the exam table, facing don injection setup for an in-plane, distal to proximal approach. (B)
Peroneus brevis insertional tendon injection using an in-plane, distal to
the anterior ankle and ultrasound machine. proximal approach. The peroneus brevis is visualized in long axis and
is calcific (asterisk). Arrows point to the needle. 5th met, Base of fifth
Transducer Orientation metatarsal; PROX, proximal.
• Th
 e peroneus brevis can be identified by following it dis-
tally from the retromalleolar groove to the base of the
fifth metatarsal in short axis and then rotating the trans- Tibialis Posterior Tendon/Tendon Sheath
ducer 90 degrees to visualize it in long axis (Fig. 22.19A). Injection
• Alternatively, the peroneus brevis can be identified by
placing the transducer parallel to the plantar aspect of
the foot with the distal aspect of the transducer over the
base of the fifth metatarsal. KEY POINTS
• Injection is performed with the transducer in long axis to • Injection should target the area of pathology.
the tendon.
  

Needle Position
• I n-plane, distal to proximal or proximal to distal (Fig. Pertinent Anatomy
22.19B). • Th
 e tibialis posterior tendon emerges distally from tibi-
alis posterior muscle that originates in the deep compart-
Target
ment of the lower leg, running posterior to the medial
• Peroneus brevis insertion/enthesopathy.
malleolus and under the flexor retinaculum. This tendon,
along with the spring ligament, supports the medial lon-
PEARLS AND PITFALLS gitudinal arch through its broad and complex attachment
• U se of a gel standoff technique may allow for improved (navicular, cuboid, cuneiforms, metatarsals 2 to 4).52
needle visualization during the injection.
• If calcifications are present in the tendon insertional fibers, Common Pathology
needle tenotomy/fenestration can also be performed.
• T
 endinopathic changes occur most commonly in the ret-
   romalleolar region or distally at the navicular insertion.53
 CHAPTER 22 Ankle Region Injection Techniques 445

• I njuries often occur insidiously without discrete injury

and are usually secondary to overuse or repetitive micro-
trauma, resulting in degeneration or a longitudinal split
thickness tear in the retromalleolar region.54
• On sonographic evaluation, tendon sheath distention
greater than 5.8 mm with anechoic fluid, hypoechoic
and hypertrophied tendon (after accounting for aniso-
tropy), or areas of discrete anechoic clefts with disruption
of the fibrillar pattern can indicate pathology.55
• A longitudinal split tear may be associated with abnor-
mal tendon dislocation or subluxation, which may be
apparent only during ankle movement.56
• Of note, it is normal to see up to 4 mm of fluid in the
tendon sheath of the tibialis posterior tendon just beyond
the medial malleolus, but this should not be present at
the navicular where the tendon sheath is absent.57

Equipment
• H igh-frequency, small footprint, linear ultrasound
transducer.
• 30 to 25 gauge 1 to 1.5 inch needle. A

Common Injectates
• P rolotherapy, orthobiologics (PRP, bone marrow con-
TP
centrate, etc.).
• Local anesthetic (diagnostic) or corticosteroid (therapeu-
tic) can be used in peritendinous injections. Tib
• Avoid intratendinous corticosteroids.

Injectate Volume
• 1 to 3 mL intratendinous, or as much as can be injected POST
B
without significant resistance.
• Fig. 22.20 (A) Ultrasound-guided retromalleolar tibialis posterior
• 1 to 5 mL peritendinous. injection setup for an in-plane, anterior to posterior approach. (B)
Retromalleolar tibialis posterior injection using an in-plane, anterior to
Technique posterior approach. The tibialis posterior tendon (TP) is visualized in
Patient Position short axis. Arrows point to the needle. Note use of gel stand-off tech-
• L ateral decubitus with the medial ankle of the targeted nique. POST, Posterior; Tib, tibia.
side facing upward.
• Unaffected leg will be positioned away from the injection
site. Target
• T
 endon or tendon sheath in region(s) of hypoecho-
Clinician Position genicity, thickening, interstitial tearing, sonopalpation
• S eated or standing at the foot of the exam table, facing tenderness.
the patient and ultrasound machine.

Transducer Orientation
• I f targeting the retromalleolar region, the transducer is PEARLS AND PITFALLS
placed in short axis to the tendon in the anatomic axial
• Identify and avoid the tibial neurovascular bundle.
plane just posterior to the medial malleolus (Fig. 22.20A). • Injections are commonly targeted to just within
• If targeting the tendon insertion, the transducer is placed the tendon sheath to avoid disrupting the tendon
in long axis to the distal tendon at the navicular insertion structure. Orthobiologic injections can target areas of
(Fig. 22.21A). hypoechogenicity as well as fill interstitial tears with
injectate. You can target the enthesopathy and insertion
Needle Position at the navicular if pathologic.
• When injecting near the retromalleolar groove, an
• P roximal, retromalleolar region: In-plane, anterior to anterior to posterior approach is preferred to avoid
posterior (Fig. 22.20B). neurovascular structures.
• Distal, navicular region: In-plane, distal to proximal (Fig.
  
22.21B).
446 SEC T I O N I I I Atlas

• Th
 e FDL then courses around the sustentaculum tali,
crosses over the flexor hallucis longus (FHL) tendon
at the level of the navicular at the knot of Henry,
joins the quadratus plantae in the sole of the foot,
and finally splits into four separate tendons that insert
on the plantar aspect of the distal phalanges of digits
4 to 5.
• The flexor digitorum accessory longus (FDAL) is the
most common accessory muscle in the foot and ankle
region, present in 6% to 12% of individuals. It has a vari-
able origin and insertion, and commonly runs through
the tarsal tunnel posterior to the FHL.58,59

Common Pathology
• Th
 e FDL is prone to tendinopathy where it courses
around the sustentaculum tali and crosses the FHL at the
knot of Henry; the FDL and FHL interact closely, with
fibrous interconnections at the knot of Henry where it is
prone to friction.60,61
• Tendinopathy of the FDL often occurs after walking
A barefoot on uneven or sandy surfaces where the toes are
not fully able to grip the surface.
• On sonographic evaluation, tendon sheath distention
with anechoic fluid, hypoechoic and hypertrophied ten-
don (after accounting for anisotropy), or areas of discrete
TP anechoic clefts with disruption of the fibrillar pattern are
suggestive of tendon injury.62

Equipment
N Tal
• H igh-frequency, small footprint, linear ultrasound
B transducer.
POST
• 30 to 25 gauge 1 to 2 inch needle.
• Fig. 22.21 (A) Ultrasound-guided distal tibialis posterior injection setup
for an in-plane, distal to proximal approach. (B) Distal tibialis posterior Common Injectates
injection using an in-plane, distal to proximal approach. The tibialis pos-
terior tendon (TP) is visualized in long axis as it nears its insertion on the
• P rolotherapy, orthobiologics (PRP, bone marrow con-
navicular (N). Arrows point to the needle. POST, Posterior; Tal, talus. centrate, etc.).
• Local anesthetic (diagnostic) or corticosteroid (therapeu-
tic) can be used in peritendinous injections.
Flexor Digitorum Longus Tendon/Tendon • Avoid intratendinous corticosteroids.
Sheath Injection Injectate Volume
• 1 to 3 mL intratendinous, or as much as can be injected
KEY POINTS
without significant resistance.
• 1 to 3 mL peritendinous.
• T
 he injection can be performed at the retromalleolar
groove, near the sustentaculum tali, or at the knot of Technique
Henry, depending on the area of pathology.
Patient Position
   • L
 ateral decubitus with the medial ankle of the targeted
side facing upward.
Pertinent Anatomy Clinician Position
• Th
 e flexor digitorum longus (FDL) muscle originates on • S eated or standing at the foot of the exam table, facing
the posterior tibia, medial to the tibialis posterior. The toward the anterior ankle and ultrasound machine.
FDL and tibialis posterior tendons cross just proximal
to the medial malleolus and the FDL tendon continues Transducer Orientation
distally posterior to the medial malleolus and tibialis pos- • P
 referred approach: The FDL tendon is visualized in
terior tendon. short axis just posterior to the tibialis posterior tendon
 CHAPTER 22 Ankle Region Injection Techniques 447

PEARLS & PITFALLS

• T he tibial neurovasculature is located in close proximity
to the FDL and must be identified prior to the injection
and avoided.
• Use of a gel stand-off technique may allow for improved
visualization during the injection.
  

Flexor Hallucis Longus Tendon/Tendon Sheath

Injection in the Tarsal Tunnel

KEY POINTS
• D
 uring the injection, care must be taken to avoid injury
to the tibial neurovasculature, which is located in close
proximity to the tendon.
  

Pertinent Anatomy
A
• Th
 e FHL muscle is located deep in the posterior compart-
ment. The FHL tendon courses posterior to the medial
malleolus over the posterior talus between the lateral and
TP medial posterior tubercles and under the sustentaculum
tali. It crosses under the FDL at the knot of Henry, con-
FDL tinuing into the sole of the foot to run between the hal-
lux sesamoid bones, inserting onto the plantar aspect of
Tib the distal phalanx.

TN Common Pathology
• T enosynovitis of the FHL in the tarsal tunnel at the level
B POST of the posterior talus and os trigonum is the most com-
mon seen pathology; however, tendinopathy may also
• Fig. 22.22 (A) Ultrasound-guided flexor digitorum longus (FDL) injec-
tion setup for an in-plane, posterior to anterior approach. (B) FDL
occur more distally at the knot of Henry or at the level of
injection using an in-plane, posterior to anterior approach. The FDL is the sesamoids.
visualized in short axis. Arrows point to the needle. POST, Posterior; • On sonographic evaluation, tendinosis is characterized
Tib, tibia; TN, tibial nerve; TP, tibialis posterior. by hypoechoic enlargement of the involved tendon and
anechoic fluid may be seen surrounding the tendon at
sites of irritation in tenosynovitis.62 Of note, the FHL
tendon sheath communicates with the ankle joint, so
with the transducer placed posterior to the medial mal- additional sonographic evaluation of the anterior joint
leolus in the transverse plane (Fig. 22.22A). recess must be performed to rule out intra-articular cause
• Alternate approach: The transducer is rotated 90 degrees to intra-sheath fluid.
to visualize the tendons in short axis. • Dynamic sonographic evaluation can reveal great
toe triggering and confirm the diagnosis of hallux
Needle Position saltans.63
• P referred approach: In-plane, posterior to anterior (Fig.
22.22B). Equipment
• Alternate approach: In-plane, proximal to distal. • H igh-frequency, small footprint, linear ultrasound
transducer.
Target • 30 to 25 gauge 1 to 2 inch needle.
• T endon in region(s) of hypoechogenicity, thickening,
interstitial tearing, sonopalpation tenderness, or tendon Common Injectates
sheath. • P
 rolotherapy, orthobiologics (PRP, bone marrow con-
• FDL tendon/tendon sheath. centrate, etc.).
448 SEC T I O N I I I Atlas

• L ocal anesthetic (diagnostic) or corticosteroid (therapeu-

tic) can be used in peritendinous injections.
• Avoid intratendinous corticosteroids.

Injectate Volume
• 1 to 3 mL intratendinous, or as much as can be injected
without significant resistance.
• 1 to 3 mL peritendinous.

Technique
Patient Position
• L
 ateral decubitus with the medial ankle of the targeted
side facing upward skyward or prone.

Clinician Position
• S eated or standing at the foot of the exam table, facing
the posterior ankle and ultrasound machine.

Transducer Orientation
• Th
 e FHL tendon is visualized in short axis just posterior
and deep to the tibial neurovasculature with transducer A
in transverse plane (Fig. 22.23A).

Needle Position
• In-plane, posterior to anterior (Fig. 22.23B).

Target
• T
 endon or tendon sheath in region(s) of hypoecho-
LPN
genicity, thickening, interstitial tearing, sonopalpation
tenderness.

PEARLS AND PITFALLS FHL

• T he tibial neurovasculature and branches vary but are

most commonly located anterior to the FHL and should Calc
be identified and avoided during injection.64
• Use of a gel stand-off technique may allow for improved
B POST
visualization during the injection. • Fig. 22.23 (A) Ultrasound-guided flexor hallucis longus (FHL) injection
• Injection may also be performed by entering on the setup for an in-plane, posterior to anterior approach. (B) FHL injection
lateral aspect of the ankle and advancing the needle using an in-plane, posterior to anterior approach. FHL is visualized in
medially anterior to the Achilles tendon to reach the short axis. Arrows point to the needle. Calc, Calcaneus; LPN, lateral
medial aspect of the FHL tendon sheath. plantar nerve; POST, posterior.
• Tendinopathy of the FDL can occur with FHL
tendinopathy at the knot of Henry and can also be a
target for intervention.
been well studied in the literature but are likely effective
   for compressive neuropathy. To date, there have been no
studies examining the specificity, sensitivity, or accuracy
of the use of ultrasound-guided hydrodissection/release
Perineural Injections in mononeuropathies of the superficial peroneal nerve,
deep peroneal nerve, or tibial nerve and its branches.
• On sonographic evaluation, the nerve may appear
KEY POINTS larger and hypoechoic proximal to the level of
entrapment, with loss of the normal fascicular
• Injections can be performed along the course of the architecture.62 Sonopalpation tenderness can assist
nerve, targeting regions of clinical symptoms, focal in localizing the region of nerve injury. The nerve is
nerve enlargement, or sonopalpation tenderness. targeted at this location during a hydrodissection/hydro-
• Diagnostic perineural injections can be used to confirm release procedure.
that symptoms are resulting from nerve injury. • Neuromas appear as focal, hypoechoic masses with
• Therapeutic hydrodissection/hydrorelease of the nerve poor internal fascicular definition, and are continuous with
can be performed to free the nerve from surrounding the nerve. These can be the target of perineural injections.
adhesions. Indications for therapeutic injections have not
  
 CHAPTER 22 Ankle Region Injection Techniques 449

Superficial Peroneal Nerve

it exits the crural fascia with the transducer in the axial
Pertinent Anatomy plane (Figs. 22.24A and 22.25A).
• Th
 e superficial peroneal (fibular) nerve generally carries • The transducer can be translated distally and proximally
fascicles from the L4-S1 root levels. along the course of the superficial peroneal nerve to iden-
• The common peroneal nerve branches from the sciatic tify the area of pathology.
nerve in the posterior distal thigh and courses around the • Injection is performed with the transducer positioned to
fibular neck before dividing into superficial and deep pero- view the nerve in short axis, unless long-axis view is indi-
neal nerves at the anterolateral aspect of the proximal fibula. cated to cover a longer segment of the nerve.
• Although great variability has been described, the super- • Injection can be performed anywhere along the course of
ficial peroneal nerve typically descends in the lateral com- the nerve.
partment of the lower leg between the peroneal muscles
and the lateral aspect of the EDL.65 Needle Position
• When it reaches the lower third of the leg, it pierces the deep • I n-plane, posterolateral to anteromedial (Fig. 22.24B
crural fascia to course superficially and terminates to divide and Fig. 22.25B).
into the medial and intermediate dorsal cutaneous nerves.65
• The superficial peroneal nerve supplies motor function
to peroneus longus and brevis and provides sensory func-
tion to the anterolateral leg and dorsum of the foot.

Common Pathology
• D ue to its superficial location, the superficial peroneal
nerve is prone to injury from direct trauma, lacerations,
ankle sprains, etc.
• The nerve is commonly compressed or stretched at the fibu-
lar neck or compressed where it pierces the deep crural fascia
at the lower third of the leg. This neural strain may trigger
a cascade of inflammation and scarring to the surrounding
soft tissue, which can result in chronic neuropathic pain.

Equipment
• H igh-frequency linear ultrasound transducer.
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• F or nerve block: Local anesthetic with or without A
corticosteroid.
• For hydrodissection/hydrorelease Mixture of normal
saline and local anesthetic solution, 5% dextrose solu-
tion, or platelet lysate solutions.

Injectate Volume
• F or nerve block: 5 to 10 mL.
• For hydrodissection/hydrorelease: 5 to 15 mL along the
course of the nerve.
Per EDL
Technique Fib
Patient Position
• S upine with the affected leg internally rotated or lateral
decubitus with the lateral ankle of the targeted side fac-
ing upward.
B ANT
Clinician Position
• Fig. 22.24 (A) Ultrasound-guided superficial peroneal perineural injec-
• S eated at the foot of the exam table, facing the posterior tion setup for an in-plane, posterolateral to anteromedial injection at
ankle and ultrasound machine. the distal third of the leg. (B) Superficial peroneal perineural injection
at the distal third of the lower leg using an in-plane, posterolateral to
Transducer Orientation anteromedial approach. Superficial peroneal nerve (circled) is visual-
ized in short axis near where it exits the crural fascia and is commonly
• Th
 e superficial peroneal nerve is most commonly iden- entrapped. Arrows point to the needle. ANT, Anterior; EDL, extensor
tified in short axis at the distal third of the leg where digitorum longus muscle; Fib, fibula; Per, peroneal musculature.
450 SEC T I O N I I I Atlas

Deep Peroneal Nerve

Pertinent Anatomy
• Th
 e deep peroneal (fibular) nerve generally carries fas-
cicles from the L4-S1 root levels.
• The common peroneal nerve branches from the sciatic
nerve in the posterior distal thigh and courses around the
fibular head before dividing into the superficial and deep
peroneal nerves.
• The deep peroneal nerve runs inferomedially, deep to the
EDL along the anterior surface of the interosseous mem-
brane, where it runs with the anterior tibial artery in the
middle of the leg. It descends with the artery anterior to
the tibiotalar joint, where it divides into the lateral and
medial terminal branches.
• The medial terminal branch runs with the dorsalis pedis
artery to the first interosseous space. The lateral terminal
branch passes beneath the EDB.
• It provides motor function to the muscles of the anterior
compartment of the leg, the EDB, and the extensor hal-
lucis brevis. It provides sensory innervation to the first
A dorsal webspace.

Common Pathology
• Th
 e nerve is commonly compressed or stretched at the
fibular neck.
• Injury to the deep peroneal nerve in the distal lower leg is
Per rare and is typically a result of an ankle sprain, ganglion
Fib cyst,66,67 or iatrogenic injury.68

Equipment
• H igh-frequency, small footprint, linear ultrasound transducer.
• 30 to 25 gauge 1 to 2 inch needle.
B ANT
• Fig. 22.25 (A) Ultrasound-guided superficial peroneal perineural injec-
Common Injectates
tion setup for an in-plane, posterolateral to anteromedial injection at • F or nerve block: Local anesthetic with or without
the mid-fibula level. (B) Superficial peroneal perineural injection using corticosteroid
an in-plane, posterolateral to anteromedial approach. Superficial pero- • For hydrodissection/hydrorelease: Mixture of normal
neal nerve (circled) is visualized in short axis where it courses over the
ankle joint. Arrows point to the needle. ANT, Anterior; Fib, fibula; Per,
saline and local anesthetic solution or 5% dextrose solu-
peroneal musculature. tion, or platelet lysate solution have been used.

Injectate Volume
Target • F or nerve block: 2 to 5 mL.
• M
 esoneurium in regions of focal flattening, proximal • For hydrodissection/hydrorelease: 5 to 15 mL along the
enlargement, or sonopalpation tenderness along the nerve. course of the nerve.

Technique
PEARLS AND PITFALLS Patient Position
• T he nerve is most commonly targeted where it pierces
• S upine or seated on the exam table.
the crural fascia since this is a common site of pathology. • Knee extended and ankle in slight plantarflexion.
• The procedure should be planned so that one can
minimize damage to the nerve and nearby muscle, Clinician Position
tendons, and vasculature. • S eated or standing at the foot of the exam table, facing
• Begin injecting while approaching the mesoneurium and
advance the needle while injecting slowly to gently push
toward the patient and ultrasound machine.
the nerve away, reducing the risk of intraneural injection.
• With proper release, accompanying vessels have been Transducer Orientation
observed to appear to have a stronger pulse, although • Th
 e deep peroneal nerve is visualized in short axis over the
the significance of this phenomenon is unknown. anterior talus deep to the extensor hallucis longus (EHL)
   and lateral to the dorsalis pedis artery (Fig. 22.26A).
 CHAPTER 22 Ankle Region Injection Techniques 451

PEARLS AND PITFALLS

• P erineural injections of the deep peroneal nerve are
mostly performed anterior to the ankle joint.
• Take care to avoid injury to the nerve and nearby
tendons and vasculature. Color Doppler should be used
to identify the dorsalis pedis artery prior to injection and an
appropriate approach should be taken to avoid injury to
the artery.
• Begin injecting while approaching the mesoneurium and
advance the needle while injecting slowly to gently push
the nerve away, reducing the risk of intraneural injection.
• With proper release, accompanying vessels are
observed to have a stronger pulse, although the
significance of this phenomenon is unknown.
  

Tibial Nerve
Pertinent Anatomy
• Th
 e tibial nerve generally carries fascicles from the L5-S2
root levels. It branches from the sciatic nerve in the pos-
A terior distal thigh and courses down the posterior calf and
into the medial ankle, where it enters the tarsal tunnel
after dividing into the medial and lateral plantar nerves.
• The tarsal tunnel is located at the medial ankle poste-
rior to the medial malleolus and is divided into an upper
EDL
EHL compartment (bound superficially by the deep aponeu-
rosis) and lower (“classic”) compartment (bound superfi-
* cially by the flexor retinaculum, also called the laciniate
ligament).

Common Pathology
Tal
• T arsal tunnel syndrome typically involves entrapment of
the tibial nerve or its branches, causing pain or paresthe-
sias in the plantar aspect of the foot.
B MED • Baxter’s neuritis is characterized by chronic heel pain from
entrapment of the first branch of the lateral plantar nerve
• Fig. 22.26 (A) Ultrasound-guided deep peroneal perineural injection by the deep fascia of the abductor hallucis muscle and/or
setup for an in-plane, lateral to medial approach. (B) Deep peroneal
perineural injection using an in-plane, lateral to medial approach. Deep
beneath the medial edge of the quadratus plantae fascia.
peroneal nerve (circled) is visualized in short axis near the dorsalis • Jogger’s foot refers to medial plantar nerve compression,
pedis artery (asterisk). Arrows point to the needle. EDL, Extensor digi- often seen with hyperpronation with running.
torum longus tendon; EHL, extensor hallucis longus muscle/tendon;
MED, medial; Tal, talus. Equipment
• H igh-frequency, small footprint, linear ultrasound
• Th
 e transducer can be translated distally and proximally transducer.
along the course of the deep peroneal nerve to identify • 30 to 25 gauge 1 to 2 inch needle.
the area of pathology.
• Injection is performed with the transducer positioned to Common Injectates
view the nerve in short axis, unless long-axis view is indi- • F or nerve block: Local anesthetic with or without
cated to cover a longer segment of the nerve. corticosteroid.
• For hydrodissection/hydrorelease: Mixture of normal
Needle Position saline and local anesthetic solution or 5% dextrose solu-
• I n-plane, lateral to medial or medial to lateral, depending tion, or platelet lysate solution may be used.
on the location of the dorsalis pedis artery (Fig. 22.26B).
Injectate Volume
Target • F or nerve block: 5 to 10 mL.
• M
 esoneurium in regions of focal flattening, proximal • For hydrodissection/hydrorelease: 10 to 15 mL along the
enlargement, or sonopalpation tenderness along the nerve. course of the nerve.
452 SEC T I O N I I I Atlas

Technique PEARLS AND PITFALLS

Patient Position
• P
 rone or lateral decubitus with the medial ankle of the • T ake care to avoid injury to the nerve and nearby
tendons and vasculature. Color Doppler should be
targeted side facing upward.
used to identify the posterior tibial artery and veins prior
to injection.
Clinician Position • Begin injecting while approaching the mesoneurium and
• S eated or standing at the foot of the exam table, facing advance the needle while injecting slowly to gently push
the posterior ankle and ultrasound machine. the nerve away, reducing the risk of intraneural injection.
• With proper release, accompanying vessels are
observed to have a stronger pulse, although the
Transducer Orientation significance of this phenomenon is unknown.
• Th
 e tibial nerve is visualized in short axis posterior to • Branches of the tibial nerve in the foot, including
the FDL tendon with the transducer placed in the axial Baxter’s nerve and the medial plantar nerve, can also
plane just posterior to the proximal medial malleolus be targeted.
(Fig. 22.27A).   
• The transducer can be translated distally and proxi-
mally along the course of the tibial nerve to identify its
branches and the area of pathology.
Saphenous Nerve
• Injection is performed with the transducer positioned to Pertinent Anatomy
view the nerve in short axis, unless long-axis view is indi- • Th
 e saphenous nerve is the sensory terminal branch of
cated to cover a longer segment of the nerve. the femoral nerve, arising in the femoral triangle, cours-
ing deep to Hunter’s canal, before becoming subcutane-
Needle Position ous by piercing the fascia lata between the gracilis and
• In-plane, posterior to anterior (Fig. 22.27B). sartorius tendons in the thigh. In the lower leg, it runs
distally behind the medial border of the tibia with the
Target great saphenous vein and divides into two branches in
• M
 esoneurium in regions of focal flattening, proximal the distal third of the lower leg.
enlargement, or sonopalpation tenderness along the • One branch continues along the margin of the tibia and
nerve. terminates at the ankle while the other branch travels

TP

FDL

L
M

Calc FHL

A B POST

• Fig. 22.27 (A) Ultrasound-guided tibial perineural injection setup for an in-plane, posterior to anterior
approach. (B) Tibial perineural injection using an in-plane, posterior to anterior approach. The tibial nerve
(circled) has split into the medial plantar nerve (M) and lateral plantar nerve (L). Arrows point to the needle.
Calc, Calcaneus; FDL, flexor digitorum longus; FHL, flexor hallucis longus; POST, posterior; TP, tibialis
posterior.
 CHAPTER 22 Ankle Region Injection Techniques 453

with the great saphenous vein anterior to the medial mal-

leolus and into the foot.69
• The branch of the saphenous nerve at the ankle supplies
the medial side of the foot.

Common Pathology
• Th
 e saphenous nerve is susceptible to injury anywhere
along its pathway. Injury may occur from direct trauma,
stretching (such as ankle dislocation), or compression
to anterior thigh, medial knee and shin, or over medial
ankle.

Equipment
• H igh-frequency, small footprint, linear ultrasound
transducer.
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
• F or nerve block: Local anesthetic with or without
corticosteroid.
• For hydrodissection/hydrorelease: Mixture of normal A
saline and local anesthetic solution or 5% dextrose solu-
tion, or platelet lysate solution may be used.
TA
Injectate Volume
• F or nerve block: 2 to 5 mL.
• For hydrodissection/hydrorelease: 5 to 15 mL along the
course of the nerve, per expert opinion.

Technique
Patient Position
• L
 ateral decubitus with the medial ankle of the targeted
side facing upward.
Tib
Clinician Position B ANT
• S eated at the foot of the exam table, facing toward the
patient and ultrasound machine. • Fig. 22.28 (A) Ultrasound-guided saphenous perineural injection
setup for an in-plane, posteromedial to anterolateral approach. (B)
Saphenous injection using an in-plane, posteromedial to anterolateral
Transducer Orientation approach. The saphenous nerve (circled) is visualized in short axis.
• Th
 e saphenous nerve can be visualized in short axis lat- Arrows point to the needle. ANT, Anterior; TA, tibialis anterior; Tib, tibia.
eral and proximal to the medial malleolus with the trans-
ducer in the anatomic axial plane (Fig. 22.28A).
PEARLS AND PITFALLS
• The transducer can be translated distally and proximally
along the course of the saphenous nerve to identify its • C are should be taken to avoid injury to the saphenous
branches and the area of pathology. nerve or greater saphenous vein.
• Injection is performed with the transducer positioned to • If a nerve block is being performed and the distal
saphenous nerve branches above the level of the block
view the nerve in short axis, unless long-axis view is indi- due to anatomic variation, and an additional block more
cated to cover a longer segment of the nerve. proximally may be necessary.
• The saphenous nerve can be difficult to identify.
Needle Position Localization may be facilitated by first identifying the
• I n-plane, posteromedial to anterolateral, or anteromedial greater saphenous vein followed by the adjacent nerve.
• Begin injecting while approaching the mesoneurium and
to posterolateral (Fig. 22.28B). advance the needle while injecting slowly to gently push
the nerve away, reducing the risk of intraneural injection.
Target • With proper release, accompanying vessels are
• M
 esoneurium in regions of focal flattening, proximal observed to have a stronger pulse, although the
enlargement, or sonopalpation tenderness along the significance of this phenomenon is unknown.
nerve.   
454 SEC T I O N I I I Atlas

Needle Position
Sural Nerve • I n-plane, posteromedial to anterolateral, or anterolateral
Pertinent Anatomy to posteromedial (Fig. 22.29B).
• Th
 e sural nerve is formed by contributions of the tibial
and common fibular nerves. Target
• It travels in the posterior calf with the small (lesser) saphe- • M
 esoneurium in regions of focal flattening, proximal
nous vein along the lateral border of the Achilles, con- enlargement, or sonopalpation tenderness along the
tinuing posterior to the lateral malleolus and deep to the nerve.
peroneal tendon sheath. It extends to the fifth metatarsal
base, branching into lateral and medial terminal branches. PEARLS AND PITFALLS
• The sural nerve provides sensation to the posterolateral
lower leg, lateral malleolus, lateral heel, and lateral foot • P re-procedural scanning should be performed to
identify the small saphenous vein to avoid intravenous
to the base of the fifth toe.
injection.
• Begin injecting while approaching the mesoneurium and
Common Pathology advance the needle while injecting slowly to gently push
• Th
 e sural nerve can be compromised as a result of trau- the nerve away, reducing the risk of intraneural injection.
matic injuries such as ankle sprains, fractures of the fifth • With proper release, accompanying vessels are
observed to have a stronger pulse, although the
metatarsal or os peroneum, in addition to compression
significance of this phenomenon is unknown.
by ganglion cysts, bony osteophytes, tenosynovitis, or
hypertrophic muscles.   

Equipment Bursa Injections

• H igh-frequency, small footprint, linear ultrasound
transducer. Retrocalcaneal Bursa Injection
• 30 to 25 gauge 1 to 2 inch needle.

Common Injectates
KEY POINTS
• F or nerve block: Local anesthetic with or without
corticosteroid. • R
 etrocalcaneal bursitis often coexists with Achilles
tendinopathy and Haglund’s deformity.
• For hydrodissection/hydrorelease: Mixture of normal
saline and local anesthetic solution or 5% dextrose solu-   
tion, or platelet lysate solution may be used.

Injectate Volume Pertinent Anatomy

• F or nerve block: 2 to 5 c. • Th
 e retrocalcaneal bursa lies in the posterior ankle
• For hydrodissection/hydrorelease: 5 to 15 mL along the between the posterior calcaneus and distal Achilles
course of the nerve, per expert opinion. tendon.
• Retrocalcaneal bursa has an anterior to posterior diam-
Technique eter less than 1.5 to 3 mm and changes shape with ankle
Patient Position plantarflexion and dorsiflexion.70
• P
 rone or lateral decubitus with the lateral ankle of the
targeted side facing upward. Common Pathology
• W hen inflamed and enlarged, the bursa will appear as
Clinician Position a comma-shaped anechoic or hypoechoic structure
• S eated or standing at the foot of the exam table, facing between the distal Achilles tendon and the calcaneus on
the anterior ankle and ultrasound machine. sonographic evaluation.
• Retrocalcaneal bursitis may be associated with
Transducer Orientation Haglund’s deformity and Achilles tendinopathy with
• Th
 e sural nerve can be visualized in short axis halfway neovascularization.
between the Achilles tendon and the lateral malleolus
with the transducer in the axial plane (Fig. 22.29A). Equipment
• The transducer can be translated distally and proximally • H igh-frequency linear ultrasound transducer.
along the course of the sural nerve to identify the area of • 30 to 27 gauge 1 to 1.5 inch needle.
pathology.
• Injection is performed with the transducer positioned to Common Injectates
view the nerve in short axis, unless long-axis view is indi- • A nesthetic and corticosteroid.
cated to cover a longer segment of the nerve. • Dextrose solution for sclerosis.
 CHAPTER 22 Ankle Region Injection Techniques 455

A A

AT 1

Per

B
* *
POST
*
• Fig. 22.29 (A) Ultrasound-guided sural perineural injection setup for Calc
B LAT 2
an in-plane, anterior to posterior approach. (B) Sural perineural injec-
tion using an in-plane, anterior to posterior approach. The sural nerve
(circled) is visualized in short axis Arrows point to the needle. Per, • Fig. 22.30 (A) Ultrasound-guided retrocalcaneal bursa injection setup
Peroneal musculature; POST, posterior. for an in-plane, lateral to medial approach. (B) Retrocalcaneal bursa
injection using an in-plane, lateral to medial approach. The retrocalca-
neal bursa (asterisks) is seen deep to the Achilles tendon (AT). Arrows
point to the needle. Calc, Calcaneus; LAT, lateral.
Injectate Volume
• 1 to 3 mL.
• I njection is performed with the transducer oriented in
Technique short axis to the Achilles tendon.
Patient Position
• P
 rone with the foot hanging off the edge of the exam Needle Position
table. • In-plane, lateral to medial (Fig. 22.30B).

Clinician Position Target

• S eated or standing at the foot of the exam table, facing • H
 ypoechoic distended bursae between the Achilles ten-
the affected lateral ankle and ultrasound machine. don and the calcaneus.

Transducer Orientation
PEARLS AND PITFALLS
• Th
 e Achilles tendon is located in long or short axis as
described above. • W
 hen approaching the bursa laterally, care must be
• The retrocalcaneal bursa can be visualized deep to the taken to avoid the sural nerve.
Achilles tendon (Fig. 22.30A).   
456 SEC T I O N I I I Atlas

Retroachilles Bursa Injection

KEY POINTS
• W
 hen imaging the retroachilles bursa, a thick layer
of gel and light transducer pressure must be used or
compression of tissues may cause displacement of
fluid, making it difficult to identify bursitis.
  

Pertinent Anatomy
• Th
 e retroachilles bursa lies superficial to the distal
Achilles tendon insertion on the calcaneus and is not
typically visualized with ultrasound in the absence of
pathology.

Common Pathology
• R etroachilles bursitis is typically a result of local mechan-
ical irritation from footwear or Haglund’s deformity.
• On sonographic evaluation, bursitis will appear as an A
anechoic or hypoechoic fluid collection between the sub-
cutaneous tissue and Achilles tendon. Hypervascularity
may also be seen.

Equipment AT
**
• H igh-frequency linear ultrasound transducer.
• 30 to 27 gauge 1 to 1.5 inch needle.

Common Injectates Calc

• A nesthetic and corticosteroid.
• Dextrose solution for sclerosis. B CAUD

Injectate Volume • Fig. 22.31 (A) Ultrasound-guided retroachilles bursa injection

setup for an in-plane, distal lateral to proximal medial approach. (B)
• 1 to 3 mL. Retroachilles bursa injection using an in-plane, distal lateral to proxi-
mal medial approach. The retroachilles bursa (asterisks) is superficial to
Technique the Achilles tendon (AT). Arrows point to the needle. Calc, Calcaneus;
CAUD, caudal.
Patient Position
• P
 rone with the foot hanging off the edge of the exam
table.
Target
Clinician Position • B
 ursa superficial to the Achilles tendon near the tendon
• S eated at the foot of the exam table, facing the affected insertion on the calcaneus.
lateral ankle and ultrasound machine.

Transducer Orientation
• Th
 e distal Achilles tendon is located in long or short axis PEARLS AND PITFALLS
as described above.
• Light transducer pressure with a gel stand-off is used to • U sing light transducer pressure with a thick layer of gel
is important to avoid compression and displacement of
visualize fluid in the retroachilles bursa (Fig. 22.31A). fluid in the Achilles bursa if only a small amount of fluid
• Injection is performed with the transducer oriented in is present.
oblique long axis to the Achilles tendon. • When approaching the bursa laterally, care must be
taken to avoid the sural nerve.
Needle position • Avoid injection into the Achilles tendon.
• In-plane, distal lateral to proximal medial (Fig. 22.31B).   
 CHAPTER 22 Ankle Region Injection Techniques 457

Other Injections
Achilles Tendon Scraping/High-Volume
Image-Guided Injection

KEY POINTS
• U se of a high-frequency linear ultrasound transducer is
recommended.
• In Achilles tendinopathy, neovessels and neonerves can
be a source of pain and tendon scraping and high-
volume image-guided injection (HVIGI) aims to separate
neonerves away from the tendon using mechanical
blunt force and fluid pressure, respectively.
  

Pertinent Anatomy
• Th
 e Achilles tendon is the longest, thickest, and strongest
tendon in the body and connects the gastrocnemius and
soleus muscles to the calcaneus.
• Kager’s fat pad is located directly anterior to the Achilles A
tendon and posterior to the ankle joint.

Common Pathology
• I n mid-portion Achilles tendinopathy, it is thought that AT
neovessels and neonerves extend from Kager’s fat pad to
the Achilles tendon.
• On sonographic evaluation, neovessels can be visualized
with color or power Doppler and serve as a surrogate
marker for neonerves, which are thought to contribute
to pain in Achilles tendinopathy.37

Equipment B LAT

• N eedle size: 27 to 30 gauge 1 to 1.5-inch needle for local • Fig. 22.32 (A) Ultrasound-guided Achilles tendon scraping setup.
anesthetic. (B) Kager’s fat pad hydrorelease using an in-plane, lateral to medial
• #11 blade scalpel. approach. The Achilles tendon (AT) is visualized in short axis. Arrows
point to the needle. LAT, Lateral.
• 18 gauge needle or meniscotome for scraping procedure.
This is not needed if the goal is just to perform HVIGI.
• High-frequency linear ultrasound transducer. Target
• Syringes, probe cover, sterile gel, gauze, bandage, local • A
 reas of vascularity extending from Kager’s fat pad to the
anesthetic. deep surface of the Achilles tendon should be targeted.

Technique Injectate Volume

Patient Position • 5 to 40 mL (use more volume if HVIGI is combined
• P
 rone with the foot hanging off the edge of the exam with tendon scraping).
table and ankle positioned in slight passive dorsiflexion • Common injectates: Anesthetic, sterile water, normal
applied by the clinician. saline, dextrose.

Clinician Position Additional Procedure Details

• S eated at the foot of the exam table, facing the affected • F ollowing administration of local anesthetic, a stab inci-
lateral ankle and ultrasound machine. sion is made on the skin with an #11 blade.
• An 18 gauge needle or meniscotome is then inserted
Transducer Orientation under ultrasound guidance, deep to the Achilles tendon
• Short axis to the Achilles tendon (Fig. 22.32A). at the site of neovascularization identified on Doppler.
• The needle or meniscotome is moved in a cephalo-cau-
Needle Entry dad direction in a swiping motion to disrupt neovessels
• In-plane, lateral to medial (Fig. 22.32B). and neonerves. Use of a meniscotome allows for a single
458 SEC T I O N I I I Atlas

swipe rather than a needle, which might require a few • I t is less commonly affected by pigmented villonodular
repetitions. synovitis (PVNS).
• Infection is another rare pathology of the joint.
PEARLS AND PITFALLS Equipment
• T endon scraping and HVIGI can be performed alone, • N eedle size: 27 to 22 gauge 1.5 to 3 inch needle.
or in combination to separate the Achilles tendon from • Sterile preparation.
Kager’s fat pad. • Fluoroscopy C-arm.
• Anecdotally, high-volume injection may result in more
post-injection discomfort, likely due to tissue stretching. Common Injectates
• Identify the sural nerve and avoid when approaching
from the lateral side. • L ocal anesthetics for diagnostics, corticosteroids.
• Color Doppler should be used to identify areas of • Biologics (PRP, bone marrow concentrate, etc.)
neovascularization, a surrogate marker for neonerves.
• As both tendon scraping and HVIGI are extratendinous Injectate Volume
procedures, clinicians may feel more comfortable
returning patients to normal loading activity more quickly • 1 to 3 mL.
compared to other intratendinous procedures that may
result in compro­mised tendon integrity and a heightened Technique 1: Anterior
risk for a tendon rupture/tear for a period of time following Patient Position
the procedure.
• Procedures are often combined with an eccentric or
• P
 atient is seated supine with the foot on a flat surface and
heavy slow resistance exercise protocol.38 joint slightly plantarflexed.
  
Clinician Position
• Standing on the side of the patient.

Fluoroscopy-guided ankle injections. C-Arm Position.

• True lateral view.
Tibiotalar Joint
Needle Position
• P alpate the dorsalis pedis pulse and option to mark.
KEY POINTS • Start the needle just lateral or medial to the dorsalis pulse.
• Identify the joint space with lateral fluoroscopy and start
• T
 he joint can be injected from either anterior or
posterior. the needle just below the joint line (Fig. 22.33).
  

Pertinent Anatomy71–73
• Th
 e tibiotalar joint is the space between the distal tibia
and the talus.
• The anterior tibiotalar joint is the most pertinent loca-
tion for injections.
• There are several structures that are superficial to the
joint, including the tibialis anterior tendon, FHL ten-
don, EDL tendon, and the neurovascular bundle con-
taining the dorsalis pedis and the deep peroneal nerve.
• The posterior tibiotalar joint can also be accessed for
injections.
• The posterior joint is narrow and traversed by a groove
that runs obliquely downward and inward.

Common Pathology
• Th
 e tibiotalar joint commonly sustains traumatic injury,
which can produce fractures, osteochondral lesions,
synovitis, effusion, and hemarthrosis.
• It is also a common site for arthropathies, including
osteoarthritis and inflammatory arthropathies such as
rheumatoid arthritis. • Fig. 22.33B Ankle Fluoro Tibiotalar Joint Intra-Articular Anteior
Approach.
 CHAPTER 22 Ankle Region Injection Techniques 459

Target C-Arm Position

• A nterior third of the joint space. • T rue lateral view.
• Inject a small amount of contrast to confirm arthrogram. • May use AP view if needle to confirm medial to lateral
orientation.

PEARLS AND PITFALLS Needle Position

• I dentify the joint with lateral fluoroscopy and start the
• T here is risk of neurovascular (dorsalis pedis, superficial needle 1cm below the joint line.
peroneal nerve) or anterior tibialis tendon injury. • Needle entry should be just lateral to the Achilles tendon.
• Palpation of the dorsalis pedis is recommended prior to
needle entry to avoid injury to the artery.
• Aim the needle slight superior and medially.
• Going medial to the artery risks the tendon injury, going
too far lateral can injure the nerve. Target
   • P osterior third of the joint space (Fig. 22.34B).
• Inject a small amount of contrast to confirm arthrogram.

Technique 2: Posterior
Patient Position PEARLS AND PITFALLS
• P
 atient is prone with foot elevated on a pillow or wedge
or hanging over the edge of table (Fig. 22.34A). • A slight bend in the needle helps navigation.
• Be aware of needle trajectory not to venture too lateral
or media: you can use the AP view to confirm.
Clinician Position • Taking a medial to Achilles approach increases the risk
• Standing on the side of the patient. of tibial neurovascular injury.
  

Subtalar Joint: Posterior Approach

KEY POINTS
• M
 ost injections will be performed with fluoroscopy,
with the patient prone and foot elevated on a pillow or
wedge or hanging over the edge of the table.
  

Pertinent Anatomy71-73
A
• Th
 e subtalar (talocalcaneal) joint is the space between the
calcaneus and the talus. It is composed of three facets
(posterior, middle, and anterior). The posterior facet is
the largest and the most common target for injections.
Although the motion at the subtalar joint is small, it pri-
mary allows inversion-eversion of the ankle and hindfoot.

Common Pathology
• Th
 e subtalar joint commonly sustains traumatic injury,
which can produce sprains, fractures, chondral lesions,
synovitis, effusion, and hemarthrosis.
• A severe inversion injury, leading to rupture of the calca-
neofibular ligament, can lead to instability.
• It is also a common site for arthropathies, including osteo-
arthritis and inflammatory arthropathies such as rheuma-
toid arthritis, reactive (Reiter’s) arthritis, and gout.

Equipment
• N eedle size: 25 to 22 gauge 2 to 3-inch needle.
B
• C-arm fluoroscopy.
• Fig. 22.34 (A) Setup. (B) Ankle fluoro IA posterior lateral view. • Contrast.
460 SEC T I O N I I I Atlas

Needle Position
• I dentify the joint with lateral fluoroscopy and start the
needle 0.5 cm below the joint line.
• Needle entry should be just lateral to the Achilles tendon.
• Aim the needle slightly superior and medially.

Target
• P osterior third of the joint space (Fig. 22.35B).
• Inject a small amount of contrast to confirm arthrogram.

PEARLS AND PITFALLS

A • P ut the ankle in dorsiflexion to open the joint more.
• A slight bend in the needle helps navigation.
• Be aware of needle trajectory not to venture too lateral
or medial; you can use the AP view to confirm.
• The posteromedial approach requires passage of the
needle in close proximity to the tibial neurovascular
bundle.
• When there is a significant subtalar joint effusion
present, an aspiration can be performed prior to
injection. Laboratory analysis of the joint fluid may be
beneficial in assessing for crystalline or inflammatory
arthropathy.
• In 14% of population there may be communication
between the ankle and subtalar joint.74
  

Subtalar Joint (Sinus Tarsi): Anterior Approach

KEY POINTS
• M
 ost injections will be performed with fluoroscopy, with the
patient side-lying and foot elevated on a pillow or wedge.
B   

• Fig. 22.35 Ankle Fluoro Subtalar Joint IA.

Pertinent Anatomy72,73
• Th
 e sinus tarsi, also known as the tarsal sinus, serves as a
Common Injectates boundary between the anterior and posterior aspects of the
• L ocal anesthetics for diagnostics, corticosteroids. joint.
• Biologics (PRP, bone marrow concentrate, etc.). • It contains five ligamentous structures, comprising the
medial, intermediate, and lateral roots of the extensor
Injectate Volume retinaculum, the cervical ligament, and the ligament of
• 1 to 2 mL. the tarsal canal.
• The sinus tarsi also contains an arterial anastomosis,
Technique nerve endings, fat, and the joint capsule.
Patient Position • The sinus tarsi is bordered posteriorly by the PSTJ, and
• P
 atient is lying prone with foot elevated on a pillow can be separated from the PSTJ in 95% of cases by the
or wedge or hanging over the edge of the table (Fig. anterior capsular ligament.75
22.35A).
Common Pathology
Clinician Position • Th
 e subtalar joint commonly sustains traumatic injury,
• Clinician standing on the side of the patient. which can produce sprains, fractures, chondral lesions,
synovitis, effusion, and hemarthrosis.
C-Arm Position • A severe inversion injury, leading to rupture of the calca-
• T rue lateral view. neofibular ligament, can lead to instability.
• May use AP view if needle to confirm medial to lateral • It is also a common site for arthropathies, including
orientation. osteoarthritis, ankylosing spondylitis, inflammatory
 CHAPTER 22 Ankle Region Injection Techniques 461

arthropathies such as rheumatoid arthritis, and crystal- Talonavicular Joint

line arthropathies such as gout.
• Ganglion cysts may also occur in this area.
KEY POINTS
Equipment • M
 ost injections will be performed with fluoroscopy,
• N eedle size: 25 to 22 gauge 2 to 3 inch needle. with the patient side-lying with the lateral aspect of the
affected foot on the table, exposing the medial aspect
• Contrast fluoroscopy C-arm.
and the talonavicular joint.
Common Injectates   
• L ocal anesthetics for diagnostics, corticosteroids.
• Biologics (PRP, bone marrow concentrate, etc.). Pertinent Anatomy72,73
• Th
 e talonavicular joint is the space between the distal
Injectate Volume talus and navicular. It is a ball and socket joint and has
• 1 to 2 mL. an incomplete fibrous capsule. There are ligamentous
structures that overlie the joint with the spring ligament
Technique along the medial inferior portion and the deltoid liga-
Patient Position ment covering the medial joint line.
• P atient is side-lying with foot elevated on a pillow or wedge. • There are several structures that are superficial to the joint.
• Alternatively, the patient can be supine with the knee These include the tibialis posterior tendon, extensor hallu-
flexed and foot flat on the table. cis longus tendon, and the saphenous nerve and vein along
• The opposite leg will need to be positioned out of the the medial aspect. The tibialis anterior, superficial peroneal
C-arm view (Fig. 22.33A). nerve, and the medial tarsal arteries are located over the
dorsomedial joint. The deep peroneal nerve and lateral
Clinician Position tarsal artery are superficial to the dorsolateral aspect of the
• Clinician is standing on the opposite side of the C-arm. joint. The dorsalis pedis artery and deep peroneal nerve
pass under the extensor retinaculum on the dorsal aspect
C-Arm Position of the joint with dorsal digital nerves passing superficially.
• T rue lateral view with the anterior subtalar joint clearly open.
• May use true AP view to confirm medial lateral needle Common Pathology
placement. • Th
 e talonavicular joint commonly sustains traumatic
injury, which can produce fractures, chondral lesions,
Needle Position synovitis, effusion, and hemarthrosis. It is also a com-
• S tart directly over the joint space anterior-inferior to the mon site for arthropathies, including osteoarthritis, post-
lateral malleolus and just above the calcaneus. traumatic arthritis, tarsal coalition, diabetic neuropathic
• The entry point is marked with a metallic wand prior to arthropathy, and congenital deformities (club foot).
sterile preparation or with a sterile sheathed needle after
sterile preparation. Equipment
• The needle is advanced slightly anterior-posterior from • N eedle size: 27 to 22 gauge 1.5 to 2 inch needle.
lateral to medial. • C-arm fluoroscopy.
Target
• M id portion of the anterior subtalar joint/sinus tarsi (Fig.
22.36).
• Can check an AP view to ensure the needle is in the mid
portion of the joint.
• Inject a small amount of contrast to confirm intra-artic-
ular spread.

PEARLS AND PITFALLS

• W hen there is a significant subtalar joint effusion present,
an aspiration can be performed prior to injection.
Laboratory analysis of the joint fluid may be beneficial in
assessing for crystalline or inflammatory arthropathy.
• Optimize joint visualization with the C-arm.
• Avoid going too deep through the joint; the AP view can
confirm needle depth.
• Option to also inject the joint from medial to lateral if
patient in the hook-lying position.
   • Fig. 22.36 Ankle Fluoro Sinus Tarsi.
462 SEC T I O N I I I Atlas

A B
• Fig. 22.37 (A) Set up. (B) Ankle Fluoro Talonavicular intraarticular.

Common Injectates PEARLS AND PITFALLS

• L ocal anesthetics for diagnostics, corticosteroids.
• Biologics (PRP, bone marrow concentrate, etc.). • T here is risk of neurovascular or tendon injury. Palpation
of the dorsalis pedis is recommended prior to needle
entry to avoid insertion of the needle into the artery.
Injectate Volume • Damage to small sensory branches adjacent to the joint
has been associated with neuropathic pain.76,77
• 1 to 2 mL.
  

Technique References
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23
Foot Injection Techniques
DOUGLAS HOFFMAN, JACOB JONES, PIERRE D’HEMECOURT,
JOHN PITTS, AND ARTHUR JASON DE LUIGI

Foot Ultrasound Introduction • Th

 e central cord originates from the plantar aspect of the
medial tubercle of the calcaneus and has a complex insertion
Ultrasound (US) has emerged as a valuable imaging modal- distally onto the MTP joint and plantar fat pad. The lateral
ity for addressing many foot disorders and allows a more cord originates on the lateral aspect of the medial tubercle
precise approach to intra-articular and soft tissue injections. of the calcaneus and inserts onto the base of the fifth meta-
US-guided injection techniques involving the plantar fas- tarsal lateral to the insertion of the peroneus brevis.
cia, medial and inferior calcaneal nerves, the intersection
of flexor hallucis longus (FHL) and flexor digitorum lon- Pathology
gus (FDL), midfoot joints, metatarsophalangeal (MTP)
joints, sesamoids, plantar plate, and Morton’s neuromas • U ndersurface partial-thickness tears are often present
are reviewed in this chapter. This chapter does not contain adjacent to a calcaneal enthesophyte.
an exhaustive list of all foot injections, but rather, serves • Enthesopathy of the lateral cord of the plantar fascia
as an outline for the different approaches to common foot (LCPF) at its insertion onto the base of the fifth metatarsal
injections. can occur in isolation or coexist with plantar fasciopathy.
Equipment
Plantar Fascia • 2 7–22 gauge, 1.5–2 inch needle for fascia injection
• 25–18 gauge, 1.5–2 inch needle for tenotomy
KEY POINTS • High- or medium-frequency linear array transducer
• D isorders of the central cord of the plantar fascia are Common Injectates
the most common cause of heel pain in the adult
population.1 Enthesopathy of the lateral cord of the • L ocal anesthetics for diagnostics, corticosteroids
plantar fascia is an often overlooked cause of lateral • Prolotherapy
foot pain and can coexist with plantar fasciopathy.2 • Orthobiologics
• Corticosteroid injections are controversial in the setting
of degenerative plantar fasciopathy, particularly when Injectate Volume
used repetitively. However, they are occasionally utilized
for pain control during the rehabilitative process and • 1 –3 mL
while addressing underlying biomechanical factors. TECHNIQUE: Approach for injection of the central
• There is no strong evidence for a preference of placing cord of the plantar fascia
a corticosteroid injection deep, superficial, or directly
within the central cord of the plantar fascia. In theory, a Patient Position
corticosteroid injection superficial to the central cord may • P rone with knee fully extended and ankle resting on a
cause fat pad atrophy. Alternatively, an injection within the towel or over the edge of the table.
central cord may propagate undersurface partial-thickness
tears, which are common with plantar fasciopathy. • Alternatively, patient lying supine, knee fully extended with
the ankle on a towel and/or hanging over edge of table.
  
Clinician Position
Pertinent Anatomy (Fig. 23.1) • Seated at end of table

• Th
 e plantar fascia is composed of three components: the Transducer Position
central, medial, and lateral cords. The central and lateral • S hort axis (SAX) to plantar fascia near its origin on the
cords are the most clinically relevant. calcaneus (in-plane approach) (Fig. 23.2A and B)

465
466 SEC T I O N I I I Atlas

Tibiocalcaneal (deltoid)
Posterior tibiotalar (deltoid) ligament
ligament Anterior tibiotalar (deltoid)
ligament

Tibionavicular (deltoid)
ligament
Calcaneal (Achilles) Dorsal tarsometatarsal
tendon (cut) ligament

Long plantar ligament

Posterior talocalcaneal
ligament

Plantar fascia
Plantar calcaneonavicular (spring)
ligament
• Fig. 23.1 Anatomy of The Medial Ankle Ligaments and Plantar Fascia.

• L
 ong axis (LAX) to the plantar fascia (in-plane approach) Technique: Approach for injection or fenestration
(Fig. 23.3A) of the lateral cord of the plantar fascia
Patient Position
Needle Position • S ide-lying with the lateral aspect of the affected foot
• S AX in-plane approach directed medial to lateral (see facing up. Towel under the ankle for comfort (Fig.
Fig. 23.2C) 23.4A)
• LAX in-plane approach directed either proximal to distal
or distal to proximal (see Fig. 23.3B) Clinician Position
• Seated at end of table
Target
• P athogenic areas of the tendon if using orthobiologics or
needle tenotomy Transducer Position
• Peritendinous if using corticosteroids • L AX to the LCPF (in-plane approach) (see Fig. 23.4A)
• SAX to the LCPF (in-plane approach) (Fig. 23.5A)
PEARLS AND PITFALLS
• A void placing injectate directly into the plantar fat pad Needle Position
when utilizing a corticosteroid.
• A tibial nerve block may minimize the need for local • L AX in-plane approach directed proximal to distal or
anesthetic when using an orthobiologic or needle tenotomy. distal to proximal (see Fig. 23.4B)
• The principle of needle fenestration is to pass the • SAX in-plane approach directed dorsal to plantar (see
needle repeatedly through the tendinopathic areas of
the central cord. The number of fenestrations can vary
Fig. 23.5B)
widely, depending on the severity and extent of the
central cord involvement. Target
• Alternating SAX and LAX imaging during the • P athogenic areas of the lateral cord if using orthobiolog-
fenestration assures that the full extent of the ics or needle tenotomy
tendinopathic portion of the tendon is addressed.
• Peritendinous if using corticosteroids
  
 CHAPTER 23 Foot Injection Techniques 467

PEARLS AND PITFALLS

• If utilizing a corticosteroid, consider placing the injectate
along the superficial border of the LCPF to minimize the
risk of tearing.
• Fenestration and/or orthobiologic injection may take
months for full recovery.

  

Medial Calcaneal Nerve and Inferior Calcaneal

Nerve (Baxter’s Nerve)

KEY POINTS
• N europathic pain is not an uncommon cause of heel pain.
• Selectively blocking the medial calcaneal nerve (MCN) or
inferior calcaneal nerve (ICN) can help decipher heel pain
arising from nerve entrapment versus plantar fasciopathy.
However, pain from an entrapment neuropathy can
coexist with symptomatic proximal plantar fasciopathy.
• Both the ICN and MCN are approached similarly with a
posterior to anterior SAX in-plane approach.
A
  

MT

Medial
C
• Fig 23.2 Sax In-Plane Approach for Injection of The Proximal MT
Central Cord of The Plantar Fascia. (A) Patient and needle position
for medial to lateral SAX in-plane approach (patient supine). (B) Patient
and needle position for medial to lateral SAX in-plane approach (patient B
prone). (C) Ultrasound image and needle position (arrow) for medial to
lateral SAX in-plane approach, corresponding to the images shown in • Fig. 23.3 LAX in-Plane Approach for Injection of the Proximal
A and B. MT, Medial tubercle of the calcaneus. Central Cord of the Plantar Fascia. (A) Patient and needle position
for distal to proximal LAX in-plane approach. (B) Ultrasound image and
needle position (arrow) for distal to proximal LAX in-plane approach
corresponding to image A. MT, Medial tubercle of the calcaneus.
468 SEC T I O N I I I Atlas

A
LCPF
MT 5

B
PB
• Fig 23.4 LAx In-Plane Approach for Injection of The LCPF. (A)
Patient and transducer position for distal to proximal LAX in-plane
approach. (B) Corresponding US image and needle position (arrow) LCPF
for distal to proximal LAX in-plane approach. May also approach this
injection from proximal to distal. LCPF, Lateral cord of the plantar fascia;
MT 5, fifth metatarsal. MT 5

Pertinent Anatomy (see Fig. 23.6)

• Th
 e MCN most commonly comes directly off the tibial B
nerve and remains in the superficial subcutaneous tis-
sue as it traverses towards the posteromedial calcaneal • Fig 23.5 SAX in-plane approach for injection of the LCPF. (A) Patient
and transducer position for dorsal to plantar SAX in-plane approach.
region. (B) Corresponding US image and needle position (arrow) for a dorsal to
• The ICN is typically the first branch of the lateral plantar plantar SAX in-plane approach. LCPF, Lateral cord of the plantar fas-
nerve (LPN). It travels posteriorly from its take-off point cia; MT 5, fifth metatarsal; PB, peroneus brevis. The top of the image
before turning inferiorly between the abductor hallucis is dorsal. To the left is medial.
(AH) and the quadratus plantae (QP) muscles. It then
courses between the flexor digitorum brevis (FDB) and • A
 trophy and fatty replacement of the ADM muscle is a
the QP, deep to the calcaneal osteophyte (if present), clue to entrapment of the ICN.
before terminating at the abductor digiti minimi (ADM)
muscle.
Equipment
• There is some variability in the take-off of the ICN and
may divide above the tarsal tunnel in 12% of cases.3 • H igh-frequency linear or hockeystick ultrasound
• The ICN is motor to the ADM muscle. transducer
• 27–22 gauge, 1.25–1.5 inch needle for perineural
Common Pathology injection

• N
 europathies involving both the MCN and ICN can Common Injectates
lead to heel pain and mimic plantar fasciopathy. An • Local anesthetics, corticosteroids
entrapment neuropathy of the ICN can occur in isola-
tion or in conjunction with plantar fasciopathy. Up to Injectate Volume
20% of cases of heel pain have been attributed to ICN • Local anesthetic 0.5–2mL
entrapment.4 Entrapment of the ICN typically occurs as
it traverses between the QP and AH muscles, or more Technique
distally between the FDB and QP muscles adjacent to Patient Position
the calcaneal osteophyte. • Supine
 CHAPTER 23 Foot Injection Techniques 469

TN

MPN

LPN
MCN ICN

• Fig 23.6 MCN and ICN. The MCN typically branches off the tibial nerve
before the bifurcation of the medial plantar nerve (MPN) and lateral plan-
tar nerve (LPN). Note that the MCN travels posterior to the ICN. ICN, A
Inferior calcaneal nerve; MCN, medial calcaneal nerve; TN, tibial nerve.

• A ffected leg is externally rotated to expose the medial

ankle. The lateral ankle rests comfortably on a towel or
over the side of the examination table (Fig. 23.6).
• Alternatively, patient is prone with ankle over the side of
the examination table.

Clinician Position CALC

• Seated directly distal to the foot being injected.
B
Transducer Position
• SAX to the targeted nerve (see Fig. 23.7A)

Needle Position
• S AX in-plane approach from posterior to anterior (see
Fig. 23.7B and C).
QP

Target
• Perineural

PEARLS AND PITFALLS

CALC
• Identify the MCN by tracing in SAX as it separates from
the tibial nerve and traverses inferiorly and posteriorly. It C
remains fairly superficial, which helps distinguish it from the
ICN, which will dive between the AH and QP muscles. • Fig 23.7 Approach to Injection of the Medial Calcaneal Nerve
• An isolated local block of the MCN will often (MCN) and Inferior Calcaneal Nerve (ICN). (A) Patient and trans-
differentiate it from ICN entrapment. In such a case, an ducer position for a posterior to anterior SAX in-plane approach for
MCN block will anesthetize the medial calcaneal region injection of either the MCN or ICN. (B) Corresponding image and nee-
but should not affect plantar heel pain if the pain arises dle position (arrow) for injection of the MCN (open white arrowhead),
from ICN entrapment. which appears as a single hypoechoic fascicle traversing posteriorly
• The ICN is identified by tracing the LPN until a small into the subcutaneous tissue superficial to the calcaneus (CALC).
single fascicle branches posteriorly toward the AH and Black arrowhead = lateral plantar nerve; open black arrowhead =
QP interval. Occasionally, the ICN branches from the medial plantar nerve. (C) Corresponding image and needle position
tibial nerve proximal to its bifurcation into the medial (arrow) for injection of the ICN (white arrowhead), which appears as a
and lateral plantar nerves. single hypoechoic fascicle branching posteriorly from the lateral plan-
• Lighten the probe pressure to assure that adjacent tar nerve (black arrowhead) and is located adjacent to the quadratus
venous structures are not compressed and properly plantae (QP) muscle before it enters the interval between the QP and
identified in planning the needle approach. AH muscles.

  
470 SEC T I O N I I I Atlas

Intersection Syndrome • L
 AX to the crossover of the FDL and FHL (in-plane
approach) (see Fig. 23.9A)
KEY POINTS
• T his represents a friction syndrome between the flexor Needle Position
digitorum longus (FDL) and flexor hallucis longus (FHL)
tendons as they cross distal to the medial tarsal tunnel • S AX in-plane approach directed dorsal to plantar (see
(master knot of Henry). Fig. 23.8B)
• The differential diagnosis of medial ankle and/or midfoot • LAX in-plane approach from distal to proximal (see Fig.
pain is broad, and an injection into the knot of Henry 23.9B)
can be both diagnostic and potentially therapeutic.
   Target
• Between the FDL and FHL at the knot of Henry
Pertinent Anatomy
• Th
 e FHL and the FDL are viewed in proximity to each PEARLS AND PITFALLS
other at the sustentaculum tali (ST) in short axis. The FDL • Identify and carefully map the medial plantar
neurovascular bundle as they traverse adjacent to the
is visualized just superficial to the ST while the FHL is knot of Henry.
located slightly distal and posterior. Scanning distal to the • Lighten the probe pressure to avoid compression
ST in short axis, the two tendons will intersect. The point of of the medial plantar vein during pre-injection
intersection, or the knot of Henry, is the common location planning.
of pathology.
  
• The medial plantar neurovascular bundle is most often
medial to the tendons at their intersection point.
Midfoot Joints
Common Pathology
• T endinosis or tenosynovitis KEY POINTS
• Adhesions between the two tendons • U S-guided midfoot injections can provide both
diagnostic and therapeutic benefits.
• Osteoarthrosis (OA) is the most common midfoot joint
Equipment disorder in the adult population.
• View radiographs as part of injection planning to
• H igh- or medium-frequency linear array ultrasound become familiar with the bony anatomy.
transducer • Patients often have multiple joints involved with midfoot
• 30–25 gauge. 1.25–1.5 inch needle OA. Careful scanning with correlative sono-palpatory
pain can help guide providers with information
Common Injectates regarding which joint(s) to inject.
• L ocal anesthetics for diagnostics, corticosteroids   
• Saline for hydrodissection
• Orthobiologics

Injectate Volume Pertinent Anatomy

• 1 -2 mL
• 5-10 mL for hydrodissection • Th
 e midfoot joints include the talonavicular, calca-
neocuboid, naviculo-cuneiform, and tarsometatarsal
Technique joints.
Patient Position • Synovial compartments of the midfoot involve joint
• S upine or seated complexes rather than separate compartments for each
• Affected leg externally rotated to expose the medial ankle. individual joint (Fig. 23.10).
Lateral ankle resting comfortably on a towel or over the • Abnormal communication between joint compartments
side of the examination table (Figs. 23.8A and 23.9A) is likely to occur in the setting of osteoarthrosis or inflam-
matory arthropathy.
Clinician Position • At-risk structures include the dorsalis pedis artery and
• Seated directly distal to the foot being injected vein, branches of the superficial and deep fibular nerves,
and extensor tendons.
Transducer Position
Common Pathology
• S AX to the crossover of the FDL and FHL (in-plane • O steoarthrosis
approach) (see Fig. 23.8A) • Inflammatory arthropathy
 CHAPTER 23 Foot Injection Techniques 471

AH

AH

FDL
FHL

B
B
• Fig 23.8 Intersection Syndrome Injection. SAX in-plane approach to
injection of the intersection of the FDP and flexor halluceis longus (FHL) • Fig 23.9 Intersection Syndrome Injection. LAX in-plane approach to
injection of the intersection of the FDP and FHL at the knot of Henry: (A)
at the knot of Henry: (A) Patient and transducer position for a dorsal
Patient and transducer position for a distal to proximal long-axis (LAX)
to plantar SAX in-plane approach. (B) Corresponding US image and
in-plane approach. (B) Corresponding US image and needle position
needle position (arrow) for the dorsal to plantar SAX in-plane approach.
(arrow) for the distal to proximal LAX in-plane approach. AH, Abductor
The MPN (white arrowhead) and medial plantar artery and vein (open
hallucis; FDL, flexor digitorum longus; FHL, flexor hallucis longus.
white arrowhead) are typically adjacent to the fexor digitorum profun-
dus (FDP) and flexor hallucis longus (FHL) tendons. Black arrowhead,
FDP; open black arrowhead, FHL; AH, abductor hallucis. Clinician Position
• Seated at the end of the table
Equipment
• H igh-frequency linear or hockeystick ultrasound
transducer Transducer Position
• 30–27 gauge, 1.0–1.25 inch if using local anesthetic • L AX to the joint (out-of-plane approach) (see Fig. 23.11A)
before injection; 27–22 gauge, 1.0–1.5 inch for injectate • SAX to the joint (in-plane approach) (see Fig. 23.12A)
Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids Needle Position
• Prolotherapy
• D orsal medial to lateral or lateral to medial (depend-
• Orthobiologics
ing on location of at-risk structures) LAX out-of- plane
Injectate Volume approach (see Fig. 23.11B)
• 0.5–1.5 mL • Dorsal medial to lateral or lateral to medial (depending
on location of at-risk structures) SAX in-plane approach
Technique (see Fig. 23.12B)
Patient Position
• S upine with posterior ankle on towel or hanging over the Target
edge of the table • D irectly between the bones into the joint.
• Alternatively, knee flexed with foot on table (Figs. 23.11A • Can also inject the overlying joint capsule with prolo-
and 23.12A) therapy or orthobiologics.
472 SEC T I O N I I I Atlas

A B
• Fig 23.10 Anteroposterior (AP) and Oblique Radiographs of The Foot Demonstrating The Midfoot Joint
Complexes (red lines). (A) AP radiograph of the foot showing the medial column joint complexes. Note that
the medial tarsometatarsal joints communicate with the naviculocuneiform joints. (B) Oblique radiograph of
the foot showing the lateral midfoot joint complexes.

PEARLS AND PITFALLS Pertinent Anatomy

• Th
 e Lisfranc joint is the articulation between the medial
• In advanced talonavicular joint arthrosis, dorsal
overhanging of bony hypertrophic changes may obscure
cuneiform and medial base of the second metatarsal.
the joint line. In this case, scan distal to proximal to • The Lisfranc ligament complex lies in an oblique plane
definitively identify the metatarsals, cuneiforms, and between the medial cuneiform and second metatar-
navicular bones. A more medial or lateral approach may sal base. It is composed of a dorsal, interosseous, and
also allow better visualization of the joint space and plantar component. The dorsal component is visible on
access to the intra-articular joint space.
• Apply light transducer pressure in pre-injection images
ultrasound.
to avoid compression of vascular structures. • At-risk structures include the medial branch of the deep
• Assess overlying extensor tendons for attritional changes. fibular nerve, which most commonly travels directly over
In the setting of OA, the joint space may communicate the Lisfranc joint.
with the overlying tendons due to capsular attrition. Thus, • Scan SAX on the first and second metatarsals from distal
the injectate that contains a corticosteroid may leak into
the tendon sheath and predispose to rupture.
to proximal until the first metatarsal disappears and the
medial cuneiform appears (Fig. 23.13A and B).
  
Common Pathology
• L igamentous injury with or without associated fracture
Approach to Injection of the Lisfranc Joint • Post-traumatic osteoarthrosis

Injections Key Points Equipment

• Th
 e Lisfranc joint complex often remains symptom- • H igh-frequency linear or hockeystick ultrasound
atic after injury due to instability or post-traumatic transducer
osteoarthrosis. • 30–27 gauge, 1.0–1.25 inch if using local anesthetic
• An injection into the joint complex may provide diag- before injection; 30–22 gauge, 1.0–1.5 inch for injectate
nostic value for surgical planning or for management of
pain. Common Injectates
• View radiographs as part of injection planning to become • L ocal anesthetics for diagnostics, corticosteroids
familiar with bony anatomy. Normal bony articulations • Prolotherapy
may be altered after injury. • Orthobiologics
 CHAPTER 23 Foot Injection Techniques 473

A
A

.
Talus NAV
Talus

B
• Fig 23.11 Midfoot Joint Injection. Long-Axis (LAX) out-of-Plane
Approach. (A) Transducer and needle position for a lateral to medial Medial
LAX out-of-plane approach for an injection into the talonavicular joint.
The approach may be medial to lateral or lateral to medial, depending B
on the location of at-risk structures. A similar approach is applied for
injections involving the naviculocuneiform and tarsometatarsal joints.
• Fig 23.12 Midfoot Joint Injection. SAX in-Plane Approach. (A)
Transducer and needle position for a lateral to medial SAX in-plane
(B) Corresponding ultrasound image and needle position (white dot) for
approach for an injection into the talonavicular joint. The approach may be
the LAX out-of-plane approach. NAV, Navicular bone.
medial to lateral or lateral to medial, depending on the location of at-risk
Injectate Volume structures. A similar approach is applied for injections involving the navicu-
• 1–2 mL locuneiform and tarsometatarsal joints. (B) Corresponding ultrasound
image and needle position (arrow) for the SAX in-plane approach.
Technique
Patient Position
• S upine with posterior ankle on towel or hanging over the first metatarsal disappears and the medial cuneiform
edge of the table (Fig. 23.14A and B; see also Fig. 23.13A appears adjacent to the second metatarsal (see Fig.
and B) 23.13).
• Alternatively, knee flexed with foot on table
Needle Position
Clinician Position
• Seated at the end of the table • J oint injections, LAX distal to proximal out-of-plane ap-
proach, beginning at the proximal first metatarsal interspace
• Alternately, SAX view of second metatarsal middle cune-
Transducer Position
iform joint
• T
 ransverse at the mid-substance of the first and sec- • For biologic injections, LAX out-of-plane approach to
ond MT and translate the probe proximately until the Lisfranc ligament complex
474 SEC T I O N I I I Atlas

MT 2 Med Cun

A C
• Fig 23.13 Sonographic Localization of Lisfranc Joint. (A) AP radiograph of the foot showing the transducer
position for localizing the Lisfranc joint. Beginning anatomic coronal at the mid-metatarsal level between the
first and second metatarsals (more distal probe position), translate the probe proximally until the first metatar-
sal disappears and the medial cuneiform (Med Cun) is visualized adjacent to the second metatarsal (proximal
probe position). (B) Ultrasound transducer position to visualize Lisfranc joint corresponding to the more proxi-
mal transducer position in A. (C) Corresponding ultrasound image of Lisfranc joint. Note the overlying dorsal
Lisfranc ligament (arrowheads). Med Cun, Medial metatarsal; MT 2, second metatarsal.

Target Pertinent Anatomy

• L
 isfranc ligament superficial to the second metatarsal
and medial cuneiform • Extensor tendons traverse dorsal to the MTP joint

PEARLS AND PITFALLS

Common Pathology
• Identify the dorsalis pedis artery and vein(s) and medial
branch of deep fibular nerve. • O steoarthrosis
• If one has difficulty injecting the Lisfranc joint, one can • Urate deposition disease
inject the middle cuneiform second metatarsal joint
since it often communicates with the Lisfranc joint. • Inflammatory arthropathy
  
Equipment
First Metatarsophalangeal Joint and Lesser • H igh-frequency linear or hockeystick ultrasound
Metatarsophalangeal Joints transducer
• 22–20 gauge, 1–1.5 inch needle for aspiration
KEY POINTS • 27–22 gauge, 1.0–1.5 inch needle for injection
• A ssess for presence of effusion if considering aspiration.
• Assess for signs of urate deposition disease if clinically Common Injectates
pertinent.
• Hyperechoic aggregates or punctate echogenic debris • L ocal anesthetics for diagnostics, corticosteroids
(snowstorm appearance), often with hypervascularity, in • Prolotherapy
dorsal synovial recess. • Orthobiologics
• Subcutaneous edema and vascularity in acute gout attack.
• Double contour sign (two echogenic lines) involving the
articular cartilage of metatarsal head. Injectate Volume
• 0.5–1 mL
  
 CHAPTER 23 Foot Injection Techniques 475

.
MT 1
. B
MT 2 Med Cun
• Fig 23.15 First Metatarsophalangeal (MTP) Joint Injection. LAX Out-
of-Plane Approach. (A) Transducer and needle position for a LAX out-
of-plane injection of the first MTP joint. The approach can be medial to
B lateral or lateral to medial. (B) Corresponding ultrasound image and needle
location (white dot) for a LAX out-of-plane approach. A similar approach
• Fig 23.14 Lisfranc Joint Injection. (A) Transducer and needle position is utilized for injections of the lesser MTP joints. MT 1, First metatarsal.
for a LAX (transverse) distal to proximal out-of-plane approach to injecting
the Lisfranc joint. (B) Corresponding ultrasound image and needle target
(white dot) for Lisfranc joint injection. Med Cun, Medial metatarsal; MT 2, PEARLS AND PITFALLS
second metatarsal.
• A void going through the extensor tendon to reach the
joint.
• Traction to phalange or/or slight plantar flexion often
Technique opens up the joint space.
Patient Position   
• S upine with posterior ankle on towel or hanging over the
edge of the table (Figs. 23.15A and 23.16A) Great Toe Sesamoid Bones
• Alternatively, knee flexed with foot on table
KEY POINTS
Clinician Position
• Seated directly distal to the foot being injected • B
 oth the tibial and fibular sesamoid articulations may be
reached with an intra-articular first MTP joint injection.
  
Transducer Position
• L AX to the joint (out-of-plane approach) (see Fig. 23.15A) Pertinent Anatomy
• SAX to the joint (in-plane approach) (see Fig. 23.16A) • M edial (tibial) and lateral (fibular) hallux sesamoids
• Intersesamoid ligament between the two sesamoid bones
Needle Position • FHL tendon runs between the two sesamoid bones plan-
tar to the intersesamoid ligament
• D orsal medial to lateral or lateral to medial LAX out-of- • The joint between the sesamoid bones and first metatar-
plane approach (see Fig. 23.15B) sal communicates with the first MTP joint.5
• Dorsal medial to lateral or lateral to medial SAX in-plane • The tibial sesamoid bone is more prone to multiple
approach (preferred approach for aspiration) (see Fig. ossification centers, and therefore more likely to have a
23.16B) bipartite or multipartite morphology.6
476 SEC T I O N I I I Atlas

FHL
A

IL MS
LS

B
• Fig 23.17 Great Toe Sesamoid Injection. Sax Axis In-Plane Approach.
(A) Transducer and needle position for a medial to lateral SAX in-plane
injection for a medial sesamoid injection. A lateral to medial approach
MT 1
can be utilized for a lateral sesamoid injection. (B) Corresponding ultra-
sound image and needle pathways showing the SAX in-plane approach
B for injecting either the superficial border of the sesamoid (solid arrow) or
the deeper sesamoid-metatarsal articulation (dotted arrow). FHL, Flexor
• Fig 23.16 First Metatarsophalangeal (MTP) Joint Injection or hallucis longus tendon; LS, lateral sesamoid; MS, medial sesamoid; IL,
Aspiration. SAX In-Plane Approach. (A) Transducer and needle posi- intersesamoid ligament.
tion for a SAX in-plane injection or aspiration of the first MTP joint. The
approach can be medial to lateral or lateral to medial. (B) Ultrasound image
of a SAX in-plane aspiration of the first MTP joint. MT 1, First metatarsal.
Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy
Common Pathology • Orthobiologics
• C hronic sesamoid pain may be due to insertional tendi-
nosis of the flexor hallucis brevis (FHB) tendons, stress Injectate Volume
fracture, avascular necrosis (AVN), and/or degenerative • 0.5–1 mL
changes of the sesamoid articulation with the metatar-
sal head.7 Technique
• Stress fractures occur secondary to repetitive overuse Patient Position
trauma most commonly seen in dancers and runners.8 • S upine with knee fully extended and ankle plantar flexed
This may overlap with secondary degenerative changes and resting on the table (Fig. 23.17A)
as the sesamoids form a true joint articulation with the
metatarsal head. Clinician Position
• Seated directly below the foot being injected
Equipment
• H igh-frequency linear or hockeystick ultrasound Transducer Position
transducer
• 30–27 gauge, 1.0–1.25 inch if using local anesthetic • S AX to the sesamoid-metatarsal articulation (in-plane
before injection; 25–22 gauge, 1.0-1.5 inch for injectate approach) (see Fig. 23.17A)
 CHAPTER 23 Foot Injection Techniques 477

PEARLS AND PITFALLS

• T he fibular sesamoid is best approached with an LAX
in-plane approach.
• Avoid the interdigital nerve and artery with the fibular
sesamoid.
  

Interdigital (Morton’s) Neuroma

Injections Key Points
• H igh-frequency linear or hockeystick ultrasound probe.
• Corticosteroids may result in temporary relief and provide
diagnostic information when more than multiple patholo-
gies are present (i.e., plantar plate or fat pad abnormalities).
• Serial alcohol injections, cryoablation, or radiofrequency
ablation may provide more long-term relief in selected
patients.
A
Pertinent Anatomy
• Th
 e interdigital nerve runs plantar to the dorsal inter-
metatarsal ligament.
LS • The intermetatarsal bursa is located dorsal to the dorsal
FHB
intermetatarsal ligament.

Common Pathology
• N euroma is somewhat of a misnomer, in that it is a fibrous
B thickening of the interdigital nerve associated with edema of
the endoneurium. The intermetatarsal bursopathy accom-
panies the abnormal digital nerve. Thus, an interdigital neu-
roma should be thought of as a neuroma-bursal complex.9
• Most common location is within the third metatarsal
LS interspace.10
• Post-surgical complications include fibrous adhesions
around nerve, symptomatic stump neuroma, or inter-
metatarsal bursopathy.11
MT 1 • Symptomatic interdigital neuroma often coexists with
C plantar plate and plantar fat pad abnormalities.
• Fig 23.18 Great Toe Sesamoid Injection. Distal to Proximal Lax
Approach. (A) Transducer and needle position for a LAX in-plane injec- Equipment
tion of the lateral sesamoid. A similar approach can be used for a medial
sesamoid injection. Taping the toes apart may allow easier access for • H igh-frequency linear or hockeystick ultrasound
lateral sesamoid injections. (B) Corresponding ultrasound image and transducer
needle pathway (solid arrow) showing the distal to proximal LAX in-plane • 30–27 gauge, 1.0–1.25 inch if using local anesthetic
approach for injecting the superficial border of the lateral sesamoid. (C) before injection; 25–22 gauge, 1.0–1.5 inch for injectate
Corresponding ultrasound image and needle pathway (dotted arrow)
showing the distal to proximal LAX in-plane approach for injecting the
lateral sesamoid/first metatarsal articulation. FHB, flexor hallucis brevis;
Common Injectates
LS, Lateral sesamoid; MT 1, first metatarsal. •  ocal anesthetics for diagnostics, corticosteroids
L
• 98% alcohol for neurolysis12
• L
 AX to the sesamoid-metatarsal articulation (in-plane • Neuroprolotherapy (5% dextrose)
approach) (Fig. 23.18A) • Radiofrequency ablation or cryoa13,14

Injectate Volume
Needle Position
• C orticosteroid—0.5-1mL
• S AX in-plane to the sesamoid articulation with the nee- • Alcohol—various volumes reported in the literature
dle approaching medial to lateral (see Fig. 23.17B) (authors use 40–60% solution when combined with a
• LAX in-plane to the sesamoid articulation from distal to local anesthetic)15
proximal (see Fig. 23.18B and C) • 3–5 mL for hydrodissection for post-surgical scar tissue
478 SEC T I O N I I I Atlas

A
*

B .
• Fig 23.19 Neuroma-Bursal Complex (Morton’s Neuroma) Injection.
Long-Axis In-Plane Approach. (A) Transducer and needle position for
a distal to proximal LAX in-plane approach, entering through the web-
space. (B) Corresponding ultrasound image of a distal to proximal LAX
in-plane neuroma-bursal complex injection. Note the extension of the
neuroma-bursal complex (white arrowheads) and fluid from the injec- MT 4 MT 3
B
tion within the intermetatarsal bursa (asterisk).
• Fig 23.20 Neuroma-Bursal Complex Injection. Sax Out-of-Plane
Technique Approach. (A) Transducer and needle position for a distal to proximal
Patient Position SAX out-of-plane approach, entering through the plantar aspect of the
webspace. (B) Corresponding ultrasound image and needle placement
• S upine
(white dot) of a distal to proximal SAX out-of-plane neuroma-bursal
• The patient has knees extended with feet hanging off the complex injection (white arrowheads). MT 3, Third metatarsal; MT 4,
edge of the table or rolled towel, allowing the provider to fourth metatarsal.
push up under the neuroma (Fig. 23.19A)
• Consider taping the toes apart if the toes are anatomically
malpositioned and obstructing the view (see Fig. 23.19A) Needle Position
Clinician Position • F or dorsal approach—LAX, in-plane to the transducer,
• Seated or standing directly below the foot being injected distal to proximal (see Fig. 23.19B and 23.21) or proxi-
mal to distal
• For plantar approach—SAX, out-of-plane distal to
Transducer Position proximal (Fig. 23.20B) or LAX, in-plane distal to
• F or dorsal approach—LAX (in-plane approach) (Fig. proximal
23.19A)
• For plantar approach—SAX (out-of-plane approach) or Target
LAX (in-plane approach) (Fig. 23.20A) • Needle directed toward the neuroma-bursal complex
 CHAPTER 23 Foot Injection Techniques 479

PEARLS AND PITFALLS Clinician Position

• Seated directly below the foot being injected
• S maller MNs may be asymptomatic. Correlate the
MN with either sono-palpatory pain or a diagnostic
injection.16 Transducer Position
• If plantar plate injury is present, then one would
consider treating that as well with prolotherapy or • LAX to the plantar plate in the sagittal plane (Fig. 23.22A)
orthobiologics.
  
Needle Position
Plantar Plates
• LAX in plane from distal to proximal (Fig. 23.22B)
KEY POINTS
Target
• C onsider prolotherapy or orthobiologics in the presence
of a plantar plate tear with associate instability. • Directly into the plantar plate tear
Cortisone is usually not indicated.
• Plantar plate tears most often occur at their insertion
onto the proximal phalanx, and can become more
conspicuous on ultrasound with dynamic dorsiflexion of
PEARLS AND PITFALLS
the MTP joint. • U se a small-gauge needle through the flexor tendon. It
   is important to avoid injecting into the flexor tendons.
• Foot deformity, such as a hammer toe, may necessitate
a proximal to distal approach to the plantar plate.
Pertinent Anatomy   
• Th
 e plantar plate represents a fibrocartilaginous structure
along the plantar aspect of the MTP joints.17 It plays a
crucial role in the stability of the MTP joint.18 Foot Fluoroscopy Injection Techniques
• The plantar plate of the first MTP joint has a central Joints
component from the metatarsal to proximal phalanx,
and medial and lateral components from the sesamoids KEY POINTS
to proximal phalanx.
• J oint position can vary between patients, especially if
• Flexor tendons traverse plantar to the plantar plate. deformities or a history of foot or ankle surgery. Adjust
the C-arm to optimize joint visualization.
Common Pathology • If using prolotherapy or orthobiologics, one can inject
the capsule of the joints as well if instability is present.
• C apsuloligamentous complex (turf toe) injuries involv-   
ing the first MTP joint most commonly involve injury
to the plantar plate. More advanced injuries may also
include other structures of the capsuloligamentous com-
plex and the FHL tendon. Calcaneocuboid Joint
• Attritional-type tears at the insertion of the plantar plate Pertinent Anatomy
onto the proximal phalanx are the most common abnor- • Th
 e anterior process of the calcaneus articulates with
mality involving the plantar plates of the lesser MTP joints. posterior portion of the cuboid, forming the calcaneocu-
boid (CC) joint
Equipment • Intermediate dorsal cutaneous nerve can travel over the
dorsum of the joint
• H igh- or medium-frequency linear array ultrasound transducer • The calcaneocuboid has a relatively prominent inferior
• 27–22 gauge, 1–1.5 inch needle joint recess
• Peroneal longus tendon traverses under the lateral and
Common Injectates plantar aspect of the joint
• P rolotherapy • The CC joint is intrinsically stable due to the congruency
• Orthobiologics for plantar plate tear of the articular surfaces, and is reinforced by ligaments
and tendon attachments19–21
Injectate Volume
• 0.5–2 mL Common Pathology
• O steoarthrosis
Technique • Traumatic injury
Patient Position • Cuboid syndrome (dropped or subluxed cuboid), dis-
• P
 rone with knee fully extended and ankle plantar flexed rupting CC joint congruity
over a rolled towel
480 SEC T I O N I I I Atlas

• Fig 23.21 Cryoablation of A Neuroma-Bursal Complex (Morton’s

Neuroma). Long-axis in-plane approach similar to Fig. 23.19. The target of
the ice ball (open arrowheads) is the interdigital nerve (black arrowheads)
at or proximal to the neuroma-bursal complex. A similar location is utilized
for a radiofrequency ablation. The white arrowheads outline the extent of
the neuroma-bursal complex. The fluid within the neuroma-bursal com-
plex (asterisk) is from local anesthesia infiltration prior to the ablation.

Equipment A
• C -arm fluoroscopy
• 27–22 gauge, 1–2 inch needle
• Contrast

Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy
• Orthobiologics
Proximal
Injectate Volume phalanx
• 1–2 mL 1st MT head

Technique
Patient Position B
• S upine with the knee bent so that the foot is flat on the
table (Fig. 23.23) • Fig 23.22 First Metatarsophalangeal (MTP) Plantar Plate Injection.
A similar approach is utilized for injection of the plantar plates of the
• Can place pillows or a bolster under the knee for comfort lesser MTP joints. LAX in-plane approach. (A) Transducer and needle
position for a distal to proximal LAX in-plane injection to the plantar plate.
Clinician Position (B) Corresponding ultrasound image and needle pathways showing LAX
• Standing ipsilateral side of the patient in-plane approach to the plantar plate (arrow). 1st MT, First metatarsal.

C-Arm Position Fluoro Technique Target

• S tart in anteroposterior (AP) projection, then oblique later- • A
 dvance and inject a small amount of contrast to con-
ally to view the lateral aspect of the calcaneal cuboid joint firm intra-articular placement (Fig. 23.24)
• C-arm aligned so joint space is “opened up,” resulting in
increased lucency PEARLS AND PITFALLS
• E ntering the joint laterally avoids the intermediate dorsal
Needle Position cutaneous nerve.
• Internal rotation of the foot can help open the joint.
• S tart directly over the lateral joint line, directing needle
from superior to inferior   
 CHAPTER 23 Foot Injection Techniques 481

Equipment
• C -arm fluoroscopy
• 27–22 gauge, 1–2 inch needle
• Contrast

Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy
• Orthobiologics

Injectate Volume
• 1–2 mL

Technique
Patient Position
• S upine with the knee bent and the foot flat on the table
• Can place pillows or a bolster under the knee

Clinician Position
• Standing ipsilateral side of the patient
• Fig 23.23 Calcanocuboidal Joint Injection with Fluoroscopy Setup.

C-Arm Position
• S tart in AP projection, then oblique laterally 20-35
degrees to bring the navicular cuboid joint into view.
• C-arm aligned so joint space is “opened up,” resulting in
increased lucency

Needle Position
• Start directly over the inferior aspect of the joint line

Target
• A dvance needle until gently touching the inferior lateral
navicular.
• Then “walk off” into the joint and inject a small amount of
contrast to confirm intra-articular positioning (Fig. 23.25).

PEARLS AND PITFALLS

• If the patient feels radiating sensation during the
injection, redirect the needle dorsal medial to avoid the
intermediate dorsal cutaneous nerve. C-arm rotation
may have to be adjusted as well.
• The naviculocuboid joint is a deeper joint. To obtain
good intra-articular flow, the needle may have to be
•Fig 23.24 Calcanocuboidal Joint Injection AP Fluoroscopic View,
advanced further into the joint.
with Contrast Showing Communication with Intercuneiform Joints.
• There is variable communication in midfoot joints.
Contrast may communicate with the adjacent joints
(anteriosubtalar, cubocuneiform, navicular cuneiform).
Naviculocuboid (Cuboideonavicular) Joint
  
Pertinent Anatomy
• I ntermediate dorsal cutaneous nerve from the superficial
peroneal nerve travels dorsal and lateral to the joint Intercuneiform Joints
Pertinent Anatomy
Common Pathology
• J oint arthritis • I ntercuneiform joints are articulations among the three
• Traumatic injury cuneiform bones (lateral-intermediate cuneiform joint
482 SEC T I O N I I I Atlas

• Fig 23.26 Intercuneiform Joint Injection with AP Fluoroscopic View,

with Contrast also Showing Communication with Medial Tarsometa-
• Fig 23.25 Naviculocuboid Joint Injection AP Fluoroscopic View, with tarsal Joints.
Contrast.

Clinician Position
• Standing ipsilateral side of the patient
and medial-intermediate cuneiform joint). The cuneo-
cuboid joint describes the joint between the cuboid and C-Arm Position
lateral cuneiform.
• Intercuneiform joints • O btain view to most “open up” the desired joint, result-
• Lateral-intermediate cuneiform joint ing in increased joint lucency
• Medial-intermediate cuneiform joint • Cubocuneiform
• The intermediate dorsal cutaneous nerve from the super- • Start in AP projection, then oblique laterally 25–40
ficial peroneal nerve travels dorsal and lateral to the degrees to visualize the joint clearly
cubocuneiform joint • Lateral-intermediate cuneiform joint
• AP view requiring lateral oblique 15–25 degrees to
Common Pathology visualize the joint clearly
• J oint arthritis • Medial-intermediate cuneiform joint
• Traumatic injury • Cuneiform and first AP view requiring medial oblique
5–15 degrees to visualize the joint clearly
Equipment
• C -arm fluoroscopy Needle Position
• 27–22 gauge, 1–2 inch needle
• Contrast • S tart directly over the mid portion of the desired joint
line
Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids Target
• Prolotherapy • A
 dvance and inject a small amount of contrast to con-
• Orthobiologics firm intra-articular placement (Fig. 23.26).

Injectate Volume
• 1–2 mL PEARLS AND PITFALLS
• N eedle trajectory risks penetration of the intermediate
Technique dorsal cutaneous nerve.
Patient Position • If the patient feels radiating sensation during the injection,
• S upine with the knee bent so that the foot is flat on the redirect needle more dorsal medial to avoid the nerve.
table C-arm rotation may have to be adjusted as well.
• Can place pillows or a bolster under the knee   
 CHAPTER 23 Foot Injection Techniques 483

• Fig 23.27 Naviculocuneiform Joint Injection with Fluoroscopy Setup.

• Fig 23.28Naviculocuneiform Joint Injection AP Fluoroscopic View
Naviculocuneiform Joints with Contrast.
Pertinent Anatomy
• Th
 e distal aspect of the navicular has three facets, one for
each cuneiform (medial, intermediate, and lateral). Clinician Position
• There is one joint capsule for all three articulations. • Standing ipsilateral side of the patient
• The naviculocuneiform (NC) joint also communicates
with the second and third tarsometatarsal joint via the C-Arm Position
medial and intermediate cuneiform intercuneiform joint.
• The dorsalis pedis artery traverses dorsally over the navic- • O btain view to most “open up” the desired joint, result-
ular, and the medial and lateral tarsal branches off the ing in increased joint lucency
dorsalis pedis can course over the NC joints.22,23 • Navicular-medial cuneiform
• AP view of the joint requiring medial oblique of
Common Pathology 15–20 degrees to visualize the joint clearly
• J oint arthritis • Navicular-intermediate cuneiform or navicular-medial
• Traumatic injury cuneiform-intermediate cuneiform
• Direct AP view; may require 5–10 degree medial
Equipment oblique to visualize the joint clearly
• C -arm fluoroscopy • Navicular lateral cuneiform or navicular-intermediate
• 27–22 gauge, 1–2 inch needle cuneiform-lateral cuneiform joints
• Contrast • AP view of the joint requiring lateral oblique of 10–20
degrees to visualize the joint clearly
Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids Needle Position
• Prolotherapy
• Orthobiologics • P alpate the dorsalis pedis pulse and position needle to
avoid damaging the artery
Injectate Volume • Start directly over the mid portion of the desired joint
• 1–2 mL line
• Alternatively, can start at Y intersection of the navicular
Technique and medial and intermediate cuneiforms
Patient Position
• S upine with the knee bent so that the foot is flat on the Target
table (Fig. 23.27) • A
 dvance and inject a small amount of contrast to con-
• Can place pillows or a bolster under the knee firm intra-articular placement (Fig. 23.28)
484 SEC T I O N I I I Atlas

PEARLS AND PITFALLS

• N eedle trajectory risks penetration of the medial dorsal
cutaneous nerve or dorsalis pedis artery.
• If the patient feels radiating sensation during the
injection, redirect needle more dorsal medial to avoid
the nerve. The C-arm rotation may have to be adjusted
as well.
  

Tarsometarsal Joints
Pertinent Anatomy
• Th
 e Lisfranc joint is composed of the five tarsometatarsal
(TMT) joints, and represents the junction between the
midfoot and forefoot.
• The joint encompasses articulations between the three
cuneiforms and the cuboid proximally, and the base of
the five metatarsal heads distally. The TMT joints have
three separate joint capsules:
• Medial cuneiform and first metatarsal base
• Intermediate and lateral cuneiforms and second and
third metatarsal bases
• Cuboid and fourth and fifth metatarsal bases
• TMT joints may communicate with the intercuneiform
joints. • Fig 23.29Fourth and Fifth Tarsometatarsal Joint Injection Setup
• The second and third TMT joints communicate with the Lateral Decubitus.
naviculocuneiform joint.
• Intermediate and medial dorsal cutaneous nerves travel
dorsally to the joints. Technique
• The dorsalis pedis artery travels dorsally and usually between Patient Position
the first and second tarsals and metatarsals. • S upine with the knee bent so that the foot is flat on the
• The lateral tarsal artery branches form the dorsalis pedis, table
usually at the level of the navicular bone over the lat- • Can place pillows or a bolster under the knee
eral cuneiform and between fourth and fifth tarsals and • Optional for the fourth and fifth metatarsal joints to
metatarsals. have patient in the lateral decubitus position (Fig. 23.29)
• The arcuate artery usually traverses just distal to the prox-
imal metatarsal heads over the second, third, and fourth Clinician Position
metatarsals.24-26 • Standing ipsilateral side of the patient

Common Pathology
C-Arm Position
• J oint arthritis
• Traumatic injury • O btain view to most “open up” the desired joint, result-
• Lisfranc ligament injury27 ing in increased joint lucency
• Medial cuneiform and first metatarsal base:
Equipment • D  irect AP view
• C -arm fluoroscopy • Intermediate and lateral cuneiforms and second and
• 27–22 gauge, 1–2 inch needle third metatarsal bases:
• Contrast • A  P view may require 5–10 degrees of lateral oblique
• Cuboid and fourth and fifth metatarsal bases:
Common Injectates • A  P view may require 10–20 degrees of lateral oblique
• L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy Needle Position
• Orthobiologics
• F
 irst three TMT joints: aim directly over desired joint,
Injectate Volume palpating and avoiding the dorsalis pedis pulse prior to
• 1–2 mL placing needle
 CHAPTER 23 Foot Injection Techniques 485

• Fig 23.30 Lateral Tarsometatarsal Joint Injection AP View, with

Contrast.

• F
 ourth and fifth TMT joints: aim at T-shaped inter-
sections of the cuboid and fourth and fifth metatarsal
heads
• Fig 23.31 First Metatarsal Phalangeal Joint Injection with Fluoroscopy
Target Setup.
• A
 dvance and inject a small amount of contrast to con-
firm intra-articular placement (Fig. 23.30)
Common Injectates
Metatarsophalangeal Joints
• L ocal anesthetics for diagnostics, corticosteroids
Pertinent Anatomy • Prolotherapy
• Th
 e metatarsophalangeal (MTP) joints have a ball-and- • Orthobiologics
socket articulation. The proximal phalanx has a prominent
dorsal lip. Injectate Volume
• The first MTP joint has distinct anatomy, including • 1–2 mL
paired sesamoids with their own articulations at the
crista or plantar aspect of the metatarsal head. Technique
• The first MTP joint communicates with the sesamoid Patient Position
articulations and has small dorsal and plantar recesses. • S upine with the knee bent so that the foot is flat on the
• The second through fifth, or lesser MTP joints, have table (Fig. 23.31)
small dorsal and larger plantar capsular recesses, which • Can place pillows or a bolster under the knee
extend from the metatarsal necks to the bases of the
proximal phalanges. Clinician Position
• The extensor tendons travel over the midline of the joints. • Standing ipsilateral side of the patient
• The dorsal digital nerves and arteries travel medial and
lateral to the bones/joints.20,21 C-Arm Position Fluoro Technique
Common Pathology • D
 irect AP view of the joint with the most joint line
• J oint arthritis lucency
• First MTP joint is the most common site for gout28
Needle Position
Equipment
• C -arm fluoroscopy • S tart needle just off the mid-line and proximal to the
• 27–22 gauge, 1–2 inch needle joint over the metatarsal head to avoid the dorsal lip of
• Contrast the proximal phalanx or osteophytes
486 SEC T I O N I I I Atlas

Equipment
• C -arm fluoroscopy
• 27–22 gauge, 1–2 inch needle
• Contrast

Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy
• Orthobiologics

Injectate Volume
• 0.5–1 mL

Technique
Patient Position
• S upine with the knee bent so that the foot is flat on the table
• Can place pillows or a bolster under the knee

Clinician Position
• Standing ipsilateral side of the patient

• Fig 23.32First Metatarsal Phalangeal Joint Injection AP Fluoroscopic C-Arm Position

View, with Contrast.
• D
 irect AP view of the joint with the most joint line
lucency
Target
• T ouch down on metatarsal head and walk off 1 mm dis- Needle Position
tal from the joint
• Inject a small amount of contrast to confirm intra-artic- • S tart needle just off the mid-line and proximal to the
ular flow (Fig. 23.32) joint over the head of the phalanx to avoid the dorsal lip
of the middle or distal base of the phalanx

Target
PEARLS AND PITFALLS
• T ouch down on head of the phalanx (Fig. 23.33).
• S tart over the metatarsal head to avoid the dorsal lip • Option to inject a very small amount of contrast to con-
of the proximal phalanx. The joint capsule extends
from the metatarsal necks to the bases of the firm intra-articular flow. If no intra-articular flow, ensure
proximal phalanges. Guiding the needle and targeting the needle is not on the dorsal lip and then reposition to
the metatarsal head will result in intra-articular direct needle distally until it drops into the joint.
placement.
• Rule out gout flare for first MTP joint pain and swelling
before injecting any orthobiologics. PEARLS AND PITFALLS
• If suspected gout, use local anesthetic, then use 22-20 • C an slightly flex the toe to open up the joint more.
gauge needle to aspirate. • These are small joints, so keep injectate volume low.
     

Metatarsosesamoid
Interphalangeal Pertinent Anatomy
• Th
 e two sesamoid bones of the first MTP joint are con-
Pertinent Anatomy tained within the tendons of the FHB and form a part of
• Th
 e interphalangeal (IP) joints are hinge joints between the plantar plate.
the phalanges. • They articulate with the plantar facets of the metatarsal
• Dorsal digital nerves and arteries travel medial and lateral head.
to the bones/joints.20-21 • A crista, or intersesamoid ridge, separates the medial and
lateral metatarsal facets.
Common Pathology • They function to distribute weight of the first ray, with
• J oint arthritis the tibial or medial sesamoid assuming most of the
• Traumatic injury weight-bearing forces.
 CHAPTER 23 Foot Injection Techniques 487

• Fig 23.33 Interphalangeal Joint Injection AP Fluoroscopic View,

with Contrast.

• Fig 23.35 Metatarsosesamoid Injection with Fluoroscopy.

Equipment
• C -arm fluoroscopy
• 27–22 gauge, 1–2 inch needle
• Contrast

Common Injectates
• L ocal anesthetics for diagnostics, corticosteroids
• Prolotherapy
• Orthobiologics

Injectate Volume
• 0.5–1 mL

Technique
Patient Position
• Supine

Clinician Position
• Same side as affected limb
• Fig. 23.34 Metatarsosesamoid with Fluoroscopy Injection Setup.
C-Arm Position
• Th
 ey have a tenuous blood supply, so injury can lead to • A
 P view where the MTP joint and sesamoids can be visu-
delayed healing. alized clearly
• Bipartite sesamoids are a normal anatomic variant, with
an incidence of 7% to 30%. Needle Position
Common Pathology • Start medially (Fig. 23.34)
• I ntractable plantar keratosis can develop under the meta-
tarsal heads Target
• Bursitis • A im for the space between tibial sesamoid and plantar
• Arthritis secondary to trauma, chondromalacia, or aspect of the metatarsal head
sesamoiditis • Inject a small amount of contrast to ensure flow in the
• Fracture29 joint (Fig. 23.35)
488 SEC T I O N I I I Atlas

PEARLS AND PITFALLS 15. P abinger C, Malaj I, Lothaller H, et al. Improved injection
technique of ethanol of Morton’s neuroma. Foot Ankle Int.
• C an be a painful injection, so use local anesthetic prior 2020;41(5):590–595.
to injection. 16. Symeonidis PD, Iselin LD, Simmons N, et al. Prevalence of inter-
• Hold the toe steady during injection as this is a sensitive digital nerve enlargements in an asymptomatic population. Foot
area and prone for patient movement.
Ankle Int. 2012;33(7):543–547.
   17. Deland JT, Lee KT Sobel M, et al. Anatomy of the plantar plate
and its attachments in the lesser metatarsal phalangeal joint. Foot
Ankle Int. 1995;16:480–548.
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luxed second metatarsophalangeal joint: flexor tendon transfer
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11. Beard N, Gouse R. Current ultrasound application in the foot 2017;46(3):116–119.
and ankle. Orthop Clin N Am. 2018;49:109–121. 28. Stewart S, Dalbeth N, Vandal AC, Rome K. The first metatarso-
12. Hughes R, Ali K, Jones H, et al. Treatment of Morton’s neuroma phalangeal joint in gout: a systematic review and meta-analysis.
with alcohol injection under sonographic guidance: follow-up of BMC Musculoskelet Disord. 2016;17:69.
101 cases. AJR Am J Roentgenol. 2007;188:1535–1539. 29. Sims AL, Kurup HV. Painful sesamoid of the great toe. World
13. Masala S, Cuzzolino A, Morini M, et al. Ultrasound-guided J Orthop. 2014;5(2):146–150. https://doi.org/10.5312/wjo.
percutaneous radiofrequency for the treatment of Morton’s neu- v5.i2.146.
roma. Cardiovasc Intervent Radiol. 2018;41:137–144.
14. Cazzato RL, Garnon J, Ramamurthy N, et al. Percutaneous MR-
guided cryoablation of Morton’s neuroma: rationale and techni-
cal details after the first 20 patients. Cardiovasc Intervent Radiol.
2016;39(10):1491–1498.
 SE C T I ON IV Advanced

24
Calcific Tendonitis
Barbotage/Lavage
JASON IAN BLAICHMAN AND KENNETH S. LEE

KEY POINTS superior, middle, and inferior facets of the greater humeral
tuberosity, respectively. The subscapularis tendon attaches
• C alcific tendonitis, or more appropriately tendinosis, of to the lesser humeral tuberosity.
the rotator cuff is a relatively common cause of shoulder
pain. Calcifications are usually self-limiting but can also
be recurrent, progressive, and debilitating. Pathophysiology
• Calcific deposits can develop in any rotator cuff tendon,
but the vast majority occur in the supraspinatus tendon, Calcific tendonitis is the result of hydroxyapatite crystal
followed by the infraspinatus and the subscapularis deposition in an otherwise healthy tendon. The exact eti-
tendons.
ology remains uncertain, with several proposed theories.1,2
• Calcific tendonitis is usually the most symptomatic
during the resorptive phase, when there is an acute The multiphasic disease model posited by Uhthoff and
inflammatory reaction to the calcification. Loehr is one of the most accepted and divides the cycle of
• Radiographs of the shoulder are essential to confirm calcific tendonitis into three stages2–6:
the diagnosis of calcific tendonitis, exclude other 1. Precalcific stage: an unknown trigger, postulated to be
potential causes of shoulder pain, and allow planning
a decrease in oxygen tension, induces fibrocartilaginous
for intervention.
• Conservative treatment, including nonsteroidal metaplasia of tenocytes into chondrocytes with formation
antiinflammatory drugs (NSAIDs), subacromial- of intracellular calcifications. This stage is asymptomatic.
subdeltoid (SASD) bursa corticosteroid injections and 2. Calcific stage: this stage is further subdivided into three
physiotherapy, should be the first line of therapy for phases.
calcific tendonitis.
2.1.  Formative phase: hydroxyapatite crystals rupture
• When conservative treatment fails, ultrasound (US)-
guided barbotage/lavage is a safe, quick, and effective into the extracellular space and coalesce, taking on
way to provide immediate and long-term relief of a chalklike consistency.
symptoms. 2.2.  Resting phase: the calcific deposits are walled-off
• A SASD bursa corticosteroid injection should be and quiescent. This phase is of variable length and
performed immediately following barbotage to prevent a
usually asymptomatic, unless there is rotator cuff
calcific bursitis flare up due to some retrograde passage
of calcium into the bursa during the procedure. impingement caused by mass effect of large calcific
• Although the shoulder is the most common site for deposits.
calcific tendinitis, other tendons can be affected, 2.3.  Resorptive phase: an unknown trigger induces angio-
including at the elbow, knee (quadriceps and patella), genesis, inflammation, and resorption of the calcific
gluteal tendons, Achilles, etc. The techniques described
deposit, which becomes liquefied, taking on a tooth-
in this chapter can be adapted and applied to other
areas. paste-like consistency. Increased internal pressure in
the deposit due to increased volume from liquefac-
  
tion may cause decompression of the calcification
into the subacromial-subdeltoid (SASD) bursa,
Clinically Relevant Anatomy inciting bursitis. This phase corresponds to the most
painful and symptomatic clinical stage, often char-
The rotator cuff is composed of four muscles arising from acterized by sudden onset of severe pain.
the scapula that attach to the humeral head. The supraspi- 3. Postcalcific stage: fibroblasts migrate into the tendon
natus, infraspinatus, and teres minor tendons attach to the defect and form a scar, with the tendon returning to a

489
490 SEC T I O N I V Advanced

relatively normal appearance. This stage is again usually in morphology.5 Further cross-sectional imaging of the
asymptomatic. shoulder with either magnetic resonance imaging (MRI) or
Several of the phases may occur concurrently within ultrasound (US) (see Fig. 24.1B and C) is recommended to
a calcific deposit, and the sequence of the stages may not assess the integrity of the rotator cuff and exclude other pos-
always be regular.5 sible etiologies for shoulder pain.1
Calcific tendonitis can occur in any rotator cuff tendon, US can also help to confirm and localize the calcifica-
but the vast majority (≈80%) of deposits are located in the tions.1 The sonographic appearance of a calcific deposit cor-
supraspinatus tendon, usually in the so-called critical zone relates with its consistency.5 In the formative and quiescent
1.5 to 2.0 cm from its insertion onto the greater tuberosity.5 phases, calcific deposits have a high density of hydroxyapa-
The infraspinatus tendon is involved 15% of the time, fol- tite crystals, which cause strong reflection of sound waves.5
lowed by the subscapularis tendon in approximately 5% of This results in the calcific deposits appearing solid and echo-
cases.5 The teres minor tendon is rarely involved.1,4 genic with pronounced posterior acoustic shadowing, mak-
ing them easy to delineate from the surrounding tendon.5
Clinical Presentation and Epidemiology As liquefaction proceeds in the resorptive phase, the calcific
deposit becomes progressively less echogenic with dimin-
Calcific tendonitis is a common disease with reported inci- ished posterior shadowing.5
dence rates ranging from 2.7% to 54%, accounting for
7% of cases of shoulder pain.3,7,8 It is usually symptomatic Treatment Options
between the ages of 40 and 60 years and is more common
in women and diabetic patients.1,2,4,5 Calcific deposits in Symptomatic calcific tendonitis can be highly debilitat-
the rotator cuff are present on radiographs in 7.5% to 20% ing, limiting activities of daily living and resulting in a sig-
of asymptomatic individuals and in 6.8% of symptomatic nificant economic impact due to missed work.7,11 Calcific
individuals.9,10 Deposits are bilateral in 10% to 20% of tendonitis is often described as a self-limiting entity, which
patients and become symptomatic in 50% of patients.4,7,10 usually resolves spontaneously4,7,10; however, a significant
Rotator cuff tears are generally not associated with calcific portion of patients will continue to remain symptomatic
tendinitis.5 for an extended period or may experience a cyclic clinical
Clinical symptoms vary significantly depending on the course, with repeated episodes of acute, disabling pain and
stage and location of calcific deposits.5 Sudden and excru- progressive loss of function.4,10
ciating pain often occurs during the resorptive phase.5 Pain There is general agreement that conservative manage-
is usually referred to the deltoid region, and limitation in ment should be the first line of treatment in the acute phase
range of motion and function can clinically mimic adhe- of calcific tendonitis.4,5,7,8,11 Conservative management
sive capsulitis or a rotator cuff tear.2,5 If the calcific deposit usually involves a combination of nonsteroidal antiinflam-
decompresses into the SASD bursa during the resorptive matory drugs (NSAIDs) and corticosteroid injections into
phase, the resultant crystal-induced SASD bursitis will usu- the SASD bursa for symptom relief, and occasionally phys-
ally dominate the clinical picture.5 During more quiescent iotherapy to prevent loss of joint mobility. Conservative
stages of calcific tendonitis, larger calcific deposits can cause therapy can be effective, but residual significant symptoms
symptoms of impingement.5 persist in approximately 30% to 50% of patients.5 Many
authors suggest a trial of conservative therapy for a period
Imaging and Sonographic Evaluation of at least 3 to 6 months; however, this could vary on an
individual basis depending on the severity of pain and the
Given the multiple clinical presentations of calcific ten- patient’s ability to tolerate a conservative approach.5
donitis, and the aforementioned overlap of symptoms with Several researchers have investigated risk factors for pre-
those of other shoulder pathologies, a differential diagnosis dicting poor outcomes from conservative management of
should always be considered clinically; however, calcific ten- calcific tendonitis, although results have been mixed. In
donitis can usually be readily distinguished from the other general, female gender, dominant arm involvement, bilat-
diagnostic considerations based on a combination of appro- eral disease, longer duration of symptoms at presentation,
priate history, physical exam, and correlative imaging. and larger number of calcifications were found to be nega-
Confirming the clinical suspicion of calcific tendonitis tive prognostic factors.8 In contrast, the significance of com-
requires imaging of the shoulder. Radiographs (Fig. 24.1A) mon radiographic parameters, such as size, morphologic
can help to confirm the presence of calcific deposits.1 Dys- features (based on the Gartner classification11), and location
trophic insertional calcifications, or enthesophytes, should of the calcific deposits, have been more inconsistent in the
not be confused with calcific tendonitis. Enthesophytes literature.8,12,13
are usually significantly smaller in size, linear in morphol- Given the often self-limiting nature of calcific tendonitis,
ogy, and located directly above, or in contact with, the an ideal intervention should not only be effective at remov-
greater humeral tuberosity, whereas calcific tendonitis is ing the culprit calcification and improving the patient’s
generally located 1 to 2 cm away from the greater humeral symptoms but should also be as minimally invasive and of
tuberosity with no osseous contact and is typically ovoid as short a duration as possible; relatively comfortable for
 CHAPTER 24 Calcific Tendonitis Barbotage/Lavage 491

*
*

A B

*
* *
BBT

C
• Fig. 24.1 Imaging of Calcific Tendonitis. A large cluster of calcifications (white arrows) in the supra-
spinatus tendon is demonstrated on (A) a transscapular radiograph, (B) a double oblique sagittal T2 fat-
saturation magnetic resonance image, and (C) a transverse sonographic image. The greater tuberosity
(white asterisks) serves as a landmark. Note the lack of surrounding edema and overlying bursitis. Large
deposits can result in mild chronic pain and may cause limitations in motion due to mechanical obstruc-
tion. BBT, Biceps tendon.

the patient; have minimal associated complications; and be Open or Arthroscopic Surgical Excision of
cost-effective.1,7,14 Several treatments have been investigated Calcifications
and employed when conservative management of calcific Surgical excision of calcifications can provide signifi-
tendonitis fails. Acetic acid iontophoresis is one potential cant clinical improvement, but prospective randomized
treatment shown to be no more effective than physical ther- controlled trials are limited. Surgical resection has been
apy or placebo.15 The efficacy of other treatments has been shown to be more effective than ESWT in reducing
demonstrated, although they are not without their own pain and radiographic resolution of calcifications, but
drawbacks. They include the following procedures. studies are inconclusive as to whether this difference is
significant by 2 years post treatment.16,17 No study has
Shockwave Lithotripsy compared surgical outcomes with US-guided barbotage.
Shockwave lithotripsy, or extracorporeal shock wave therapy Although surgery is an effective treatment for calcific
(ESWT) uses shock waves to dissolve the calcifications. This tendonitis, controversy remains over the optimal surgical
treatment has been demonstrated to be effective at resolving management, with ongoing debate regarding repairing
calcific deposits and significantly improving clinical symp- the resultant tendon defect.16,17 Surgery has significant
toms.5,7,14 However, the utility of ESWT is limited due to potential drawbacks, including higher risk of complica-
several factors, including: a protracted treatment course tions such as infection, adhesive capsulitis, reflex sympa-
requiring at least three sessions separated by 2 to 4 weeks, thetic dystrophy, protracted recovery and rehabilitation
during which the patient often remains symptomatic; sig- period, and significantly increased costs.1,7,11 For these
nificant pain often experienced by patients during the reasons, surgery is currently considered the option of last
procedure; and the need for specialized equipment, which resort, to be used only when other less-invasive methods
increases the cost of offering this treatment.1,7,14 have failed.7
492 SEC T I O N I V Advanced

Barbotage/Lavage Calcific Tendinitis

and
Barbotage
Two-needle barbotage under fluoroscopic guidance was
first described by Comfort and Arafiles in 1978,17 and
Farin et al. first demonstrated the feasibility of US-guided
barbotage in 1995.18,19,20 These studies described a barbo-
tage technique with fenestration, which involves punctur-
ing the calcific deposit with a needle multiple times. Citing
concern regarding the potential risk of tendon injury
caused by fenestration, Aina et al. first described a modi-
fied US-guided single-needle technique in 2001.28 No
high-quality studies have compared the efficacy of lavage
with simple fenestration, but subsequent double-needle
approaches have also largely forgone fenestration.21,22 • Fig. 24.2 Barbotage Technique. Under ultrasound guidance, the
More recent randomized controlled studies have demon- 18-gauge needle is advanced into the calcific deposit along the axis
strated no significant difference in clinical outcomes up to of the tendon fibers, and directed cranially to allow gravity to assist
1 year between the single- and double-needle lavage tech- with aspiration of the calcific debris. (Inset, top) Once the needle tip is
nique, with the main difference being a slightly shorter positioned within the calcific deposit, continuous small pumps of the
syringe plumber are applied, causing breakdown of the calcification
procedure time treating denser calcifications using the due to dissolution and pressure waves from the injected fluid. (Inset,
double-needle technique.23,24 bottom) Between each pump, the buildup of backpressure pushes fluid
Clinical trials have generally shown significant pain relief and calcific debris back into the syringe without the operator need-
and improvement of symptoms with US-guided barbotage ing to actively aspirate. It is important to avoid fenestrating the calcific
both in the short term and at 1 year post treatment.7,14,25 deposit because doing so might allow the injected fluid to decompress
through the resultant holes and prevent backpressure from building up.
Barbotage also results in a statistically significant decrease
in the size of calcific deposits versus conservative therapy
at 1 year post treatment.25 The self-limiting natural his- • Th
 e single-needle technique relies on the buildup of
tory of calcific tendonitis becomes more relevant during backpressure within the calcific deposit to dissolve and
a more protracted time frame, and longer-term follow-up carry calcific debris in a retrograde fashion back into the
studies have shown that clinical outcomes of patients who syringe.
were treated with barbotage are not significantly different • The double-needle technique creates a lavage circuit, with
from patients treated conservatively at 5 and 10 years post one needle used to push fluid into the calcific deposit to
treatment.14,26 dissolve it and the second needle serving as an outflow
tract for the injected fluid and calcific debris to egress.
Equipment This technique generally uses larger, 16-gauge needles.
•  igh-frequency (>10 MHz) linear US
H
• 18- to 20-gauge 1.5-inch needle for lavage
Patient Position
• 25-gauge 1.5-inch needle for initial anesthetic
• Optional: 30-gauge 0.5-inch needle for initial skin • Th
 e patient is placed in a semireclined supine position.
anesthetic • The ipsilateral arm is ideally placed behind the patient’s
• 10-mL syringes with 50:50 mixture of anesthetic and back with palm toward the stretcher, which results in
bacteriostatic sterile saline for lavage anterior rotation of the greater tuberosity of the humeral
• 10-mL syringe for initial anesthetic head along with the distal supraspinatus tendon, uncov-
• 5-mL syringe for corticosteroid ering it from the overlying acromion.
• If the calcification is located in a different tendon, slight
Common Injectates alterations in patient positioning may be necessary. The goal
• A nesthetic: 1% lidocaine for barbotage, 0.5% ropivacaine is to be able to visualize the entire calcification under US.
for SASD bursa injection
• F or SASD bursa injection: corticosteroid (40 mg triam-
Clinician Position
cinolone acetonide or methylprednisolone acetate) and local
anesthetic • Th
 e clinician is positioned in a comfortable standing or
Author’s Preferred Technique: seated fashion adjacent to the targeted shoulder.
• Both single- and double-needle techniques have been
described. We use the single-needle technique at our
Transducer Position
institution (Fig. 24.2), which is described in detail later,
followed by a SASD bursa corticosteroid injection.27 The • Th
 e US transducer is positioned over the site of calcific
double-needle technique is subsequently described for tendonitis and oriented along the long axis of the rotator
completeness.22,23 cuff fibers.
 CHAPTER 24 Calcific Tendonitis Barbotage/Lavage 493

* *

A B

C D
• Fig. 24.3 Ultrasound-Guided Barbotage Example. (A) A calcific deposit (white asterisk) is identified in
the anterior supraspinatus tendon. (B) An 18-gauge needle (black arrowheads) has been advanced into
the calcification in a single pass with the needle tip (white arrow) located in the center of the deposit (white
asterisk). (C) Following barbotage (white arrow), the calcification has essentially completely resolved and is
no longer seen. (D) The needle is pulled back slightly and repositioned so that its tip (black arrow) is located
in the subacromial bursa. A mixture of corticosteroid and local anesthetic is then injected into the bursa,
which will become mildly distended (white dashed line).

Single-Needle Technique which is essential for barbotage. Fenestration will allow

Needle Position the injectate to decompress through the resultant holes
in the deposit.
• A
 fter local anesthetic is administered, the 18-gauge nee-
dle should be advanced in plane with the US probe, and Lavage
along the long axis of the rotator cuff tendon fibers, to
minimize potential injury to the tendon. • O nce the 18-gauge needle is positioned with its tip in the
calcific deposit, the first syringe containing a 50:50 mix-
Target ture of local anesthetic and saline is connected directly to
the needle, and the syringe is oriented with the needle tip
• Th
 e largest calcific deposit should be targeted first with directed cranially, to allow gravity to assist with calcium
the goal of advancing the needle tip into the center of the aspiration (see Fig. 24.2).
deposit in a single pass without interruption of the medial • At this point, the clinician begins applying repeated
wall or fenestration of the calcification (Fig. 24.3A and B). intermittent small pumps on the syringe plunger, lavag-
• Maintaining integrity of the wall of the deposit is key to ing the center of the calcification with small volumes of
ensure buildup of backpressure within the calcification, injectate, which causes breakdown of the calcification
494 SEC T I O N I V Advanced

from the inside due to dissolution and pressure waves • I f there is difficulty dissolving dense calcifications, the
(see Fig. 24.2, inset top). needles can be gently rotated and laterally displaced while
• Between each pump, the buildup of backpressure pushes still inside the calcification to increase fragmentation.22
fluid and calcific debris back into the syringe without • Once all of the calcium deposits have been treated,
requiring active aspiration from the operator (see Fig. the free needle is removed and the other needle tip is
24.2, inset bottom). pulled back and repositioned in the SASD bursa, and the
• The clinician should periodically check the syringe for syringe containing the corticosteroid mixture is attached
calcific debris and switch to the next prepared syringe if and injected into the bursa.
there is significant buildup of calcium debris within.
• This process is continued until as much calcium as pos- Complications
sible is removed and the syringe remains relatively clear
(see Fig. 24.3C). Barbotage is generally very well tolerated with most studies
• If there are multiple significant deposits, the needle should reporting minimal immediate complications, usually consist-
be repositioned and the process should be repeated. US ing of mild vasovagal reactions.7,14 Transient worsening of
evaluation of the deposits during lavage is helpful to symptoms may occur in the 48 hours following the procedure
ensure all areas of the deposits are being treated. due to SASD bursitis.7 Frozen shoulder and septic bursitis have
• Once all of the calcium deposits have been treated, the nee- also been documented, although they are uncommon.14,28
dle tip is pulled back and repositioned in the SASD bursa, Temporary recurrence of symptoms approximately 15 weeks
and the syringe containing the corticosteroid mixture is after treatment has been described in at least one study but was
attached and injected into the bursa (see Fig. 24.3D). found to be generally less intense than prebarbotage symptoms
• The average needle-in to needle-out time is approxi- and controlled adequately with NSAIDs.7
mately 10 minutes.
Postprocedure Care and Follow-Up
Double-Needle Technique The patient should be advised to rest the shoulder for 48
Needle Position hours following the procedure and to avoid heavy lifting
for 2 weeks. NSAIDs medication can be used for pain relief
• A
 fter anesthetic is administered, two 16-gauge needles as needed and physiotherapy can be resumed after 1 week.
are advanced in plane with the US probe, and along the Patients should also be warned that their symptoms may
long axis of the rotator cuff tendon fibers, to minimize become worse for the first few days until the corticosteroid
potential injury to the tendon. injection takes effect. Follow-up shoulder radiographs can
be obtained several weeks following the procedure to ensure
Target a decreased burden of rotator cuff calcification.

• Th
 e largest calcific deposit should be targeted first. The first
needle is inserted into the lower portion of the calcium PEARLS AND PITFALLS
deposit with the bevel turned upward to face the probe.22,23 • It is not necessary to remove all of the calcification, as
The second needle is then inserted parallel and superficial lavage often incites a reaction by the body that usually leads
to the first needle with the bevel turned downward, so that to removal of most, if not all, of the residual calcifications.1
both needle bevels face one another.22,23 Ideally the needle • If the needle becomes blocked, first try switching the
tips should be located within 2 to 3 mm of each other.22,23 syringe. If this fails to resolve the blockage, a smaller-
gauge needle can be threaded through the 18-gauge
needle to attempt to unblock it. If this also fails, switching
Lavage to a new needle may be necessary, but this is uncommon.
• If the calcification is too firm to break up with lavage,
• O nce the 16-gauge needles are positioned with tips in the fenestration can be used as a last-ditch effort. Although
calcific deposit, a syringe containing a 50:50 mixture of anes- this precludes aspiration of debris, the mechanical
disruption of the calcific deposit will usually elicit a
thetic and saline is connected directly to one of the needles. reaction from the body that will result in resorption of at
• At this point, the clinician begins applying repeated least some of the calcium.
intermittent small pumps on the syringe plunger, lavag- • Barbotage leading to a tendon tear is a theoretical risk
ing the center of the calcification with small volumes of but is very uncommon when proper technique is use,
injectate, which causes breakdown of the calcification including ensuring a needle approach along the long
axis of the tendon.
from the inside due to dissolution and pressure waves. • Barbotage should be followed immediately by a
• As the calcification dissolves, the injectate and calcium subacromial-subdeltoid (SASD) bursa injection, as the
debris will egress from the deposit via the free needle. procedure itself, and release of some of the calcific
• This process is continued until as much calcium as pos- debris into the bursa during the procedure, will likely
sible is removed and the fluid draining out of the free irritate the bursa.
needle becomes relatively clear.   
 CHAPTER 24 Calcific Tendonitis Barbotage/Lavage 495

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shoulder. Clin Orthop Relat Res. 2001;(387):72–82. needle technique. Radiology. 2001;221(2):455–461.
25
High-Volume Ultrasound-
Guided Capsular Distention
for Adhesive Capsulitis
ALYSSA NEPH SPECIALE AND BRIAN DAVIS

KEY POINTS gap covered exclusively by capsular tissue. It is bordered by

the supraspinatus tendon superiorly, subscapularis tendon
• A dhesive capsulitis occurs due to thickening and inferiorly, and coracoid process medially. The RI contains
fibrosis of the coracohumeral ligament (CHL), the long head of the biceps tendon. The joint capsule is
glenohumeral ligament, rotator interval (RI), and axillary
joint recess. reinforced by the CHL and superior glenohumeral ligament
• The condition is more common in middle-aged (SGHL) in this location, forming the “biceps pulley.”9 The
females with a history of diabetes mellitus but is also RI contributes to stabilization of the joint and the biceps
linked to collagen vascular disease, thyroid disease, tendon. The inferior portion of the GHJ capsule is termed
rheumatologic disorders, trauma, and surgery.1–3 the “axillary recess” and lies between the anterior and pos-
• Course is reportedly self-limiting but may persist for up
to 18 to 24 months or longer.4–6 terior bands of the inferior glenohumeral ligament (IGHL)
• If conservative measures fail, hydrodistention may be (Fig. 25.1A).10
considered as a treatment option. Hydrodistention
has been found to be superior to manipulation under
anesthesia (MUA) in one study7 and superior during
Common Pathology
earlier stages of disease and treatment course.8
• Recommend using high-volume saline and anesthetic Adhesive capsulitis (AC), or “frozen shoulder,” can be a
rather than corticosteroid for distention due to risk of debilitating condition, affecting 2% to 5% of the popula-
chondrotoxicity, hyperglycemia in diabetes mellitus, tion, middle-aged females more than males. Risk factors
labile hypertension, and lack of superior benefit with include diabetes mellitus (13.4% prevalence of AC),2 thy-
addition of steroids. roid disease, rheumatologic disorders, collagen vascular dis-
• Use a 20- to 25-gauge 3.5-inch or 10-cm needle for an
out-of-plane approach to the glenohumeral joint (GHJ) ease, and Parkinson disease.1–3 Secondary AC often results
during injection (authors’ preferred method due to from surgery or trauma. The course of AC is typically self-
decreased tissue disruption). limiting but may persist upward of 18 to 24 months or
• Perform preprocedure and postprocedure shoulder joint longer for full resolution through the three characteristic
range of motion testing. phases: freezing stage, frozen stage, and thawing phase.4–6
• Perform proprioceptive neuromuscular facilitation (PNF)
and active release therapy (ART) immediately following In addition, it has been suggested that there is a higher inci-
the procedure and start physical therapy (PT) within 2 to dence of contralateral AC in the future in younger patients
4 hours after procedure for maximal sustained benefit (<50 years old) and those with diabetes.11
of capsular distention. Arthroscopic findings in AC include replacement of
   the subscapularis recess with scar tissue, tightened axil-
lary recess, reduced joint fluid volume, and contracture of
RI and CHL. Histopathologic appearance demonstrates
Anatomy tissue similar to that found in Dupuytren contracture,
consisting of dense type III collagen, fibroblasts, contrac-
The glenohumeral joint (GHJ) is a diarthrodal joint, sta- tile myofibroblasts, and neovascularization.12 Clinically,
bilized by the capsule, glenohumeral and coracohumeral external rotation is typically affected first and progresses
ligaments (CHLs), glenoid labrum, and rotator cuff mus- to include limitations in flexion, abduction, and internal
culature. The rotator interval (RI) is a tendinous triangular rotation.

496
 CHAPTER 25 High-Volume Ultrasound-Guided Capsular Distention for Adhesive Capsulitis 497

Coracoacromial ligament Coracoclavicular ligament

Coracohumeral
Clavicle
Rotator interval ligament

Supraspinatus

Biceps brachii
tendon
Subscapular

Humerus
Scapula

Axillary recess

• Fig. 25.1 Normal shoulder anatomy demonstrating glenohumeral and coracohumeral ligaments, and the
rotator interval with the long head of the biceps tendon.

Imaging to have better outcomes in pain and ROM compared with

intra-articular or subacromial steroid injections or hydro-
Magnetic resonance imaging (MRI) or ultrasound (US) dilation alone.22 However, the study that found dilation
imaging is preferred over x-ray to rule out significant rotator to be inferior to intra-articular corticosteroid only used a
cuff tear or other pathology prior to interventional treat- volume of 9 mL for dilation, which is inadequate to cause
ment. MRI and MR arthrography (MRA) can demonstrate capsular distention.23–25 Although the use of corticosteroid
thickening of the CHL, thickening and reduction in the size may aid in reducing inflammation due to capsular stretch
of the axillary recess or RI, and obliteration of the subcora- during hydrodistention and reduce risk of recontracture of
coid fat triangle.13 Similar pathologic thickening may be the capsule,22,26 the authors have had very successful results
seen on US (higher sensitivity with US arthrography than with use of anesthetic and saline alone and prefer to avoid
US alone) as well as hypoechoic soft tissue and hypervascu- the chondrotoxic effects of steroid when possible.27,28 In
lar synovium on power Doppler within the RI.14,15 addition, avoiding steroid is essential in the setting of poorly
controlled diabetics, labile hypertension, and steroid sen-
Treatment Options sitivity. Dilation of the joint capsule with the goal of cap-
sular rupture is controversial because there is no evidence
Typically, the first-line treatment for AC is physical therapy that rupture is required for desired outcome. Some studies
(PT), including strengthening, stretching, mobilization, have even shown that capsular preservation may actually
US, and medications such as nonsteroidal antiinflamma- result in increased ROM and decreased pain in the short
tory drugs (NSAIDs) or oral steroids.16,17 The authors rec- term.29,30 The volume used for hydrodilation has widely
ommend pursuing injection therapy after at least 6 weeks ranged from 10 to 90 mL, most commonly in the 25- to
of conservative measures and advanced imaging. Although 50-mL range.7,22,25,31–33 The authors recommend avoiding
hydrodistention has shown improved efficacy in the earlier intentional capsular rupture by monitoring for backflow of
stages of treatment, it may not be approved by insurance injectate in the syringe and patient’s tolerance to pressure
prior to a course of conservative treatment.8 RI, subacro- during injection. Another described hydrodilation approach
mial, and intra-articular steroid injections can also be per- is via the rotator cuff interval. One study by Yoong et al.
formed.18,19 There is no proven difference in outcome after showed good results in the treatment of AC with rotator cuff
subacromial versus intra-articular injection.18,20 interval hydrodilation with 21 mL of combination of local
Capsular hydrodistention under pressure has long been anesthetic and steroid; however, the authors have not had
regarded as an effective treatment option to rapidly improve clinic experience with this technique.34 Orthobiologic treat-
range of motion (ROM) in AC by stretching or ruptur- ments such as platelet-rich plasma (PRP), platelet lysate, and
ing the contracted joint capsule.21 There is no consensus platelet-poor plasma (PPP) can also be considered as dilation
on the inclusion of corticosteroid within the injectate. In solutions due to antiinflammatory and chrondroprotective
some studies, hydrodilation with cortisone has been shown cytokines, and one study showed that intra-articular PRP
498 SEC T I O N I V Advanced

injection had better results for AC compared with steroid • N eedles: 18-gauge 1.5-inch needle (to draw medica-
injection.35,36 Although there is a paucity of data for use in tions); 25-gauge 1.5-inch needle (for local anesthesia);
AC, the editors have had good success using platelet lysate 20- to 25-gauge 3.5-inch or 20-gauge 10-cm Chiba
and PPP to replace saline for dilation solution in practice. (Cook Medical, Bloomington, IN) or 2- to 3.5 inch
Another option if conservative measures fail is manipu- spinal needle (for injectate)
lation under anesthesia (MUA), which has been found to • Injectate:
be inferior to hydrodistention in regards to pain and ROM • Up to 12 mL of local anesthetic for the skin and extra-
in one study.7,37 MUA should be avoided in elderly osteo- articular soft tissue such as 1% lidocaine without
porotic patients due to the risk of fracture. If MUA fails, epinephrine.
arthroscopic capsular release of the CHL, anterior capsule, • 10 mL of preferred intra-articular anesthetic
and subscapularis bursa can be pursued.38 This technique • Recommend use of ropivacaine 0.5% over bupiva-
may be challenging with tighter capsular contracture due to caine and especially lidocaine due to risk of chon-
difficulty inserting the arthroscope.39 Although arthroscopic drotoxicity with intra-articular injection.43
capsular release has been shown to have slightly better out- • 50 mL of preservative-free 0.9% normal saline solu-
comes than hydrodistention, both arthroscopy and MUA tion or preferred dilation solution (connected to tub-
require general anesthesia, increasing the risk of adverse out- ing and primed, Fig. 25.2B)24
comes in certain populations. • Option to use platelet lysate, PRP, and/or PPP as part
Indications for High-Volume Ultrasound- of dilation solution.
Guided Injection for Adhesive Capsulitis
Patient Selection
Candidates for capsular hydrodistention or high-volume
ultrasound-guided injection (HVUGI) are those with AC
who fail at least 6 weeks of conservative PT, modalities, and
medication management, unless conservative measures are
contraindicated or there are severe functional limitations.
Hydrodistention has been found to have improved efficacy
in the early stages8 and in those with less severe limitations
in ROM at the time of procedure (“freezing” rather than
“frozen” stage) but may not be approved by insurance prior
to a trial of conservative treatment.40 Long-term outcomes
with HVUGI may be less favorable in diabetic patients.41
Authors’ preferred diagnostic criteria for AC include greater
than 25% reduction of passive ROM in two or more of the
four cardinal shoulder motions (internal rotation, external
rotation, abduction, and extension) without another expla-
nation for the loss of motion, such as GHJ osteoarthritis or
impingement. Preprocedurally, we test and record the degree
of shoulder motion in abduction, external rotation, internal
rotation, and extension, as well as the Apley scratch test. We
perform GHJ ROM testing with the scapula fixed and shoul-
der in 90 degrees of abduction (or at end range if patient can-
not achieve 90 degrees) and elbow in 90 degrees of flexion. A
Normal ROM in this position is at least 45 degrees of internal
rotation, 90 degrees of external rotation, 90 to 110 degrees of
abduction (isolated GHJ), and 45 to 60 degrees of extension.42

Equipment
• M usculoskeletal US machine with a high-frequency linear
or curvilinear array transducer (10 to 18 MHz preferred)
• Sterile probe cover and sterile US gel (entirely sterile pro-
cedure recommended) B
• Sterile gloves
• Fig. 25.2 (A) Patient position, transducer position, and needle position
• ChloraPrep cleansing solution sticks × 2 for the out-of-plane approach for glenohumeral capsular distention. (B)
• Two extension tubing sets Setup of intravenous tubing connected end to end and attached to
• Syringes: 10 mL, 20 mL, 60 mL 60-mL syringe to allow for easier injection of saline under pressure.
 CHAPTER 25 High-Volume Ultrasound-Guided Capsular Distention for Adhesive Capsulitis 499

Deltoid
Deltoid

Infraspinatus

Infraspinatus

A LATERAL B H LATERAL

• Fig. 25.3 (A) Out-of-plane injection approach from distal to proximal. White arrow shows needle tip.
(B) Distended joint recess as shown by white arrow after saline distention. H, Humerus.

Author’s Preferred Technique

Right
Patient Position GH JT
• L ateral recumbent with affected side up.
• Arm bent at patient’s side; may have bolster under arm
for comfort. Deltoid
• Prep entire forequarter region of posterior and anterior
shoulder with two ChloraPrep cleansing solution sticks,
and apply sterile probe cover and gel to transducer.

Clinician Position Infraspinatus

H
• S itting or standing behind patient with US machine in
visual line, across from clinician.

Transducer Orientation Glenoid labrum

LATERAL 4.0 cm
• O
 ver the posterior aspect of the GHJ, parallel with infra-
spinatus fibers (see Fig. 25.2A). • Fig. 25.4 In-plane injection approach from lateral to medial. White
arrow shows shaft of the needle entering posterior capsule and joint
Needle Orientation and Technique recess. H, Humerus. GH JT, Glenohumeral Joint.
• P rocedure can be performed with the needle out of plane
(Fig. 25.3A) or in plane (Fig. 25.4) to the transducer.
• Suprascapular or interscalene nerve block prior to the pro- • L eave the needle in place, switch the syringe, and inject
cedure may be considered for anesthesia. Oral anxiolyt- 10 mL preferred anesthetic into the joint, ensuring ade-
ics may be considered in some patients, but intravenous quate capsular distention (see Fig. 25.3A and B).
(IV) anxiolytics or narcotics are typically not required • Leave the needle in place and then attach IV tubing (see
or recommended due to increased risk of adverse effects Fig. 25.2B) primed and connected to a 50-mL syringe of
and necessity for monitoring. In the current opioid crisis, dilating solution (tubing allows for easier injection under
judicious use of postprocedure narcotics is optional. pressure).
• Skin wheal and local anesthesia with 1% lidocaine using • Slowly inject dilation solution, monitoring the patient’s
25-gauge 1.5- to 2-inch needle, walking down toward comfort and ensuring that the joint capsule continues to
the humeral head and glenoid labrum. expand. Small aliquots and occasional release of pressure
• Monitor for nearby vascular structures to avoid intravas- is preferred to maintain patient comfort.
cular injection. • Inject volume until there is backflow of injectate in the
• HVUGI performed with 20- to 25-gauge, 2- to 3.5-inch syringe, extracapsular leak of fluid, or the patient in unable
spinal needle or 10-cm Chiba needle. Insert needle along to tolerate the pressure any longer. In the authors’ experi-
same trajectory, anesthetizing deeper tissues and extracap- ence, total injectate volume can range from 20 to 70 mL
sular area with local anesthetic. Then penetrate the capsule. with the most common volume between 35 and 50 mL.
500 SEC T I O N I V Advanced

• W
 rap sterile gauze around the base of needle and remove • If you feel sudden loss of resistance during saline
needle while applying pressure to site of entry. Apply injection, the capsule may have ruptured. Fluid will
bandage. be observed extracapsular, and additional injection of
dilation solution is likely unnecessary.
• Remember to provide proprioceptive neuromuscular
Postprocedure Protocol facilitation, active release therapy, and passive stretch
post procedure (once anesthetic has taken full effect)
The physician should perform 5 to 10 minutes of pro- and start physical therapy within 2 to 4 hours to reduce
prioceptive neuromuscular facilitation (PNF) and active loss of beneficial capsular stretch secondary to the
release therapy (ART) along with passive stretching and distention.
deep breathing following the procedure once the local • Commonly, during the postprocedural stretching, the
provider will feel or hear “pops” that indicate breaking of
anesthetic has taken effect. All cardinal movements should adhesions followed by immediate improvement in range
be addressed to stretch out the capsular fibers. Retest and of motion.
record the ROM after PNF or ART in abduction, external • Performing shoulder pulley exercises and self-stretching
rotation, internal rotation, extension, and the Apley scratch is critical for successful outcome.
test for comparison with pretest values. These can also be   
compared with posttherapy values. Recommend schedul-
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• C an consider performing a suprascapular or
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• For the in-plane approach, the needle bevel should servative treatment of shoulder idiopathic adhesive capsulitis and
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• Take short breaks during infusion of the saline under shoulder: evaluation with US-arthrography using a sonographic
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26
Ultrasound-Guided Needle
Tenotomy and Ultrasound-
Guided Tenotomy and
Debridement With Tenex
Health TX System
RYAN C. KRUSE AND MEDERIC M. HALL

Pathology
KEY POINTS
• A subset of tendinopathy appears to become chronic The term “tendinopathy” includes a wide array of potential
and nonresponsive to conservative treatments such as histopathology involving the tendon and its paratenon or
activity modification and exercise-based rehabilitation. sheath. Chronic tendon pain is felt to predominately rep-
• Ultrasound-guided needle tenotomy is a simple office- resent a condition characterized histologically as mucoid
based procedure that has been shown effective at collagen degeneration with other variable features such as
multiple tendon locations throughout the body.
• Ultrasound-guided tenotomy and debridement with collagen disorganization, fibrocartilaginous metaplasia,
the Tenex Health TX System provides a less-invasive calcification, and neovascularity. These changes are often
and cost-effective option for chronic tendinopathy referred to as tendinosis. Although primarily an overuse and
compared to traditional surgical management. degenerative process with an absence of acute inflammatory
• An in-depth understanding of the regional anatomy and infiltrate, inflammatory mediators are present.1 Clinically,
the ability to obtain optimal ultrasound images of the
region are essential prerequisites of either procedure. tendinopathy is characterized by pain and dysfunction with
mechanical loading of a tendon and can lead to significant
  
time loss from sport and work.2 While the optimal treat-
ment for this group remains poorly defined in the literature,
Introduction minimally invasive ultrasound-guided mechanical treat-
ments have shown favorable results.3–8
Tendinopathy is a clinical condition characterized by pain
and dysfunction related to mechanical loading of a tendon. Treatment Options
While often self-limited and responsive to conservative
measures, such as activity modification and exercised-based Ultrasound-guided percutaneous needle tenotomy was first
rehabilitation, a subset of patients goes on to develop described in the early 1980s as a nonsurgical treatment
chronic and recalcitrant symptoms. While the optimal option for common extensor tendinopathy.9 Subsequent
treatment for this group remains poorly defined in the lit- studies have reported favorable outcomes across multiple
erature, minimally invasive ultrasound-guided mechanical tendon locations.10–13 The basic principle of the procedure
treatments have shown favorable results. In this chapter we is to stimulate a healing response within a region of dis-
review ultrasound-guided needle tenotomy and ultrasound- organized nonhealing tendon tissue via local acute trauma
guided tenotomy and debridement with the Tenex Health produced by multiple needle fenestrations.14,15
TX System. Procedural technique, post-procedure care and Despite early encouraging outcomes with simple nee-
rehabilitation, and patient selection are discussed. dle fenestration, there are inherent limitations with this

502
 CHAPTER 26 Ultrasound-Guided Needle Tenotomy and Ultrasound-Guided Tenotomy and Debridement 503

technique. The Tenex Health TX system (Tenex Health, Lake 0

Forest, CA) is an ultrasonic cutting instrument designed to

focally debride and remove pathologic tissue from tendons
allowing for both a true tenotomy and debridement.16 The ACH X

rationale is that when the pathologic tissue is removed, a 1

chronic degenerative process is converted to an acute pro-

cess, introducing inflammatory growth factors and promot- A CALC
PROX
ing tendon healing.17 Recent advances in the technology
now allow for removal of hard calcifications and bone. Early 0

clinical experience has been favorable, even for challenging

locations such as the Achilles insertion.6 The procedure is ACH
X

safely performed in a clinical setting under local anesthe-

1
sia, which reduces cost significantly compared to an open or
endoscopic tenotomy. Furthermore, the minimally invasive
nature allows for less post-procedure pain and faster recov- B PROX CALC
ery than traditional surgical approaches.4 0

Techniques
ACH
A pre-procedural ultrasound should be performed to con- X 1
firm pathology amendable to treatment and to identify local
CALC
structures at risk such as nerves and blood vessels. Ergonom-
ics for both patient and physician should be considered.
Nuances in treatment of each individual tendon location C PROX 3
are outside the scope of this chapter. An in-depth under- • Fig. 26.1 Ultrasound-Guided Tenotomy and the Debridement
standing of the regional anatomy and the ability to obtain Procedural Technique. Long-axis image of Achilles tendon demon-
optimal ultrasound images of the region are essential prereq- strating procedural technique. (A) After obtaining local anesthesia, a
uisites of either procedure. #11 blade (arrows) is used to make an incision down to the tendon. (B)
The TX MicroTip (open arrowheads) is then introduced superficial/pos-
While there may be variance in clinical practice, we have terior to the tendon and the hypertrophied paratenon and connective
found that ultrasound-guided needle tenotomy and ultra- tissue are debrided from the tendon. (C) The MicroTip is then guided
sound-guided tenotomy and debridement are safely and into the tendon and the regions of tendinosis are debrided. In this
effectively performed in an outpatient setting under local example, there was concomitant retrocalcaneal bursitis and a limited
or regional anesthesia. We recommend a sterile technique bursectomy was performed. ACH, Achilles tendon; CALC, calcaneus;
PROX, proximal.
including a sterile ultrasound transducer cover and sterile
acoustic coupling gel. Our local anesthetic preference is a
50:50 mixture of 1% lidocaine without epinephrine and being treated (Fig. 26.1A). We prefer to perform the inci-
0.5% ropivacaine. Between 4 and 10 mL should provide sion under live ultrasound guidance to maximize safety. The
adequate anesthesia in most cases. This can be titrated to incision should always be performed in line with the ten-
patient comfort using the lowest effective dose. don or fascia to avoid iatrogenic horizontal fiber laceration.
Occasionally, more than one incision/entry site is required
Ultrasound-Guided Needle Tenotomy/ to effectively address the full extent of the pathologic tissue.
The TX MicroTip is then guided into the region of
Fenestration
pathologic tissue (see Fig. 26.1B and C). The cutting energy
After anesthesia is obtained, a large-gauge needle (typically is activated via a foot pedal and a gentle oscillating motion
18 to 20 G) is advanced with live ultrasound guidance to should be used to allow for debridement and aspiration of
the area of pathology, and multiple fenestrations are made tissue. The tip of the device should stay within the tendon
through the pathologic tissue. Whenever possible, fenestra- while the foot pedal is activated, if possible, to avoid excess
tions should be made parallel to tendon fibers in order to leakage of irrigation fluid into the local muscle and subcuta-
avoid unnecessary trauma to surrounding normal tissue. neous tissues. Care should be taken to only move the device
While determining the necessary amount of tissue fenestra- in a linear direction to avoid torque at the hub, which can
tion is subjective, a change in tissue resistance to the needle lead to device failure. With improper technique, the inter-
will be appreciated as adequate fenestration is achieved.13 nal needle may fracture at the hub. This will be accompa-
nied by an auditory change to a higher pitch. The internal
Ultrasound-Guided Tenotomy and needle may also be visualized extending farther beyond the
external needle. If there is any concern for device failure,
Debridement With the TX System
the procedure should be terminated immediately, and the
Once anesthesia is achieved, a #11 blade is used to make a device carefully removed from the patient for inspection.
5-mm skin incision and create a tract to the tendon or fascia When removing the MicroTip one should ensure not to
504 SEC T I O N I V Advanced

leave a fractured internal needle in the procedure site. As the

pathologic tissue is removed there will be a tactile change in
resistance at the tip of the device and the debrided region
will often demonstrate hyperechoic microbubbles from the
irrigation fluid. Calcifications will lose posterior acoustic
shadowing artifact and should visibly decrease in size as the
MicroTip moves freely through the debrided tissue region
(Fig. 26.2). Energy times will vary based on location and
extent of pathology, with as little as 30 seconds for focal
regions in small tendons and up to 10 minutes in large
regions of calcified tissue when using the TX1 or TX2 sys-
tem. Cumulative energy time (both hard and soft tissue)
may be extended to 15 minutes when using the TX-Bone,
but hard tissue applications should generally not exceed 10
minutes. Energy should always be administered in a pul-
satile fashion to allow for adequate aspiration and cooling
of the device. The recommended duty cycle is 15 seconds
on, 45 seconds off, on HIGH cutting power. This is of par-
ticular importance with the TX-Bone as continuous energy
administration may result in superficial burns at the skin A
surrounding the entry site. The device will provide an audi-
tory signal if aspiration slows and has a safety mechanism
to shut off the cutting energy if the device becomes clogged
and aspiration stops.
ACH

Post-Procedure Care and Rehabilitation

CALC
Upon completion of the procedure, either a small adhesive
bandage is applied to the needle entry site or the skin inci- B PROX
sion is closed with a single adhesive wound closure strip
followed by gauze and a transparent film dressing. A com-
pression sleeve is recommended if possible. We recommend
avoiding submersion of the procedure site for 72 hours
after needle tenotomy and for 2 weeks after tenotomy and
debridement with the TX system. Post-procedure rehabili-
tation will vary slightly by the site, the degree of pathology,
ACH
*
and the functional demands of the patient. We currently use
a criterion-based rehabilitation protocol, which commonly
takes between 6 and 12 weeks for return to activities.
CALC
Patient Selection and Rationale C PROX

Regardless of the technique chosen, optimal outcomes • Fig. 26.2 Achilles Calcification Treated With the Tenex System. Pre-
and post-procedure images of an Achilles insertional calcification
begin with appropriate patient selection. In our experi- treated with the TX-Bone MicroTip. (A) Lateral X-ray demonstrates a
ence, patients most likely to respond to tenotomy have large calcification (arrow) within the Achilles tendon insertion. (B) Long-
clinical features of focal tendon pain with loading and axis ultrasound image prior to procedure shows the same calcification
correlative findings on diagnostic ultrasound or magnetic (arrow) represented as a hyperechoic linear structure with posterior
resonance imaging. Patients should have chronic symp- acoustic shadowing. (C) Post-procedure image confirms complete
debridement of the calcification with anechoic fluid–filled defect at site
toms (>3 months) and fail appropriate initial conservative of prior calcification (asterisk). ACH, Achilles tendon; CALC, calcaneus;
treatment, which should include activity modification/load PROX, proximal.
management and an exercise-based rehabilitation program.
Although further research is needed to identify negative more traditional surgical approach or consideration of the
prognosticating factors, we recommend careful evaluation TX-Bone. Other factors, such as history of local corticoste-
for significant tendon tearing (>50% of cross-sectional area), roid injections, non-loading pain, and diffuse widespread
associated ligament instability (e.g., radial collateral liga- pain, also should be considered.
ment laxity of the lateral elbow in association with common The decision to proceed with ultrasound-guided nee-
extensor tendinosis), and bony impingement (e.g., Haglund dle fenestration versus ultrasound-guided tenotomy and
deformity at the Achilles insertion), which may require a debridement with the TX system is largely one of available
 CHAPTER 26 Ultrasound-Guided Needle Tenotomy and Ultrasound-Guided Tenotomy and Debridement 505

resources and clinician preference at this point, with no stud- 5. Battista CT, et al. Ultrasonic percutaneous tenotomy of common
ies directly comparing the two treatment options. However, extensor tendons for recalcitrant lateral epicondylitis. Tech Hand
we have found that tenotomy and debridement with the Up Extrem Surg. 2018;22(1):15–18.
TX system often results in much less post-procedure pain 6. Chimenti RL, et al. Percutaneous ultrasonic tenotomy reduces
insertional Achilles tendinopathy pain with high patient sat-
and allows for the introduction of earlier rehabilitation. In
isfaction and a low complication rate. J Ultrasound Med.
fact, we only prescribe over-the-counter analgesics post- 2019;38(6):1629–1635.
procedure. We hypothesize this is because the TX system 7. Elattrache NS, Morrey BF. Percutaneous ultrasonic tenotomy as
allows for focal removal of the pathologic tissue and local a treatment for chronic patellar tendinopathy—jumper’s knee.
aspiration/irrigation of nociceptive mediators with much Operat Tech Orthopaed. 2013;23(2):98–103.
less trauma to the surrounding healthy tissue. In contradis- 8. Stover D, et al. Ultrasound-guided tenotomy improves physical
tinction, the primary goal of needle fenestration is to create function and decreases pain for tendinopathies of the elbow: a ret-
a traumatic injury to stimulate a healing response. There rospective review. J Shoulder Elbow Surg. 2019;28(12):2386–2393.
are certain clinical scenarios in which ultrasound-guided 9. Yerger B, Turner T. Percutaneous extensor tenotomy for chronic ten-
tenotomy and debridement with the TX system offers a nis elbow: an office procedure. Orthopedics. 1985;8(10):1261–1263.
clear advantage, including addressing calcifications within 10. Housner JA, Jacobson JA, Misko R. Sonographically guided per-
cutaneous needle tenotomy for the treatment of chronic tendino-
tendons, associated hypertrophic and inflamed bursal tis-
sis. J Ultrasound Med. 2009;28(9):1187–1192.
sue, and local bony impingement. A clear limitation of the 11. Mattie R, et al. Percutaneous needle tenotomy for the treatment
TX system is length of the MicroTip. The longest Micro- of lateral epicondylitis: a systematic review of the literature. PM R.
Tip currently available (TX 2) is approximately 2 inches in 2017;9(6):603–611.
length. Deep targets in large patients (such as gluteal ten- 12. McShane JM, Nazarian LN, Harwood MI. Sonographically
dons) may not be possible; needle fenestration offers a good guided percutaneous needle tenotomy for treatment of com-
alternative in these cases. mon extensor tendinosis in the elbow. J Ultrasound Med.
2006;25(10):1281–1289.
13. Peck E, Jelsing E, Onishi K. Advanced ultrasound-guided
References interventions for tendinopathy. Phys Med Rehabil Clin N Am.
1. Dean BJF, Dakin SG, Millar NL, Carr AJ. Review: emerg- 2016;27(3):733–748.
ing concepts in the pathogenesis of tendinopathy. Sur- 14. Finnoff JT, et al. Treatment of chronic tendinopathy with ultra-
geon. 2017;15(6):349–354. https://doi.org/10.1016/j.surge. sound-guided needle tenotomy and platelet-rich plasma injec-
2017.05.005. tion. PM R. 2011;3(10):900–911.
2. Neph A, Onishi K, Wang JH. Myths and facts of in-office regen- 15. Krey D, Borchers J, McCamey K. Tendon needling for treat-
erative procedures for tendinopathy. Am J Phys Med Rehabil. ment of tendinopathy: a systematic review. Phys Sportsmed.
2019;98(6):500–511. 2015;43(1):80–86.
3. Morrey BF. A new safe and effective treatment for chronic refrac- 16. Barnes DE. Ultrasonic energy in tendon treatment. Operat Tech-
tory tendinopathy. Ortho Rheum Open Access J. 2018;11(5). niq Orthopaed. 2013;23(2):78–83.
4. Barnes DE, Beckley JM, Smith J. Percutaneous ultrasonic tenot- 17. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopa-
omy for chronic elbow tendinosis: a prospective study. J Shoulder thology of common tendinopathies: update and implications for
Elbow Surg. 2015;24(1):67–73. clinical management. Sports Med. 1999;27(6):393–408.
27
High-Volume Image-Guided
Injections
MARIA-CRISTINA ZIELINSKI, NICOLA MAFFULLI, OTTO CHAN,
AND ROMAIN HAYM

KEY POINTS to evaluate the progression or the improvement of the

tendinopathy.5
Features of the high-volume image-guided injection technique:
• It is designed to improve pain, function, and to reduce
tendon thickness. Ultrasound Imaging Findings
• It enables patients follow a specific tendon loading
program by reducing pain. Sonographic features of tendinopathy include abnormal
• Ultrasound imaging is crucial to ensure correct needle tendon size (thickness), shape (bulging), changes in echo-
placement at the interface between the paratenon and
peritendinous structures.
genicity, altered fibrillar appearance, the presence of fluid,
• The injection is extra-tendinous, eliminating the risks sheath thickening, and neovascularization in the tendon or
associated with intratendinous corticosteroid injection. its sheath. Neovessels are associated with abnormal nerves
   ingrowth, which are thought to contribute to tendinopathic
pain.6,7 Color Doppler and power Doppler ultrasonography
are established methods to detect increased blood flow asso-
ciated with neovascularization within the tendons.8 Neovas-
Pathology cularization in the absence of pain may not be pathologic,
and can just indicate a physiologic response to recent physi-
Tendinopathies can be acute or chronic and can affect cal activity; however, neovascularization within the tendi-
athletic and sedentary patients, leading to long periods of nopathic area is generally present in patients with chronic
sport cessation and interfering with the activities of daily painful tendinopathy.9,10
living.1,2 Intrinsic (age, gender, body composition, tendon
temperature, systemic diseases, muscle strength, flexibility, Treatment Options
previous injuries, anatomic variants, genetic predisposi-
tion and blood supply) and extrinsic factors (overloading, Conservative treatment of tendinopathy can be disappoint-
underloading, training loading error, drugs), alone or in ing, and 25% to 45% of patients may require surgery.1,11
combination, can cause tendinopathy.3 Pathologic ten- Surgery used to be indicated after a 6-month period of non-
dons become increasingly painful in response to loading. operative management,12 but is now advocated only as a
Clinically, they appear swollen and thickened, and are last resort.
painful on palpation. Platelet-rich plasma (PRP) injections have become pop-
The diagnosis of tendinopathy is based on careful his- ular in clinical practice for chronic tendinopathy, as it is
tory and detailed clinical examination.4 High-resolution hypothesized that a variety of growth factors may promote
real-time ultrasonography is frequently used to image ten- a healing response in the tissue.13–16 However, the results of
don disorders and confirm the diagnosis.5 Ultrasonography randomized controlled trials (RCTs) have been mixed, and
is an operator-dependent technique that can influence the at present there is insufficient evidence for the effectiveness
image obtained, depending on transducer handling and of PRP for tendinopathy of the main body of the Achilles
machine settings. Consequently, the interobserver reliabil- tendon.17
ity of ultrasonographic assessment of tendon structures can There is no accepted standard regimen for the manage-
be problematic, and changes over time may make it difficult ment of tendinopathies, but the inclusion of progressive

506
 CHAPTER 27 High-Volume Image-Guided Injections 507

tendon loading through heavy load concentric and/ PATIENT SELECTION

or eccentric exercise as part of the management plan is
• P atients who failed conservative treatment in the past
crucial.18,19 Loading exerts beneficial effects on tenocyte
• Patients unable to tolerate tendon loading
homeostasis and promotes tendon collagen synthesis, • Patients in whom conservative treatment aggravates
and can result in decreased pain and increased perfor- symptoms
mance.20–22 If the clinical symptoms of tendinopathy do • Patients unable to have surgery because of
not resolve, other nonoperative treatments are available, comorbidities
• Patients who do not want surgery
including extracorporeal shockwave therapy or nitric
oxide patches. Injections at the interface between the   
tendon and peritendinous tissues should also be consid-
ered if physiotherapy and shockwave therapy are unsuc-
Equipment (e.g., Achilles Tendon) see Fig. 27.1
cessful in reducing pain and facilitate tendon loading.12
The rationale behind high-volume image-guided injec- •  uer Lock syringes (5 × 10 mL)
L
tions (HVIGIs) for the management of tendinopathy is • High-pressure Luer Lock connecting tube
to use a large quantity of fluid to mechanically sever the • Green needle (21 G × 40 mm)
neovessels and the accompanying nerve ingrowth, either • Sterile gloves
by direct mechanical trauma or through pressure-mediated • Aseptic solution (Hydrex Pink Chlorhexidine Gluconate
secondary ischemia.23–25 In addition, the local anesthetic 0.5% w/v and 70% denatured alcohol [DEB])
used in the HVIGI contributes to reducing nociception • Cotton wool gauze and skin plaster
by producing a short-term local block of the neonerves, • High frequency linear ultrasound transducer
and through longer-term neonerve neurotoxicity. Local
anesthetics produce a variable neurotoxic effect.26 The
use of corticosteroids likely counteracts the mechanically
Technique (Achilles Mid-portion
induced reaction to the injection of the large volume of Tendinopathy HVIGI)
fluid; it may also contribute to slowing down the re-forma-
Common Injectates
tion of adhesions between the tendon and peritendinous
tissues.27,28 • L ocal anesthetic, typically: Bupivacaine 0.5%
HVIGI may be more effective than PRP in improving • Corticosteroid, typically: Depo-Medrone
outcomes of chronic tendinopathies in the short term and • Normal saline
similar results long term,29 with numerous studies confirm-
ing the value of HVIGI in tendinopathies.28,30,31 In patients
Injectate Volume
with chronic tendinopathies, HVIGI significantly reduces
pain and stiffness, reduces tendon thickness and intratendi- • 1 0 mL of local anesthetics mixed with
nous vascularity on ultrasonographic imaging, and improves • 0.25 mL of corticosteroid (= 10 mg)
function at both the short-term follow-up (2 weeks) and • followed by 40 mL of normal saline
up to an average of 30.3 weeks.10,32–36 The success rate of
HVIGI in returning patients to the desired level of sport is Patient Position
up to 68%.10 • S upine, with the affected leg externally rotated to expose
Corticosteroids are an adjunct to the high-volume injec- the medial ankle. The lateral ankle rests comfortably on a
tion (very diluted with 0.25 mL in 50 mL of local anes- towel or over the side of the examination table
thetics + saline), and are injected at the interface between • Alternatively, the patient can be placed prone with a pil-
the Achilles Tendon and Kager’s fat to minimize the risk low or bolster under the shin
of tendon rupture or other adverse events associated with
intratendinous injections.28 Some authors believed that Clinician Position
HVIGI without corticosteroids yielded similar effects on • Seated directly distal to the foot being injected
pain reduction and functional improvement in comparison
to HVIGI with corticosteroids.27 However, a recent level Transducer Ultrasound
1 RCT found HVIGI with corticosteroids had better out- • Short axis to Achilles tendon
comes in pain reduction, improved function, and reduced
tendon thickness.28,37 Needle Orientation
The clinical diagnosis and management of tendinopa- • 2 1 G × 40 mm needle is inserted from a medial approach
thies are not straightforward. Hence, patients should under- in-line with the transducer
stand that symptoms may recur with either conservative or
surgical approaches.27 Below we describe the technique for Target
the Achilles tendon in detail but see Table 27.1 for general • I nterface between the anterior surface of the Achilles ten-
instructions for other areas. don and Kager’s fat pad, with the bevel facing away from
508 SEC T I O N I V Advanced

TABLE   Local Anesthetic and Corticosteroid Dosages, Saline Volumes, Needle Approach and Injection Site,
27.1 Ultrasound Transducer Placement, and Equipment Needed for the High-Volume Image-Guided Injection
(HVIGI) of Different Pathologies.
Needle Approach
Local Corticosteroid Saline and Injection Site
HVIGI Anesthetic Dosage Volume (US Imaging Plane) Equipment
Achilles Bupivacaine Depo-Medrone 4 × 10 mL Medial approach, 5 × 10 mL Luer Lock
tendinopathy 0.5% 0.25 mL (=10 mg) interface between syringes
10 mL Achilles tendon and Long connecting tube
Kager’s fat pad (US Green needle (21 G ×
transverse plane) 40 mm)
Patellar Bupivacaine Depo-Medrone 3 × 10 mL Medial or lateral 4 × 10 mL Luer Lock
tendinopathy 0.5% 0.25 mL (=10 mg) approach, interface syringes
10 mL between patellar Long connecting tube
tendon and Hoffa’s fat Green needle (21 G ×
pad (US transverse 40 mm)
plane)
Shoulder Bupivacaine Depo-Medrone — Lateral approach into 2–3 × 10 mL Luer
subacromial 0.5% 40 mg the SASD bursa (US Lock syringes
impingement 20–30 mL transverse plane) Long connecting tube
(rotator cuff Green needle (21 G ×
tendinopathy, 40 mm)
SASD bursitis)
Sinus tarsi Bupivacaine Triamcinolone — Anterolateral approach 1 × 10 mL Luer Lock
syndrome 0.5% 40 mg perpendicular to skin, syringe
10 mL deep at the apex of the Long connecting tube
sinus tarsi. Green needle (21 G ×
40 mm)
Elbow lateral Bupivacaine Depo-Medrone — Distal approach until 3 × 3 mL Luer Lock
epicondyle 0.5% 40 mg needle is in contact syringes
tendinopathy 10 mL with bone, at Long connecting tube
(“tennis elbow”) common extensor Orange needle (25 G
tendon enthesis (US × 25 mm)
longitudinal plane)
Plantar fasciopathy Bupivacaine Depo-Medrone — Medial approach, at 1 × 10 mL Luer Lock
0.5% 40 mg plantar fascia insertion syringe
10 mL onto calcaneus (US Long connecting tube
transverse plane) Green needle (21 G ×
40 mm)
Greater trochanteric Bupivacaine Depo-Medrone — Lateral approach until 2 × 10 mL Luer Lock
pain syndrome 0.5% 40 mg needle is in contact syringes
(gluteal 20 mL with bone, at lateral Long connecting tube
tendinopathy) facet of greater 22 G spinal needle
trochanter
Small tendons Bupivacaine Depo-Medrone — Transverse or longitudinal 1–2 × 10 mL Luer
tendinopathy/ 0.5% 40 mg approach, interface Lock syringe
tenosynovitis 10–20 mL between tendon and Short connecting tube
(tibialis posterior, tendon sheath (US TS Orange needle (25 G
finger flexor, etc.) or LS plane) × 25 mm)
Morton’s neuroma Bupivacaine Depo-Medrone — Approach from dorsum 1 × 10 mL Luer Lock
0.5% 40 mg via intermetatarsal syringe
10 mL space, directly into the Long connecting tube
fibrotic capsule of the Green needle (21 G ×
neuroma (US on plantar 40 mm)
aspect, transverse
across metatarsal
heads)

SASD, Subacromial-subdeltoid; US, ultrasound.

 CHAPTER 27 High-Volume Image-Guided Injections 509

Aseptic solution (Hydrex Pink 0.5%w/v Chlorhexidine Gluco- Dividing tray Skin plaster
nate w/v and 70% DEB)

Orange Needle (25 G x 25 mm)

Depo-Medrone 40 mg (1 mL)
Green Needle (21 G x 40 mm)
Cotton wool gauze

Triamcinolone Acetonide 40 mg (1 mL)

Absorbent paper towel

10 mL Bupivacaine Hydrochloride 0.5%

Sterile gloves High-Pressure Luer Lock Connecting Tube Normal Saline 4 x 10 mL Luer Lock Syringes (5 x 10 mL)

• Fig. 27.1 Equipment for the High-Volume Image-Guided Injection. DEB, Denatured alcohol.

the tendon. Care is taken to avoid placing the needle into program includes concentric-eccentric Heavy Slow Resis-
the tendon itself. The needle tip is repositioned in real tance,39 eccentrics18 if previously well tolerated, concentric-
time after each syringe to be as close as possible to the eccentric-plyometrics combined loading,40 progressing to
anterior surface of the Achilles tendon. sport-specific high-intensity and high-speed plyometrics.41
Please see Table 27.1 for details on dosages, volumes, If the tendon pain was severe and the tendon was irritable
needle placement and equipment for different pathologies, up until the injection, isometric exercises are initially per-
and Figs. 27.2 and 27.3 for injection sites and ultrasound formed.42 Care is also given to initially avoid compressive
views. loads onto the affected tendons (for example: ankle dorsi-
flexion in insertional Achilles tendinopathy, etc.), and are
eventually reintroduced at a later stage.43,44 Patients are also
Post-Injection Management, educated to monitor tendon pain and adjust the loading
Physiotherapy, Return-to-Sport progression if pain increases past a 5/10 on the Numerical
Pain Rating Scale (NPRS) during loading, increased stiff-
Patients are advised to rest the injected limb for 3 days, ness the following morning, or worsening over time.45–47
and are made aware of a possible steroid flare reaction.32 By day 10, patients are advised to start a course of super-
Immediately after the procedure, patients are referred to vised physiotherapy to improve any relevant biomechani-
a specialist physiotherapist for initial post-injection man- cal and functional issues, and progress the tendon loading
agement, and tendon loading program.38 On day 4, the program; plyometrics or stretch-shortening cycle training
progressive tendon loading program is selected and spe- is introduced as soon as tolerated, aiming to transition to
cifically adapted38 to each patient taking previous history, sport-specific training to match the physical requirements
current symptoms, tendon’s tolerance to loading, and short- (speed, duration, intensity) and technical skills of the target
and long-term goals into consideration. The 12–16 weeks activity/sport at pre-tendinopathy levels.
510 SEC T I O N I V Advanced

LEFT

0cm AT

le
Need
(Med) (Lat)
Kager

1cm

Achilles Tendon Injection Site (Medial approach) Achilles Tendon Ultrasound View

FR 17
LEFT
CHI
0cm Frq 15.0
Gn 35
S/A 2/1
PT Map A/0
D 2.3
DR 60
AO% 100

Needle

Hoffa
1cm
(Med) (Lat)

Patellar Tendon Injection Site (Medial approach) Patellar Tendon Ultrasound View
• Fig. 27.2 Needle approach, transducer positioning, and ultrasound view of the high-volume image-
guided injection of Achilles tendon and patellar tendon.
 CHAPTER 27 High-Volume Image-Guided Injections 511

Skin

Needle
0cm
Subcut.
fat

(Prox) (Dist)

al
Glute ons
2cm Tend
GT

Greater Trochanter Injection Site Greater Trochanter Ultrasound View

0cm
Deltoid
Needle
SAS
D bu
rsa
tus
spina
Supra

1cm Humeral
Head

Subacromial-Subdeltoid Space Injection Site Subacromial-Subdeltoid Space Ultrasound View

0cm
dle
Nee

r Ten don
on Extenso
Comm

Humerus
lat Epic. Radial
9cm
Head
(Prox) (Dist)

Lateral Epicondyle Injection Site Lateral Epicondyle Ultrasound View

0cm Skin

Nee Heel pad

dle

PF

1cm
Calc.
(Med) (Lat)

Plantar Fascia Injection Site (Medial approach) Plantar Fascia Ultrasound View
Needle

0cm Ext. Dig. Brevis

Talus Calc.
rsi
s Ta
Sinu

2cm

Sinus Tarsi Injection Site (Lateral approach) Sinus Tarsi Ultrasound View

(Plantar)
0cm Plantar Soft tissues

Morton

Mela
Mela
Head III
Mela Head IV
Head II
1cm
Needle

(Dorsal)

Morton Neuroma Injection Site Morton Neuroma Ultrasound View

0cm
Tib. post
Tendon Needle

ath
She

7cm

Tibialis Posterior Injection Site (Medial approach) Tibialis Posterior Ultrasound View
• Fig. 27.3 Needle approach, transducer positioning, and ultrasound view of the high-volume image-
guided injection for subacromial-subdeltoid space, sinus tarsi, and lateral epicondyle.
512 SEC T I O N I V Advanced

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tation exercise increases peritendinous type I collagen synthesis in
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ology and management. J Royal Society Med. 2004;97:472–476. 2007;17:61–66.
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dinopathy—current options for treatment. Disability Rehabil. J Sports Med. 2009;37:1855–1867.
2008;30:1666–1676. 22. Kjær M, Langberg H, Heinemeier K, et al. From mechanical
3. Magnan B, Bondi M, Pierantoni S, et al. The pathogenesis of loading to collagen synthesis, structural changes and function
Achilles tendinopathy: a systematic review. Foot Ankle Surg. in human tendon. Scandinavian J Med Sci Sports. 2009;19:500–
2014;20:154–159. 510.
4. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports 23. Tan SC, Chan O. Achilles and patellar tendinopathy: current
Med Arthrosc Rev. 2018;26:16–30. 2018/01/05. https://doi. understanding of pathophysiology and management. Disabil
org/10.1097/jsa.0000000000000185. Rehabil. 2008;30:1608–1615.
5. Van Schie H, De Vos R, De Jonge S, et al. Ultrasonographic tis- 24. Wheeler PC, Mahadevan D, Bhatt R, et al. A comparison of
sue characterisation of human Achilles tendons: quantification of two different high-volume image-guided injection procedures
tendon structure through a novel non-invasive approach. Brit J for patients with chronic noninsertional Achilles tendinopathy:
Sports Med. 2010;44:1153–1159. a pragmatic retrospective cohort study. 2016;55:976–979.
6. Maffulli N. Tendon problems: a basic science primer. J Sports 25. Wheeler PC, Tattersall CJCjosmojotCAoSM. Novel Interven-
Traumatol Related Res. 1999;21:3–10. tions for Recalcitrant Achilles Tendinopathy: Benefits Seen Following
7. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports High-Volume Image-Guided Injection or Extracorporeal Shockwave
Med Arthroscopy Rev. 2009;17:112–126. Therapy-A Prospective Cohort Study; 2018.
8. Öhberg L, Lorentzon R, Alfredson H. Neovascularisation in 26. Verlinde M, Hollmann MW, Stevens MF, et al. Local anesthetic-
Achilles tendons with painful tendinosis but not in normal ten- induced neurotoxicity. Intl J Mol Sci. 2016;17:339.
dons: an ultrasonographic investigation. Knee Surg Sports Trau- 27. Abdulhussein H, Chan O, Morton S, et al. High volume image
matol Arthroscop. 2001;9:233–238. guided injections with or without steroid for mid-portion
9. Longo UG, Rittweger J, Garau G, et al. No influence of age, gen- Achilles tendinopathy: a pilot study. Clin Res Foot Ankle. 2017;
der, weight, height, and impact profile in Achilles tendinopathy in 5:249.
masters track and field athletes. Am J Sports Med. 2009;37:1400– 28. Boesen AP, Langberg H, Hansen R, et al. High volume injection
1405. with and without corticosteroid in chronic midportion Achilles
10. Maffulli N, Spiezia F, Longo UG, et al. High volume image tendinopathy. Scandinavian J Med Sci Sports. 2019.
guided injections for the management of chronic tendinopathy 29. Boesen AP, Hansen R, Boesen MI, et al. Effect of high-volume
of the main body of the Achilles tendon. Physical Therap Sport. injection, platelet-rich plasma, and sham treatment in chronic
2013;14:163–167. midportion Achilles tendinopathy: a randomized double-blinded
11. Alfredson H. Chronic midportion Achilles tendinopathy: an update prospective study. Am J Sports Med. 2017;45:2034–2043.
on research and treatment. Clin Sports Med. 2003;22:727–741. 30. Andia I, Maffulli N. Platelet-rich plasma for muscle injury and
12. Maffulli N, Longo UG, Kadakia A, et al. Achilles tendinopathy. tendinopathy. Sports Med Arthroscopy Rev. 2013;21:191–198.
J Foot Ankle Surg. 2019 2019/04/30. https://DOI: 10.1016/j. 31. Andia I, Maffulli N. A contemporary view of platelet-rich plasma
fas.2019.03.009. therapies: moving toward refined clinical protocols and precise
13. De Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma indications. Regenerat Med. 2018;13:717–728.
injection for chronic Achilles tendinopathy: a randomized con- 32. Chan O, O’Dowd D, Padhiar N, et al. High volume image
trolled trial. JAMA. 2010;303:144–149. guided injections in chronic Achilles tendinopathy. Disabil Reha-
14. Hansen M, Boesen A, Holm L, et al. Local administration of bil. 2008;30:1697–1708.
insulin‐like growth factor‐I (IGF‐I) stimulates tendon col- 33. Crisp T, Khan F, Padhiar N, et al. High volume ultrasound
lagen synthesis in humans. Scandinavian J Med Sci Sports. guided injections at the interface between the patellar tendon and
2013;23:614–619. Hoffa’s body are effective in chronic patellar tendinopathy: a pilot
15. Khan K, Forster B, Robinson J, et al. Are ultrasound and mag- study. Disabil Rehabil. 2008;30:1625–1634.
netic resonance imaging of value in assessment of Achilles ten- 34. Humphrey J, Chan O, Crisp T, et al. The short-term effects of
don disorders? A two year prospective study. Brit J Sports Med. high volume image guided injections in resistant non-insertional
2003;37:149–153. Achilles tendinopathy. J Sci Med Sport. 2010;13:295–298.
16. Olesen JL, Heinemeier KM, Langberg H, et al. Expression, con- 35. Maffulli N, Del Buono A, Oliva F, et al. High-volume image-
tent, and localization of insulin-like growth factor I in human guided injection for recalcitrant patellar tendinopathy in athletes.
achilles tendon. Connect Tissue Res. 2006;47:200–206. Clin J Sport Med. 2016;26:12–16.
17. Andia I, Martin JI, Maffulli N. Advances with platelet rich 36. Morton S, Chan O, King J, et al. High volume image-guided
plasma therapies for tendon regeneration. Expert Opin Biol injections for patellar tendinopathy: a combined retrospective and
Therap. 2018;18:389–398. prospective case series. Muscles Ligaments Tendons J. 2014;4:214.
18. Alfredson H, Pietilä T, Jonsson P, et al. Heavy-load eccentric calf 37. Wheeler PC, Mahadevan D, Bhatt R, Bhatia M. A com-
muscle training for the treatment of chronic Achilles tendinosis. parison of two different high-volume image-guided injec-
Am J Sports Med. 1998;26:360–366. tion procedures for patients with chronic noninsertional
19. Loppini M, Maffulli N. Conservative management of tendinopa- Achilles tendinopathy: a pragmatic retrospective cohort study. J
thy: an evidence-based approach. Muscles Ligaments Tendons J. Foot Ankle Surg. 2016;55(5):976–979. https://doi.org/10.1053/j.
2011;1:134. jfas.2016.04.017.
 CHAPTER 27 High-Volume Image-Guided Injections 513

38. Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related 43. Cook J, Purdam C. Is compressive load a factor in the develop-
tendinopathies: a review of selected topical issues by participants ment of tendinopathy? Brit J Sports Med. 2012;46:163–168.
of the Second International Scientific Tendinopathy Symposium 44. Docking S, Samiric T, Scase E, et al. Relationship between com-
(ISTS), Vancouver, 2012. 2013;47:536–544. pressive loading and ECM changes in tendons. 2013;3:7.
39. Beyer R, Kongsgaard M, Hougs Kjær B, et al. Heavy slow resis- 45. GrävareSilbernagel K, Thomee R, Thomee P, et al. Eccentric over-
tance versus eccentric training as treatment for Achilles tendi- load training for patients with chronic Achilles tendon pain—
nopathy: a randomized controlled trial. 2015;43:1704–1711. a randomised controlled study with reliability testing of the eval-
40. GrävareSilbernagel K, Crossley KMJjoo, therapy sp. A proposed uation methods. 2001;11:197–206.
return-to-sport program for patients with midportion Achilles 46. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid
tendinopathy: rationale and implementation. 2015;45:876–886. injections, eccentric decline squat training and heavy slow resis-
41. Silbernagel KG, Thomeé R, Eriksson BI, et al. Continued sports tance training in patellar tendinopathy. 2009;19:790–802.
activity, using a pain-monitoring model, during rehabilitation 47. Malliaras P, Barton CJ, Reeves ND, et al. Achilles and patellar
in patients with Achilles tendinopathy: a randomized controlled tendinopathy loading programmes. Sports Med. 2013;43:267–
study. 2007;35:897–906. 286.
42. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces
analgesia and reduces inhibition in patellar tendinopathy.
2015;49:1277–1283.
28
Ultrasound-Guided Release
of Trigger Finger and de
Quervain Tenosynovitis
RICARDO E. COLBERG AND JAVIE R A. JURADO

Ultrasound-Guided Trigger Finger Release (PIP) joints. The A1 pulley is found at the level of the
metacarpal head and MCP joint, and this measurement is
at the First Annular (A1) Pulley roughly equivalent to the distance between the proximal
edge of the A1 pulley and the MCP crease (Fig. 28.1).11
KEY POINTS There is a neurovascular bundle at both the radial and ulnar
side of the tendon.11 The digital arteries originate from the
• C ompared to open surgery, releasing the A1 pulley
under ultrasound guidance has a better safety profile
superficial palmar arch (artery), which is roughly 1 inch
with a lower risk of complications and a quicker return proximal to the MCP joint.
to work.1
• Percutaneous release is performed through a small
puncture incision that does not require sutures. Common Pathology
• Ultrasound image guidance allows the physician to
visualize the neurovascular bundle before making
Stenosing tenosynovitis of the finger flexor tendons, more
the incision as well as during the procedure, which commonly referred to as “trigger finger,” can lead to pain and
diminishes the risk of neurovascular injury.2–5 loss of mechanical hand function. In the acute phase, inflam-
• Return to basic daily activities and resuming full mation of the tendon and the synovial lining of the tendon
duties at work is quicker since the wound heals more sheath causes severe pain with finger bending. The inflam-
quickly.1,6,7
• This procedure should be avoided in patients that
mation eventually can cause mechanical catching or locking
present with evidence of Dupuytren contracture. of the tendon at the A1 pulley as the tendon gets so swollen
• The Colberg criteria help confirm a complete release of that it does not glide well under the pulley with finger flexion
the A1 pulley.8 and extension.12 The friction created from the catching leads
   to chronic thickening of the A1 pulley, which may lead to a
permanently locked finger.13 The severity of the trigger fin-
Anatomy ger is graded based on the Quinnell grading system14:
• Grade 1—pain with flexion at the A1 pulley with no
The flexor tendons in the finger lay palmar (volar) to the mechanical symptoms
metacarpal bones with the flexor digitorum profundus • Grade 2—painful catching at the A1 pulley with active
(FDP) closer to the metacarpal bone and the flexor digito- release with the same finger extension
rum superficialis (FDS) farthest from the metacarpal bone. • Grade 3—painful locking that requires passive release
The FDP and FDS tendons are surrounded by a common with the other hand
synovial tendon sheath. There are five annular ligaments, • Grade 4—permanently locked finger
referred to as “A pulleys,” which are superficial to the ten-
don sheath that hold the tendons close to the bone. The A1 Ultrasound Imaging Findings
pulley is the most proximal and clinically significant liga-
ment.9,10 The length of the A1 pulley can be estimated by Ultrasound is used to evaluate the A1 pulley, flexor ten-
measuring the distance between the palmar creases of the dons, and neurovascular structures, as well as to diagnose
metacarpophalangeal (MCP) and proximal interphalangeal mechanical catching of the tendon (Fig. 28.2). In the

514
 CHAPTER 28 Ultrasound-Guided Release of Trigger Finger and de Quervain Tenosynovitis 515

Equipment
• N eedles: 25-gauge, 1.5-inch needle/18-gauge, 1.5-inch
needle with a blade at the tip (Nokor Admix, Becton,
Dickinson and Company, Franklin Lakes, NJ) (Fig.
28.3). Other instruments such as the hook knife have
also been reported and shown to be effective.2
• Musculoskeletal ultrasound machine with a high-fre-
quency linear array transducer.
Technique
Patient Position
• S eated with the palmar side of the hand facing up and the
hand resting at the edge of the table in order to allow hyper-
extension of the MCP joint. The palmar side is cleansed in
a sterile fashion from mid-palm down to the distal inter-
phalangeal joint, creating a sterile field (Fig. 28.4A).
• For patients with risk of vasovagal syncope, we recom-
Tendon sheath mend having them lay down supine with the hand facing
up, resting at their side at the edge of the table.

Clinician Position
• Seated distal to the trigger finger.
Tendon of the flexor
digitorum superficialis Transducer Orientation
• Fig. 28.1 Anatomy of the Flexor Tendons and Pulleys. (From • S hort axis to the metacarpal bone and flexor tendon to
Waldman S. Atlas of Common Pain Syndromes. 4th ed. Elsevier,
Philadelphia, PA; 2019.)
identify the neurovascular structures.
• Long axis to the flexor tendon over the A1 pulley and the
MCP joint to perform the release.
cross-sectional view, the A1 pulley is at the level of the
metacarpal head superficial to the tendon sheath. The neu- Needle Orientation
rovascular structures are seen radial and ulnar (i.e., lateral • I n-plane with the transducer with a distal to proximal
and medial) to the tendons (see Fig. 28.2A). The A1 pulley approach toward the A1 pulley.
can be further evaluated in the longitudinal view for any
evidence of tendinopathy such as hypoechoic thickening Target
of the tendon and/or hyperemia in the tendon sheath or • I nject local anesthesia with a 25-gauge, 1.5-inch needle
A1 pulley on power Doppler imaging.15,16 Hypertrophy of from distal to proximal over the A1 pulley and inside the
the A1 pulley and a swollen nodule in the tendon with a tendon sheath (see Fig. 28.4B)
mechanical catching at the A1 pulley (see Fig. 28.2C) dur- • Create a puncture incision in the skin using the 18-gauge
ing dynamic ultrasound examination confirms the diagno- Nokor needle and advance towards the A1 pulley and
sis of trigger finger.15 flexor tendons.
• Make an incision through the A1 pulley and the tendon
Treatment Options sheath from distal to proximal (see Fig. 28.4A). Irrigate
the tendon with normal saline solution to ensure a com-
Patients are generally first treated with nonsteroidal anti- plete release.
inflammatory drugs (NSAIDs), finger night splints, cor-
tisone injection, and/or physical therapy.17 Injecting the Injectate Volume
trigger finger using ultrasound guidance improves accu- • L ocal anesthesia: 1 to 3 mL of local anesthetic
racy of the placement of the needle, avoiding neurovas- • Author prefers 1% lidocaine with epinephrine (1:100,000)
cular structures.18,19 Cortisone injection and splinting • Irrigation: 3 mL normal saline solution
have been shown to provide significant relief in 50% to
56% of patients.20–24 However, more than 30% of cases
Pearls and Pitfalls
do not resolve, especially if the treatment did not start
before the onset of mechanical symptoms.23,24 These cases • A
 void puncturing the neurovascular structures and blood
require a release of the A1 pulley by either open surgery, vessels by keeping the Nokor needle tip (blade) in the
palpation guided, or ultrasound-guided release of the A1 visual field at all times.
pulley.1,8,25–29
516 SEC T I O N I V Advanced

A RIGHT TRIGGER FINGER A 1 PULLEY RELEASE RING B RIGHT MIDDLE FINGER TRIGGER FINGER RELEASE

C RIGHT MIDDLE FINGER TRIGGER FINGER RELEASE

• Fig. 28.2Flexor digitorum superficialis and profundus at the metacarpophalangeal joint (oval: A1 pulley).
(A) Short-axis view of the tendons and surrounding neurovascular structures. (B) Finger in full extension
with the nodule (oval) away from the A1 pulley. (C) Finger in flexion with the nodule (oval) catching at the
A1 pulley.

• D espite popular belief, epinephrine is safe to use near fin-

gers, even for digital nerve blocks, and it greatly reduces
the amount of bleeding that occurs with the procedure,
A minimizing complications.30
• This procedure should be avoided in patients that have
widespread hand pain, complex regional pain syndrome,
or evidence of Dupuytren contracture.
• Complete release of the A1 pulley can be confirmed after
the procedure using the Colberg criteria (Fig. 28.5B–D)8:
1. Irrigate the tendon and the area where the A1 pulley
was released in order to visualize an anechoic defect
between the two ends of the severed A1 pulley (see
Fig. 28.5B and D).
2. Perform a dynamic ultrasound evaluation of the tendon
by doing active and passive range of motion in order
to visualize the tendon gliding smoothly without any
mechanical catching/locking (see Fig. 28.5E and F).
3. Have the patient make a fist 10 times by doing full
B RIGHT RING FINGER TRIGGER FINGER RELEASE
active range of motion of the hand/fingers, closing
• Fig. 28.3 Nokor Admix 18-gauge, 1.5-inch hypodermic needle and opening all of the fingers to make sure there
(A) with blade at the tip and ultrasound image of the needle (B). is no residual mechanical catching/locking of the
­tendon.
 CHAPTER 28 Ultrasound-Guided Release of Trigger Finger and de Quervain Tenosynovitis 517

from eliminating the mechanical catching of the trigger

finger.8,31

Post-Procedure
Once the A1 pulley has been released, an adhesive ban-
dage is placed over the puncture incision and it may be
removed 24 hours post-procedure. Patients are instructed
to avoid heavy lifting or gripping for 2 weeks. Patients can
perform all basic activities of daily living and light duties
as tolerated 24 hours post-procedure. If there is pain,
patients can ice the treated area and take acetaminophen
or an over-the-counter NSAID as needed. Patients may
have mild residual soft tissue swelling after the release that
will resolve within the first 4 weeks post-procedure.

Complications Post-Procedure
Possible complications after the procedure, although
A extremely rare, include residual pain, infection, flexor ten-
don laceration, neurovascular injury, and incomplete release
of the A1 pulley.32 The thumb presents two additional chal-
lenges to the procedure: (1) the thumb digital nerve can
cross over the A1 pulley and is at risk of laceration; and
(2) the thumb frequently has a sesamoid bone within the
adductor pollicis and abductor pollicis brevis tendons,
which may displace the tendon and make it difficult to nav-
igate the needle into the A1 pulley without lacerating the
tendon.5,33 These are similar to complications that may be
seen with open surgery and palpation-guided percutaneous
release.12 Open surgeries carry a risk rate of 12% to 28%,
ranging from nerve injury, vascular injury, wound infection
to wound dehiscence and scar hypertrophy.34–36 Ultrasound
B RIGHT MIDDLE FINGER TRIGGER FINGER RELEASE minimizes the risks associated with palpation-guided percu-
taneous release, especially the risk of an incomplete release,
• Fig. 28.4 (A) Position of patient, clinician, transducer, needle, and tendon laceration and neurovascular injury.5 PIP joint flex-
ultrasound machine. (B) Flexor digitorum superficialis and profundus
at the metacarpophalangeal joint. Oval: A1 pulley. Arrow: 25-gauge,
ion contracture and diabetes are risk factors for residual pain
1.5-inch hypodermic needle distal to the A1 pulley inside the tendon at the PIP joint after releasing the trigger finger.37
sheath. The fluid was injected from distal to proximal inside the ten-
don sheath. It can be seen spreading through the superficial and deep
aspect of the tendon sheath proximal to the A1 pulley. Ultrasound-Guided Release of De
Quervain Tenosynovitis
• I f a patient does not pass any of the three tests, residual KEY POINTS
A1 pulley fibers may be present and the incision should
be extended proximal or distal according to where the • C ompared to open surgery, an ultrasound-guided first
residual catching is identified. The Colberg criteria compartment release has a better safety profile with a
lower risk of complications.38
should be performed again to ensure complete release of • It is performed through a small puncture incision that
the A1 pulley. does not require sutures.39
• If done correctly, patients should not feel any residual • Ultrasound image guidance allows the physician to
catching/locking after the procedure and rate of recur- visualize the neurovascular bundle before making
rence is less than 1%.8 the incision, as well as during the procedure, which
diminishes the risk of neurovascular injury.38
• Avoid immobilizing after the procedure in order to mini- • Return to basic daily activities and resuming full duties
mize scar tissue formation around the tendon that may at work is quicker since the wound heals more quickly.
lead to flexion contracture. • This procedure should be avoided in patients with
• Preexisting PIP joint flexion contracture is a risk factor a history of first dorsal compartment release and
for residual pain at the PIP joint after releasing the trig- recurrence.
ger finger because the finger range of motion increases   
518 SEC T I O N I V Advanced

A RIGHT MIDDLE FINGER TRIGGER FINGER RELEASE B RIGHT MIDDLE FINGER TRIGGER FINGER RELEASE

C RIGHT TRIGGER FINGER A 1 PULLEY RELEASE RING D RIGHT TRIGGER FINGER A 1 PULLEY RELEASE INDEX

E RIGHT MIDDLE FINGER TRIGGER FINGER RELEASE F RIGHT MIDDLE FINGER TRIGGER FINGER RELEASE

• Fig. 28.5 Flexor digitorum superficialis and profundus at the metacarpophalangeal joint before and after
A1 pulley release. (Oval: A1 pulley). (A) Longitudinal view of tendons showing intact A1 pulley before
release. truncated rectangle: 18-gauge Nokor needle. The needle was advanced from distal to proximal.
(B) Longitudinal view of tendons post-release showing an empty space where the A1 pulley used to be.
(C) Cross-sectional view of the tendons showing intact A1 pulley and neurovascular bundles (arrows). (D)
Cross-sectional view of the tendons showing a transected A1 pulley (empty space inside the rectangle
between (the two ends of the A1 pulley after release). (E) Finger in full extension with the nodule away from
the area of the A1 pulley. (F) Finger in full flexion with the nodule gliding smoothly through the area where
the A1 pulley used to be not catching anymore.

Anatomy
extensor retinaculum within six dorsal compartments. The
The extensor retinaculum is a bandlike structure that extends abductor pollicis longus and extensor pollicis brevis tendons
over the dorsal wrist at the level of the distal radius. It holds are found in the first compartment. In some cases, the two
the abductor and extensor tendons of the wrist and fingers in cross the compartment in a common tendon sheath, while in
place (Fig. 28.6). These tendons cross the wrist joint under the other cases they travel through the compartment separated by
 CHAPTER 28 Ultrasound-Guided Release of Trigger Finger and de Quervain Tenosynovitis 519

• Fig. 28.6
Anatomy of the Extensor Retinaculum and First Dorsal Compartment. (From Greene W. Netter’s
Orthopaedics. Saunders, Philadelphia, PA; 2006. Used with permission of Elsevier. All rights reserved.)

a septum.40 The radial artery and vein as well as the superficial small branches covering the area.39 In over 60% of patients
radial nerve are adjacent to the first dorsal compartment. with de Quervain tenosynovitis, an intra-compartment sep-
tum can be identified, separating the APL and EPB tendons
Common Pathology in the axial view.40

de Quervain tenosynovitis, one of the most common tenosy- Treatment Options

novitis, occurs at the first dorsal compartment and involves the
abductor pollicis longus and extensor pollicis brevis tendons. Patients are generally first encouraged to rest, avoid painful
Inflammation and swelling cause mechanical catching/locking activities, and wear a thumb spica wrist splint. Additionally,
and tenderness at the extensor retinaculum.41–43 The Finkelstein patients may be treated with NSAIDs, a cortisone injection,
test can be performed to confirm the diagnosis (pain reproduced and physical therapy.41–45 Injecting the first dorsal compart-
with flexing the thumb into the palm of the hand, forming a fist ment with ultrasound guidance ensures accurately placing
around the thumb and ulnar deviating the wrist).42 the needle inside the tendon sheath while avoiding the neu-
rovascular structures.46 However, many cases do not resolve,
Ultrasound Imaging Findings especially if the treatment did not start before the osnet of
the mechanical symptoms. These cases require a release of the
Ultrasound can be used to visualize pathology in the exten- extensor retinaculum and incision of the tendon sheath by
sor retinaculum, abductor pollicis longus (APL) and extensor either open surgical release or an ultrasound guided release.38
pollicis brevis (EPB) tendons, and neurovascular structures.39
The extensor retinaculum can be identified in the longitudinal Equipment
view above both tendons over the distal radius (Fig. 28.7A).39
Fig. 28.5B shows the extensor retinaculum in short-axis view • N
 eedles: 25-gauge, 1.5-inch needle/18-gauge, 1.5-inch
covering the radial styloid and the APL and EPB tendons. In needle with a blade at the tip (Nokor Admix, Becton,
the axial view, the radial artery is found volar to the first dorsal Dickinson and Company, Franklin Lakes, NJ) (see
compartment and the superficial radial artery dorsally, with Fig. 28.2)/20-gauge, 1.5-inch needle. A release using
520 SEC T I O N I V Advanced

RIGHT WRIST FIRST DORSAL COMPARTMENT RELEASE

A

RIGHT WRIST FIRST DORSAL COMPARTMENT RELEASE

B
• Fig. 28.7 Ultrasound images of abductor pollicis longus and extensor pollicis brevis at the end of the
radius and patient position. (A) Longitudinal view of tendons showing intact extensor retinaculum with the
finger in full extension. (Circle: small cutaneous branch from superficial radial nerve.) (B) Cross-sectional
view of the tendons showing intact extensor retinaculum. (Oval: superficial radial nerve.) (C) Position of
patient, clinician, transducer, needle, and ultrasound machine.

a regular hypodermic needle (20 or 21 gauge) has also

Nerve Block
been described in the literature.38
• Ultrasound machine with a high-frequency linear array Needle Orientation
transducer. • I n-plane with the transducer in short axis to the super-
ficial radial nerve about 3 inches proximal to the first
Technique dorsal compartment of the wrist.
Patient Position
• S eated or supine with the wrist in neutral between prona- Target
tion and supination (thumb up). The radial side of the • I nject using the 25-gauge, 1.5-inch needle to create a
distal forearm and wrist is cleansed in sterile fashion in superficial radial nerve block.
order to create a sterile field (see Fig. 28.7C). • Then inject additional local anesthesia from distal to
proximal in longitudinal axis over the first dorsal com-
Clinician Position partment, injecting into the soft tissue and tendon
• Seated distal and volar to the thumb. sheath.

Transducer Orientation de Quervain Release

• S hort axis to identify the neurovascular structure and Needle Orientation
perform the nerve block. • I n-plane with the transducer, with a distal to proximal
• Longitudinal axis over the tendons of the first dorsal approach toward the first dorsal compartment of the
compartment of the wrist for the release. wrist.
 CHAPTER 28 Ultrasound-Guided Release of Trigger Finger and de Quervain Tenosynovitis 521

A RIGHT WRIST FIRST DORSAL COMPARTMENT RELEASE B RIGHT WRIST FIRST DORSAL COMPARTMENT RELEASE

RIGHT WRIST FIRST DORSAL COMPARTMENT RELEASE

C
• Fig. 28.8The extensor retinaculum during the procedure and after the incision made. Arrow: location
of the 18-gauge, 1.5-inch needle with a blade at the tip. (A) Longitudinal view of the needle cutting the
extensor retinaculum. (B) Short-axis view of the needle cutting the extensor retinaculum. (C) Short-axis
view of the extensor retinaculum post-procedure with the incision created. (Oval: incision through the
extensor retinaculum.)

Target • C omplete incision of the extensor retinaculum can be

• C reate a puncture incision in the skin using the 18-gauge seen in Fig. 28.8C.
Nokor needle and advance toward the extensor retinacu- • Patients can perform all basic activities of daily living and
lum and first dorsal compartment. light duties as tolerated 24 hours post-procedure. A thumb
• Make an incision through the extensor retinaculum and spica brace may be offered for severe cases to be worn for 1
tendon sheath from distal to proximal (Fig. 28.8A–C). week in order to avoid instability of the tendon.
Irrigate the tendon with normal saline solution to ensure • Patients may have mild residual soft tissue swelling
a complete release. after the release that will resolve within the first 4 weeks
post-procedure.
Injectate Volume
• If done correctly, patients should not feel any residual
• L ocal anesthesia: 3 mL 1% lidocaine plain for the super- catching/locking after the procedure.
ficial radial nerve block • Avoid immobilizing for more than 1 week after the pro-
• 1 mL to 3 mL of local anesthetic; Author prefers 1% cedure in order to minimize scar tissue formation around
lidocaine with epinephrine (1:100,000) the tendon that may lead to extension contracture.
• Irrigation: 3 mL normal saline solution • This procedure should be avoided in patients that previ-
ously had a surgery in the first dorsal compartment of the
Pearls and Pitfalls wrist, have widespread hand pain, or complex regional
pain syndrome.
• A void puncturing the neurovascular structures and blood
vessels by keeping the Nokor needle tip (blade) in the
visual field at all times.
Post-Procedure
• Complete release of the first dorsal compartment may
be confirmed after the procedure applying the Colberg An adhesive bandage is placed over the puncture incision
criteria mentioned above. and it may be removed 24 hours post-procedure. Patients
522 SEC T I O N I V Advanced

are given a thumb spica brace to wear during the night for 28th Annual Meeting for the American Medical Society for
1 week and are instructed to avoid heavy lifting or grip- Sports Medicine; April 12–17, 2019; Orlando, FL.
ping for 2 weeks. Patients can perform all basic activities 9. Fiorini HJ, Santos JBG, Hirakawa CK, Sato ES, Faloppa F,
of daily living and light duties as tolerated 24 hours post- Albertoni WM. Anatomical study of the A1 pulley: length and
location by means of cutaneous landmarks on the palmar surface.
procedure. If there is pain, patients can ice the treated area
J Hand Surg. 2011;36A:464–468.
and take acetaminophen or an over-the-counter NSAID as 10. Wilhelmi BJ, Snyder NIV, Verbesey JE, Ganchi PA, Lee WP.
needed. Patients may have mild residual soft tissue swelling Trigger finger release with hand surface landmark ratios: an ana-
after the release that typically resolve within the first 4 weeks tomic and clinical study. Plast Reconstr Surg. 2001;108:908–915.
post-procedure. 11. Kaplan 3rd SJ, FW. Anatomical study of the A1 pulley: length
and location by means of cutaneous landmarks on the palmar
surface. J Hand Surg. 2011;36(6):1114.
Complications Post-Procedure 12. Langer D, Maeir A, Michailevich M, Luria S. Evaluating hand
Complications are rare and include residual pain, infection, function in clients with trigger finger. Occupation Therap Intl.
bruising, tendon laceration, neurovascular injury, incom- 2017;2017.
plete release, and instability of the tendons leading to sub- 13. Lundin AC, Eliasson P, Aspenberg P. Trigger finger and tendino-
sis. J Hand Surg (European Volume). 2012;37(3):233–236.
luxation.38,40,47 These complications are similar to the ones
14. Quinnell RC. Conservative management of trigger finger. The
seen with an open surgical release.48,49 Open surgery carries Practitioner. 1980;224:187–190.
a risk of adverse events of up to 42%, including pain, nerve 15. Guerini H, Pessis E, Theumann N, et al. Sonographic appearance
injury, wound complications, and tendon subluxation.48 of trigger fingers. J Ultrasound Med. 2008;27(10):1407–1413.
Ultrasound minimizes the risks associated with open sur- 16. Sato J, Ishii Y, Noguchi H, Takeda M. Sonographic appearance
gery, especially the risk of neurovascular injury since the of the flexor tendon, volar plate, and A1 pulley with respect to the
nerves and blood vessels can be visualized at all times.5,50 severity of trigger finger. J Hand Surg. 2012;37(10).
Tendon subluxation is a rare complication, but if present 17. Amirfeyz R, McNinch R, Watts A, et al. Evidence-based manage-
may require surgery to repair the retinaculum. Immobili- ment of adult trigger digits. J Hand Surg. 2017;42(5):473–480.
zation with the thumb spica splint attempts to reduce the 18. Lee DH, Han SB, Park JW, et al. Sonographically guided ten-
risk of subluxation.51 In addition, given the anatomic vari- don sheath injections: implications for trigger finger treatment. J
Ultrasound Med. 2011;30(2):197–203.
ability of the superficial radial nerve and its branches, there
19. Mardani-Kivi M, Karimi-Mobarakeh M, Babaei Jandaghi A,
is also risk of injuring this nerve or one of the branches and Keyhani S, Saheb-Ekhtiari K, Hashemi-Motlagh K. Intra-sheath
they should be identified with ultrasound imaging prior to versus extra-sheath ultrasound guided corticosteroid injection for
initiating the procedure.52,53 Given this, a palpation-guided trigger finger: a triple blinded randomized clinical trial. Physician
release is not recommended for de Quervain tenosynovitis Sportsmed. 2017:1–5.
due to the high risk of neurovascular injury. Ultrasound 20. Patel MR, Bassini L. Trigger fingers and the thumb: when to
guidance should always be used. splint, inject or operate. J Hand Surg Am. 1992;17(1):110–113.
21. Rodgers JA, McCarthy JA, Tiedeman JJ. Trigger fingers and
themb: when to splint, inject and operatre. Orthopedics.
References 1998;21(3): discussion 309–310.
1. Nikolaou VS, Malahias MA, Kaseta MK, Sourlas I, Babis GC. 22. Benan DA, Nakhdjevani A, Lloyd MA, Schreuder FB. The effi-
Comparative clinical study of ultrasound-guided A1 pulley cacy of steroid injection in the treatment of trigger finger. Clin
release vs open surgical intervention in the treatment of trigger Orthop Surg. 2012;4(4):263–268.
finger. World J Orthop. 2017;8(2):163. 23. Rozental TD, Zurakowsky D, Blazer PE. Trigger finger prognos-
2. Smith J, Rizzo M, Lai JK. Sonographically guided percutaneous tic indicator of recurrence following corticosteroid injection. J
first annular pulley release. J Ultrasound Med. 2010;29(11):1531– Bone Joint Surg Am. 2008;90(8):1665–1672.
1542. 24. Benson LS, Ptaszek AJ. Injection versus surgery in the treatment
3. Weiss ND, Richter MB. Percutaneous release of trigger digits. of trigger finger. J Hand Surg Am. 1997;22(1):138–144.
Am J Orthop (Belle Mead, NJ). 2017;46(4):E263–E267. 25. Kuo LC, Su FC, Tung WL, Lai KY, Jou IM. Kinematical and
4. Werthel JD, Cortez M, Elhassan BT. Modified percutaneous functional improvements of trigger digits after sonographically
trigger finger release. Hand Surg Rehabil. 2016;35(3):179–182. assisted percutaneous release of the A1 pulley. J Orthop Res.
5. Zhao JG, Kan SL, Zhao L, et al. Percutaneous first annular pulley 2009;27(7):891–896.
release for trigger digits: a systematic review and meta-analysis of 26. Marij Z, Aurangzeb Q, Rizwan HR, Haroon R, Pervaiz MH.
current evidence. J Hand Surg. 2014;39(11):2192–2202. Outpatient percutaneous release of trigger finger: a cost effective
6. Gilberts EC, Beekman WH, Stevens HJ, Wereldsma JC. Pro- and safe procedure. Malaysian Orthop J. 2017;11(1):52.
spective randomized trial of open versus percutaneous surgery for 27. Mishra SR, Gaur AK, Choudhary MM, Ramesh J. Percutaneous
trigger digits. J Hand Surg. 2001;26(3):497–500. A1 pulley release by the tip of a 20G hypodermic needle before
7. Dierks U, Hoffmann R, Meek MF. Open versus percutaneous open surgical procedure in trigger finger management. Techniques
release of the A1-pulley for stenosing tendovaginitis: a prospective Hand Upper Extremity Surg. 2013;17(2):112–115.
randomized trial. Tech Hand Extrem Surg. 2008;12(3):183–187. 28. Rojo-Manaute JM, Rodríguez-Maruri G, Capa-Grasa A, Chana-
8. Colberg R, Fleisig G, Drogosz M, Pantuosco J. A novel U/S- Rodríguez F, Soto MD, Martín JV. Sonographically guided
guided trigger finger release and diagnostic testing techniques. intrasheath percutaneous release of the first annular pulley for
Oral poster session presented at: 2019 AMSSM Annual Meeting. trigger digits, Part 1. J Ultrasound Med. 2012;31(3):417–424.
 CHAPTER 28 Ultrasound-Guided Release of Trigger Finger and de Quervain Tenosynovitis 523

29. Jou IM, Chern TC. Sonographically assisted percutaneous release 42. Som A, Singh P. Finkelstein Sign. StatPearls Publishing. 2019.
of the A1 pulley: a new surgical technique for treating trigger 43. Roh YH, Noh JH, Gong HS, Baek GH. Effects of metabolic syn-
digit. J Hand Surg. 2006;31(2):191–199. drome on the functional outcomes of corticosteroid injection for
30. Ilicki J. Safety of epinephrine in digital nerve blocks: a literature de Quervain tenosynovitis. J Hand Surg Euro Vol. 2017;42(5):481.
review. J Emerg Med. 2015;49(5):799–809. 44. Huisstede BM, Gladdines S, Randsdorp MS, Koes BW. Effec-
31. Salim N, Abdullah S, Sapuan J, Haflah NH. Outcome of corti- tiveness of conservative, surgical, and post-surgical interventions
costeroid injection versus physiotherapy in the treatment of mild for trigger finger, Dupuytren’s disease, and de Quervain’s disease.
trigger fingers. J Hand Surg Eur Vol. 2012;37(1):27–34. A systematic review. Archives Physical Med Rehabil. 2017.
32. Paulius KL, Maguina P. Ultrasound-assisted percutaneous trigger 45. Cavaleri R, Schabrun SM, Te M, Chipchase LS. Hand therapy
finger release: is it safe? Hand. 2009;4(1):35–37. versus corticosteroid injections in the treatment of de Quervain’s
33. Cebesoy O, Karakurum G, Kose KC, Baltaci ET, Isik M. Percu- disease: a systematic review and meta-analysis. J Hand Therap.
taneous release of the trigger thumb: is it safe, cheap and effec- 2016;29(1):3–11.
tive? Int Orthopaedic. 2007;31(3):345–349. 46. Kutsikovich J, Merrell G. Accuracy of injection into the first
34. Everding NG, Bishop GB, Belyea CM, Soong MC. Risk fac- dorsal compartment: a cadaveric ultrasound study. J Hand Surg.
tors for complications of open trigger finger release. Hand. 2018;43(8): 777–e1.
2015;10(2):297–300. 47. Güleç A, Türkmen F, Toker S, Acar MA. Percutaneous release
35. Finsen V, Hagen S. Surgery for trigger finger. Hand Surg. of the first dorsal extensor compartment: a cadaver study. Plastic
2003;8(2):201–203. Reconstru Surg Global Open. 2016;4(10).
36. Will R, Lubahn J. Complications of open trigger finger release. J 48. Rogozinski B, Lourie GM. Dissatisfaction after first dorsal com-
Hand Surg Am. 2010;34(4):594–596. partment release for de Quervain tendinopathy. J Hand Surg Am.
37. Siddiqui AA, Rajput IM, Adeel M. Outcome of percutaneous 2016;41(1):117–119.
release for trigger digits in diabetic and non-diabetic patients. 49. Bruijnzeel H, Neuhaus V, Fostvedt S, Jupiter JB, Mudgal CS,
Cureus. 2019;11(5):e4585. Ring DC. Adverse events of open A1 pulley release for idiopathic
38. Lapègue F, André A, Pasquier Bernachot E, et al. US-guided per- trigger finger. J Hand Surg Am. 2012;37(8):1650–1656.
cutaneous release of the first extensor tendon compartment using 50. Danda RS, Kamath J, Jayasheelan N, Kumar P. Role of ultra-
a 21-gauge needle in de Quervain’s disease: a prospective study of sound in the treatment of de Quervain tenosynovitis by local ste-
35 cases. Eur Radiol. 2018. roid infiltration. J Hand Microsurg. 2016;8(1):34–37.
39. Colberg RE, Henderson RG. Ultrasound-guided first dorsal 51. Horn BJ, Zondervan R, Hornbach E. Prevention of tendon sub-
compartment release for refractory de Quervain tenosynovitis: a luxation in de Quervain’s tenosynovitis release using retinacular
case report. PM R. 2019;11(6):665. repair. Spartan Med Res J. 2016;1(1):4705.
40. Sato J, Ishii Y, Noguchi H. Ultrasonographic evaluation of the 52. Abrams RA, Brown RA, Botte MJ. The superficial branch of
prevalence of an intracompartmental septum in patients with de the radial nerve: an anatomic study with surgical implications. J
Quervain’s disease. Orthopedics. 2016;39(2):112–116. Hand Surg. 1992;17(6):1037–1041.
41. Peck E, Ely E. Successful treatment of de Quervain tenosyno- 53. Robson AJ, See MS, Ellis H. Applied anatomy of the superficial
vitis with ultrasound-guided percutaneous needle tenotomy branch of the radial nerve. Clin Anat. 2008;21(1):38–45.
and platelet-rich plasma injection: a case presentation. PM R.
2013;5(5):438–441.
29
Compartment Pressure
Testing
JONATHAN T. FINNOFF AND JACOB REISNER

artery and vein.2 The tibialis posterior muscle is contained

KEY POINTS
in its own fascia and is sometimes referred to as the fifth
• C hronic exertional compartment syndrome (CECS) compartment of the leg.2
is a painful condition characterized by an increase in
intracompartmental pressure (ICP) with exercise.1
• This is seen most commonly in the four muscular Common Pathology
compartments of the leg but has also been described
in the foot, the four compartments of the arm, and Chronic exertional compartment syndrome (CECS) most
the hand.1,2 This chapter focuses on compartment commonly affects the anterior (40% to 60%) and deep pos-
pressure testing for the leg, but the principles can be terior compartments (32% to 60%), followed by the lateral
applied to the other locations. (12% to 35%) and superficial posterior compartments (2%
• Preexercise and postexercise ICP is the “gold standard”
test to diagnose CECS.
to 20%).2 Thickened and less-compliant compartment fas-
• Compartment pressures are obtained by inserting cia, reduced microcapillary capacity, and venous congestion
an ICP monitor with palpation guidance into the four have all been postulated to contribute to the development of
compartments of the leg. CECS, but the pathophysiology is still debated.2
• ICPs are obtained prior to exercise and at 1 minute and In normal muscle physiology, there is a 20% increase in
5 minutes post exercise.
• CECS is confirmed using the Pedowitz criteria3 if the
muscle volume during exercise and, as a result, intracom-
preexercise ICP greater than 15 mm Hg, 1-minute partmental pressure (ICP) increases.4 In CECS, increased
postexercise ICP greater than 30 mm Hg, or 5-minute compartment pressure during exercise may also lead to tran-
postexercise ICP greater than 20 mm Hg. sient neuropraxia manifesting as transient changes in sensa-
   tion and strength. The neurologic symptoms are related to
the nerve contained in the effected compartment. CECS
involving the anterior compartment may present with deep
Pertinent Anatomy peroneal neuropraxia with foot drop and first web space
numbness that progressively develops with activity.2 CECS
The leg contains four distinct compartments: anterior, lat- of the lateral compartment may present with activity-
eral, superficial posterior, and deep posterior.2 The ante- related progressive ankle eversion weakness and dorsal foot
rior compartment contains the tibialis anterior muscle, numbness.2 CECS involving the superficial and/or deep
extensor hallicus longus muscle, extensor digitorum lon- posterior compartment may present with activity-related
gus muscle, peroneus tertius muscle, deep peroneal nerve, progressive plantar foot paresthesias and ankle plantar flex-
and the anterior tibial artery and vein.2 The lateral com- ion weakness.2
partment contains the peroneus longus muscle, peroneus The differential diagnosis for CECS includes medial tib-
brevis muscle, and superficial peroneal nerve (which exits ial stress syndromes, stress fracture, fascial defects or hernia-
through the fascia of the lateral compartment in the dis- tions, popliteal artery entrapment syndrome, claudication,
tal third of the leg).2 The superficial posterior compart- peripheral nerve entrapment syndromes, and lumbosacral
ment contains the plantaris muscle, gastrocnemius muscle, radiculopathy. Clinical suspicion will guide the work-up,
soleus muscle, sural nerve, and branches of tibial artery but ICP testing is the “gold standard” test to confirm the
and vein.2 The deep posterior compartment contains the diagnosis of CECS.2–4 Normally, increases in compartment
flexor digitorum longus muscle, tibialis posterior muscle, pressures return to normal within 3 to 5 minutes after exer-
flexor hallucis longus muscle, popliteus muscle, tibial cise.4 A delay in normalizing pressures or pre-exercise pres-
nerve, posterior tibial artery and vein, and the peroneal sure measurements greater than 15 mm Hg are suggestive

524
 CHAPTER 29 Compartment Pressure Testing 525

of CECS.4 The Pedowitz criteria (Table 29.1) are the estab- Clinician Position
lished gold standard for diagnosing CECS.
• Standing next to patient.
Equipment
Needle Position
• S TIC ICP Monitor System (C2Dx, Schoolcraft, MI);
or Compass ICP Monitor System (Centurion Medical • A nterior compartment (Fig. 29.1A): four fingerbreadths
Products, Williamston, MI). below the tibial tuberosity and one fingerbreadth lateral
• ChloraPrep skin applicator (Becton Dickenson, Franklin to the tibial crest directed in an anterior to posterior
Lakes, NJ) direction.5
• Needle size: 27 gauge, 1.25 inch for local anesthesia and • Lateral compartment (see Fig. 29.1B): three finger-
18-gauge 2.5-inch ICP monitor needle breadths below the fibular head directed in a lateral to
• Local anesthesia: 1% lidocaine medial direction toward the fibula.5
• Sterile gauze • Superficial posterior compartment (see Fig. 29.1C): one
• Tubular elastic retention netting handbreadth below the popliteal crease over the medial
• Bandages mass of the calf directed to toward the medial head of the
gastrocnemius.5
• Deep posterior compartment (see Fig. 29.1D): one
Technique handbreadth distal to the tibial tuberosity and one fin-
Patient Position gerbreadth posterior the medial edge of the tibia. The
needle is directed in a medial to lateral direction through
• Supine with bolsters supporting both ankles. the soleus into the deep posterior compartment. This
occurs at a depth of approximately 4 cm.5
  Pedowitz Criteria for the Diagnosis of
TABLE Chronic Exertional Compartment Syndrome Protocol
29.1 by Intracompartmental Pressure.3
• Th
 e needle entry site is marked with a skin marker.
Time Pressure measurement • The skin at the needle entry site is cleansed using
Pre exercise >15 mm Hg ChloraPrep skin applicator.
• The skin and subcutaneous tissue at the needle entry site
1-min post exercise >30 mm Hg
are anesthetized using approximately 1 mL of 1% lido-
5-min post exercise >20 mm Hg caine. Care is taken not to inject local anesthetic into the
muscles of the compartment.

Proximal Proximal

FH

A B
Proximal Proximal

TT

C D
• Fig. 29.1Needle Entry Sites for Intracompartmental Pressure Testing of the Four Leg Compartments.
(A) Anterior compartment. (B) Lateral compartment. (C) Superficial posterior compartment. (D) Deep pos-
terior compartment. Diamond, needle entry site; dashed line, popliteal crease; FH, fibular head; solid line,
medial edge of tibia; TT, tibial tubercle.
526 SEC T I O N I V Advanced

• Th
 e ICP monitor is assembled as directed by the • Th
 e ICP monitor needle is withdrawn from the
manufacturer. compartment
• The ICP monitor is turned on and aligned in the posi- • Sterile gauze is applied over the needle entry site.
tion of needle insertion. • Tubular elastic retention netting is donned to secure
• The ICP monitor is zeroed while holding the pres- gauze in place.
sure monitor in the same plane/position that it will be • The patient follows a graded exercise protocol until maxi-
inserted into the compartment. mal symptoms are achieved.
• A small amount of saline is injected into the compartment • Patients discontinue exercising and are immediately
to create a continuous fluid cylinder into the compartment. taken to the examination room.
• The compartment pressure monitor is held in position • They are placed in a supine position with their ankles on
until the compartment pressure stabilizes, at which time a bolster.
the compartment pressure is recorded. • The tubular elastic retention netting is cut off and the
compartment(s) in question are retested at 1 and 5 min-
utes post exercise.
• The needle entry site is covered by a simple dressing.
PEARLS AND PITFALLS
• B ased on the study by Peck et al.,6 ultrasound-guided References
needle placement was not shown to be superior to
palpation-guided needle placement based on surface 1. L iu B, Barrazueta G, Ruchelsman DE. Chronic exertional compart-
landmarks described by Perotta et al.5 ment syndrome in athletes. J Hand Surg Am. 2017;42(11):917–923.
• A bolster is used to “float” the calf musculature to 2. Rajasekaran S, Finnoff JT. Exertional leg pain. Phys Med Rehabil
eliminate the theoretical risk of spuriously elevating Clin N Am. 2016;27(1):91–119.
compartment pressures due to direct pressure to the
3. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified
compartments by the examination table.
• Care should be taken to only anesthetize the skin criteria for the objective diagnosis of chronic compartment syn-
and subcutaneous tissues at the needle entry sites to drome of the leg. Am J Sports Med. 1990;18(1):35–40.
eliminate introducing fluid into the compartment which 4. Brennan Jr FH, Kane SF. Diagnosis, treatment options, and reha-
may theoretically elevate the compartment pressure. bilitation of chronic lower leg exertional compartment syndrome.
• Patients should be encouraged to exercise until their Curr Sports Med Rep. 2003;2(5):247–250.
leg pain is maximal. Ideally, the activity that provokes 5. Perotto A. Anatomical Guide for the Electromyographer, 5th ed.
their symptoms should be used for the exercise portion Springfield, IL: Thomas Books; 2011.
of the test. 6. Peck E, Finnoff JT, Smith J, Curtiss H, Muir J, Hollman JH.
• The normal saline used for the intracompartmental Accuracy of palpation-guided and ultrasound-guided needle tip
pressure monitor can be replaced with 1% lidocaine,
placement into the deep and superficial posterior leg compart-
thereby reducing pain during compartment pressure
testing. ments. Am J Sports Med. 2011;39(9):1968–1974.
7. Peck E, Finnoff JT, Smith J. Neuropathies in runners. Clin Sports
   Med. 2010;29(3):437–457.
30
Ultrasound-Guided
Anterior and Lateral
Compartment
Fasciotomies for Chronic
Exertional Compartment
Syndrome
JONATHAN T. FINNOFF AND JACOB REISNER

However, their duration of action is limited and anterior com-

KEY POINTS
partment injections can cause temporary weakness, resulting
• C hronic exertional compartment syndrome (CECS) in foot drop. Ultrasound-guided (USG) needle fenestra-
is characterized by pain and increased intra- tion of the anterior and lateral compartments was reported
compartmental pressure with exertion.1 as a treatment in the case of a collegiate lacrosse player with
• Ultrasound-guided (USG) fasciotomies have been
described for the treatment of anterior and lateral leg
CECS, who returned to full activity after 10 days and had
compartment CECS.2 resolution of symptoms at the 18-month follow-up.7
• USG fasciotomies are performed through a 3-mm Open surgical fasciotomy is the traditional and best-
skin incision, reducing tissue trauma, and potentially described definitive treatment for CECS.1,7 Waterman
reducing complications, and facilitating more rapid et al.7 reviewed 754 fasciotomy procedures performed for
return to activity.2
CECS in a military population. In this population 77% of
   cases involved a release of both the anterior and lateral com-
partments. They reported a complication rate of 15.7%,
Pertinent Anatomy and Common with infection being the most common followed by neu-
Pathology rologic injury. The recurrence rate was 44.7%, and 5.9%
went on to surgical revision.8 More recently, endoscopic
For more information refer to Chapter 29 (Compartment procedures involving a balloon catheter dilation have been
Pressure Testing). described.9 Ultrasound-assisted surgical procedures also
have been reported in a recent case series. This procedure
Traditional Treatment Options utilized Metzenbaum scissors but required initial nonguided
blunt dissection to the fascial plane.10
There are several nonsurgical treatment options for chronic USG fasciotomy using a V-shaped meniscotome for the
exertional compartment syndrome (CECS). Activity modi- anterior and lateral compartments was first described in a
fication is one option in cases where a specific activity (i.e., cadaveric model by Lueders et al. in 2017.2 Since then it
cycling or running) provokes symptoms.1 In runners with has been translated into clinical practice and was recently
anterior compartment symptoms and a heel strike pattern, described in a case report of a 41-year-old female runner
gait re-training and adopting a forefoot running pattern may who underwent anterior compartment USG fasciotomy
assist in treating CECS.1,2 Intramuscular botulinum toxin A without complications; she returned to full activity 7 days
injections have also been used in the treatment of CECS.4–6 after the procedure.11 Recently, a retrospective review of

527
528 SEC T I O N I V Advanced

• Th
 e start (3 cm distal to the fibular head) and finish (10
cm proximal to the inferior aspect of the lateral malleo-
lus) locations for the procedure are marked on the skin.
• The optimal course of the fasciotomy from proximal to
distal is determined with ultrasound and marked on the
skin.

Patient Position
• S upine.
• Legs extended in neutral rotation.

Clinician Position
• Fig. 30.1 Three-millimeter V-shaped meniscotome. • Seated next to the patient.
Local Anesthesia
50 USG fasciotomies showed a single complication, “sharp Transducer Position
nerve pain,” that resolved without treatment in 2 weeks, and • A
 lternating between the long- and short-axis views rela-
an average return to full activity of 10 days.12 tive to the needle/meniscotome trajectory.
Needle Position
Equipment
• A lternating between a 25-gauge, 2-inch needle and
• H igh-resolution ultrasound machine with a high-fre- 22-guage, 3.5-inch needle, guided in-plane relative to
quency linear array transducer. the ultrasound transducer, the skin surface at the proxi-
• Indelible marker. mal incision site, adjacent subcutaneous tissues, and the
• Needle size: 25-guage, 2-inch and 22-gauge, 3.5-inch fascia along the pre-marked course of the fasciotomy are
needles. anesthetized.
• Local anesthetic: a mixture of 4 mL 1% lidocaine, 4 mL • Multiple needle entry sites, spaced approximately 3
0.5% lidocaine with epinephrine, 4 mL of 0.2% ropiva- inches apart, are required to anesthetize the entire length
caine, and 8 mL of sterile saline per compartment. of the fascia.
• Number 11-blade scalpel.
• A 3.00-mm V-shaped meniscotome (Smith and Nephew, Injectate Volume
Inc., Andover, MA) (Fig. 30.1). • 1 0 to 20 mL per compartment.
• Skin closure: Dermabond (Ethicon, LLC, San Lorenzo, • Recommended injectate: a mixture of 4 mL of 1% lido-
Puerto Rico), benzoin tincture (3M, Maplewood, MN), caine, 4 mL of 0.5% lidocaine with epinephrine, 4 mL of
and three ¼ × 1.5-inch Steri-Strips (3M, Maplewood, 0.2% ropivacaine, and 8 mL of sterile saline.
MN).
Target
Technique • S uperficial to the fascia and deep to the subcutaneous
Pre-Procedure Planning—Anterior Compartment tissue layer.
• Th
 e anterior compartment borders are identified with • The injection will create a plane, separating the subcuta-
ultrasound. neous tissue from fascia.
• The common peroneal nerve (CPN), superficial peroneal
Fasciotomy
nerve (SPN), and deep peroneal nerve (DPN) are identi-
fied and their course is marked on the skin. Transducer Position
• The start (3 cm distal to tibial tuberosity) and finish • A
 lternate between long-short-axis views relative to the
(10 cm proximal to the inferior aspect of the lateral meniscotome.
malleolus) locations for the procedure are marked on
the skin. Meniscotome Position
• The optimal course of the fasciotomy from proximal to • A No.11-blade scalpel is used to make a 3-mm skin inci-
distal is determined with ultrasound and marked on the sion at the proximal fasciotomy start site for each respec-
skin. tive compartment (Fig. 30.2).
• The V-shaped meniscotome is introduced through the
Pre-Procedure Planning—Lateral Compartment skin incision in a proximal to distal direction.
• Th
 e lateral compartment borders are identified with • The deep portion of the meniscotome is pushed through
ultrasound. the fascia while maintaining the superficial portion of the
• The CPN and SPN are identified and their course is meniscotome above the fascia, such that the fascia is cap-
marked on the skin. tured in the cleft of the V-shaped cutting blade.
 CHAPTER 30 Ultrasound-Guided Anterior and Lateral Compartment Fasciotomies for CECS 529

*
TT Distal Proximal

* **
** ** *
SPN
LM

FH Anterior compartment
<

CP
<

N
A

<
<
<

<

• Fig. 30.2 Anatomy Pre-Scan Markings. Anterior compartment fasci- *

otomy course (asterisk). Lateral compartment fasciotomy course (open
arrows). Proximal border of anterior compartment fasciotomy (arrow- Lateral Medial
heads) and lateral compartment fasciotomy border (open circles).
Distal border of anterior and lateral compartment fasciotomies (closed Anterior compartment
circles). CPN, Common peroneal nerve; FH, fibular head; LM, lateral
malleolus; SPN, superficial peroneal nerve; TT, tibial tubercle.
B
• Fig. 30.3 (A) Long-axis view of V-shaped meniscotome cutting
through fascia of anterior compartment with superficial blade seen
• Th
 e V-shaped meniscotome is advanced distally along the superficial to fascia and deep blade seen deep to the fascia. (B) Short-
predetermined fasciotomy course, maintaining visualiza- axis view of the V-shaped meniscotome cutting the fascia of the ante-
tion on the meniscotome cutting blade with ultrasound. rior compartment with the tip of the superficial blade seen superficial
• Care is taken to ensure the fascia remains in the cleft of to the fascia and the tip of the deep blade seen deep to the fascia.
*, Anterior compartment fascia; arrowhead, V-shaped meniscotome.
the V-shaped cutting blade to ensure the fascia is tran-
sected as the meniscotome is advanced (Fig. 30.3).
local infection is a potential complication. Although the
Target procedure is performed in an office-based setting, sterile
• Th
 e fascia is transected by the meniscotome along the technique is utilized at all times and the patient is advised
predetermined fasciotomy course from the start to finish not to submerge the incision for 48 hours.
locations to ensure adequate transection of the fascia.
Pearls and Pitfalls
Skin Closure • O ral analgesics may be considered prior to and immedi-
• D ermabond is used to approximate the skin margins. ately after the procedure for patient comfort.
• Two inches of benzoin tincture is applied circumferen- • A 22-gauge, 3.5-inch needle can be placed under the
tially around the incision site and allowed to dry. ultrasound probe on the patient’s skin to assist in mark-
• Three ¼ × 1.5-inch Steri-Strips are applied across the ing the course of relevant structures (e.g., CPN, DPN,
incision site to re-enforce the Dermabond closure. and SPN).
• Compressive sleeves or stockings are placed over the leg. • Frequently alternate between long- and short-axis views
to ensure the fascia remains in the cleft of the V-shaped
Post-Procedure Instructions meniscotome tip throughout the procedure (see Fig.
Ice the area three to four times per day for 15 minutes for 30.3).
7 days. Elevate the legs for a minimum of 15 minutes sev- • Keeping the deep portion of the V-shaped meniscotome
eral times a day for 7 days. Ambulate as tolerated after the just deep to the fascia may reduce muscle tissue damage
procedure. Increase activity as tolerated after 7 days. Wear and pain during the procedure.
compressive sleeves or stockings for 3 to 4 weeks. Perform • Frequently alternate between long- and short-axis views
self-massage/tissue mobilization for 3 to 4 weeks. to ensure the meniscotome is advanced under direct
ultrasound visualization while monitoring relevant adja-
Potential Complications cent tissues/structures (e.g., neurovascular structures,
Potential complications include injury to the CPN or SPN. tendons, etc.), and ensuring the meniscotome remains
Care should be taken to identify and mark each nerve’s on the pre-planned fasciotomy course.
course in relation to the planned fasciotomy (see Fig. 30.2). • Additional local anesthetic may be administered during
Pain and swelling at the incision site and along the fasci- the fasciotomy for patient comfort. This may be injected
otomy course may be observed. This may be mitigated with in a distal to proximal direction to allow the menisco-
post-procedure compression. Finally, with the skin incision, tome to remain in place.
530 SEC T I O N I V Advanced

• P
 ost-procedure, ice, compression, and elevation will 7. Finnoff JT, Rajasekaran S. Ultrasound-guided, percutaneous
reduce swelling. needle fascial fenestration for the treatment of chronic exertional
compartment syndrome: a case report. PM R. 2016;8(3):286–290.
8. Waterman BR, Laughlin M, Kilcoyne K, Cameron KL, Owens
References BD. Surgical treatment of chronic exertional compartment syn-
drome of the leg: failure rates and postoperative disability in an
1. D iebal AR, Gregory R, Alitz C, Gerber JP. Effects of forefoot
active patient population. J Bone Joint Surg Am. 2013;95(7):592–
running on chronic exertional compartment syndrome: a case
596.
series. Int J Sports Phys Ther. 2011;6(4):312–321.
9. Wittstein J, Moorman 3rd CT, Levin LS. Endoscopic com-
2. Rajasekaran S, Finnoff JT. Exertional leg pain. Phys Med Rehabil
partment release for chronic exertional compartment syn-
Clin N Am. 2016;27(1):91–119.
drome: surgical technique and results. Am J Sports Med.
3. Lueders DR, Sellon JL, Smith J, Finnoff JT. Ultrasound-guided
2010;38(8):1661–1666.
fasciotomy for chronic exertional compartment syndrome: a
10. Balius R, Bong DA, Ardevol J, Pedret C, Codina D, Dalmau
cadaveric investigation. PM R. 2017;9(7):683–690.
A. Ultrasound-guided fasciotomy for anterior chronic exer-
4. Isner-Horobeti ME, Dufour SP, Blaes C, Lecocq J. Intramus-
tional compartment syndrome of the leg. J Ultrasound Med.
cular pressure before and after botulinum toxin in chronic exer-
2016;35(4):823–829.
tional compartment syndrome of the leg: a preliminary study. Am
11. Finnoff J, Johnson W. Ultrasound-guided fasciotomy for chronic
J Sports Med. 2013;41(11):2558–2566.
exertional compartment syndrome: a case report. Clin J Sport
5. Hutto WM, Schroeder PB, Leggit JC. Botulinum toxin as a novel
Med. 2020;30(6):e231–e233.
treatment for chronic exertional compartment syndrome in the
12. Reisner J, Johnson W, Hollman J, Sellon J, Finnoff J. Safety and
U.S. military. Mil Med. 2019;184(5-6):e458–e461.
feasibility of ultrasound-guided fasciotomy for chronic exertional
6. Baria MR, Sellon JL. Botulinum toxin for chronic exertional
compartment syndrome. In: AMSSM 29th Annual Meeting;
compartment syndrome: a case report with 14 month follow-up.
2020.
Clin J Sport Med. 2016;26(6):e111–e113.
31
Principles of Perineural
Injections
JEFFREY A. STRAKOWSKI

Ultrasound-Guided Perineural Injections hypoechoic muscle. Once reliably identified, the nerve can
be followed back to the preferred location. Increasing the
KEY POINTS speed of scanning of the nerve in the short-axis view can also
improve its conspicuity.3
• In-plane injections should be used for peripheral nerves
The peripheral nerve image can be optimized by tog-
because of the relative vulnerability of the target.
• The image should be optimized for maximum gling the transducer to create an orthogonal position of
conspicuity of the nerve and to reliably identify the the nerve and minimize anisotropic artifact.4 Typically, the
border of the outer epineurium. highest-frequency transducer that can adequately penetrate
• The nerve should be scanned proximally and distally to to the desired depth should be used. The depth should be
the injection field in both the short- and long-axis views
set so that the nerve takes up a large portion of the image
prior to the procedure.
• Applying a small amount of hypoechoic injectate adjacent rather than a small area at the surface. The focal zone should
to the nerve will increase the nerve’s conspicuity. be placed at the level of the nerve, and the gray-scale gain
• The flow of the injectate should be observed carefully to should be set to create the greatest contrast between the
ensure that it is not intraneural. outer epineurium and surrounding tissue.
  
Common Pathology
Peripheral Nerve Anatomy and Image
The most consistent abnormal finding with focal neuropa-
Optimization thies is enlargement of the nerve.5 The mechanism of this
Anatomy is complex but can include: blocking of axoplasmic flow,
endoneurial edema, distal axonal degeneration, perineural
Peripheral nerves have a characteristic fascicular pattern that and endoneurial inflammation, perineural fibrosis, axons
is readily distinguished from the fibrillar pattern of tendons sprouting, remyelination, and thickening of the perineu-
(Fig. 31.1).1 The hypoechoic fascicles are seen among the rium and epineurium.6 Assessment of the cross-sectional
intervening hyperechoic inner epineurium. In the short-axis area at the area of maximal nerve swelling is the most com-
view, the contrast of this tissue creates the appearance of a monly used parameter to distinguish nerve abnormality.
honeycomb. The fascicles reflect the bundle of nerve fibers This is performed by tracing the inner border of the outer
surrounding by perineurium. The inner epineurium con- epineurium and the calculation is performed by most ultra-
sists of connective tissue and intraneural vascular structures. sound machines. Techniques that help distinguish patho-
The highly reflective outer border is the outer epineurium.2 logic enlargement include comparison to unaffected areas
of the same nerve and, when needed, comparison to the
Scanning and Image Optimization opposite limb. Sufficient inspection should be performed to
determine whether the enlargement is focal, which is typical
Peripheral nerves should initially be scanned in the short- of entrapment neuropathies, or more diffuse, as seen with
axis view for identification and recognition of the surround- stretch injuries. The internal echotexture of the nerve also
ing anatomy. The long-axis view also should be included for should be assessed. Enlargement or distortion of the inter-
a complete perspective (Fig. 31.2). When the nerve is sur- nal fascicles often suggests more severe injury. The effect of
rounded by relatively isoechoic tissue, such as tendons, and surrounding tissue, such as scarring, should also be identi-
is difficult to identify, scanning should be done to follow the fied.7 In the context of trauma, careful inspection should
nerve to a more conspicuous location such as surrounding be performed to establish that the nerve is in continuity.

531
532 SEC T I O N I V Advanced

0.2 mm
0.5 dextrose. The purpose is to provide direct therapeutic effect
from the injectate and, when appropriate, use the injected
1.5 volume to alleviate compression and encroaching scar by
hydrodissecting the nerve.15,16
2.5

3.5
Peripheral Nerve Injection Technique
Equipment
4.5
• N eedles:
5.5
• 27-gauge, 1.0-inch needle to anesthetize the skin
• 25-gauge, 1.5-inch needle for most superficial injections
• Fig. 31.1Ultra-high frequency (70 MHz) sonogram demonstrating the • 25-gauge, 3.5-inch needle for deeper injections
fascicular pattern of the ulnar nerve (yellow arrow) at the distal forearm • Injectate options:
in the short-axis view. Note the contrast of the fibrillar pattern of the • Local anesthetic (e.g., 1% lidocaine, 0.25%
neighboring flexor carpi ulnaris tendon (blue arrow). bupivacaine)
• Normal saline solution
0.2 mm • 5% dextrose
0.5
• Steroid (e.g., dexamethasone 4 mg/mL, triamcino-
1.5
lone acetonide (Kenalog) 40 mg/mL)
• Platelet products: platelet-rich plasma (PRP) or plate-
2.5 let lysate
• Ultrasound machine with a high-frequency (10 to 15
3.5 MHz) linear array transducer
• Sterile conduction gel
4.5 • Sterile gloves
5.5 Peripheral Nerve Injection Principles
• Th
 ere should be complete knowledge of the function of
the peripheral nerve prior to the procedure.
6.5

• The nerve and surrounding tissue should be thoroughly

• Fig. 31.2 Ultra high frequency (70MHz) sonogram demonstrating the pre-scanned in both short- and long-axis views. This
fascicular pattern of the medial plantar branch of the tibial nerve (yellow
arrows) in long axis.
includes both cranially and caudally to the injection field.
• The field should be scanned with varying transducer
pressure to assess for neighboring vessels that could be
Identification of a complete neurotmesis leads to the con- potentially collapsed.
sideration of surgical treatment for repair. • Doppler imaging should also be used, with pre-scanning
to further assess for vascular structures.
Indications for Peripheral Nerve Injections • The image should be optimized so the margins of outer
epineurium are adequately visualized.
Ultrasound-guided peripheral nerve injections are per- • The injections should be performed with an in-plane
formed for anesthetic blocks for pain management dur- view of the needle and a short-axis view of the nerve.
ing surgery or other procedures, diagnostic blocks to help • Aseptic technique should be used with all injections.
determine the source of pain, and therapeutic treatment • Anoblique stand-off of sterile conduction gel can help
of a known peripheral nerve injury.8–10 The nature of the with needle visualization prior to insertion. This is par-
injectate and relative volume is based on the indication and ticularly beneficial with superficial targets.17
type of procedure.11 Ultrasound guidance has changed the • It is helpful to slowly introduce a small amount of the
nature of anesthetic and therapeutic injections by allow- hypoechoic injectate to increase the conspicuity of the
ing direct visualization of the nerve, enabling the clinician outer epineurium (Fig. 31.3), then proceed with the
to change the needle position and target multiple nerves remainder of the injection.
from the same external landmark.12,13 Diagnostic blocks • The flow of the injectate should be carefully observed
are performed by injecting a small amount of local anes- during the procedure to avoid intraneural injection and
thetic around the nerve, instead of wide infiltration into potential injury.18
the surrounding tissue, in an effort to help determine the • Doppler imaging can be used during the procedure to
pain generator. Ultrasound guidance provides greater preci- highlight the flowing of the injectate.
sion of diagnostic injections over nonguided injections.14 • When using higher volumes of injectate, it is often useful
Procedures performed for therapeutic effect can consist of to alternate between short- and long-axis views to con-
any combination of local anesthetic, steroid, saline, and firm injectate flow along the nerve sheath.
 CHAPTER 31 Principles of Perineural Injections 533

Obique standoff of sterile gel • Th

 e patient is generally scheduled for follow-up evalu-
Inguinal ligament
ation 2 to 6 weeks after the procedure to assess the
response to treatment.

LCN References
A 1. Martinoli C, Bianchi S, Dahmane M, Pugliese F, Bianchi-Zamo-
rani MP, Valle M. Ultrasound of tendons and nerves. Eur Radiol.
Inguinal ligament 2002;12(1):44–55.
2. Strakowski JA. Introduction to Musculoskeletal Ultrasound: Getting
Started. New York: Demos Medical; 2015.
3. Strakowski JA. Ultrasound Evaluation of Focal Neuropathies.Cor-
relation with Electrodiagnosis. New York: Demos Medical; 2014.
LCN
4. Kremkau FW. Diagnostic Ultrasound: Principles and Ultrasound.
St. Louis: Sauders; 2002.
B 5. Walker FO, Cartwright MS, Wiesler ER, Caress J. Ultrasound of
nerve and muscle. Clin Neurophysiol. 2004;115(3):495–507.
• Fig. 31.3 Sonograms demonstrating a perineural injection of the lat- 6. Rempel D, Dahlin L, Lundborg G. Pathophysiology of nerve
eral cutaneous nerve (LCN) of the thigh. The injection is performed
compression syndromes: response of peripheral nerves to load-
with an in-plane view to the transducer and the nerve is seen in the
ing. J Bone Joint Surg Am. 1999;81(11):1600–1610.
short-axis view. The inguinal ligament and hypoechoic oblique standoff
of sterile gel is also seen. (A) A small amount of injectate is placed 7. Martinoli C, Bianchi S, Pugliese F, et al. Sonography of entrap-
between the nerve and inguinal ligament as the needle is slowly with- ment neuropathies in the upper limb (wrist excluded). J Clin
drawn to increase conspicuity of the small nerve. (B) After a clear halo Ultrasound. 2004;32(9):438–450.
is created with the initial slow injection and the outer epineurium is 8. Markovic M, Crichton K, Read JW, Lam P, Slater HK. Effective-
more conspicuous, the remainder of the injectate is introduced. ness of ultrasound-guided corticosteroid injection in the treat-
ment of Morton’s neuroma. Foot Ankle Int. 2008;29(5):483–487.
9. Tagliafico A, Serafini G, Lacelli F, Perrone N, Valsania V, Mar-
tinoli C. Ultrasound-guided treatment of meralgia paresthetica
• L ocal anesthetics are used for anesthetic blocks and (lateral femoral cutaneous neuropathy): technical description and
to anesthetize the skin for other injections. There is results of treatment in 20 consecutive patients. J Ultrasound Med.
potential neurotoxicity and they are therefore mini- 2011;30(10):1341–1346.
mized with therapeutic injections, particularly repeated 10. Pasquali C, Vulcano E, Novario R, Varotto D, Montoli C, Volpe
hydrodissections. A. Ultrasound-guided alcohol injection for Morton’s neuroma.
• Generally, higher volumes of injectate are used for Foot Ankle Int. 2015;36(1):55–59.
hydrodissections. This can be in the range of 4 to 15 mL. 11. Strakowski JA. Ultrasound-guided peripheral nerve procedures.
Phys Med Rehabil Clin N Am. 2016;27(3):687–715.
There is not complete consensus regarding the compo-
12. Yamamoto H, Sakura S, Wada M, Shido A. A prospective, ran-
sition of the injectate, but it can involve any combina- domized comparison between single- and multiple-injection
tion of local anesthetic, injectable steroid, normal saline techniques for ultrasound-guided subgluteal sciatic nerve block.
solution, PRP, and 5% dextrose.19 There are anecdotal 13. Re M, Blanco J, Gómez de Segura IA. Ultrasound-guided
reports and some initial studies of the therapeutic effect nerve block anesthesia. Vet Clin North Am Food Anim Pract.
of 5% dextrose around peripheral nerve injures; however, 2016;32(1):133–147.
further studies are needed.20 14. Lento PH, Strakowski JA. The use of ultrasound in guiding mus-
• The use of PRP and platelet lysate are also advocated by culoskeletal interventional procedures. Phys Med Rehabil Clin N
some for enhancing recovery of peripheral nerve injuries. Am. 2010;21(3):559–583.
Further studies are also needed to demonstrate efficacy 15. Cass SP. Ultrasound-guided nerve hydrodissection: what is it? A
for this purpose.21–23 review of the literature. Curr Sports Med Rep. 2016;15(1):20–22.
16. Dettori N, Choudur H, Chhabra A. Ultrasound-guided treat-
Post-Procedure ment of peripheral nerve pathology. Semin Musculoskelet Radiol.
2018;22(3):364–374.
• P ost-injection scanning should be considered, particu- 17. Smith J, Finnoff JT. Diagnostic and interventional musculoskel-
larly after higher-volume injections, to assess the injectate etal ultrasound: part 1. Fundamentals. PM R. 2009;1(1):64–75.
placement. Dynamic ultrasound to assess nerve mobil- 18. Choquet O, Morau D, Biboulet P, Capdevila X. Where should
ity after hydrodissection can also provide insight into the the tip of the needle be located in ultrasound-guided peripheral
effect of the injection. nerve blocks? Curr Opin Anaesthesiol. 2012;25(5):596–602.
• The patient should be able to resume nonstressful activi- 19. Lam SKH, Reeves KD, Cheng AL. Transition from deep regional
ties immediately after the injection. blocks toward deep nerve hydrodissection in the upper body and
• Ice and over-the-counter analgesic medications can be torso: method description and results from a retrospective chart
used if there is a temporary increase in discomfort after review of the analgesic effect of 5% dextrose water as the pri-
mary hydrodissection injectate to enhance safety. Biomed Res Int.
the injection.
2017;2017:7920438.
534 SEC T I O N I V Advanced

20. Dufour E, Cymerman A, Nourry G, Balland N, Couturier C, 22. Malahias MA, Chytas D, Babis GC, Nikolaou VS. Platelet-rich
Liu N, et al. An ultrasonographic assessment of nerve stimula- plasma guided injections: clinical application in peripheral neu-
tion-guided median nerve block at the elbow: a local anesthetic ropathies. Front Surg. 2014;1:41.
spread, nerve size, and clinical efficacy study. Anesth Analg. 23. Kuffler DP. Platelet-rich plasma promotes axon regeneration,
2010;111(2):561–567. wound healing, and pain reduction: fact or fiction. Mol Neuro-
21. Kuffler DP. Platelet-rich plasma and the elimination of neuro- biol. 2015;52(2):990–1014.
pathic pain. Mol Neurobiol. 2013;48(2):315–332.
32
Ultrasound-Guided Release
of the Transverse Carpal
Ligament (Carpal Tunnel)
ADAM M. POURCHO, PHILLIP HENNING, AND JAY SMITH

A B B R E V I AT I O N S
CSA cross-sectional area
CTR carpal tunnel release
and transverse carpal ligament (TCL) (roof ) (Figs. 32.1
CTS carpal tunnel syndrome and 32.2B and C). The TCL is approximately 1.5 to 4
TCL transverse carpal ligament mm thick on average.1–3 The proximal TCL inserts on
TSZ transverse safe zone the scaphoid bone and traverses medially to the pisiform,
LAX long-axis view while the distal TCL inserts on the trapezium and traverses
US ultrasound medial to the hook of the hamate (see Fig. 32.2B and C).
USCTR ultrasound-guided carpal tunnel release The proximal portion of the TCL is the distal continua-
USG ultrasound guidance tion of the antebrachial fascia, with transverse instead of
SAX short axis longitudinally oriented fibers.1,2,4,5 The radial side of the
TCL divides into two layers, a superficial layer and a deep
layer, to accommodate the tendon of the flexor carpi radia-
lis (FCR).1,2,4
KEY POINTS The carpal canal contains the median nerve and nine
tendons: the flexor pollicis longus (FPL), the four flexor
• U ltrasound-guided carpal tunnel release (USCTR) has
the advantage of a smaller incision size, as well as the
digitorum superficialis (FDS), and the four flexor digito-
advantage of being performed in an office/procedure room rum profundus (FDP) (see Fig. 32.1). The FPL has its own
setting using only local anesthesia, potentially lowering cost. synovial sheath, while the FDS and FDP have a common
• Ultrasound guidance (USG) allows the ability to directly synovial sheath. The FCR, flexor carpi ulnaris, ulnar nerve,
visualize all carpal tunnel structures and control the and palmaris tendons are external to the CT.3 The abductor
transverse safe zone (TSZ).
• USCTR has documented faster recovery and less
pollicis brevis (APB) and flexor pollicis brevis (FPB) have
post-procedure pain medication use when compared to anatomic connections on the radial side of the TCL, while
mini-open carpal tunnel release (MOCTR). ulnarly, the flexor digiti minimi brevis (FDMb) originates
• Pre-scanning protocol and knowledge of the anatomy from the TCL.2–4
of the carpal tunnel with special attention to potential The median nerve is anatomically located in the forearm
anatomic variants of the median nerve is recommended
prior to performing any carpal tunnel release (CTR)
between the FDS and FDP muscles. As the nerve travels dis-
procedures. tally, it becomes more superficial just proximal to the TCL
by looping radially around the FDS muscles and tendons in
  
the distal forearm.1,2,4,6 The palmar cutaneous branch arises
off the radial side of the median nerve, most commonly
Ultrasound-Guided Transverse Carpal between the FCR and palmaris longus (if present), provid-
ing sensation to the palmar surface of the thumb (see Fig.
Ligament Release 32.1).7 From here, the median nerve travels superficially
Pertinent Anatomy between the tendons of the FPL and FDS to the index and
middle fingers. The median nerve normally travels in the
The carpal tunnel (CT) is a fibro-osseous canal on the CT as a single nerve, prior to dividing into radial and ulnar
volar side of the wrist, formed by the carpal bones (floor) branches at the distal border of the TCL.

535
536 SEC T I O N I V Advanced

Transverse carpal
ligament

Ulnar nerve Median nerve Flexor carpi

Flexor digitorum radialis
superficialis Flexor pollicus longus
Flexor digitorum 1 Extensor pollicis brevis
profundus Abductor pollicis longus

6
Extensor carpi ulnaris Extensor carpi radialis brevis
2
5 Extensor carpi radialis longus
3
Extensor digiti minimi 4
Extensor digitorum Extensor pollicis longus
Extensor indicis

Dorsal compartments
• Fig. 32.1 Anatomy. Anatomic view of the carpal tunnel.

FCR
a
FS X
FPL FS FS FS
S FP P
FP FP
FP

T
L

B RT WRIST SAX ULN

APB
FPB a

t FCR FPL H
FS FS FS FS
FP FP FP
FP

A C RT WRIST SAX ULN

• Fig. 32.2 Ultrasound of the Carpal Tunnel With Anatomic Correlates. (A) Transducer positioning for
sonographic short-axis (SAX) view of the proximal (solid rectangle) and distal (dotted rectangle) carpal
tunnel (CT). (B) US SAX correlate, with transducer positioned as shown in Fig. 32.2A, of the proximal CT
with ulnar (ULN) to the right. Note the bony landmarks of the scaphoid (S) radially and the pisiform (P)
ulnarly. The median nerve (dotted circle) is situated superficial within the CT. (C) US SAX correlate, with
transducer positioned as shown in Fig. 32.2A, of the distal CT with ULN to the right. Note the transverse
safe zone (TSZ) (double arrow), in this patient bordered on the ULN side by the hook of the hamate (H).
a, Ulnar artery; APB, abductor pollicis brevis; C, capitate; FCR, flexor carpi ulnaris; FP, flexor digitorum
profundus; FPB, flexor pollicis brevis; FPL, flexor pollicis longus; FS, flexor digitorum superficialis; L, lunate;
solid circles, ulnar nerve; t, trapezoid; T, triquetrum.
 CHAPTER 32 Ultrasound-Guided Release of the Transverse Carpal Ligament (Carpal Tunnel) 537

The thenar motor branch (TMB) (also referred to as the on the radial side of the median nerve, and the second, on
recurrent motor branch of the median nerve) typically origi- the ulnar side of the median nerve. The latter crosses the
nates from the antero-ulnar aspect of the radial division at nerve prior to going through the fibro-osseous tunnel before
the distal TCL and travels vertically in a palmar direction becoming subcutaneous.7,27 Damage to this nerve during
around the distal TCL to innervate the thenar muscula- surgery has been shown to cause the development of a neu-
ture (see Fig. 32.1).8–26 The TMB is a critically important roma, and therefore, demands consideration when perform-
structure within the CT region because it is the primary ing USCTR.33
motor innervation to the thenar muscles in most people.8–26 There is one anatomic variation of the ulnar nerve
A detailed knowledge of anatomic variations of the TMB that warrants mention. In 1% to 3% of the population,
(mentioned later in this chapter) is recommended prior to the nerve travels in an osseo-fibrous canal (different from
performing procedures on or about the CT. Guyon’s canal) situated on the anteromedial portion of the
In the palm, the median nerve supplies sensation to the TCL, extending approximately 4 cm from the pisiform to
palmar surface of the thumb, index and middle finger, and the hook of the hamate bifurcation.1,2
radial palmar surface of the ring finger, while also providing The palmaris longus (PL) muscle has the greatest number
motor innervation of the thenar eminence as well as the first of possible variants in the human body.34,35 Two variants are
and second lumbricals via the TMB.4,7,26 particularly important when considering USCTR and must
be identified before surgery. The first variant involves the PL
Anatomic Variants traversing the CT, possibly contributing to symptomatol-
ogy. The second, referred to as a reverse PL, involves the
There are many reported anatomic variants of the wrist, muscle belly in a distal rather than proximal position. In the
involving vessels, nerves, tendons, and muscle; some of case of a reverse PL, the muscle belly may extend into the
these have significant clinical relevance when it comes to CT, possibly increasing or contributing to compression.30,34
USCTR.8–12,15,18,26–28 The operator should be aware that The low-lying FDS muscle bellies, as well as more proxi-
the presence of one anatomic variant should alert to the mally located lumbrical muscle bellies, may also dynami-
presence of potential additional anatomic variants. cally impinge on the median nerve with dynamic testing.
The most common variant of the median nerve itself is There are also reports at the wrist of other anatomic variants
a bifid median nerve with or without a persistent median to the tendons, including accessory FDS to the index finger
artery (PMA).2,27 A PMA, which is present in 12% to 23% and the palmar surface.2,30,34,35
of the population, arises from the ulnar artery and trav- The CT can also be compromised by any number of cys-
els distally along the ulnar side of the median nerve and tic or mass-like structures.36 If discovered, care should be
may contribute to symptoms of carpal tunnel syndrome taken to note these structures and make appropriate refer-
(CTS).8–12,15,18,26–28 The superficial location of the PMA in rals for either diagnosis or treatment.
the CT puts the artery at risk for injury during USCTR, The sonographer should always report the presence of
and its presence should be noted prior to attempting release. anatomic variants of the nerves, ligaments, and tendons
Furthermore, a PMA is often associated with a bifid or trifid about the TCL, which might otherwise be damaged or
median nerve. The use of color Doppler can help to identify require additional treatment during any surgical release of
this variant.2,27 the TCL.
PMA with bifid median nerve can also often be associated
with an anomalous FDS muscle belly that can be seen dynami- Pathophysiology/Diagnosis
cally with flexion and extension of the fingers.1,2,8,15,25,29,30
Another variant is proximal bifurcation of the median nerve, Median nerve entrapment at the TCL, leading to CTS, is
which can be seen in 1% to 3% of the population. Early divi- the most common peripheral entrapment neuropathy, with
sion of the terminal branches is even less common.1,2,8,15,25,29,30 an incidence of 3.5% to 6.2%.37–39 Approximately 450,000
Anatomic variants of the TMB are common and pres- surgical releases are performed annually in the United
ent in 46% to 90% of the population. There are four main States, with a total cost of over 2 billion dollars.37–39 More
anatomic variants of the TMB: the distal ligamentous (most than 90% of patients report clinical improvement following
common); the subligamentous branch (33%); the transliga- release.37–40
mentous branch (8% to 12%); and the ulnar division take The diagnosis of CTS is primarily clinical, with most
off (rare).8,10–17,20,24–26,31 Hypertrophy of the thenar mus- patients complaining of numbness and tingling in the
cles has been associated with transligamentous TMB.8 A lateral three digits of the hand with or without associ-
firm understanding of normal and anatomic variants of the ated weakness. Patients may have a positive Tinel’s sign
TMB and identification of the TMB and possible variants over the median nerve at the TCL or a positive Phalen’s
with ultrasound (US) prior to any USG procedures about test. Electrodiagnostic (EDX) testing may be obtained to
the TCL is highly recommended.32 assess the severity of injury to the median nerve and dif-
There are two main variants of the palmar cutaneous ferentiate CTS from competing diagnoses, such as periph-
nerve described in the literature. The first variant arises eral neuropathy or cervical radiculopathy.41,42 Isolated or
538 SEC T I O N I V Advanced

predominant TMB involvement has been implicated in • Th

 e TMB of the median nerve
some patients with CTS who present with disproportion- • The ulnar nerve and artery:
ate thenar atrophy or weakness, particularly in the setting • Location of the superficial palmar arch to the hook of
of a relatively normal-appearing median nerve.8,11,17,19, the hamate
20,22,23,26,43 • Location of the ulnar nerve to the hook of the hamate
• The vasculature and presence of anatomic variants,
Sonographic Evaluation/Findings including persistent median artery (if present)
• Measurement of length of the TCL in sagittal plane
Recently, the use of musculoskeletal US has increas- • The native transverse safe zone
ingly been used to evaluate and manage patients with • Distance between the median nerve and ulnar artery
CTS.1,2,24,32,42,44–49 The most commonly reported find- or hamate
ings on US in the setting of CTS are that of median • The FCR, FDS, FDP, flexor carpi ulnaris (FCU), and
nerve enlargement, focal median nerve constriction, FPL tendons
reduced median nerve gliding (dynamically), TCL bow- • Superficial palmar artery and palmar fat pad
ing, flexor tenosynovitis, or space-occupying lesions • The bony acoustic landmarks of scaphoid, pisiform, tra-
(e.g., ganglia, tumors, thrombosed or anomalous arter- pezium, and hook of hamate
ies, abnormal muscle slips, or supernumerary muscles Contraindications to USCTRS
or tendons).2,6,36,42,45–48,50 Other studies have indicated • Inability to adequately visualize at-risk structures:
cross-sectional area (CSA) at the proximal TCL may pro- • TMB/recurrent motor branch of the median nerve
vide more conventional diagnostic parameters.6,51 The • Palmar cutaneous branch of the median nerve
normal CSA can vary from 6.5 to 12 mm2, depending • Ulnar vessels
on the study.6,51 Enlargement of the median nerve CSA • Superficial palmar arterial arch
(with contralateral comparison) in conjunction with • Median and ulnar palmar digital nerves
EDX testing and clinical examination should lead to an • Variant anatomy that would preclude establishment of a
accurate diagnosis. In postoperative evaluation, US may safe transverse safe zone
identify incomplete TCL transection, TCL regrowth, • Presence of mass lesion or other process that requires
scarring and adhesions, improvement of CSA, and injury treatment beyond CTR
to the median nerve or its palmar cutaneous or TMB in
patients with continued symptoms.42,49,52–56 Treatment Options
Sonographic evaluation of the CT typically begins in
the anatomic axial plane and eventually in the anatomic Conservative treatment options for CTS typically include
sagittal plane. In the axial view, the nerve has a “honey- activity modification, occupational therapy, bracing, ste-
comb” appearance, with individual hypoechoic fascicles roid injections, and alternative medicine (i.e., acupuncture,
separated by echogenic septa representing the interfas- low-level laser, yoga, and static magnetic field therapy). For
cicular perineurium (see Fig. 32.2B and C). The nerve patients who fail conservative treatment, surgical release is
bundles are less susceptible to anisotropy, unlike other considered the definitive treatment. Although historically
structures, such as muscles and ligaments. Differential performed via a large (3 to 5 cm) palmar incision, CTR
anisotropy with toggling of the transducer can be used techniques have evolved to reduce trauma with less-inva-
to make the nerve more conspicuous for identification. sive treatments.49,60–62 The goal of less-invasive treatments
The nerve is followed from the pronator quadratus in the is improving cosmesis, reducing postoperative pain, and
forearm through the proximal and eventually distal CT. promoting faster recovery.49,52,57,58,63 The currently avail-
Dynamic maneuvers, with flexion and extension of the able CTR techniques include mini-open CTR (mOCTR)
fingers, is recommended to identify possible muscle vari- via a single 1 to 3 cm palmar incision, endoscopic CTR
ants. Color Doppler should be used to identify vascular (ECTR) via one (wrist) or two (wrist and palm) 1 to 2
anatomy. Sagittal plane (longitudinal images) is useful in cm incisions, and more recently, ultrasound-guided CTR
cases of focal compression, showing the compressed por- (USCTR) via a single less than 1 cm wrist or palmar
tion of the median nerve as well as the proximal and/or incision.49,57,59,64–75
distal swollen portion of the nerve (“notch sign”).1,44,45
Special care is taken to note the aforementioned anatomic Ultrasound-Guided Release
variants as they pertain to the TCL.
It is suggested that the following structures are viewed as The primary goal of CTR is to transect the TCL while avoid-
part of a pre-screening protocol:32,57–59 ing injury to the neurovascular structures.59–61,76,77 Although
• The median nerve: ECTR may promote a faster recovery than mOCTR, there is a
• With CSA measurements at the distal border prona- concern that limited visualization of the surrounding structures
tor quadratus, the proximal TCL, and the distal TCL during ECTR may increase complications.60,61,66,76 USCTR
• The palmar cutaneous branch of the median nerve combines a single or dual incision (Manos procedure) with direct
 CHAPTER 32 Ultrasound-Guided Release of the Transverse Carpal Ligament (Carpal Tunnel) 539

US visualization of at-risk structures.52,53,57,58,67,70,72–75,78–84

Clinician Position
Despite many different devices being used to perform USCTR,
review of the current publications on USCTR report a greater • C linician is seated either between patient’s underarm and
than 98% clinical success rate without any documented neu- body or between patients arm and head, per clinician
rovascular injuries.49,52,57,58,67–71,73,74,78,81,83–85 Rojo-Maudate preference (see Fig. 32.3B).
et al published their randomized clinical trial comparing • US display located directly in front of clinician’s line of
mOCTR versus USCTR, demonstrating a five times faster vision.
functional recovery, pain reduction, and pain medication dis-
Transducer Orientation
continuation with USCTR.68
ECTR techniques and most USCTR techniques place • A
 combination of orthogonal anatomic axial and sagittal
the surgical device within the TSZ. The TSZ is defined as a views are used for the procedure (Fig. 32.4A–C).
region bordered radially by the median nerve and ulnarly by
Technique
the hook of the hamate or ulnar vessels, whichever lies more
radial (see Fig. 32.2C).32,84 The TSZ has been shown to vary • U sing USG, the surgical limb is marked with pre-surgi-
from approximately 4.4 to 12.4 mm, and was statistically cal skin markings. The superficial palmar arch, hook of
larger in men when compared to women, but exhibits sig- hamate, pisiform, median nerve, ulnar nerve and artery,
nificant inter-individual variability. In some cases, a 0 mm scaphoid, and trapezium are marked prior to start of pro-
TSZ has been documented.32,52,57,58,81,84 It can be there- cedure. The proximal wrist crease (starting point) is also
fore technically challenging to establish a consistent TSZ marked (Fig. 32.3A and B).
while performing CTR. During ECTR, the size of the TSZ • The SX-One MicroKnife is first primed via the manufac-
is determined by the size of the introducer and endoscopic turer’s recommendations with sterile saline.
device.44,61,66,76,86 This is contrasted to USCTR, in which • Following aseptic preparation, an USG in-plane proximal-
the cutting instrument is smaller, requiring a small inci- to-distal anesthetic of ∼8 mL of 1% lidocaine without epi-
sion, but also presenting the same challenge of establishing nephrine is injected into the superficial palmar fascia and
a TSZ.67,68,70–75,83–85 deep to the TCL with a 21-gauge, 50 mm needle.
More recently, the SX-One MicroKnife (Sonex Health • This needle is withdrawn, and using USG, a second
LLC, Rochester, MN), a disposable device with ability to 21-gauge, 2 inch needle is used to hydrodissect the
protect the TSZ, has become available. A cadaveric inves- median nerve away from the flexor tendons and TCL
tigation using the SX-One device to perform USCTR on using 10 mL of sterile 0.9% normal saline, making the
cadaveric specimens documented a 100% rate of TCL TCL more conspicuous.
release and no neurovascular injury.87 Initial studies on this • Following adequate anesthesia, a #15 blade scalpel with
device have shown promising results, with faster recovery the blade positioned upward is used to make a vertical
and return to normal function with no reported neurovas- stab incision through the antebrachial fascia, at the prox-
cular injuries to date.49,52,57,58,81 imal wrist crease.
• USG is then used to accurately place the device into
the CT, ulnar to the median nerve within the TSZ. The
Equipment distal end of the device is advanced until 1 cm distal to
•  igh-frequency linear transducer (e.g., 12 to 5 MHz)
H the hook of the hamate, taking care to note the location
• Arm board of the SPA (see Fig. 32.4A). A ureteral dilator can be
• Surgical drapes inserted through the track first to help accommodate the
• Lidocaine ∼8 to 10 mL device more easily.
• Dilator • US evaluation in two orthogonal planes is utilized to
• 21-gauge, 2-inch needle ensure proper positioning of the device within the TSZ
• A #15 blade (see Fig. 32.4A).
• Skin glue vs 4-0 sutures for closure • Once proper positioning is sonographically confirmed,
• Steri-strips the handle on the device is depressed and locked, filling
• Sterile towels and gauze the balloons with sterile saline and expanding the TSZ
• Sterile saline (10 mL) (see Fig. 32.4B).
• Cutting device (SX-One MicroKnife by Sonex, hook • The device can then be adjusted ulnarly or radially to cre-
knife, Gou wire) ate an optimal cutting position away from the path of the
median nerve and ulnar neurovascular structures.
Authors’ Preferred Technique • Following confirmation of adequate placement of the device
Patient Position and cutting angle, the blade is then deployed from a distal to
• S upine or lateral recumbent, with the arm on an arm proximal direction, cutting the TCL (see Fig. 32.4C).
board and a pillow between the patient’s knees (Fig. • After release, the blade is left recessed in the proximal
32.3B) location.
540 SEC T I O N I V Advanced

Mn
P
S

H
T

A B
• Fig. 32.3Pre-Surgical Markings and Patient Position. (A) Picture of incision placement at the proxi-
mal wrist crease along the distal forearm and device direction of insertion (arrow). Black skin markings
represent pre-surgical marking scanning protocol to assist with safe procedure. (B) With the patient posi-
tioned supine (or lateral recumbent) and arm outstretched on an arm board, the device is inserted as
demonstrated in the photo. a, Superficial palmar arch; H, hook of hamate; Mn, median nerve; P, pisiform;
S, scaphoid; T, trapezoid; U, ulnar nerve.

Confirmation of Complete Release wound heals (5 to 7 days). Patients are allowed to return
Following release, the balloons are deflated, and the device to usual activities as tolerated, letting pain be their guide.
is used to probe the TCL to ensure complete release. The Indeed, some patients with comorbid functional limita-
device should be superficial to the hook of the hamate and tions, such as those in wheelchairs, are allowed to imme-
the TCL ligament through the probing process. If com- diately resume ambulation.58,81 Recommended follow-up
plete release is not obtained, the device can be reused by screening surveys are the Boston Carpal Tunnel Question-
re-inflating the balloons and resetting the blade to the distal naire and the Quick Disabilities of the Arm, Shoulder, and
retracted position. Following the above steps, a repeat pass Hand.88,89
can be made.
On confirmation of complete release, the device can Complications
be removed from the incision so excess fluid and blood Pillar pain, or pain over the prominences of the trape-
can be expressed through the wound. The incision is zial ridge, scaphoid tubercle, pisiform, or the hook of the
closed with skin glue and steri-strips, or suture if pre- hamate, is present in as many as 60% of individuals follow-
ferred. A sterile gauze and occlusive dressing are applied ing CT release.31,39,56,61,62,76,86,90,91 This can be debilitating,
to the wound. causing a decrease in strength and delayed return to work/
Post-procedure neurologic and physical exam are recom- recreational activities. Early data on USCTR show an early
mended to ensure no neurologic or tendon injuries have return to prior level of function with faster decrease in per-
occurred. The published average total time of the procedure operative and operative pillar pain when compared to mini-
is approximately 7 minutes, with an average incision length open technique.
of less than 5 mm.49,52,57,58,81 Iatrogenic injury to any of the aforementioned nervous
structures is a potential complication of any CTR proce-
Post-Procedure Management dure. Perhaps the most-feared complication of CT release
Following the procedure, patients are instructed to keep is injury to the TMB; the theoretical risk increases dramati-
the incision covered with bio-occlusive dressing until the cally in the setting of anatomic variations in the origin or
 CHAPTER 32 Ultrasound-Guided Release of the Transverse Carpal Ligament (Carpal Tunnel) 541

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with increased wound complications in diabetic patients under- 2018;37(8):2075–2081.
going primary, open carpal tunnel release. Plast Reconstr Surg. 81. Henning T, Lueders D, Chang K, Yang L. Ultrasound-guided
2019;144(4):632e–638e. carpal tunnel release using dynamic expansion of the transverse
63. Rojo-Manaute JM, Capa-Grasa A, Chana-Rodriguez F, safe zone in a patient with postpolio syndrome: a case report.
et al. Ultra-minimally invasive ultrasound guided carpal tun- Pharm Manag PM R. 2018;10(10):1115–1118.
nel release: a randomized controlled trial. J Ultrasound Med. 82. Rowe NM, Michaels J, Soltanian H, Dobryansky M, Peimer
2016;35(6):1149–1157. CA, Gurtner GC. Sonographically guided percutaneous carpal
64. Kim PT, Lee HJ, Kim TG, Jeon IH. Current approaches for car- tunnel release: an anatomic and cadaveric study. Ann Plast Surg.
pal tunnel syndrome. Clin Orthop Surg. 2014;6(3):253–257. 2005;55(1):52–56; discussion 56.
65. Papatheodorou LK, Sotereanos DG. Treatment recommenda- 83. Nakamichi K, Tachibana S, Yamamoto S, Ida M. Percutaneous
tions for carpal tunnel syndrome and peripheral nerve repair. carpal tunnel release compared with mini-open release using
64:273–280. ultrasonographic guidance for both techniques. J Hand Surg.
66. Hansen TB, Majeed HG. Endoscopic carpal tunnel release. Hand 2010;35(3):437–445.
Clinics. 2013;30(1):47–53. 84. Nakamichi KTS. Ultrasonographically assisted carpal tunnel
67. Capa-Grasa A, Rojo-Manaute JM, Rodriguez FC, Martin JV. release. J Hand Surg. 1997:853–862.
Ultra-minimally invasive sonographically guided carpal tun- 85. McShane JM, Slaff S, Gold JE, Nazarian LN. Sonographically
nel release: an external pilot study. Orthop Traumatol Surg Res. guided percutaneous needle release of the carpal tunnel for treat-
2014;100(3):287–292. ment of carpal tunnel syndrome: preliminary report. J Ultrasound
68. Rojo-Manaute J, Capa-Grasa A, Chana-Rodriguez F, et al. Ultra- Med. 2012;31(9):1341–1349.
minimally invasive ultrasound guided carpal tunnel release: a ran- 86. Boeckstyns ME, Sorensen AI. Does endoscopic carpal tunnel release
domized controlled trial. J Ultrasound Med. 2016;35:1149–1157. have a higher rate of complications than open carpal tunnel release?
69. Rojo-Manaute JM, Capa-Grasa A, Rodriguez-Maruri GE, An analysis of published series. J Hand Surg Br. 1999;24(1):9–15.
Moran LM, Martinez MV, Martin JV. Ultra-minimally invasive 87. Presley J, Smith J, Barnes D, Lachman N, Kakar S, Sellon J. Ultra-
sonographically guided carpal tunnel release: anatomic study of a sound-guided carpal tunnel release (USCTR) using dynamic safe
new technique. J Ultrasound Med. 2013;32(1):131–142. zone expansion: a cadaveric validation study [abstract]. Clin J
70. Wang PH, Li CL, Shao CJ, Wu KC, Chern TC, Jou IM. Ultra- Sport. 2017;27(suppl):221.
sound-guided percutaneous carpal tunnel release in patients on 88. Levine DW, Simmons BP, Koris MJ, et al. A self-administered
hemodialysis: early experiences and clinical outcomes. Ther Clin questionnaire for the assessment of severity of symptoms and
Risk Manag. 2019;15:711–717. functional status in carpal tunnel syndrome. J Bone Joint Surg
71. Burnham RS, Loh EY, Rambaransingh B, Roberts SL, Agur AM, Am. 1993;75(11):1585–1592.
Playfair LD. A controlled trial evaluating the safety and effective- 89. Hudak PL, Amadio PC, Bombardier C. Development of an
ness of ultrasound-guided looped thread carpal tunnel release. upper extremity outcome measure: the DASH (disabilities of the
Hand (N Y). 2019. 1558944719842199. arm, shoulder and hand) [corrected]. The Upper Extremity Col-
72. Mittal N, Sangha H, Flannery J, Robinson LR, Agur A. Ultra- laborative Group (UECG). Am J Ind Med. 1996;29(6):602–608.
sound-guided incisionless carpal tunnel release using a hook 90. Kuschner SH, Brien WW, Johnson D, Gellman H. Com-
knife: a cadaveric study. Pharm Manag PM R. 2019;11(10): plications associated with carpal tunnel release. Orthop Rev.
1101–1106. 1991;20(4):346–352.
73. Petrover D, Silvera J, De Baere T, Vigan M, Hakime A. Percuta- 91. Palmer AK, Toivonen DA. Complications of endoscopic and open
neous ultrasound-guided carpal tunnel release: study upon clini- carpal tunnel release. J Hand Surg Am. 1999;24(3):561–565.
cal efficacy and safety. Cardiovasc Intervent Radiol. 2017;40(4): 92. Vasiliadis HS, Tokis AV, Andrikoula SI, et al. Microsurgical dis-
568–575. section of the carpal tunnel with respect to neurovascular struc-
74. Markison RE. Percutaneous ultrasound-guided MANOS carpal tures at risk during endoscopic carpal tunnel release. Arthroscopy.
tunnel release technique. Hand. 2013;8(4):445–449. 2006;22(8):807–812.
33
Ultrasound-Guided
Percutaneous Bone Spur
Excision and Cheilectomy
BRIAN J. SHIPLE

inflammatory spondyloarthropathies such as ankylosing

KEY POINTS spondylitis.2,3
• B one spurs that form along joints are known Osteophytes and enthesophytes have similar develop-
as osteophytes, and bone spurs that form at mental process and composition.3,4 Osteophytes are typi-
the attachment of tendons to bones are called cally lateral outgrowths of bone at the joint line and are
enthesophytes. features of degenerative and inflammatory joint diseases
• Bone spurs may cause pain by causing joint or mechanical stress from joint instability.2,5 The degree
impingement, nerve irritation, and direct mechanical
irritation to soft tissue. of spurring can vary considerably, and there is some evi-
• Not all bone spurs cause pain. Many bone spurs dence that small spurs can be unrelated to associated joint
that are identified may be asymptomatic, and the pathology.6,7
osteophyte or enthesophyte a sign of the underlying Enthesophytes are also common and form in the direc-
degenerative or inflammatory pathology or instability. tion of tension of the involved ligament or tendon.3 Enthe-
• A cheilectomy is the removal of bony irregularities, or
osteophytes, at the osteochondral margin of a joint sophytes can form at any tendon or ligament enthesis and
that limit joint range of motion. Classically this applies are associate with microtears or in response to inflamma-
to a hallux rigidus patient from the dorsal surface of tory pathology, and risk factors include spondyloarthritis
the great toe, but this term may be applied to any joint and age.8,9 One radiographic survey found heel spurs at
where there is an impinging bone spur. the Achilles tendon or plantar fascia in 25% of the popula-
• Minimally invasive percutaneous bone spur or
intratendinous calcification removal using a cannula or tion.10 Similar to osteophytes, enthesophytes do not always
Tenex TX-Bone tool is a novel way to remove impinging indicate pain or disease.8,11–15
bone spurs along joint surfaces or enthesophytes at
tendon attachments.
• Patient selection should be based on careful Imaging and Ultrasound Findings
examination, diagnostic blocks, and diagnostic imaging
(e.g., ultrasound, x-ray, and magnetic resonance Conventional radiographs are the standard imaging modal-
imaging [MRI]/computed tomography [CT]). ity for the assessment of osteoarthritis, and osteophytes are
  
a common radiographic feature. Radiographic grading of
osteophytes or enthesophytes is often subjective. Different
semiquantitative scoring systems have been described.16–18
Anatomy and Pathology Few studies have examined the reliability of these scales or if
there is a clinical correlation, and there is an no established
Bony exostosis, or bone spurs, is thought to develop in universal or standardized grading method for osteophytes or
response to inflammatory or mechanical stimuli.1 There enthesophytes.19
are three main types of bony proliferation: (1) chondro- Radiographs are in imperfect way of assessing osteophyte
osteophyte or osteophyte at the synovium-articular carti- formation and enthesophyte changes.20 In some studies,
lage junction along the joint margins; (2) traction spur or ultrasound has been shown to be more sensitive than con-
enthesophyte at the insertion of a tendon or ligament; and ventional radiography in detecting osteophytes in the hand
(3) syndesmophytes within the vertebral column along the and knee.21–25 Sonographic findings of bone spurs, whether
annulus fibrosus or spinal ligament and associated with an osteophyte or enthesophyte, include a hyperechoic

544
 CHAPTER 33 Ultrasound-Guided Percutaneous Bone Spur Excision and Cheilectomy 545

cortical protrusion with acoustic shadowing. Different grad-

ing systems have been described, but few studies have exam-
ined the reliability of these scales and clinical correlation,
and a review of these scales is beyond the scope of this chap-
ter.17–19 Dynamic ultrasound can also be used to visualize
impingement due to osteophytes.26
Ultrasound evaluation can also be used for preprocedural
planning, and the osteophyte or enthesophyte should be
assessed for its size (length, width, and depth) in long and
short axis. Examination of surrounding neurovascular struc-
tures is necessary to assess a treatment pathway (e.g., place an
instrument safely down to the bone spur for possible removal).

Treatment Options
Asymptomatic osteophytes or enthesophytes do not need
treatment, and conservative management includes medica- • Fig. 33.1
The Jamshidi 11-gauge × 4.5-inch trocar and cannula used
tions, changing footwear, or adding padding. Ultrasound- to remove bone spurs and enthesophytes.
guided fenestration and cortisone injection have been
reported to be an effective way to manage anterior ankle
impingement. In a retrospective case series of 49 patients
with anterior ankle impingement, Nazarian et al. showed
4/79.6% of patients were able to avoid surgical treatment
of their painful anterior ankle impingement at follow-up
(average 27 months).27
Symptomatic spurs that fail conservative management
may need to be removed. Open or arthroscopic/endo-
scopic surgery is the standard of care for painful osteophytes
that limit motion or cause impingement,28–30 and painful
enthesophytes within a tendon.31,32 Using a cheilectomy to
remove painful dorsal osteophytes for hallux rigidus has been
well described in the literature, with open, arthroscopic,
and percutaneous approaches being described.33 The litera-
ture on percutaneous approaches is limited. Percutaneous
• Fig. 33.2 TX-Bone (TXB) Micro Tip. Tenex Health TX-Bone (TXB)
minimally invasive techniques for dorsal cheilectomy have Micro Tip device designed for bone removal. The Tenex TX-Bone tool is
been reported with a wedge burr (Wright Medical, Mem- a 14-gauge needle to facilitate debriding bone spurs and enthesophytes.
phis, TN) and have similar complications to an open chei-
lectomy.33–36 One limitation may be a higher reoperation Ultrasound-guided percutaneous spur excision has not
rate with the percutaneous palpation-guided approach. One been widely described in the literature. Excision of a pain-
publication comparing open versus minimally invasive chei- ful osteophyte or enthesophyte can be performed with an
lectomy with a wedge burr had a higher reoperation rate 11-gauge × 4.5-inch Jamshidi trocar and cannula (Fig. 33.1)
with the minimally invasive approach (12.8% compared or an OnControl trocar and cannula or more recently with
with 2.6% with open surgery).36 the aid of the Tenex TXB Micro Tip bone tool (Fig. 33.2).
Minimally invasive arthroscopic and endoscopic resec-
tion of bone spurs and exostosis have also been reported Patient Selection
at varying locations. Anterior ankle impingement37,38 has
also been managed with arthroscopic removal of bone Any patient with a painful osteophyte or enthesophyte
spurs, effectively treating pain and loss of motion. Suc- that is safely accessible may be a candidate for a bone
cessful arthroscopic and endoscopic resection of olecranon spur excision, cheilectomy, or tendon enthesophyte exci-
spur39–41 and endoscopic management of chronic Osgood- sion. Whether a bone spur needs to be addressed as part
Schlatter disease42 have also been described in a case series. of a patient’s treatment plan can be assessed by a process of
Compared with open procedures, arthroscopic procedures exclusion and the use of carefully targeted diagnostic blocks.
have shorter recovery time and quicker resumption of Many bone spurs that are identified may be asymptomatic,
sport.43,44 Endoscopic calcaneoplasty of Haglund deformity and the osteophyte or enthesophyte may be a sign of the
has been shown to be superior to open techniques, with less underlying degenerative or inflammatory pathology.
morbidity and fewer complications.45,46 Osteophytes can In cases of calcaneal heel spur, radiographic and histo-
occur at other locations, but the literature on percutaneous logic findings suggest that changes within the fascia rather
and arthroscopic/endoscopic spur excision is limited. than the spur are primarily responsible for pain.47 In one
546 SEC T I O N I V Advanced

study of subjects who underwent an endoscopic plantar fas- • D iagnostic ultrasound machine with a high-frequency
ciopathy, 53.8% of the patients had a calcaneal spur. The linear array transducer or a low-frequency curvilinear
spur was never resected in these subjects, and the outcomes transducer for deeper approaches
of the plantar fasciopathy remained the same whether the • Sterile probe cover and sterile gel
patients had an associated spur or not.48 Other studies have • Percutaneous cutting tool: Jamshidi 11-gauge × 4.5-in
also shown good results with treating the plantar fascia trocar and cannula, Tenex TX-Bone Micro Tip Bone tool
alone, again showing that, although calcaneal spurs may kit, or 11- to 15-gauge OnControl trocar and cannula
be present, there are many other causes of heel pain (e.g.,
plantar fasciitis, tears in the plantar fascia, fat pad atrophy, Injectates
calcaneal fractures).49–51 • L idocaine 1% or 2% with and/or without epinephrine
The challenge of localizing the source of pain extends to and normal saline for skin wheel and local anesthesia and
other locations of osteophytosis or enthesophytes. Image- irrigation as needed. If 11-blade is planned as the intro-
guided diagnostic blocks can be very helpful in confirm- ducer to puncture the skin, consider using epinephrine
ing whether the bone spur is a cause of pain or not. Use for the skin wheel.
a minimal amount of 1% lidocaine around the bone spur • Ropivacaine 0.2% to 0.5% and lidocaine 1% or 2% to
to increase the diagnostic accuracy of the block and assess help provide longer-term anesthesia from the procedure.
whether good anesthesia is achieved within a few minutes of • Optional: an orthobiologic injectate to help facilitate
the injection. Commonly, osteophytes are associated with healing of any damaged tissue after the bone spur removal
degenerative or inflammatory joint disease or instability, (e.g., dextrose prolotherapy, platelet-rich plasma [PRP]
and enthesophytes are associated with partial tearing of liga- amniotic membrane graft, bone marrow concentrate).
ment on tendon. The spur may be asymptomatic or only
one of a number of factors contributing to pain. Identifying Injectate Volume
and treating the underlying source of pain is possibly essen- • L
 ocal anesthesia:
tial for a successful treatment plan. • Skin wheel 2 to 5 mL of lidocaine 1% with or without
The ultrasonic percutaneous treatment of osteophytes epinephrine
and enthesophytes is early, and more research is needed • 3 to 10 mL of mixture of 1 lidocaine 1 or 2% with
on patient outcomes and possible adverse events. Caution or without epinephrine mixed with an equal part of
should be taken in patient selection. Joint pain, night pain, ropivacaine 0.2% to 0.5%
and resting pain may be negative prognostic factors, and
symptoms of impingement or osteophyte rubbing against Ultrasound-Guided Bone Spur Resection
footwear may be positive prognostic signs that the patient
will respond well to percutaneous treatment. (Author’s Preferred Technique)
Patient and Clinician Position
Equipment
• P atient position will vary depending on the target osteo-
• S terile procedure tray with nonfenestrated sterile tray phyte or enthesophyte.
cover • The physician should preferably be seated across from
• Fenestrated drape or sterile cloth or paper towels to the ultrasound screen and the patient’s limb between
create a sterile field the physician and the ultrasound screen for good
• Sterile prep applicators (e.g., ChloraPrep or Betadine) ergonomics.
with manufacturer-required drying time to establish a
dry sterile barrier prior to the procedure Transducer Orientation
• 4 × 4 gauze sponges
• Sterile surgical marking pen • S hort- and long-axis views over the bone spur to identify
• Introducer with an 18-gauge needle or an 11-blade neurovascular structures and plan how much bone needs
disposable scalpel to be removed to address the soft tissue impingement or
• Sterile 3- to 10-cc syringe for skin to target local restricted joint range of motion. Power Doppler imaging
anesthesia can be used to help localize neurovascular structures.
• 27-gauge needle for skin wheel anesthesia • The pathway to access the bone spur needs to be planned
• 25- to 22-gauge needle for anesthetizing the soft tis- to minimize risk of iatrogenic injury to the neurovascular
sue pathway to the target structures.
• Steri-Strips for wound closure • Detailed knowledge of the neurovascular anatomy will
• Tincture of benzoin for sterile adhesive to hold Steri- help to ensure a safe pathway to place the cheilectomy
Strip in place tool. Always use Doppler settings (e.g., Doppler perfusion
• 2 × 2 gauze for hemostasis under waterproof wound index [DPI] or color Doppler) prior to starting the proce-
dressing dure to make sure no significant blood vessels or nerves are
• Tegaderm for waterproof sterile wound barrier in the way of the cheilectomy tool placement.
 CHAPTER 33 Ultrasound-Guided Percutaneous Bone Spur Excision and Cheilectomy 547

• O
 nce the pathway for the needle has been chosen, the LT ISCHIAL BONE SPUR
entry point should be marked on the skin with a sterile
surgical marking pen.

Needle Orientation +
+
• Th
 e needle should be placed in-plane to ensure visualiza- 1
SPUR
tion of the needle tip and cutting device. This may neces-
ISCHIUM
sitate a distal to proximal or medial to lateral approach,
etc., depending on the patient’s target bone spur location.
• A smaller-gauge anesthetic needle can be used to confirm
the pathway for the cutting device to safely access the
spur, keeping in mind the neurovascular anatomy and
musculoskeletal tissues in the pathway and adjacent to
the spur.
• Anesthetic should be injected around the spur/perios- • Fig. 33.3
Left ischial bone spur at origin of conjoined hamstring ten-
teum, ensuring to cover the three-dimensional location don in an avid hiker and mountain climber with a history of chronic
of the spur. Local anesthesia with a 27- to 25-gauge, hamstring origin tendinopathy.
1.25-inch needle to make a skin wheel and a 25- to
22-gauge, 1.5- to 4-inch needle to anesthetize a path-
way for the cutting tool to the bone spur.
• In enthesophytes, note any soft tissue defects adjacent
to the bone spur that “open up” when injecting the
anesthetic. These can represent interstitial tears or
delaminating tears and may also need to be addressed
(e.g., with an orthobiologic injection) in addition to
removing the bone spur. HS TENDON

11 GAUGE JAMSHIDI
Target CANNULA
SPUR LT ISCHIUM
• E nsure adequate anesthesia of the bone spur and adja-
cent soft tissue to facilitate a painless procedure. When
possible, an adjacent nerve block should be considered to • Fig. 33.4 Left ischial bone spur with Jamshidi cannula placed in-
help with pain during the procedure (e.g., tibial and sural plane against the bone spur from a lateral to medial approach and
ready for the cheilectomy procedure.
nerve block for Achilles spur or Haglund resection).
• An 18-gauge, 1- or 1.5-inch hypodermic needle or an
11-blade disposable scalpel is used as an introducer • Th
 e cannula is then twisted clockwise and counterclock-
to puncture the patient’s skin to facilitate entry of the wise and advanced through the bone spur like a leather
larger-bore cutting tools. punch or kitchen apple core tool until the cannula is seen
• The cutting tool is placed through the introducer hole to be all the way through the bone spur on ultrasound
under, and advanced under, ultrasound guidance to the imaging. The bone spur is now inside the cannula (Figs.
surface of the bone spur using in-plane views. Orthogonal 33.3–33.5).
out-of-plane views are obtained to confirm needle place- • An additional pass can be attempted to remove more of
ment. Alternate probe positions will ensure the three the spur. In the author’s experience, two passes through
dimensions of the bone spur are addressed during the a 3-mm bone spur will fill the cannula up approximately
procedure. 2 cm into the cannula. Removing more bone may be dif-
ficult and may increase the risk of leaving a loose body in
Consideration if Using the Jamshidi Trocar the surgery site.
• I f using the Jamshidi trocar and cannula, the trocar is • If more of the spur needs to be removed a second
removed from the cannula. A 3- to 5-cc syringe with Jamshidi trocar and cannula can be placed back through
lidocaine with epinephrine is placed on the open Luer- the surgical opening and the procedure repeated
Lock port after removing the trocar in the event the
patient needs more anesthesia. This also covers the Luer Consideration if Using the Tenex Bone Needle
port opening and helps maintain sterility. Blood back- • I n May 2019, the Tenex TXB Micro Tip tool became
ing into the cannula alerts the physician for the need commercially available. The Tenex TXB cutting tool uses
for more hemostasis, and lidocaine with epinephrine is a foot pedal to activate the needle and begin the bone
injected through the cannula. spur removal.
548 SEC T I O N I V Advanced

LT ISCHIUM S/P CHILECTOMY 2 MONTHS LATER LT ANT TIBIAL BONE SPUR 1 x 0.65CM

+2

+ +
+
1

+
LT ISCHIUM
+1
SPUR
LT SN
REMOVED
1 C 2.33 cm
A 0.43 cm2
d1 0.70 cm 1 L 0.98 cm
d2 0.79 cm 2 L 0.65 cm

• Fig. 33.5The left ischium 8 weeks later showing the bone spur has • Fig. 33.7
Short-axis view of an anterior medial ankle tibial bone spur
been removed with some minor specs of bone left in the soft tissue causing anterior impingement in a triathlete.
area. Note the proximity of the sciatic nerve to the bone spur removal
site.
LT ANTERIOR TIBIAL BONE SPUR CHILECTOzMY
LT TIBIAL BONE SPUR W/ ANTERIOR IMPINGEMENT

TIBIA + + SPUR
1 TB TOOL
SPUR 1+
TALUS

1 L 0.78 cm
1 L 0.36 cm • Fig. 33.8Tenex TX-Bone Micro Tip tool placed against the bone spur
• Fig. 33.6 A tibial bone spur causing left anterior ankle impingement in and ready for the cheilectomy procedure.
a triathlete with a history of pseudogout and keloid scar former.

• Th
 e cutting tool removes bone tissue using ultrasonic LT ANTERIOR IMPINGEMENT 8 WKS POST CHILECTOMY
cavitation and irrigation.
• Ultrasound guidance with alternating in-plane and out-
of-plane views should be used to make sure the bone spur
has been fully removed.
• The TXB Micro Tip should start along the superficial
aspect of the spur and remove bone in layers, moving
deeper until the desired amount of bone is removed
(Figs. 33.6–33.9). Most enthesophytes or bone spurs are
removed with 1 to 3 minutes of cutting time with the
TXB tool.

Post Procedure
Once the bone spur is removed, diagnostic ultrasound can
confirm if there is adequate removal. The spur site should be • Fig. 33.9 Eight weeks post cheilectomy showing some small bony
debris left in the soft tissue where the bone spur used to be as well
studied in short and long axis. If the spur was causing joint
as scant joint fluid in the tibial talar joint and some thickening of the
impingement, dynamic ultrasound with passive joint range synovial tissue just superficial to the ankle joint. At 3-month follow-up
of motion should be used to confirm the impingement has the patient’s impingement pain and ankle dorsiflexion had returned to
been resolved. If a portion of the spur or enthesophyte in a normal.
 CHAPTER 33 Ultrasound-Guided Percutaneous Bone Spur Excision and Cheilectomy 549

tendon was not adequately removed, a decision to repeat the to full rehabilitation, and 8 to 12 weeks to determine if a
procedure should be made. The goal is to remove all or most regenerative injection treatment is needed or the procedure
of the bone spur or enthesophyte. needs to be repeated. During the postprocedure follow-up
Once the decision is made that the bone spur resec- evaluation, the physician should examine the patient for
tion is adequate, the decision should be made to address improvement in symptoms. Diagnostic ultrasound and/
any soft tissue defect, such as a tendon tear, ligament tear, or radiographs should be obtained to confirm successful
or joint capsule tear. The possibility of needing to address removal of the bone spur or enthesophyte.
an associated soft tissue lesion should be made even before Patients with advanced osteoarthritis that have an
the procedure and reflected in the consent, if the physician impinging bone spur are at higher risk of being a nonre-
decides to do the treatment at the time of the bone spur sponder, but in the author’s hands the results have been suc-
resection. Associated soft tissue pathology can be treated cessful at restoring joint motion and pain relief, especially
with an orthobiologic injection at the time of the treatment when combined with an advanced orthobiologic medicine
(e.g., PRP, prolotherapy, etc.). Some physicians will decide procedure, such as a bone marrow concentrate injection to
to do this treatment at the time of the bone spur resection, help treat the arthritic joint.
and others may decide to delay this treatment until 4 to 8
weeks after the bone spur resection procedure. The author Complications Post Procedure
prefers to use an orthobiologic at the time of the bone spur
resection using a different needle entry site. Complications are similar to those of open or arthroscopic/
After bone spur removal, compression with sterile gauze endoscopic bone spur removal, including infection, bleed-
can be used for up to 4 to 10 minutes and will usually achieve ing, and continued or worsening pain. Failure to adhere to
hemostasis. Bone spurs have a blood supply and, if hemosta- sterile technique could result in a wound infection and in
sis is slow or incomplete, a simple suture closure with Nylon cases of bone spur removal from a joint could result in a sep-
suture material may also be used depending on the depth of tic joint. In the author’s 10 years of experience, he has not
the procedure. Once hemostasis has been achieved, tincture experienced an infection with this procedure and he has not
of benzoin with Steri-Strips can be used to close the incision used preprocedure antibiotics or placed any patient on post-
site and the Steri-Strips covered by a 2 × 2 sterile gauze and procedure antibiotics. Therefore the author does not recom-
Tegaderm. mend routinely using antibiotics to help prevent infection
The patient is instructed to keep the waterproof dressing but would not view a physician’s decision to use antibiotics
on until postoperative day 5. If needed, the dressing can be in this case as improper.
replaced with a simple adhesive bandage to keep the wound Hemostasis is the most common challenge a physician
clean and dry. Steri-Strips may be removed between 6 and will encounter on larger bone spurs. Apart from having to
7 days. If a suture was placed, it should be removed in 7 to use a suture or two, the author has not encountered a patient
10 days. he was not able to achieve hemostasis. Although rare, the
For lower extremity spur excisions, the patient should physician should be prepared for a case of uncontrolled
be non–weight bearing for 1 to 4 days to ensure hemosta- bleeding. Other options available to the in-office physician
sis is maintained and allow the postprocedure pain to sub- could include silver nitrate sticks, a battery-operated surgi-
side. The goal of non–weight bearing is to allow the early cal Bovie, or Gelfoam.
inflammatory phase to pass. For enthesophyte removal in Iatrogenic neurologic injury can occur, and in the surgi-
a weight-bearing limb a walking boot is recommended to cal literature complications of hallux valgus surgery include
support the debrided tendon after the non–weight-bearing injury to the dorsomedial cutaneous nerves.52–54 A decision
period and for a total of 2 weeks to allow for early healing to remove a spur on or near a nerve is precision work and
of the tendon. can cause a minor temporary nerve injury that will recover
Protected weight bearing as tolerated can resume on day 2 in days to weeks and rarely months.55 However, an inadver-
to 5, and range of motion exercises should be started on day 3. tent nerve transection can occur without advanced knowl-
The patient may work on range of motion outside of the boot edge of the neuroanatomy, and this risk should be discussed
3 to 5 times a day, keeping the Visual Analog Scale (VAS) with the patient and noted on the signed informed consent.
pain score no higher than a 3 out of 10. Resistance training In the author’s experience he has not encountered a perma-
should start once the VAS pain score is at 3 out of 10 or less nent nerve injury.
and should not be allowed to go over 3 out of 10 as healing Bony debris may remain in the soft tissue using either
progresses. This may take up to 2 to 4 weeks to achieve that technique described earlier. Manipulation and compression
level of pain control. After the initial 2-week healing period, of the soft tissue toward the incision site, and irrigation of
the boot may be weaned and used for longer weight-bearing the tissue can be used to try and remove the remaining bony
periods to keep the VAS pain score less than a 3 out of 10. debris. Small pieces of bone left behind in a tendon or liga-
Patients with painful impinging bone spurs usually notice ment again is common and is not of any consequence. Usu-
early pain relief within days to a week or two, but full heal- ally on long-term follow-up, the remaining small pieces of
ing may require 2 to 4 months. The patient may be brought bone are adsorbed as the soft tissue continues to remodel
back for a wound check at 1 week, 4 weeks for progression and heal (Figs. 33.10 and 33.11). Leaving a loose body in a
550 SEC T I O N I V Advanced

joint has not occurred in the author’s experience and the risk given to addressing associated tendon pathology, with an
of occurring should be very low risk, but not zero. advanced orthobiologic injection in the tendon defect left
In some uncommon situations, the enthesophyte or behind to guard against this rare complication and stimulate
bone spur may grow back, especially if the joint stability is early healing.
not addressed as part of the treatment plan. Spur reoccur-
rence can occur with or without recurrent symptoms.31,56 PEARLS AND PITFALLS
All area pathology should be addressed prior to deciding if • P ercutaneous osteophyte and enthesophyte resection
repeat bone excision is needed to restore tendon function or require real-time ultrasound guidance and precise
to try to help the patient’s joint movement. No studies have needle placement.
examined recurrence rates after a percutaneous approach. • The goal of the procedure is to remove painful bony
exostosis and restore or improve joint motion; however,
In one study of open versus minimally invasive cheilectomy
the procedure may not work and could leave a loose
with a wedge burr for hallux rigidus, the open group did body behind or make the patient’s pain worse.
not require further surgery for impingement, while the • Informed consent must be obtained bearing out these
minimally invasive group 4% required repeat surgery for facts as well as the lack of controlled studies with
dorsal impingement pain.41 In symptomatic cases, a deci- efficacy and adverse event data.
• The Tenex 1 and 2 tools have been used to remove
sion to repeat the procedure may be made and may still be
very small enthesophytes and bone spurs but often
successful. fail to do an adequate job of removing bone from
In addition, tendon rupture is a potential risk of enthe- larger lesions of over 1 to 2 mm in size. The Tenex
sophyte resection. Enthesophytes can occupy a larger per- TX-Bone Micro Tip was designed to remove bone. In
centage of the cross-sectional area of a tendon and resection the author’s experience, it is proving to be an efficient
way to remove impinging osteophytes and tendon
could cause the tendon to be substantially weakened until
enthesophytes. One limitation is the TX-Bone Micro
it is healed. The tendon should be supported (e.g., taping, Tip is 1.3-inch long, and preprocedural planning
shoe inserts/heel wedges, prescription orthotics, a boot, should take into account whether the tip can reach the
and/or bracing) and weight bearing limited for the first 2 pathologic site.
weeks after the treatment. Strong consideration should be • A Jamshidi trocar and cannula has been used by
the author successfully for 10 years to safely remove
intratendinous enthesophytes and impinging bone
spurs.
• Using the techniques described in this chapter a bone
spur approximately 0.5 × 0.5 cm to 1 × 1 cm in size
can be safely removed.
AT   

References
*
1. Venne G, Tse MY, Pang SC, Ellis RE. Mechanically-
• Fig. 33.10 Ultrasound of TX-Bone needle (arrows) approaching induced osteophyte in the rat knee. Osteoarthritis Cartilage.
Haglund deformity. The needle track is through the Achilles tendon and 2020;28(6):853–864.
the Haglund deformity is removed in layers from superficial to deep. 2. van der Kraan PM, van den Berg WB. Osteophytes: relevance
Asterisks, Retrocalcaneal bursa; AT, Achilles tendon. and biology. Osteoarthritis Cartilage. 2007;15(3):237–244.

A B C
• Fig. 33.11 Preprocedure radiograph (A) and postprocedure radiographs immediately after the TX-Bone
(B) and at 3 months (C) demonstrating the removal of the Haglund deformity. The bony debris visible imme-
diately following the procedure in the retrocalcaneal bursa (B) is resorbed at the 3-month follow-up (C).
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3. Rogers J, Shepstone L, Dieppe P. Bone formers: osteophyte and 22. Koski JM, Kamel A, Waris P, et al. Atlas-based knee osteophyte
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cal technique, surgical findings and results]. Z Orthop Unfall. Minimally invasive dorsal cheilectomy of the first metatarsal: a
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34
Intraosseous Injections
STEVEN SAMPSON, HUNTER VINC ENT, AND SONALI LAL

such pathologic changes and is illustrated through objective

KEY POINTS
findings such bone marrow edema. Because of the cross-talk
Knee osteoarthritis treatment summary: between subchondral bone and articular cartilage, lesions
Intra-articular (IA) arthrocentesis (if needed) in the subchondral tissue can ultimately affect the overall
3 to 8 mL IA (if needed) health of articular cartilage and lead to degeneration, if not
5 to 10 mL tibial plateau intraosseous (IO)
5 to 10 mL femoral condyle IO
properly treated.1 This chapter provides instruction on tar-
Patellofemoral osteoarthritis treatment summary: geting subchondral bone in the treatment of joint pain, par-
IA arthrocentesis (if needed) ticularly for hip and knee osteoarthritis. Other less common
3 to 8 mL IA (if needed) anatomic locations such as the ankle, hand, foot, shoulder,
5 to 10 mL femoral trochlear IO and clavicle will also be demonstrated.
2 to 3 mL patella IO
Hip osteoarthritis treatment summary:
IA arthrocentesis (if needed) Treatment Options and Published Studies
3 to 8 mL IA (if needed)
5 to 8 mL acetabular IO Treatment options for bone marrow lesions include bisphos-
5 to 10 mL femoral head IO phonates, extracorporeal shock wave therapy, arthroplasty,
   subchondroplasty with bone cement (calcium phosphate or
polymethyl methacrylate), platelet-rich plasma (PRP), bone
Pertinent Anatomy marrow concentrate (BMC), and mesenchymal stem cells.4,5
Astur et al. performed a review of subchondroplasty with
To understand the role of intraosseous (IO) injections in the calcium phosphate that showed, in 164 subjects, significant
treatment of advanced osteoarthritis with experienced practi- improvement in the International Knee Documentation
tioners, it is important to understand the functional anatomy Committee (IKDC) score or Knee injury and Osteoarthritis
of subchondral bone. Subchondral bone is located beneath Outcome Score (KOOS) and 70% reduction in total knee
the calcified cartilage line forming what is known as the arthroplasty at 2 years. Side effects were one deep venous
osteochondral unit. The structure consists of a plate of corti- thrombosis and two cases of extravasation of cement into the
cal bone, where the bone marrow and trabecular bone areas joint, and 25% still had complaints of pain.6
emerge. Despite the calcified cartilage layer and the cortical Sanchez et al. conducted a study (n = 30) of case-matched
plate being nonporous, it is well known that communication IO and intra-articular (IA) PRP versus IA alone in patients with
between the articular cartilage and subchondral bone does severe medial or patella femoral OA. They used leukocyte-poor
exist (Fig. 34.1).1 The intercommunication between these PRP, low concentration (1.5 to 2.5×) with 5 mL injected into
layers has been identified to play a more significant role in the medial tibia plateau (MTP) and medial femoral condyle
osteoarthritis (OA) progression than previously thought.2 (MFC) 2 cm above the chondral surface (i.e., 10 mL injected
into subchondral bone of each knee). The IO and IA group
Pathophysiology had significant improvements in KOOS, Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC),
Although the pathophysiology of joint osteoarthritis has and visual analog scale (VAS) score in comparison with the IA
long been attributed to wear and tear of articular carti- alone group at the 6- and 12-month follow-up intervals. They
lage over time, a growing volume of evidence suggests that reported that 53% and 46.7% reached the minimum clinically
joint osteoarthritis may be the result of a multidimensional important difference (MCID) for pain reduction at 6 and 12
change in the whole joint inflammatory environment. It is months, respectively, versus 26.7% and 16.7% for the IA only
proposed that the inflammatory state of other structures group.7 Fiz et al. treated 40 patients with severe hip OA who
such as synovium and subchondral bone can contribute to failed IA PRP with IA 8 mL and IO (5 mL each in acetabulum
the overlying health of the joint.3 Significant research has and femur), placing the PRP 1 cm above the bone. There was
identified subchondral bone as a primary starting place for significant improvement in WOMAC and Hip disability and

553
554 SEC T I O N I V Advanced

Osteoarthritis Outcome Score (HOOS), 40% met MCID at transfusions, and six required revision surgery, whereas only
12 months, and there were no adverse events.4 three patients in the BMAC group received a total knee
Hernigou recently published outcomes on long-term arthroplasty (TKA) at 6, 8, and 12 years later.8 Another
follow-up (mean 12 years) for young patients with bilateral study published by Davidson et al. presented outcomes for
knee steroid - induced osteonecrosis. One knee was random- 49 patients (age 10 to 17 years old) with osteochondritis
ized to receive total knee arthroplasty, and the other knee dissecans who were treated using high-volume subchondral
received autologous BMAC. There were 30 patients and BMAC, and 76.9% had healing on postprocedural imaging
60 knees injected with 10 mL into each of the medial and and no serious side effects.9 Kasik et al. treated 20 patients
lateral tibial and femoral compartments of the knee (i.e., with knee arthritis and bone marrow edema with a subchon-
40 mL injected into the subchondral bone of each treated dral injection of BMAC and demineralized bone matrix in
knee). Both groups had similar knee scores, with 21 of 30 addition to arthroscopic surgery, with a mean of 14.5-month
preferring the BMAC-treated knee. There were no serious follow-up. VAS decreased from 7 to 1.3, IKDC scores
adverse events in the BMAC-treated knee; the surgery knees increased from 29.2 to 66.1, and three of the four patients
had one infection, five had thrombophlebitis, nine required who had postprocedure imaging showed improvement.10

A
• Fig. 34.1
The Complex Yet Important Role of Subchondral Bone on Joint Homeostasis. (Courtesy of
Mikel Sanchez and Nico Fiz.)
 CHAPTER 34 Intraosseous Injections 555

B
• Fig. 34.1—cont’d

Lastly, Kyle et al. reported on two cases of knee subchondral The current published research demonstrates very prom-
edema treated with IO BMAC, and both had symptom and ising results for the use of BMAC to treat bone marrow
imaging improvements.11 lesions of the knee and osteonecrotic lesions of the knee and
An additional study published in 2018 by Hernigou et al. hip. There is some reported positive benefit of IO PRP for
with 30-year follow-up looked at outcomes for the treat- subchondral lesions in OA but not as robust.
ment of stage I or II hip osteonecrosis (Fig. 34.2) with cel-
lular therapy versus core decompression. The study enrolled
125 patients (i.e., 250 hips) with bilateral hip osteonecrosis Technique
from 1988 to 1998; the hip with the larger-sized osteone- Fluoroscopic Guidance: Knee Osteoarthritis
crotic lesion on magnetic resonance imaging (MRI) was
  
treated with percutaneous cellular therapy (i.e., BMAC) and
Patient position: Supine, knee in extension. Alternatively,
the hip with the contralateral smaller lesion was treated with
can place the knee in hook lying with a bolster under the
core decompression. At the most recent follow-up (average
knee for support.
of 25 years post treatment), 24% (i.e., 30 hips) in the cel-
Clinician position: Contralateral side as the treatment limb.
lular therapy group versus 76% (i.e., 95 hips) in the core
Setup: Sedation or MAC optimal, Completely sterile field,
decompression group had undergone total hip arthroplasty.
In addition, only 28% versus 72% also had progression to Equipment Needed
collapse on repeat MRI at the follow-up, cellular therapy   
versus core decompression, respectively.12 Several additional 25- to 22-gauge needle
studies have also been published on the topic of cellular 18- to 15-gauge bone trocar 1-inch to 2.7-inch length
therapy for the treatment of hip osteonecrosis,13–19 with the Automated power driver and/or mallet
goal of developing best practices for treatment. Syringes as necessary for volume
556 SEC T I O N I V Advanced

A Stage I Stage II Stage III Stage IV

B
Ficat stage I Ficat stage 2 Ficat stage 3 Ficat stage 4
• Fig. 34.2 Avascular Necrosis. Stage 1: MRI with signs of boney edema, and often presented as groin pain
in patient. Stage 2: associated with pain and stiffness, MRI shows geographic defect. Stage 3: Pain and
stiffness with occasional radiation to knee, MRI shows increased edema, and eventual cortical collapse.
Stage 4: end stage degenerative changes with evidence of cortical collapse.

Procedural Steps e. Under fluoroscopic guidance, the trocar is advanced

1. Tibial Plateau IO Infiltration: approximately 1.5 to 2.0 cm, directed in a parallel tra-
a. Using fluoroscopic guidance, the medial joint line is jectory toward the articular surface, into the medial
identified in the anteroposterior (AP) and lateral views. portion of subchondral bone in the tibial plateau
Ensure the medial and lateral tibial plateau are aligned in (Fig. 34.5).
the lateral view and the anterior and posterior plateaus f. Once the trocar is correctly placed, it is optional to
are aligned in AP. Mark the skin approximately 2 cm inject contrast to view the spread of injectate through
distal to the joint line and centered in the midline sagit- the bone and observe if there is excess vascular uptake.
tal plane (Fig. 34.3). g. Approximately 5 to 8 mL of injectate is infiltrated
b. If available, linear ultrasound should be used to iden- through the trocar.
tify vasculature that could course in the needle trajec- 2. MFC IO Infiltration:
tory. Use color flow Doppler to identify smaller vessels. a. Using fluoroscopic guidance, the medial joint line
Adjust needle entry/skin mark to avoid vasculature. is identified in the AP and lateral views. Ensure the
c. Optional to add a small amount of local anesthetic, medial and lateral femoral condyles are aligned in the
with 0.25% ropivacaine being the preferred choice. lateral view and the anterior and posterior plateaus
d. An 18- to 15-gauge trocar used for bone biopsy is are aligned in AP. Mark the skin approximately 2 cm
introduced into the skin and advanced down to the proximal to the joint line and centered in the midline
periosteum (Fig. 34.4). sagittal plane (Fig. 34.6).
 CHAPTER 34 Intraosseous Injections 557

3
4
2

A B
• Fig. 34.3 Subchondral bone injections for joint osteoarthritis. (A) Subchondral bone injections for Tibial
plateau (1) and Medial Femoral Condyle (2). (B) Subchondral bone injections for Patella (3) and femoral
condyle (4). (Courtesy of Mikel Sanchez.)

c. Optional to add a small amount of local anesthetic,

with 0.25% ropivacaine being the preferred choice.
d. The trocar is advanced to the level of the periosteum
and again advanced 1.5 to 2 cm toward the medial
portion of the femoral condyle, in a parallel trajectory
to the articular surface (Fig. 34.7).
e. Once the trocar is in the desired position, it is optional
to inject contrast to view the spread of injectate through
the bone and observe if there is excess vascular uptake.
f. Five to 8 mL of injectate is infiltrated into the sub-
chondral bone.
3. Lateral Femoral Condyle: The same landmarks and tech-
nique are used for the lateral femoral condyle, except
using the lateral joint line as a starting point. See Fig.
34.8 as a reference for the placement of the bone trocar
in the middle portion of subchondral bone in the lateral
femoral condyle.
4. Patellar IO Infiltration: If a patient has significant patel-
lofemoral degeneration, IO infiltration can also be used
in treating the patella.
a. Under fluoroscopic guidance, the midlateral or
medial portion of the patella is identified in lateral
and AP views.
b. The bone trocar is advanced to the level of periosteum
• Fig. 34.4 Bone trocar advanced into subchondral bone of tibial pla-
and advanced approximately 1 to 2 cm toward the
teau with injectate ready for infiltration. middle portion of the patella (Fig. 34.9).
c. Once proper trocar placement is achieved, it is
optional to inject contrast to view the spread of injec-
b. If available, use ultrasound to identify vasculature tate through the bone and observe if there is excess
that could course in the needle trajectory. Use color vascular uptake.
flow Doppler to identify smaller vessels. Adjust nee- d. Two to 4 mL of injectate can be infiltrated into the
dle entry/skin mark to avoid vasculature. patella.
558 SEC T I O N I V Advanced

A
A

B
B
• Fig. 34.5 (A) Anteroposterior and (B) lateral fluoroscopy views of bone
trocar in subchondral bone. • Fig. 34.7 (A) Anteroposterior and (B) lateral fluoroscopic views of
bone trocar in the subchondral bone in medial femoral condyle.

• Fig. 34.6Bone trocar is advanced into subchondral bone, approxi-

mately 2 cm proximal to the joint line.
• Fig. 34.8
Anteroposterior fluoroscopic view of bone trocar advanced into
subchondral bone of lateral femoral condyle. (Courtesy of Chris Williams.)
 CHAPTER 34 Intraosseous Injections 559

Alternative Techniques
For femoral condyle and tibial plateau IO injections, one can also
directly target a specific bone marrow lesion as seen on MRI. Tech-
nique would be similar, except instead of targeting 2 cm above or
below the joint line and injecting subchondral 1.5 to 2 cm into the
bone, vary needle position to match specific lesion (Fig. 34.10).

Fluoroscopic Guidance: Hip Osteoarthritis and

Avascular Necrosis
  
Patient position: Supine, hip in 30 degrees of flexion.
Clinician position: Same side as the treatment limb.
Setup: Sedation or MAC optimal, completely sterile field.

PEARLS AND PITFALLS

• R emember, it is important not to advance the trocar
beyond the articular cartilage, as this could create
A a new cartilaginous lesion. Furthermore, in cases of
osteoporosis, severe OA, or articular cartilage damage,
it is expected to experience less resistance as injectate
flows from subchondral bone to intra-articular (IA).
• Patients may experience more postprocedural pain
with intraosseous (IO) infiltration versus standard IA
orthobiologic injection in the first 48 to 72 hours. This
can be due to changes in pressure within the bone.
• Infection secondary to IO infiltration can be more serious
than standard IA injection and should be treated as so.
  

Equipment Needed
  
18-gauge needle
15-gauge bone trocar
B Automated power driver and/or mallet
Syringes, as needed, for volume
• Fig. 34.9 (A) Anteroposterior and (B) lateral fluoroscopic views of
bone trocar placement into the patella. (Courtesy of Chris Williams.)

A B
• Fig. 34.10 Injecting specific lesions for both femoral and tibial plateau lesions for intraosseous patella
injections, one can alternatively inject from the anterior aspect of the patella instead of lateral (see Figs.
34.11 and 34.12). (A) Injecting lateral femoral condyle under fluoroscopic guidance (B) Injecting medial
femoral condyle undergo fluoroscopic guidance.
560 SEC T I O N I V Advanced

Procedural Steps 1 cm lateral to the sartorius muscle, directly superfi-

1. Femoral Head IO Infiltration: cial to the femoral neck.
a. Obtain a true AP projection of the hip joint and c. The bone trocar is advanced down to the periosteum
proximal femur. of the femoral neck at a 45-degree angle, in line with
b. With the proper anatomy identified under fluoro- the anatomic angle of the femoral neck. The trocar
scopic guidance, the skin is marked approximately should be advanced to within approximately 1 cm of
the articular surface (Figs. 34.13–34.15).
d. Once the trocar is correctly placed, it is optional to
inject contrast to see the flow of injectate and make
sure there is not excessive vascular uptake.
e. Approximately 5 to 10 mL of injectate is infiltrated
through the trocar.
2. Femoral Head IO Technique 2
a. Patient positioned in the lateral decubitus position. A
30-degree bend in the target hip with the contralat-
eral hip at 15 degrees to identify the correct femur on
fluoroscopy. Pillows and inflated bean bag are helpful
to maintain the patient position while under MAC
(Fig. 34.16).
b. Using AP and lateral fluoroscopic views triangulate a
needle trajectory starting below the greater trochanter
headed toward the middle superior femoral head and
mark the skin.
c. Insert an 11-gauge 6-inch trocar into the periosteum
1 to 2 cm below the greater trochanter, aiming for the
superior and middle portion of the femoral head.
d. Attach the power drill and guide the needle using
intermittent fluoroscopy, alternating between the AP
and lateral views. Ensure the needle traverses through
the middle of the femoral neck.
e. Once the trocar is correctly placed, it is optional to
inject contrast to see flow of injectate and make sure
there is not excessive vascular uptake.
• Fig. 34.11 Anterior Approach to Intraosseous Patellar Injection.

A B
• Fig. 34.12 (A) Anteroposterior and (B) lateral fluoroscopic images for anterior approach to intraosseous
patella injection.
 CHAPTER 34 Intraosseous Injections 561

• Fig. 34.15 Anteroposterior fluoroscopic view of bone trocar within

subchondral bone and close to articular surface of femoral head.
(Courtesy of Chris Williams.)

• Fig. 34.13 Subchondral bone injection locations for hip osteoarthritis, f. Approximately 5 to 10 mL of injectate is infiltrated
including the acetabulum and femoral head. (1) acetabulum subchondral
through the trocar.
bone injections. (2) femoral head subchondral. bone injection. (Courtesy of
Mikel Sanchez and Nicolas Fiz.) g. Use the power drill to remove the trocar.
3. Acetabulum IO Infiltration:
a. Using fluoroscopic guidance, a standard AP hip x-ray
image is obtained and the femoroacetabular joint line
is identified.
b. The skin is marked approximately 3 cm proximal
to the joint line and centered in the midline sagittal
plane, just superior to the greater trochanter.
c. A 15-gauge trocar is introduced into the skin and
4
advanced down to the acetabular periosteum. Under
fluoroscopic guidance, the trocar is advanced at a
20-degree cranial-caudal angle, directed parallel to
the horizontal plane.
d. The trocar is advanced to within approximately 1 cm
of the articular surface (Figs. 34.17 and 34.18).
e. Once the trocar is correctly placed, it is optional to
inject contrast to see flow of injectate and to make
sure there is not excessive vascular uptake.
f. Approximately 5 to 8 mL of injectate is infiltrated
5 through the trocar.

PEARLS AND PITFALLS

• D uring femoral intraosseous (IO) infiltration, penetrating
the skin lateral to the sartorius muscle minimizes the
risk of injury to the lateral femoral cutaneous nerve.
• Infection secondary to IO infiltration can be more
• Fig. 34.14 (Top) Bone trocar alignment and trajectory shown with serious than standard intra-articular (IA) injections and
injectate attached. (Bottom) Anteroposterior fluoroscopic view of bone should be treated as so.
trocar (arrow) within subchondral bone and close to articular surface of
femoral head. (Courtesy of Nicolas Fiz.)   
562 SEC T I O N I V Advanced

A C

B D
• Fig. 34.16 Fluoroscopic view of trocar in ideal position for femoral head infiltration. (A and B) Patient posi-
tioned in the lateral decubitus position with notable wedge or inflatable bag placed anterior and posterior
around patient to secure position while sedated. (C) C-arm placed in the anteroposterior (AP) fluoroscopic
view. (D) AP and lateral fluoroscopic view of femur with 11-gauge trocar advanced into the femoral head
from a lateral to medial trajectory.
 CHAPTER 34 Intraosseous Injections 563

Ultrasound Guidance: Knee Osteoarthritis

Patient position: Supine with approximately 30 to 40 degrees
of knee flexion.
Clinician position: Same side as the treatment limb.
Setup: Sedation or MAC optimal, completely sterile field.
2
Equipment Needed
18- or 22-gauge needle
15-gauge bone trocar
Automated power driver and/or mallet
Syringes, as needed, for volume

Procedural Steps
3 1. Preparing for IO Infiltration
a. Under ultrasound guidance, identify the medial joint
line and the medial meniscus.
b. Using a 25-gauge needle or surgical marker, mark the
anatomic midpoint of the medial meniscus. The red
arrow in Fig. 34.19 shows the location of the needle
at the midpoint of the meniscus.
c. With the needle acting as the anatomic midpoint,
measure 2 cm proximal along the femur and 2 cm
distal along the tibia (Fig. 34.20).
2. Tibial Plateau IO Infiltration:
a. Using a 15-gauge bone access trocar, pierce the skin
and advance the trocar down the level of the perios-
• Fig. 34.17(Top) Bone trocar alignment and trajectory for acetabulum teum. Ensuring a firm position on the tibia, add a
intraosseous injection. (Bottom) Anteroposterior fluoroscopic view for small amount of caudal tilt to the trocar (≈10 to 15
acetabulum subchondral bone injection. (2) trajectory of injection into
acetabulum with correlating fluoroscopic image. (3) Arrow shows tip of
degrees) and angle the trocar tip toward the joint line.
the boney trocar under fluoroscopic guidance (Courtesy of Nicolas Fiz.) b. Using a mallet, lightly seed the trocar into the perios-
teum, ensuring the same trajectory (Fig. 34.21).

• Fig. 34.19 Ultrasound image showing the medial joint line with the
• Fig. 34.18 Anteroposterior Fluoroscopic View of Acetabulum red arrow aligning with medial meniscus. This image is used to create
Subchondral Bone Injection. a starting point for accurate measuring.
564 SEC T I O N I V Advanced

A B
• Fig. 34.20
With the needle confirmed in the medial meniscus, it acts as a midpoint to accurately measure
2 cm proximal (A) and distal (B) for intraosseous infiltration.

• Fig. 34.21 Mallet being used to lightly seed the trocar into the
periosteum. • Fig. 34.22 Automated power driver used to advance the trocar
approximately 1 to 1.5 cm in the same trajectory.

c. Attach the automated power driver to the trocar and

advance approximately 1 to 1.5 cm (Fig. 34.22). 3. Femoral Condyle IO Infiltration:
Alternatively, this can be performed with manual a. Using a 15-gauge bone access trocar, pierce the skin
advancement. and advance the trocar down to the level of the
d. Attach injectate to the trocar and infiltrate 5 to 10 mL periosteum.
of orthobiologic (Fig. 34.23). b. Ensuring a firm position on the femoral condyle, add
e. The trocar can be removed manually or with assis- a small amount of cranial tilt to the trocar (≈10 to 15
tance from the power driver. degrees) and angle the trocar tip toward the joint line.
 CHAPTER 34 Intraosseous Injections 565

• Fig. 34.23 Intraosseous Infiltration of Injectate Into Tibial Plateau.

• Fig. 34.25 Injectate Being Infiltrated Into Medial Femoral Condyle.

Ultrasound Guidance: Hip Osteoarthritis

  
Patient position: Supine.
Clinician position: Same side as the treatment limb.
Setup: Sedation or MAC optimal, completely sterile field.

Equipment Needed
  
18/22-gauge needle
15-gauge bone trocar
Automated power driver and/or mallet
Syringe volumes, as needed. for injectate

Procedural Steps
1. Femoral Head IO Infiltration:
a. Isolate the femoral head using the sagittal oblique
view under ultrasound guidance, ensuring a clear
view of the femoral head-neck junction.
b. Maintaining approximately a 45-degree angle, guide
the 15-gauge bone access trocar toward the junction
of the surgical neck of the femur and femoral head
(Fig. 34.26).
• Fig. 34.24Automated power driver being used to advance bone tro-
c. Advance the trocar down to the level of the bone,
car into medial femoral condyle.
and attach the automated power driver to the
trocar.
d. Advance the trocar into the femoral head approxi-
mately 1 to 2 cm, until the trocar is firmly set.
c. Using a mallet, lightly seed the trocar into the perios- e. Remove the automated power driver, and infiltrate 5
teum, ensuring the same trajectory. to 10 mL of injectate.
d. Attach the automated power driver to the trocar and Ultrasound guidance is used to identify the femoral head-
advance approximately 1 to 1.5 cm (Fig. 34.24). neck junction (FH) and guide the bone trocar down to the level
e. Attach injectate to the trocar and infiltrate 5 to 10 mL of the femoral head (arrow). Note the 45-degree insertional
of orthobiologic (Fig. 34.25). angle of the trocar in the sagittal oblique ultrasound view.
566 SEC T I O N I V Advanced

FH F
A

90°

45°

• Fig. 34.26 Ultrasound-Guided Intraosseous Femoral Head Infiltration. • Fig. 34.27 Ultrasound-guided intraosseous acetabulum infiltration,
Ultrasound guidance used to identify the femoral head-neck junction confirmed with fluoroscopy. Ultrasound guidance used to identify the
(see FH) and guide the bone trocar down to the level of the femoral femoral-acetabular joint (square), and guide the bone trocar down to
head (arrow). Note the 45-degree insertional angle of the trocar in the the level of the acetabulum. Trocar location confirmed within the ace-
sagittal oblique ultrasound view. tabulum with fluoroscopy (circle). Note the 90-degree anterior/poste-
rior angle of the power driver at the anatomic midpoint.
2. Acetabulum IO Infiltration:
a. Using the curvilinear probe, identify the femoral-ace-
tabular joint and center the acetabulum on the ultra- Other Intraosseous Injections
sound screen.   
b. Move the probe laterally and posteriorly, until the Distal Clavicle/Acromion (Fig. 34.28)
probe is approximately midline between anterior and Ankle: Distal tibia and talus (Fig. 34.29)
posterior acetabulum. Metacarpal (Fig. 34.30)
c. Using an in-plane approach, advance the 15-gauge Sesamoid (Fig. 34.31)
bone access trocar down to the level of the acetabulum, Distal fibula (Fig. 34.32)
approximately 1 cm superior to the articular surface. Proximal Humeral Head (Fig. 34.33)
d. Attach the automated power driver, and advance the Glenoid (Fig. 34.34)
trocar approximately 1 to 2 cm until the trocar is Metatarsal (Fig. 34.35)
firmly set within the acetabulum (Fig. 34.27). Foot: Medial cuneiform (Fig. 34.36)
e. Remove the automated power driver and infiltrate 5 Wrist: Scaphoid (Fig. 34.37)
to 8 mL of injectate.

PEARLS AND PITFALLS

• U ltrasound-guided intraosseous (IO) injections are an
advanced procedure and should be performed only
after a practitioner has learned fluoroscopic-guided IO
injections.
• Because of the porous nature of subchondral bone, the
IO injection may flow from the subchondral bone to the
articular surface.
  
 CHAPTER 34 Intraosseous Injections 567

C
• Fig. 34.28(A) Acromial bone intraosseous setup; (B) acromial intraosseous injection; (C) distal clavicle
intraosseous injection. (Courtesy of John Pitts.)
 A

B
• Fig. 34.29 (A) Setup; (B) ankle tibia and talus intraosseous needle at target (lateral); (C) ankle tibia and talus intraosseous needle at target (antero-
posterior). (Courtesy of Chris Williams.)

A B
• Fig. 34.30 Medial Tibia Plateau. Metacarpal Intraosseous injection: (A) ultrasound set up for metacar-
pal injection; (B) Fluoscopic image of metacarpal intraosseous injection. (Courtesy of Neil Ghodadra.)
 CHAPTER 34 Intraosseous Injections 569

A B C
• Fig. 34.31Sesamoid Intraosseous. (A and B) different fluoroscopic views of sesamoid intraosseous injec-
tion. (C) MRI image of sesamoid pathology prior to intraosseous injection. (Courtesy of Steven Sampson.)

A B
• Fig. 34.32 Lateral Fibula Intraosseous. (A) Anteroposterior; (B) Lateral. (Courtesy of Chris Williams.)
570 SEC T I O N I V Advanced

• Fig. 34.33 Proximal Humeral Head. (Courtesy of John Pitts.)

A B
• Fig. 34.34 Glenoid. (A) Close up fluoroscopic view of glenoid intraosseous injection; (B) anteroposterior
fluoroscopic view of Humeral Head intraosseous injection. (Courtesy of Chris Williams.)
 CHAPTER 34 Intraosseous Injections 571

A C
• Fig. 34.35Toe Magnetic Resonance Imaging. Metatarsal Intraosseous Injection: (A) MRI image showing
boney edema at 1st metatarsal phalange joint; (B) Anteroposterior view of intraosseous injections to 1st
metatarsal phalange joint under fluoroscopic guidance; (C) Lateral View of Fluoroscopic guidance for 1st
metatarsal phalange intraosseous injection. (Courtesy of John Pitts.)

• Fig. 34.36 Medial Cuneiform. (Courtesy of John Pitts.)

572 SEC T I O N I V Advanced

A B C
• Fig. 34.37(A) Proximal scaphoid intraosseous setup; (B) proximal scaphoid lateral; (C) proximal scaphoid
(anteroposterior). (Courtesy of Chaz Fausel.)

References 11. Kyle N, Kunze BS, Serino J, Chahla J, Gomoll AH, Mandelbaum B.
Focal chondral and subchondral bone lesions of the knee: cur-
1. Delgado D, et al. Current concepts in intraosseous platelet-rich rent evidence for the use of biologic treatment. Operat Tech Sports
plasma injections for knee osteoarthritis. J Clin Orthop Trauma. 2018. Med. 2020;28(1):150716
2. Pan J, Wang B, Li W, et al. Elevated cross-talk between subchondral 12. Hernigou P, Dubory A, Homma Y, et al. Cell therapy versus simul-
bone and cartilage in osteoarthritic joints. Bone. 2012;51:212e217. taneous contralateral decompression in symptomatic corticosteroid
3. Barr AJ, Campbell TM, Hopkinson D, Kingsbury SR, Bowes MA, osteonecrosis: a thirty year follow-up prospective randomized study
Conaghan PG. A systematic review of the relationship between of one hundred and twenty five adult patients. Int Orthop (SICOT).
subchondral bone features, pain and structural pathology in 2018;42:1639–1649. https://doi.org/10.1007/s00264-018-3941-8.
peripheral joint osteoarthritis. Arthritis Res Ther. 2015;25(17):228. 13. Hernigou P, Daltro G, Hernigou J. Hip osteonecrosis: stem cells for
4. Fiz N, Pérez JC, Guadilla J, et al. Intraosseous infiltration of life or behead and arthroplasty? Int Orthop (SICOT). 2018;42:1425–
platelet-rich plasma for severe hip osteoarthritis. Arthrosc Tech. 1428. https://doi.org/10.1007/s00264-018-4026-4.
2017;6:e821–e825. 14. Hernigou P, Guerin G, Homma Y, et al. History of concentrated
5. Sundaram K, Vargas-Hernandez JS, Sanchez TR, et al. Are sub- or expanded mesenchymal stem cells for hip osteonecrosis: is
chondral intraosseous injections effective and safe for the treatment there a target number for osteonecrosis repair? Int Orthop. 2018.
of knee osteoarthritis? A systematic review. J Knee Surg. 2019. https://doi.org/10.1007/s00264-018-4000-1.
6. Astur DC, de Freitas EV, Cabral PB, et al. Evaluation and man- 15. Andriolo L, Merli G, Tobar C, Altamura SA, Kon E, Filardo G.
agement of subchondral calcium phosphate injection technique Regenerative therapies increase survivorship of avascular necrosis
to treat bone marrow lesion. Cartilage. 2019;10(4):395‐401. of the femoral head: a systematic review and meta-analysis. Int
https://doi.org/10.1177/1947603518770249. Orthop. 2018. https://doi.org/10.1007/s00264-018-3787-0.
7. Sánchez M, Delgado D, Pompei O, et al. Treating severe 16. Liu L, Gao F, Sun W, et al. Investigating clinical failure of core
knee osteoarthritis with combination of intra-osseous and decompression with autologous bone marrow mononuclear
intra-articular infiltrations of platelet-rich plasma: an obser- cells grafting for the treatment of non-traumatic osteonecrosis
vational study. Cartilage. 2019;10(2):245‐253. https://doi. of the femoral head. Int Orthop. 2018. https://doi.org/10.1007/
org/10.1177/1947603518756462. s00264-018-3918-7.
8. Hernigou P, Auregan JC, Dubory A, Flouzat-Lachaniette CH, 17. Hauzeur JP, De Maertelaer V, Baudoux E, Malaise M, Beguin Y,
Chevallier N, Rouard H. Subchondral stem cell therapy versus Gangji V. Inefficacy of autologous bone marrow concentrate in stage
contralateral total knee arthroplasty for osteoarthritis following three osteonecrosis: a randomized controlled double-blind trial. Int
secondary osteonecrosis of the knee. Int Orthop. 2018. https:// Orthop. 2017. https://doi.org/10.1007/s00264-017-3650-8.
doi.org/10.1007/s00264-018-3916-9. 18. Hernigou P, Thiebaut B, Housset V, et al. Stem cell therapy in
9. Davidson K, Grimm NL, Christino, et al. Retroarticular drill- bilateral osteonecrosis: computer-assisted surgery versus con-
ing with supplemental bone marrow aspirate concentrate for ventional fluoroscopic technique on the contralateral side. Int
the treatment of osteochondritis dissecans of the knee. Orthop J Orthop. 2018. https://doi.org/10.1007/s00264-018-3953-4.
Sports Med. 2018;6. 19. Lebouvier A, Poignard A, Cavet M, et al. Development of a
10. Kasik CS, Martinkovich S, Mosier B, et al. Short-term outcomes simple procedure for the treatment of femoral head osteonecro-
for the biologic treatment of bone marrow edema of the knee sis with intra-osseous injection of bone marrow mesenchymal
using bone marrow aspirate concentrate and injectable deminer- stromal cells: study of their biodistribution in the early time
alized bone matrix. Arthroscopy Sports Med Rehabil. 2019. points after injection. Stem Cell Res Ther. 2015;6:68. https://doi.
org/10.1186/s13287-015-0036-y.
35
Advanced and Emerging
Interventional Techniques
NIDAL ELBARIDI, VIRLYN BISHOP, ORLANDO LANDRUM,
MARKO BODOR, AND JOHN PITTS

Spinal Cord and Dorsal Root Ganglion • B

 urst stimulation (5 pulses 500HZ 40 times per second)
—altered waveform pattern of stimulation that mimics
Stimulation organic nerve firing. This pattern of stimulation results
in subthreshold perception and improved pain control
Products available: compared to traditional stimulation.2-8
• Boston Scientific: Spectra Wavewriter
  
• Abbott: The Proclaim Elite, (recharge free system)
• Nevro: HF-10 Many studies have indicated that SCS is a safe, success-
• Medtronic ful treatment for a variety of chronic pain syndromes. In
• Stimwave 2005, North et al.9 conducted the first randomized, con-
• Nalu. trolled trial comparing 60 participants with failed back sur-
gery syndrome who underwent either SCS or repeat lumbar
Spinal Cord Stimulation spine surgery. Significantly more individuals in the SCS
group endorsed pain relief. When compared to conservative
KEY POINTS
managements, SCS patients experienced greater reductions
in leg pain, as well as an increase in quality of life.10 In a
Spinal cord stimulation is based on the gate control theory, similar study, Kemler et al.11 found that SCS was superior
an idea put forth by Patrick Wall and Ronald Melzack in 1965, to physical therapy for patients with CRPS. The vast collec-
stating that “control of pain may be achieved by selectively
activating the large, rapidly conducting fibers.”1 Two years
tion of studies investigating the efficacy of SCS is constantly
later, the first dorsal column stimulation, conducted by Dr. increasing, although most indicate that it is an effective,
Norman Shealy, occurred.2 Based on these early studies, minimally invasive therapy for patients with neuropathic
spinal cord stimulator (SCS) therapy succeeded by applying pain conditions.1
electric fields to membranes, altering their electric potentials The SENZA-RCT trial,12 a multicenter, randomized, con-
and leading to either the activation or inhibition of the
neuron. SCS can increase the concentration of inhibitory
trolled trial evaluating the safety and efficacy of 10-kHz high-
neurotransmitters and inhibit the nociceptive sensorimotor frequency (HF10) therapy for the management of chronic back
reflex, a polysynaptic spinal reflex intrinsic to pain sensation.1 and leg pain, represented a major change in the traditional SCS
It is most successful for patients with pain due to failed back treatment algorithm. The NEVRO system delivered electrical
surgery syndrome, complex regional pain syndrome (CRPS) stimulation pulses at high frequency (10,000 Hz) as compared
types I and II, and intractable neuropathic pain.3 In current
times, about 50,000 SCSs are implanted every year.
with traditional low-frequency SCS systems (typically around
• T  raditional spinal cord stimulation (40 to 60 Hz)— 50 Hz). Significant pain relief was seen in both low back and
provides repetitive electrical stimulation, which is lower extremity pain without inducing paresthesia.
interpreted by the brain as a paresthesia sensation over New SCS programming sequences targeting microglia
the painful body part. The SCS lead is located in the and astrocytes (Medtronic DTM) are emerging as another
midline dorsal epidural space.
• H  igh-frequency stimulation (10k Hz)—involves
potential stimulation technology for targeting pain signal-
stimulation with increased frequency rate, which results ing in the central nervous system. Microglia and astrocytes
in targeting different neuronal targets and subthreshold within the central nervous system (CNS) have been shown
perception (able to have stimulation without to play a significant role in the development and mainte-
paresthesia). High-frequency SCS leads are located in nance of neuropathic pain. Following peripheral nocicep-
the midline epidural space.
tive activation (via nerve injury, infection, or inflammation),

573
574 SEC T I O N I V Advanced

microglia become activated and release pro-inflammatory Common Pathology

cytokines such as TNF-a, IL-1b, and IL-6, thereby initiating
the pain process. Microglia propagate the neuroinflamma- Similar to SCS, patients can receive DRG stimulators, which
tion by recruiting other microglia and eventually activating are devices that interfere with pain signaling from the DRG,
nearby astrocytes, which prolongs the inflammatory state an easy-to-reach structure in the spine that contains a large
and leads to chronic neuropathic pain.13 amount of sensory nerves. This device is used to treat pain
SCS does not eliminate or mechanically alter the source signaling from areas that are difficult to treat through SCS,
of pain but, instead, blocks the transmission of pain signals such as within the hands, groin, knee, chest, or abdomen. This
in the dorsal columns so that the patient perceives less pain- method does not eliminate the source of pain but, instead,
ful stimuli. The device is programmed to provide each patient blocks the sensation so that the patient feels less of it. The
with settings that are best suited to their condition. Before a device is programmed to provide each patient with settings
permanent stimulation system is implanted, patients undergo that are best suited to their condition. In addition, patients are
a trial of spinal cord stimulation (typically 5 to 7 days) with given a remote that they can use to control their DRG stimu-
temporary lead insertion to determine if the amount of relief lator, allowing them to further personalize their settings and
they receive is meaningful enough to implant a permanent sys- receive the most relief possible. Before a permanent stimulator
tem. The amount of relief provided varies from person to per- device is placed in the body, patients can trial an external ver-
son and, if the trial stimulator is unsuccessful, it can easily be sion. The amount of relief provided varies from person to per-
removed and the patient can pursue other forms of treatment. son and, if the trial stimulator is unsuccessful, it can easily be
removed and the patient can pursue other forms of treatment.
Common Pathology • Mononeuritis of Lower Extremity Unspecified (G57.90)
• Other Nerve Root and Plexus Disorder (G54.8)
Current FDA approval is targeted for patients with various • Mononeuritis of Lower Extremity RIGHT (G57.91)
pain syndromes due to failed back surgery syndrome/post- • Mononeuritis of Lower Extremity LEFT (G57.92)
laminectomy syndrome, CRPS types I and II, intractable • Failed Back Surgery Syndrome (M96.1)
neuropathic pain, visceral abdominal pain, and intractable • Off label use: Abdominal pain and vascular claudication
angina pectoris.3 Success has been reported for off-label use
for the treatment of vascular, abdominal, and pelvic pain. Pertinent Anatomy

Dorsal Root Ganglion Stimulation • T raditional spinal cord stimulation is performed via the
interlaminar approach with resulting lead placement in
Products available: the epidural space.
• Abbott: Proclaim dorsal root ganglion (DRG) • Vertebral body, pedicles, and dorsal epidural space
• Stimwave
Equipment
KEY POINTS SCS kit, per manufacturer, varies
Similar to normal SCS, dorsal root ganglion (DRG) stimulation
is based on the gate control theory, an idea put forth by Patient Position:
Patrick Wall and Ronald Melzack in 1965 stating that
“control of pain may be achieved by selectively activating the • Prone with pillow under abdomen to reduce lumbar lordosis
large, rapidly conducting fibers.”1 Typical SCS has multiple
shortcomings, such as inability to target specific dermatomes
and vulnerability to position changes. DRG stimulation, on Clinician Position
the other hand, can directly stimulate affected nerve roots.1
DRG stimulation is based on targeting a different part of the Standing on the side of patient
spinal cord, specifically the DRG. The application of DRG
SCS results in specific stimulation/pain relief that is extremely
focused in a dermatomal pattern that mimics its spinal C Arm Position
nerve level. The SCS lead is lateral and exits neural foramen
(currently limited to lower thoracic and lumbar levels). • A
 P and lateral views are necessary to track lead advance-
To determine the efficacy of DRG, Timothy et al.14 ment and final position.
performed a randomized trial, comparing DRG and SCS
stimulation in patients with CRPS. This study found that 81.2%
of patients that underwent DRG were relieved of their pain Needle Position
at 3 months, compared to 55.7% of those who underwent
traditional SCS. This finding was consistent at 12 months. • N
 eedle starting point typically is placed 1.5 to 2 vertebral
Similar studies had conclusions consistent with the study levels below intended level to be accessed.
by Timothy et al.,14 finding that DRG stimulation provides • Reason for the difference in needle origin to needle
sustained relief in patients with focal neuropathic pain. target is to keep needle tip/SCS lead located in the
   dorsal aspect of the epidural space.
 CHAPTER 35 Advanced and Emerging Interventional Techniques 575

• Th
 e interlaminar approach/access is safely done utilizing fixation expandable system at spine fracture level. Indicated
a loss of resistance syringe to identify safe entry into the for vertebral fracture expansion, fixation, stabilization, and
epidural space. ultimately reduction and stabilization of same level.

Target KEY POINTS

• T raditional/Burst/High frequency stimulation—needle Vertebral Augmentation (Vertebroplasty, Balloon
tip final position midline in dorsal aspect of epidural Kyphoplasty, Spine Jack)
space. SCS lead midline space between T7 to T9. Vertebral compression fractures affect 26% of women over the
• DRG stimulation—needle tip slightly contralateral to age of 50 and 40% of women over 80 years of age. Of these
midline of desired exiting foramen. Needle tip one level individuals, more than one-third develop chronic back pain.15
inferior to exiting foramen. Typically, individuals with vertebral compression fractures
are treated conservatively with analgesics, bed rest, external
fixation, and/or rehabilitation. However, the most frequently
PEARLS AND PITFALLS prescribed medications are poorly tolerated by elderly
patients, and bed rest can further demineralize the vertebrae,
• B esides traditional radicular symptoms, spinal cord
making these patients more susceptible to additional
stimulation can be useful. DRG/SCS has superior pain
fractures. Furthermore, surgical fixation is often unsuccessful
relief of distal extremity. However, reports of injury to
due to weakness within the osteoporotic bone. Therefore,
DRG or exiting nerve root have been reported. So,
physicians have explored other treatment options for patients
caution while placing the DRG lead is imperative (Figs.
with vertebral compression fractures.
35.1 and 35.2).
Vertebroplasty is a minimally invasive procedure in
• SCS trial is the most important predictor of potential
which acrylic bone cement is injected into a pathologically
success. Trials vary from 3 to 7 days. SCS trials involve
compressed vertebral body. Studies have shown short- and
evaluating the patient’s degree of pain relief.
long-term pain relief in 70% to 95% of patients.16 Kyphoplasty
   is similar in concept to percutaneous vertebroplasty, except
that an inflatable balloon is used to expand a collapsed
vertebral body as close as possible to its natural height
Spine Fracture Therapies before introducing the mechanical fixation by injecting
polymethylmethacrylate (PMMA), a cement-like material, into
Products available the cavity created by the balloon. In theory, the expansion
• Medtronic: of a cavity by the balloon permits infusion of bone cement
into the cavity under lower pressure than the bone cement
Kyphon Balloon Kyphoplasty, Vertebroplasty, Sacro- injected during vertebroplasty. Doing so can stabilize the
plasty for vertebral column and sacral fracture repair compression fracture while realigning the endplate of the
Stryker: AVAflex Ballon Kyphoplasty, iVAS Balloon vertebral body.15 Stabilization of the bone limits movement
Kyphoplasty for vertebral augmentation and sacroplasty. within the fracture, thereby relieving symptoms of pain. One
Spine Jack novel system that includes implantation of a of the primary reasons for choosing kyphoplasty in lieu of
vertebroplasty is decreased cement leakage, which is a main
complication with resulting compression of exiting spinal nerve
roots or central spinal cord compression. A 2017 review article
consisting of 22 studies reported 54.7% and 18.4% cement
leakage for vertebroplasty and kyphoplasty, respectively.17
Additionally, a review published in 2018 of 16 studies showed
that kyphoplasty had significantly less risk of cement leakage
versus vertebroplasty compared to vertebroplasty.18 There
were no significant differences in pain and functional scores.
  

Sacroplasty
First described in the literature in 1982, sacral insufficiency
fractures (SIFs) affect 1% to 5% of patients in at-risk popula-
tions. This condition most commonly affects elderly women
with osteoporosis, as well as those with pelvic radiation,
steroid-induced osteopenia, rheumatoid arthritis, multiple
myeloma, Paget disease, renal osteodystrophy, and hyper-
parathyroidism.19 SIFs are thought to occur when stress is
applied to sacral bones with insufficiency, with pain symp-
toms resulting from micromotion within the fracture site.
However, there is often a delay in diagnosing individuals
• Fig. 35.1 Right dorsal root ganglion stimulation lead placement at with SIFs due to the vagueness of symptoms and similarities
L4-5 and L5-S1 on an anteroposterior fluoroscopy image. to other diseases that frequently affect elderly populations.
576 SEC T I O N I V Advanced

T9

E1 T9
T10

T10
AADM-6763
AADM-6763

Right Trial

T12
After bend test
After bend test

T12

A B
• Fig. 35.2 (A and B) Thoracic sacral insufficiency fracture lead placement at T9 on anteroposterior and
lateral fluoroscopy images.

Once diagnosed, patients are typically treated conservatively cement is inserted through the needles, hardening along the
with analgesics, bed rest, external fixation, and/or rehabilita- fracture. Pain reduction is almost immediate, with some
tion. However, the most frequently prescribed medications patients endorsing alleviation of symptoms only 30 minutes
are poorly tolerated by elderly patients and bed rest can fur- after treatment.
ther demineralize the vertebrae, making these patients more
susceptible to additional fractures.15 Therefore, physicians Pertinent Anatomy
have explored other treatment options for patients with SIFs. • Th
 e vertebral body is comprised of anterior and posterior
The injection of cement into the sacrum was initially elements with the connecting element being the pedicle.
used to treat painful bony metastases, expanding to SIFs in • The pedicle is both the entryway and safe zone for the
2002.19 During this procedure, PMMA cement is injected procedure being done (see Fig. 13.2).
into the fractured sacrum with the assistance of imaging
devices. This stabilizes the fracture, minimizing micromo- Common Pathology
tion and relieving pain. The goal is to alleviate symptoms • C ompression fracture (with resulting pain) can occur
while increasing mobility, limiting the need for narcotics from multiple causes (osteoporotic compression frac-
and bed rest. A study conducted by Lyders et al. looked at tures, multiple myeloma, spinal tumors, hemangioma,
the efficacy of sacroplasty. myeloma, metastasis, and lymphoma)
By analyzing 52 patients that underwent sacroplasties, • Most compression fractures occur between T9 and L4
the authors concluded that this procedure is safe and effec-
tive, providing rapid relief of pain in individuals with SIFs. Equipment
Participants endorsed a 50% reduction in pain at 2 days, • Vertebral augmentation kit, per manufacturer, varies
80% reduction at 2 weeks, and 90% reduction at 1 year.19
Furthermore, patients relied less on narcotic medications Common Injectates
and endorsed improved ability to complete activities of daily • L ocal anesthetics: Lidocaine 0.5%, Lidocaine 2%,
living (ADLs) following the procedure. A notable complica- Bupivacaine 0.25%
tion is the unexpected extrusion of PMMA cement outside • PMMA powder/barium sulfate/tobramycin powder
of the sacrum, resulting in neurologic sequelae, although
this is rare.19 This study did not include a control group Injectate Volume
and, therefore, it should ideally be repeated with a random-
ized controlled trial design. However, the results are promis- • 6 to 10 mL is typical for local anesthetic injectate
ing, indicating that sacroplasty is an effective treatment for • PMMA or Cortoss cement (injectate averages 2 to 3 mL
SIFs. per level)
Similar to a balloon kyphoplasty, this procedure is
Lumbar Spine
intended to reduce pain while increasing stability for patients
with the use of a biological cement. During this procedure, Patient Position
bone needles are inserted into the affected area with the • P
 rone with abdomen on a pillow to reduce lumbar
assistance of fluoroscopy. Once in the correct position, bone lordosis
 CHAPTER 35 Advanced and Emerging Interventional Techniques 577

C-Arm Position Target

• A ppropriate vertebral body level is confirmed in the • D
 esired target is anterior (1/3) vertebral body, preferred
anteroposterior (AP) view by identifying the 12th rib contralateral vertebral body to facilitate unipedicular
and counting from there. approach/treatment
• Proceduralist will advance the needle biplanar in AP and
lateral views.
• Appropriate planning for trajectory and end point being PEARLS AND PITFALLS
posterior 1⁄3 of vertebral body. • M ost fractures above T2 are not operated on in an
office-based setting.
Needle Position • Recommend 11-gauge needle (reports of pedicle
• P lan for trajectory by localization of local anesthetic fracture with smaller 13-gauge needle, most likely
secondary to challenges with needle positioning with
needle under fluoroscopy at superior lateral aspect of the
smaller needle)
pedicle (respective 10 and 2 o’clock positions). • Cement leak is the most common complication—
• Needle/trocar is advanced using both AP and lateral avoided based on needle position in anterior (1/3) of
views to identify needle tip within the pedicle (NOT vertebrae and intermittent radiographic imaging to
violating the medial pedicle body) until it passes the pos- clarify cement extravasation (Fig. 35.3).
• Second most common complication is infection—
terior vertebral body wall.
adherence to strict sterile technique with optional use of
• Transpedicular is most common route due to its inherent antibiotic (both intravenously and via PMMA mixture) to
safety. Prevents neural compression via cement extravasa- help decrease the risk
tion. Guide trocar to the 10 o’clock (left side) or 2 o’clock   
(right side) entry to prevent medial border violation.
• Trocar needle is advanced using mallet and intermittent
fluoroscopy imaging to clarify tip staying within the ped- Cervical Spine
icle as it advanced
NOTE: This is usually not performed in office-based setting,
Target and rarely by non-orthopedic surgeons or neurosurgeon
• Central anterior 1⁄3 of vertebral body. Patient Position
• S upine position, neck extended with towel or bolster
PEARLS AND PITFALLS under shoulders
• R ecommend monitored anesthesia care (MAC) • Larynx and trachea displace medially, carotid artery
• If possible, perform a transpedicular approach, with laterally
focus on not violating medial border. • Needle entry adjacent to medial border of right ster-
• Using blend of contrast/bone cement injected slowly to nocleidomastoid muscle under direct image guidance
identify any extravasation into perineural structures. (specifically ultrasound to assess presence of vascular
   structures)

Thoracic Spine20-24 C-Arm Position

Patient Position • B
 iplanar technique with straight AP and lateral views,
with neck in neutral position and cervical extension
• Prone
Needle Position
C-Arm Position
• A
 nterolateral (cervical spine)—anterior approach into
• O
 blique AP view with ipsilateral pedicle 25% medial to
the vertebral body, avoiding blood vessels, trachea,
lateral edge of the vertebral body
esophagus, and neural structures. Additional ultrasonog-
Needle Position raphy imaging is optimal to identify a safe trocar path.
• E xtrapedicular approach/intercostotransverse (tho- Target
racic)—avoids pleural and parenchymal injury. Trocar
• Central anterior (1/3) vertebral body.
passes lateral to the transverse process and medial to the
rib border. Traditional transpedicular approach is limited
due to narrower pedicles and difficulty with central ver- PEARLS AND PITFALLS
tebral body endpoint.
• H igh risk procedure given the concentrated anatomy
• Parapedicular—approach to obtain more central end- with vascular and neurologic structures in proximity.
point orientation, increased risk of damage to other ana- • Cement leakage can occur between 12% to
tomical structures. 84% of treated vertebrae, but many of those are
• Can be done with two-needle or one-needle technique, asymptomatic.25
depending on need and vertebral body level.   
578 SEC T I O N I V Advanced

A B C
• Fig. 35.3 (A to C) Thoracic kyphoplasty images using fluoroscopy. (A) in anteroposterior (AP) at T11 on
the right and T12 on the left. (B) Lateral image of T11 and T12 with needle placement. (C) AP image with
cement in T11 and T12 after needle removal.

Minimally Invasive Lumbar Decompression in this study, 5.6% of MILD patients required a repeat oper-
ation at 2 years, compared to the national average of 12.5%
Minimally Invasive Lumbar Decompression to 16.9% for individuals that received spinal fusions and
Procedure 14.4% to 26.0% for individuals that underwent interspinous
process distraction.26 This study and similar experiments
KEY POINTS
indicate the MILD is successful in alleviating symptoms of
Minimally invasive lumbar decompression (MILD) is a procedure LSS, providing more durable results than ESIs and other
to treat lumbar spinal stenosis (LSS) in part due to ligament spinal operations. MILD procedure training requires atten-
flavum hypertrophy. Pain that is present in the axial spine with dance at a specific hands-on training course provided by the
radicular symptoms (indicative of neurogenic claudication) is most
likely to respond. Finding the greatest stenotic level on magnetic
company, thus only a general explanation is presented here.
resonance imaging (MRI) with ligamentum flavum thickening
(noting that both level and laterality are a must to determine
targeted areas). It is an outpatient procedure performed under
Common Pathology
monitored anesthesia (i.e., MAC). It treats lumbar decompression LSS often leads to neurogenic claudication, which causes
by using a 5.1 mm gauge trocar with associated tools to remove
a hypertrophied ligamentum flavum and small portions of the
extremity and lower back pain that can significantly reduce
lamina, causing lumbar spina stenosis (LSS). an individual’s quality of life. Approximately 19.4% of indi-
viduals between the ages of 60 and 69 experience LSS, making
  
spinal surgeries common procedures within this population.27
To evaluate the efficacy of MILD, scientists have compared Usually, this condition affects both sides of the body, although
this procedure to other common treatments for LSS, such as symptoms can be asymmetric, with one side experiencing
epidural steroid injections (ESI). In a randomized controlled worse effects. About 43% of individuals with LSS experience
study performed by Peter et al.,26 treatment outcomes for numbness, often exacerbated by prolonged periods of stand-
patients with LSS and neurogenic claudication symptoms ing and walking.27 LSS is often accompanied by bulging discs,
were compiled from 26 interventional pain management foraminal narrowing, facet hypertrophy, facet arthropathy, and
centers. In total, 149 MILD patients were compared to 131 degenerative disc disease. To treat this condition, many phy-
patients that were treated with ESIs. They found that MILD sicians offer MILD procedures, where excess bones and liga-
procedures provided sustained relief, with patients endors- ments are removed to minimize stress on spinal nerves.
ing significant improvements in their pain, symptoms, and
physical functionality levels for up to 2 years following treat- Pertinent Anatomy
ment. In addition, there were no procedure-related adverse • Th
 e proceduralist needs to understand and visualize on
events or spinal instability for those that underwent MILD fluoroscopy the spinous processes, lamina, ligamentum
procedures.26 Individuals that received ESIs also endorsed flavum, and pedicles.
alleviation of their symptoms, however, the effects were not
as durable and many required repeat injections to sustain Common Pathology
their pain relief. When compared to other spinal procedures, • M
 ILD is indicated for a thickened ligamentum flavum (2.5
MILD patients are less likely to require surgical reoperation; mm or greater), which causes narrowing of the spinal canal.
 CHAPTER 35 Advanced and Emerging Interventional Techniques 579

• I t is typically accompanied by neurogenic claudication, Needle Position

resulting in pain and numbness of the lower back, legs, • E pidurogram by translaminar Tuohy needle (Fig. 35.4A
and buttocks. and B).
• It is interesting to note that other conditions may find • Trocar will be placed just lateral to the spinous process at
benefit in pain relief and function due to increased canal the lamina (Fig. 35.5A and B).
space. Some of these conditions include bulging disc, • Ligamentum flavum and boney connections are removed
facet hypertrophy, and foraminal narrowing. via bone Rongeur, then tissue sculpture, and is performed
under live fluoroscopy (Fig. 35.6).
Equipment • Instruments are advanced posterior to epidurogram and
•  -arm fluoroscopy
C should not go anterior.
• Trocar
• One sculptor/rongeur Target
• Tissue sculptor • I nterlaminar space for hypertrophied ligamentum fla-
vum as identified preoperatively (via MRI) and possibly
Common Injectates intraoperatively via epidurogram. When debulking of
• C ontrast for epidurogram lamina and superficial ligamentum flavum are removed,
• Local anesthetic, with or without, corticosteroids is optional. stenotic lesion improves on epidurogram.
Injectate Volume
PEARLS AND PITFALLS
• 2 to 5 mL of contrast
• 2 to 5 mL of injectate • H ave a clear idea of the epidural space to clarify safety
margins.
Patient Position • It is imperative to have an epidurogram to delineate
the safety border to prevent any damage or harm to
• Prone with abdomen on a pillow to reduce lumbar lordosis neuronal structures.
• Contralateral oblique view with aligned lamina gives
Clinician position target zone and placement of trocar with included tools.
• Side of patient • Refreshing the epidurogram allows for evaluation of
tissue removal progression.
Fluoroscopy Position • Pre-planning and starting alignment are key to the
success of the procedure.
• P osterior-anterior, lateral, and contralateral oblique view • Alignment should be delineated on the patient by using
(for epidurogram) a sterile marker and fluoroscopy to note the alignment
• The fluoroscopy machine is rotated to obtain a contralat- of multiple vertebral levels based on both mid-pedicular
eral view as the optimal working view lines and central spinous processes.
• Tissue removal is conducted under live fluoroscopy   

A B
• Fig. 35.4 (A) Epidurogram anteroposterior view. (B) Contralateral oblique view.
580 SEC T I O N I V Advanced

A B
• Fig. 35.5 (A) Trochar placement anteroposterior. (B) Contralateral oblique view.

market as an alternative to conventional decompres-

sive surgery in managing symptomatic lumbar spinal
pathology.
• In the 1990s, several IDP devices displaying significant
differences in design, materials, surgical techniques, and
indications appeared in Europe and South America, for
which there are ongoing trials of evaluation for a host
of clinical indications. Kaech et al. first reported on the
interspinous “U” (Coflex), suggesting that it was indi-
cated for protection against adjacent level disc disease
and restabilization of a lumbar laminectomy.28a Krappel
et al. reported on the DIAM implant, which was indi-
cated for a number of conditions, including degen-
erative disc disease, herniated nucleus pulposus, and
lumbar instability.28b The X-Stop device (Medtronic,
Tolochenaz, Switzerland) was approved by the US Food
and Drug Administration (FDA) in 2005 for the treat-
ment of neurogenic intermittent claudication (NIC) sec-
ondary to lumbar stenosis.
• Typically, patients complain about low back pain with
or without pseudoradicular pain or dysesthesia. The
• Fig. 35.6 Contralateral oblique view of bone Rongeur deployed. operative “gold standard” to treat degenerative lumbar
spinal disease is decompressive laminectomy, with or
without fusion of the affected segment. However, some
Interspinous Spacer Implantation investigators began to explore novel minimally inva-
sive approaches to stabilize the lumbar spine. Various
Vertiflex/Superion Procedure
authors suggest that advantages of IPD compared with
Background standard surgical decompression techniques are the
• W ithin 10 years, it is estimated that 64 million older option of local anesthesia, preservation of bone and soft
adults will be afflicted with LSS, making it the most tissue, reduced risk of epidural scarring, and cerebrospi-
common indication for spine surgery in individuals older nal fluid leakage, with a shorter hospital stay and reha-
than 65.28 bilitation period, as well as reversibility of the surgical
• A large number of interspinous process devices (IPDs) procedure that does not interfere with future surgical
have been recently introduced to the lumbar spine ­ treatment options.
 CHAPTER 35 Advanced and Emerging Interventional Techniques 581

• W ith interspinous spacer devices, the main selection cri- open posterior lateral interbody fusion or circumferen-
terion is that a patient’s symptoms must be relieved by tial fusion) has been reported to be 2.5% per year. This
forward flexion of the lumbar spine. means that one in four individuals will require a repeat
• This phenomenon is often referred to as the “shopping operation within 10 years of the initial arthrodesis. There
cart sign” due to the improvement in walking endurance are a number of risk factors for accelerated adjacent seg-
in stenotic patients when assuming a forward flexed posi- ment disease. These include being less than 60 years of
tion of lumbar spine. age, termination of the fusion construct at the L5 level,
• Flexion of the stenotic lumbar spine stretches the redun- arthrodesis of three or more levels, and stand-alone
dant ligamentum flavum and enlarges the neural foram- decompression of the segment adjacent to instrumented
ina, thus relieving lower extremity symptoms. levels.
• Interspinous spacer devices mechanisms of action all • Spinous process fracture is the most common complica-
generally work by preserving forward flexion of the tion of interspinous spacer devices.
lumbar spine while increasing the central, subarticular, • Consequently, a patient with severe osteoporosis
lateral recess, and neuroforaminal spaces by restricting (defined as lumbar spine T-score <2.5 on BD DEXA
dynamic narrowing of the mentioned spaces/zones of scan) may represent a contraindication for interspinous
lumbar spine during extension (Gazzeri et al., 2014). device placement, because of the increased risk of frac-
• The annual incidence of surgery for adjacent-segment ture of the spinous process either intraoperatively or
disease following posterior decompression and fusion (or postoperatively.

KEY POINTS
• T he pathoanatomic feature of NIC in lumbar degenerative repeat surgery, six patients developed urinary retention
diseases is the venous stasis in lumbar spine extension, leading to catheterization, and two subjects developed
causing neurologic symptoms, including motor weakness thrombophlebitis.29
in the lower extremities, pain, tingling, and sensory deficit, • In a similar study performed by Bini et al.,30 121 patients
which make walking for a long distance impossible with LSS underwent Vertiflex procedures, receiving
(Gazzeri et al., 2015). Superion® Interspinous Spacers. Subjects endorsed a
• Standard recommendations for the implantation of an 53% decrease in extremity pain following implantation
IPD is mild to moderate central canal stenosis with NIC with 86% of patients confirming statistically significant
from spinal stenosis. reduction in pain after 1 year. In addition, 76% of patients
• Patients with LSS and NIC refractory to conservative confirmed that Vertiflex helped relieve axial pain. Sixty-
treatments typically undergo posterior decompressive, four percent had improvement in their Oswestry Disability
laminectomy with pedicle fixation at one or more levels, Index score, indicating that Vertiflex can significantly
or laminotomy combined with interlaminar stabilization. reduce lower back pain while improving functionality.30
However, these open spine surgeries are more These findings, along with those from the study by Jason
invasive with potentially greater risk of postoperative et al.,29 indicate that Vertiflex is an effective procedure
complications for elderly individuals as they require that is significantly safer than other spinal surgeries
general anesthesia for the procedure and prolonged bed performed to treat LSS.
rest during recovery29. Considering LSS occurs most • For the 75% of spacer patients who have remained free
commonly in individuals that are advanced in age (over of reoperation with an intact implant, almost 85% of
the age of 65), alternative, minimally invasive techniques patients achieved success on at least two of three ZCQ
are often preferred. domains. Leg pain symptom amelioration remains most
• Vertiflex is implanted through a minimally invasive notable with an average improvement of 75% at 5 years
procedure, allowing for interspinous stabilization that can over preoperative values. This suggests that the spacer
treat localized stenosis in patients that cannot undergo continues to offer sufficient indirect decompression of
more intensive surgeries.29 The procedure is shorter, neural structures in the lateral recesses and foramina to
does not require general anesthesia, and rarely disrupts suppress claudicant and radicular symptoms31.
muscles and nerves within the area. In a study performed • The annual incidence of surgery for adjacent-segment
by Jason et al.,29 13 Vertiflex patients were compared disease following posterior decompression and fusion (or
to 73 LSS patients who underwent open surgery: 45 open posterior lateral interbody fusion or circumferential
underwent laminectomy alone or with pedicle screw fusion) has been reported to be 2.5% per year. This
fixation and 28 received limited laminotomy combined means that one in four individuals will require a repeat
with Coflex® implantation at one or two levels. The operation within 10 years of the initial arthrodesis
results indicated that Vertiflex implants are most effective, (incidence and prevalence of surgery at segments
immediately and after 5 years, in alleviating symptoms for adjacent to a previous posterior lumbar arthrodesis).32
individuals with localized LSS.29 With Vertiflex, there were • Percutaneous IPD devices, like Superion, preserve
no postoperative infections or hematomas, whereas six posterior stabilizing elements of the spine, which
of the 45 patients that underwent laminectomy with or prevents excessive physiological motion at the implanted
without pedicle screw fixation experienced cerebrospinal level, theoretically lowering the risk of future segmental
fluid leak. In addition, two of these individuals required a instability.33
  
582 SEC T I O N I V Advanced

Procedure Description
Common Pathology
• F luoroscopic guidance used to identify target lumbar lev-
• I ndividuals with LSS who develop NIC often have vari- els for treatment
ous degrees of narrowing that occurs in the central spinal • A 22-gauge spinal needle is inserted under AP and lateral
canal, lateral recesses, subarticular zones, and neurofo- imaging to obtain optimum trajectory and to anesthetize
ramen. Narrowing in these various regions develops path of trochars in interspinous space down to level of
because of gradual degenerative changes, resulting in posterior laminar line.
degenerative bulging discs, hypertrophy of the ligamen- • A scalpel is then used to make a stab incision through
tum flavum, and facet joint hypertrophy. Claudication skin/subcutaneous tissue and guided under AP and lat-
pain, as well as radicular pain, may benefit from treat- eral imaging to make incision through the supraspinous
ment with the Vertiflex procedure. LSS occurs naturally ligament.
with age but can also be due to injury. NIC symptoms • Per manufacturer kit supplied, a trochar needle is placed
can occur with or without low back pain. Classic NIC to access the interspinous space along incision path and
symptoms are buttock, thigh and/or leg weakness, ach- advanced with gentle malleting under lateral imaging
ing, cramping, and numbness in the legs, which may or until tip is visualized at the posterior laminar line.
may not be painful. • A dilator is used to open the interspinous space ade-
• With interspinous spacer devices, the main selection cri- quately to place a working cannula.
terion is that a patient’s symptoms must be relieved by • Through the working cannula, a presized reamer is used to
forward flexion of the lumbar spine. prep the interspinous space just posterior to the laminar line.
• This phenomenon is often referred to as the “shopping • A lever device is used to secure implant and place through
cart sign” due to the improvement in walking endurance the working cannula for positioning prior to deploying.
in stenotic patients when assuming a forward flexed posi- • A Superion implant is then carefully deployed by slowly
tion of lumbar spine. opening while simultaneously using sagittal rocking
• Flexion of the stenotic lumbar spine stretches the redun- motions to ensure the device’s wings capture on the supe-
dant ligamentum flavum and enlarges the neural foram- rior and inferior spinous processes.
ina, thus relieving lower extremity symptoms. • AP and lateral fluoroscopic views are obtained to confirm
• Interspinous spacer devices mechanisms of action all Superion implant deployed in appropriate AP and lateral
generally work by preserving forward flexion of the orientations on the spinous processes prior to malleting
lumbar spine while increasing the central, subarticu- the implant until it comes to rest along the posterior
lar, lateral recess and neuroforaminal spaces by restrict- aspect of lamina (Fig. 35.7A and B).
ing dynamic narrowing of the mentioned spaces/ • All deployment devices and working cannula are
zones of lumbar spine during extension (Gazzeri et al., removed.
2014). • Deep/subcutaneous tissues are closed with two to three
With the Vertiflex procedure, a small device is placed subcutaneous interrupted sutures (2.0 Vicryl).
between spinous processes: thin, bony projections on • Skin closure may be with either running subcuticular
the back of the spine. Unlike other procedures, such as suture closure (4.0 Monocryl) or skin staples.
MILD, no bone or ligaments are removed. This leads to a
more rapid recovery and less trauma to muscles and other PEARLS AND PITFALLS
structures.
• M RI imaging that shows mild-moderate central stenosis
Pertinent anatomy: The superspinous and interspinous
with NIC is the “hallmark” indication for procedure, but
ligaments run vertically throughout the entire spine. Ven- patients with severe central stenosis, lateral recess
trally, they connect to the ligamentum flavum. Superiorly stenosis, subarticular stenosis, and neuroforaminal
and inferiorly, they connect the adjacent spinous processes stenosis also may benefit.
and are an integral contributor to spinal stability. • It should be standard practice to order flexion and
extension x-rays of lumbar spine (standing x-ray
Equipment preferable) to evaluate for dynamic listhesis at level of
device implantation.
• 2 2-gauge spinal needle • Implantation of Superion device is contraindicated if
• Scalpel there is greater than grade I anterolisthesis or dynamic
• Manufacturer’s kit of supplies listhesis greater than 5 mm at level of stenosis
• Significant scoliosis or lateral listhesis (in which
spinous processes are not sagittally aligned) are both
Technique contraindications to implantation.
Patient Position • Positioning for procedure should emphasize
• P atient positioned in prone position on fluoroscopic exaggerated flexion of lumbar spine (either with pillows
table or commercial positioning devices) in order to facilitate
placement of instruments for device insertion
• Pillows or commercially available gel padded positioners
are used to accentuate lumbar flexion.   
 CHAPTER 35 Advanced and Emerging Interventional Techniques 583

A B
• Fig. 35.7 (A and B) Fluoroscopy anteroposterior and lateral images of Superion device implantation.

Non-Spinal Therapies: Peripheral Nerve for an average of 22 months following the procedure. Paul
Stimulation et al.37 considered 100 patients who received PNS in private
practice to treat chronic craniofacial, thorax, lumbosacral,
Products available: abdominal, pelvic, and groin pain conditions. On average,
   these individuals received a pain reduction of 4.2 ± 2.5 points
SPR Therapeutics: Sprint peripheral nerve stimulator (PNS) on an 11-point scale. In addition, 72% of patients noted that
system they were using fewer analgesic medications.37 These studies,
Stimwave and many more like them, indicate that PNS is a successful
treatment for chronic pain conditions caused by injury to
Bioness: Stimrouter individual nerves.
  
  
KEY POINTS
Invented in the mid-1960’s, peripheral nerve stimulation (PNS)
Common Pathology
interferes with chronic pain signaling from nerves located Similar to SCS, patients can receive PNS, devices that interfere
outside of the spine, thereby treating chronic pain conditions,
such as peripheral nerve dysfunction, CRPS, and cranial
with chronic pain signaling from nerves located outside of the
neuralgia. Similar to normal SCS, PNS is based on gate spine. PNS is used to treat chronic pain due to damaged periph-
control theory, an idea put forth by Patrick Wall and Ronald eral nerves, migraines, and overactive bladder. This method
Melzack in 1965 stating that “control of pain may be achieved does not eliminate the source of pain but, instead, blocks the
by selectively activating the large, rapidly conducting fibers.”1 sensation so that the patient feels less of it. The device is pro-
Stimulating “gates” closes them, competitively regulating
nociceptive inputs. Other theories propose that PNS prevents
grammed to provide each patient with settings that are best
activation of c-fiber nociceptors, inhibits the depolarization suited to their condition. Before a permanent stimulator device
and conduction propagation of axons, decreases is placed in the body, patients can trial an external version. The
hyperexcitability of dorsal horn neurons, or depletes excitatory amount of relief provided varies from person to person and, if
amino acids while increasing the concentration of inhibitory the trial stimulator is unsuccessful, it can easily be removed and
transmitters.34 When chronic pain conditions are unresponsive
to conservative therapies such as medications, therapy, and
the patient can pursue other forms of treatment.
nerve blocks, PNS may be considered.
To evaluate the efficacy of PNS, Mobbs et al.35 reviewed Pertinent Anatomy
patients with blunt or sharp nerve trauma, iatrogenic injuries • P eripheral nerve that fits pain pattern is clarified by der-
from surgery, inadvertent injection of a nerve, and post- matomal or cutaneous nerve distribution.
surgery for entrapment or tumor who were treated with PNS.
Out of the 38 cases reviewed, 60% endorsed significant
• Nerve is localized with ultrasound to clarify its location
reduction of pain and improvements in their quality of life.35 and surrounding structures.
Similarly, Konstantin et al.36 evaluated 10 patients with
intractable occipital neuralgia who underwent PNS. Seventy Common Pathology
percent of these participants expressed satisfying control of • C rush injury or surgery
their pain and a decrease in their oral pain medication intake
• Endocrine dysregulation
584 SEC T I O N I V Advanced

• T oxins (alcohol, lead, mercury, insecticides) • M icrodiscectomy: Microdiscectomy was first pioneered
• Medications (chemotherapy, antibiotics); dietary imbal- in the 1970s. It involves a paramedian skin incision,
ances—vitamins E, B-12.38-41 followed by sequential dilators and, finally, a METRx
tubular retractor with operative microscope is used to
Equipment perform a smaller laminotomy and discectomy.
• Transforaminal endoscopic discectomy: Procedure
• Ultrasound that is typically muscle-sparing using the natural split
between muscles of the back as opposed to cutting
Implanted Flexible Percutaneous Lead References through them, avoiding the resulting increased recovery
• E xternal battery source and altered biomechanics.42 Most optimal indication
• Controller is a lumbar disc herniation with a far lateral-to-lateral
herniation. Some advantages of the technique
include: shorter rehab time frame, reduced blood loss,
Patient position reduced scar tissue formation, and the ability to use
• Pending nerve to targeted local anesthetic only when compared to open and
microdiscectomy procedures.43
Clinician Position   
• Side of patient

Ultrasound Position The road to developing percutaneous disc decompression

• T
 ransducer orientation can be either long or short axis treatments began in the 1950s, when percutaneous access to
(depending on anatomy and preference) the disc was first used to perform needle biopsies of the disc.
In the 1960s, this concept was expanded to treat radicular
Needle Position pain due to herniated discs. At that time, physicians pro-
• P
 erineural with utilization of final lead position based on vided treatment by injecting chymopapain percutaneously.
imaging and amount of stimulation necessary to repli- However, this frequently led to the accidental injection of
cate pain pattern. chymopapain into the subarachnoid, causing serious com-
plications and doubt regarding the efficacy of percutaneous
Target treatments. In the 1970s, scientists in Japan, as well as in
• Painful peripheral nerve the United States, began using endoscopic techniques to
percutaneously access discs, providing a safer, more precise
PEARLS AND PITFALLS alternative for disc injuries.44
Percutaneous disc decompression has been performed for
• U ltrasound evaluation is key.
• Identification of nerve prior to lead implantation is many years now, with a variety of techniques for the removal
instrumental to outcome. of affected disc tissue: chemonucleolysis, automated percu-
  
taneous lumbar discectomy, percutaneous laser disc decom-
pression, and nucleoplasty.45 A study performed by Charles
et al.45 considered the efficacy of nucleoplasty for patients
Percutaneous Disc Decompression with spinal stenosis. During this procedure, small amounts
Products available of nucleus pulposus are removed, allowing for inward disc
   retraction, thereby reducing compression of nearby nerves.
Stryker: Dekompressor Patients were evaluated at 1 week, 2 weeks, 4 weeks, 6
HydroCision: Minimally invasive discectomy weeks, 6 months, and 1 year after their surgery. All sub-
PercResector jects reported reduced pain and improved functionality at
EndoResector each of these intervals. In addition, they endorsed decreased
MicroResector usage of analgesic medications for 4 to 10 months following
  
their nucleoplasty. From this study, the authors concluded
KEY POINTS that percutaneous disc decompression is less costly than
open procedures while providing substantial relief of pain.
Intervertebral disc-related pain can be attributed to disc
degeneration or herniation, which is often accompanied by In addition, nucleoplasty results in lower mortality rates,
inflammation. This condition often leads to stress on nearby a shorter recovery period, and less incidental injury to the
nerves, resulting in referred extremity pain. With nearly 80% nerve root than other, open procedures to treat stenosis and
of individuals with lipopolysaccharide-binding protein (LBP) disc disease. Charles et al.45 and Alexandre et al.46 confirmed
endorsing chronic pain, it is important to identify successful these results, identifying 1,390 patients that endorsed alle-
treatments in order to minimize health care expenditures.
Discectomy is removal of herniated disc and there are multiple viation of symptoms following nucleoplasty.
approaches to disc surgery including: Many other studies have indicated similar success with
• Open discectomy: Traditional surgery involves incision other types of percutaneous disc decompression. For exam-
with direct surgical visualization. The first open ple, Ahn et al.47 endorsed improvement of symptoms in
laminectomy and discectomy were performed in 1934. 88% of his 111 laser decompression patients. Grönemeyer
 CHAPTER 35 Advanced and Emerging Interventional Techniques 585

et al.48was able to eliminate or reduce back pain in 73% of Needle Position

patients using laser decompression. Choy et al.49 had similar • N eedle/guided wire entry is started 11 to 16 cm lateral
results, reporting a 78% success rate at 2-year follow-ups to midline to avoid damage to muscle planes. Needle is
with 333 laser decompression patients.44 These findings advanced like discogram approach.
indicate that percutaneous disc decompression is a success- • Sequential dilators are advanced until largest diameter is
ful treatment for individuals with discogenic pain, regard- seated.
less of the specific technique used. • Endoscope and tools are then advanced with correlated
use of fluoroscopy and endoscope during treatment
Common Pathology process.

In between spinal vertebrae, there are discs, which are gel- Target
like cushions that allow for spinal mobility, act as shock • Herniated disc
absorbers, and hold the spine together. With age or injury,
these discs can begin to bulge outward, increasing inflam-
PEARLS AND PITFALLS
mation and stress on nearby nerves. When this occurs with
discs in the lower region of the spine, the sciatic nerve can • T ransforaminal endoscopic spine discectomy is an
be injured, causing sciatica. In these instances, patients usu- elegant procedure that can be used to treat disc
ally experience pain in the legs or feet that may be alleviated herniations, which are not responsive to conservative
care or basic interventional techniques.
by a percutaneous disc decompression. During this mini- • The most important key point is using both
mally invasive procedure, small amounts of the disc tissue endoscopic and fluoroscopic views to get a robust
are removed, relieving pressure on the nearby sciatic nerve. three-dimensional picture and being cognizant of the
This treatment is most successful in patients with discs that anatomical safety boundaries.
are mildly compressed and have not ruptured. Most people • Fluoroscopic evaluation from AP, oblique and lateral
views (in conjunction), with a solid understanding of
that undergo percutaneous disc decompression note that spine anatomy on endoscope
their pain is relieved almost immediately following surgery. • Having a clear understanding of Kambin’s triangle
• Potential challenges, which may suggest another
Pertinent Anatomy surgical technique/approach, include recurrent
• E xiting nerve root, traversing nerve root, disc annulus, herniated disc, central or lateral recess spinal stenosis,
migrated/extruded disc bulge or L5 disc bulge with high
superior articulating process, vertebral endplates, sinu- iliac crests, and spondylolisthesis.
vertebral nerves, spinal arteries, and intervertebral veins
  
• Kambin’s triangle:
1. The hypotenuse is the exiting nerve root.
2. The base is the superior border of the caudal vertebra. Emerging Procedures
3. The height represents the superior articular process/
traversing nerve root. Cervical Anterior Longitudinal Ligament
Injection
Common Pathology
• Herniated disc bulges with radicular symptoms KEY POINTS
Equipment • A nterior longitudinal (ALL) ligament injuries are
likely often missed in evaluating cervical pain and
•  -arm fluoroscopy
C
instability.
• Guidewire • ALL injuries usually occur concomitantly with other
• Curved dilator cervical injuries. Patients may have a component of
• TESSYS endoscopic system extension-based exacerbation of symptoms or feeling
• Sequential size reamers of instability.
• ALL injury causes minor cervical destabilization, so
• Tissue grasper
surgery is not commonly indicated for these injuries.
• Bone rongeur • Since this problem is underdiagnosed and surgery is
not often indicated, if conservative measures fail, there
Patient Position are not many options for care in those with chronic
• Prone or lateral position problems.
• Videofluoroscopy or digital motion x-ray can provide
Clinician Position a high degree of diagnostic accuracy for identifying
vertebral instability in patients with chronic pain
• Side of patient stemming from whiplash injuries.
• Anterior widening of the vertebral body space or
Fluoroscopy position retrolisthesis in extension is suggestive of ALL laxity.50
• AP, oblique, lateral view   
586 SEC T I O N I V Advanced

Pertinent Anatomy Cervical Intradiscal Injection

• Th
 e ALL is a thick ligamentous band traveling along the
anterior vertebral bodies and discs from the atlas to the sacral. KEY POINTS
• It resists spinal hyper extension.
This technique has been fine-tuned by the author, Marko
Common Pathology Bodor, MD, and requires advanced interventional skills and
an in-depth understanding of cervical anatomy prior to
• Th
 e ALL can be injured with whiplash injuries with the attempting.
C5-6 band being the most susceptible.51
  
• Hyperextension injury
Cervical spine discs can cause neck pain as a result of
Technique
trauma or disc degeneration. Pain may radiate from the
Author has developed a technique to reliably inject the neck to the trapezius, shoulders, arms, and chest (Fig.
C2-C7 ALL ligament using a combination of linear 35.13 from Slipman CW, Plastaras C, Patel R, et al. Pro-
ultrasound and fluoroscopic guidance. This requires great vocative cervical discography symptom mapping. Spine J.
ultrasound and anatomy skills, excellent ultrasound nee- 2005;5(4):381–388). The combination of ultrasonography
dle visualization skills, and spatial orientation skills and
should not be attempted by those just begging to perform
an image-guided procedure. This is a high-risk injection
procedure and this technique has not been validated or
published so will not be described in detail and should
not be undertaken without hands-on training. Author
uses platelet-rich plasma (PRP) or bone marrow concen-
trate, which in other areas can improve ligament healing.
Author uses ultrasound to guide a needle under the great
vessels toward the anterior vertebral body. Similar technique
to a stellate ganglion block and similar technique can be used
for intradiscal. Once the needle is close to the anterior verte-
bral body, fluoroscopy is used to obtain AP and lateral views to
further place the needle accurately into the ligament. Contrast
confirms ligamentous flow. The ultrasound and needle must be
rotated and positioned differently to target multiple levels and
is particularly tricky to inject the C2-4 ligament. Risks include
great vessel and vertebral artery penetration, thyroid injury, and • Fig. 35.9 EP ALL ligament ultrasound needle trajectory.
injury to the trachea or esophagus. The later risks are reduced
by taking a right-side approach (Figs. 35.8 to 35.12).

• Fig. 35.10 EP C6 ALL ligament injection lateral fluoroscopic view con-

• Fig. 35.8 EP ALL ligament injection set up. firmation with contrast.
 CHAPTER 35 Advanced and Emerging Interventional Techniques 587

Pertinent Anatomy
Cervical spine discs have a crescent-shaped anterior annulus
fibrosus and a thin posterior layer of collagen (Fig. 35.14).
The nucleus pulposus dehydrates and becomes fibrocarti-
laginous in the second and third decades.52 The upper discs,
C2-3, C3-4, and C4-5, are smaller in size than the lower
discs, C5-6, C6-7 and C7-T1. The anterior longitudinal
ligament, longus colli muscle, oropharynx, esophagus, and
larynx lie anterior to the discs, while the posterior longitudi-
nal ligament (PLL), meninges, and spinal cord lie posterior.
Laterally, the vertebral artery is exposed between and vari-
ably below C6 in front of the transverse processes, while
the carotid sheath, including the carotid artery, jugular vein,
and vagus nerve, is located anterolaterally and more super-
ficially (Figs. 35.15, 12.x). The spinal nerves and brachial
plexus lie between the anterior and middle scalene muscles
posterior to the carotid sheath. The lung apices and great
vessels are close to the C7-T1 disc.

• Fig. 35.11 EP C2-3 ALL ligament injection lateral fluoroscopic view Common Pathology
confirmation with contrast.
Tears of the annulus fibrosus and defects of the fibrocarti-
laginous disc matrix can occur secondary to trauma or disc
degeneration. Normal mature cervical discs have transverse
clefts located at their posterior aspects between the uncinate
processes to facilitate neck rotation. (See Fig. 35.14 from
functional anatomy of the spine, Bogduk N. Handbook of
Clinical Neurology. Vol. 136 [3rd series], Neuroimaging,
Part II (Elsevier 2016).)

Equipment
High performance ultrasound machine with linear (5 to
12 MHz) and curvilinear (1 to 5 MHz) transducers, ster-
ile covers for the transducers and controls, C-arm fluoro-
scope, carbon fiber imaging table, needle holder, surgical
pen, #30 1” needle, #25 2” spinal needle with stylet with a
smooth 10- to 15-degree curve at the distal 4 to 5 mm, 1
mL syringe.

Common Injections
Orthobiologics (PRP, bone marrow concentrate, etc.)
• Fig. 35.12EP C6 ALL ligament injection AP fluoroscopic view confir-
mation with contrast.
Injectate Volume
Averages 0.2 to 0.3 mL but can range from 0.1 to 0.5 mL
and fluoroscopy facilitates a safe and minimally invasive
cervical disc injection technique while avoiding the carotid
Technique
and vertebral arteries, trachea, larynx, and esophagus. The Patient Position
cervical discs are approximately half as high, wide, and Supine, with the neck extended and comfortably posi-
long as the lumbar discs, thus 1/2 x 1/2 x 1/2 or ⅛ of tioned. The patient should avoid swallowing once the
the volume. Cervical disc procedures must be performed spinal needle is being advanced to the disc because acti-
with the greatest degree of care, precision, and procedural vation of the sternohyoid muscle will cause the needle to
experience. move.
588 SEC T I O N I V Advanced

• Fig 35.13 Composite map of C5-6 disc pain patterns obtained from 27 patients. (From Slipman CW,
Plastaras C, Patel R, et al. Provocative cervical discography symptom mapping. Spine J. 2005;5[4]:381–
388, with permission.)

The fluoroscopy C-arm is set up so it can rotate around

the axis of the neck and easily obtain AP, oblique, and lateral
fluoroscopic views. Starting in the AP view, the C-arm is
angled caudally to obtain end-plate views of the disc being
targeted, then it is rotated 20 to 30 degrees to the patient’s
u right (Fig 35.18). The discs are typically injected from the
patient’s right side because the esophagus is on the left.
Using the needle holder as a pointer, potential radiographic
trajectories to the disc at 10, 20 and 30 degrees C-arm rota-
Front Side tion are identified and marked with a surgical pen. The pen
af
marks define a line over which the ultrasound transducer is
placed. Ultrasound is then used to determine an optimal tra-
np
jectory toward the disc passing between the carotid sheath
and thyroid cartilage or trachea. The trajectory typically passes
u u
through the thyroid gland, avoiding larger blood vessels and
Top nodules if present. Throughout this process, it is important
• Fig 35.14 Cervical disc diagram showing a crescent-shaped annulus that the ultrasound transducer and C-arm remain at the same
fibrosus (af), fibrocartilaginous nucleus pulposus (np), uncinate pro- cranial-caudal angulation (Fig. 35.19).
cesses (u), vertebral arteries (solid black circles,) and a normal pos- Once an optimal trajectory has been determined using
terior transverse cleft (thin black triangle). (From Bogduk N. Functional ultrasound (Fig. 35.20), the C-arm is rotated to match the
anatomy of the spine. Handbook of Clinical Neurology, Vol. 136 (3rd
series), Neuroimaging, Part II (Elsevier 2016), with permission.)
degree of rotation of the transducer, then the transducer is
removed and fluoroscopy is used to confirm that the trajec-
tory leads to the point of entry at the lateral aspect of the
Clinician Position disc. A typical degree of C-arm rotation is 20 to 30 degrees
Standing next to the patient’s right side, C-arm monitors for the C5-6 and C6-7 discs. Greater rotation may be neces-
rostral to the patient’s head and facing the physician, ultra- sary at upper levels to bypass the thyroid cartilage.
sound machine, and monitor to the physician’s left.
Needle Position
Transducer and C-Arm Position Once an optimal trajectory has been determined, the skin
Initially, an ultrasound examination of the neck is per- is anesthetized using 1.0 mL of local anesthetic, then a #25
formed, assessing the carotid artery and jugular vein, thy- 2″ spinal needle is advanced toward the disc using intermit-
roid gland and cartilage, vertebral artery, and esophagus or tent fluoroscopy and bevel steering (Fig. 35.21). If increased
oropharynx if visibly present. Sono-assisted palpation can needle resistance or patient discomfort is encountered, ultra-
be performed between the carotid sheath and trachea using sound is used to check the position of the needle and ensure
the examiner’s little finger to assess for tenderness over each that it is not going into the larynx or trachea (Fig. 35.22).
disc (Figs. 35.16 and 35.17). Prior to entry and in order to ensure patient safety, the
 C2-C3 disc Pharynx

Carotid sheath

Uncovertebral joint Vertebral artery

Neural foramen
Superior articular process C3
Spinal cord
Facet joint
Dorsal nerve root

Inferior articular process C2

Lamina C2

C2 spinous process

• Fig 35.15
Axial T1-weighted gradient echo MR image of the cervical spine at C2-3. (From Osborn AG,
Satzman KL, Anderson J, et al. Imaging Anatomy: Brain and Spine. Elsevier, Philadelphia; 2020.)

SCM
Phr
Jug
Thy AS
Ca Vag C5 MS
C6
C7

Eso LC V

C7 Vertebra

• Fig 35.16 Axial ultrasound view of the left side of the neck at the level of the C7 vertebra (panoramic 5–12
MHz). Sternocleidomastoid muscle (SCM), vagus nerve (Vag), collapsed jugular vein (Jug), phrenic nerve
(Phr), thyroid (Thy), carotid artery (Ca), anterior scalene (AS), spinal nerves (C5, C6, C7), middle scalene
(MS), esophagus (Eso), longus colli (LC), vertebral artery (V). The left side was chosen to show the esopha-
gus, which is made more visible by having the patient swallow.

Ca

C6 C7 T1

A B
• Fig 35.17 (A) Longitudinal ultrasound view of the cervical spine through the carotid sheath in a 60-year-
old male: carotid artery (Ca), anterior aspects of vertebrae (C6, C7, T1), discs (arrows); (B) Transducer
location on neck.
590 SEC T I O N I V Advanced

• Fig 35.20 An optimal trajectory to the disc has been determined

using fluoroscopy and ultrasonography. The skin is being anesthetized
prior to insertion of the spinal needle. The pen marks denote possible
fluoroscopic trajectories to the C4-5 disc. The middle trajectory was
chosen on the basis of ultrasonography.

• Fig 35.18 Fluoroscopic view of the cervical spine with 20 degrees

angulation and 30 degrees rotation. The needle holder marks a poten-
tial trajectory to the C4-5 disc, which will need to be confirmed with
ultrasonography.

• Fig 35.19Operative setting for cervical disc injection. The physician

has a good view of the monitors and is using ultrasound to determine
the best possible trajectory to the C4-5 disc. The ultrasound trans-
• Fig 35.21 The needle has been inserted and is aimed at the C4-5 disc.
ducer and C-arm are aligned.

needle can be directed to touch an adjacent vertebra before

advancement into the disc. Once the tip of the needle enters
the disc, intermittent AP and lateral views are used to guide
Ca
placement, which often requires taking full advantage of the
needle’s curve (Fig. 35.23). Final advancement is done in TC
the lateral view to ensure that the needle does not penetrate
beyond the disc (Figs. 35.24 to 35.26).

Target
The target for entry into the disc is the lateral aspect of
5.5
the disc at or slightly lateral to the inflection point of the JPEG

curve of the uncinate process. Final placement is at the • Fig 35.22Ultrasound view of the needle (arrow) seen in the short-axis
center of the disc as confirmed on AP and lateral fluoro- passing by the carotid artery (Ca) and thyroid cartilage is on its way to
scopic views. the C4-5 disc.
 CHAPTER 35 Advanced and Emerging Interventional Techniques 591

• Fig 35.23 Anteroposterior (AP) fluoroscopic view of the needle as it • Fig 35.25 Anteroposterior fluoroscopy view of the needle in final posi-
enters the C4-5 disc. tion in the C4-5 disc.

• Fig 35.26 Photograph of the needle in final position in the C4-5

disc.

• Fig 35.24 Lateral fluoroscopic view of the needle in final position in

the C4-5 disc. The needle has been advanced a few millimeters deeper
than usual in order to reach a posterior disc tear.
592 SEC T I O N I V Advanced

PEARLS AND PITFALLS 11. K emler MA, Barendse GA, van Kleef M, et al. Spinal cord stim-
ulation in patients with chronic reflex sympathetic dystrophy. N
Cervical disc access requires precise ultrasound and fluoroscopy Engl J Med. 2000;343(9):618–624.
skills and a good rapport between the patient and the physician 12. Kapural et al. Anesthesiology 2015;123:851-860
to facilitate relaxation and minimize movement. MR images need 13. Vallejo et al. Anes Anesthesiol. 2015;123:851-860.
to be reviewed prior to each procedure to assess for relative 14. Timothy RD, Robert ML, Jeffery K, et al. Dorsal root ganglion
contraindications such as spinal stenosis or anatomical variants stimulation yielded higher treatment success rate for complex
along the intended needle trajectory. If there is concern that the
regional pain syndrome and causalgia at 3 and 12 months:
needle might pass through the esophagus or oropharynx, the
patient can swallow a small amount of barium sulfate suspension
a randomized comparative trial. Pain. 2017;158(4):669–
beforehand to outline these structures on fluoroscopy. There is 681.
normally slightly more resistance to injection of a cervical disc 15. Yu C-W, Ming-Kai H, Chen L-H, et al. Percutaneous balloon
than a lumbar disc, but too much resistance may require slight kyphoplasty for the treatment of vertebral compression frac-
repositioning of the needle to improve compliance. Use of a 1 tures. BMC Surg. 2014;14:3.
ml syringe facilitates precise delivery of injectate. An increase in 16. Mehbod A, Aunoble S, Le Huec JC. Eur Spine J. 2003;12 (suppl 2):
disc height is often seen immediately following injection. In some S155–S162. Epub 2003 Sep 19.
cases, such as status post thyroidectomy or at C2-3,a there 17. Zhan Y, Jiang J, Liao H, Tan H, Yang K. Risk factors for cement
may not be enough space to pass a needle between the carotid leakage after vertebroplasty or kyphoplasty: a meta-analysis
sheath and thyroid cartilage, and a trajectory through the anterior
of published evidence. World Neurosurg. 2017;101:633–642.
scalene may be considered, being careful to avoid the phrenic
nerve or any variant intramuscular spinal nerves.
https://doi.org/10.1016/j.wneu.2017.01.124.
   18. Wang B, Zhao CP, Song LX, Zhu L. Balloon kyphoplasty versus
aWe have successfully used the described technique for injections of percutaneous vertebroplasty for osteoporotic vertebral compres-
the C3-4 through C7-T1 discs, but have not yet had the opportunity to sion fracture: a meta-analysis and systematic review. J Orthop
do C2-3. Surg Res. 2018;13(1):264. Published 2018 Oct 22. https://doi.
   org/10.1186/s13018-018-0952-5.
19. Lyders EM, Whitlow CT, Baker MD, Morris PP. Imaging and
treatment of sacral insufficiency fractures. Am J Neuroradiol.
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35. Mobbs RJ, Nair S, Blum P. Peripheral nerve stimulation for decompression for herniated lumbar disks: a 4-year follow-up in
the treatment of chronic pain. J Clin Neurosci. 2007;14(3):216– 200 patients. J Clin Laser Med Surg. 2003;21(3):131–138.
221; discussion 222-3. 49. Choy DS, Ascher PW, Ranu HS. Percutaneous laser disc decom-
36. Konstantin VS, Hrachya N, Wess C. Peripheral neurostimula- pression. A new therapeutic modality. Spine (Phila Pa 1976). 1992;
tion for treatment of intractable occipital neuralgia. Neurosur- 17(8):949–956.
gery. 2006;58(1):112–119; discussion 112-9. 50. Freeman MD, Katz EA, Rosa SL, Gatterman BG, Strömmer
37. Paul V, David V, Bruce M, Adele B. Peripheral nerve field stim- EMF, Leith WM. Diagnostic accuracy of videofluoroscopy for
ulation for chronic pain: 100 cases and review of the literature. symptomatic cervical spine injury following whiplash trauma. Int
Pain Med. 2011;12(9):1395–1405. J Environ Res Public Health. 2020;17(5):1693. Published 2020
38. Ilfeld BM. Continuous peripheral nerve blocks: an update of Mar 5. https://doi.org/10.3390/ijerph17051693.
the published evidence and comparison with novel, alternative 51. Stemper BD, Yoganandan N, Pintar FA, Rao RD. Anterior
analgesic modalities. Anesth Analg. 2017;124(1):308–335. longitudinal ligament injuries in whiplash may lead to cervi-
39. Timothy RD, Sameer J, Corey H, Krishnan C. Neurostimula- cal instability. Med Eng Phys. 2006;28(6):515–524. https://doi.
tion for intractable chronic pain. Brain Sci. 2019;9(2):23. org/10.1016/j.medengphy.2005.09.011.
40. Slavin KV. Peripheral nerve stimulation for neuropathic pain. 52. Oda J, Tanaka H, Tsuzuki N. Intervertebral disc changes with
Neurotherapeutics. 2008;5(1):100–106. aging of human cervical vertebra. From the neonate to the eight-
41. Krishnan C, Andrew N, Paul JC, Kayode W. Review of recent ies. Spine (Phila Pa 1976). 1988;13(11):1205–1211.
advances in Peripheral Nerve Stimulation (PNS). Curr Pain
Headache Rep. 2016;20(11):60.
36
Needle Arthroscopy of the
Knee, Shoulder, and Hip
DON BUFORD, BRICE W. BLATZ, AND NICOLA HYDE

Needle Arthroscopy—Background procedure room with the disposable needle arthroscope as

the only imaging modality.7–9 These advances have lowered
Arthroscopy is a surgical procedure in which a video imaging the per-procedure instrument cost of diagnostic arthroscopy
device is placed into a joint to allow visualization and assess- to as little as $500.7–9
ment of the joint space. With additional instrumentation, With the advent of needle arthroscopy, the number of
surgery can be performed without making large incisions or physicians interested in using diagnostic joint arthroscopy
a large dissection to open up the joint. Masaki Watanabe, a has increased, largely because hospital surgical privileges,
Japanese surgeon, is generally credited with being the first to residency training, and surgical malpractice insurance are
use arthroscopy for knee evaluation and surgery in the late currently not required. Physicians who have shown inter-
1950s.1 In 1964, Robert W. Jackson met Watanabe in Japan est in needle arthroscopy include physiatrists, rheumatolo-
and brought this revolutionary surgical technique back to gists, and interventional radiologists. In the office, needle
North America.2 arthroscopy is used both for diagnosis and as a delivery sys-
Arthroscopy provides a magnified direct view of intra- tem for injecting intra-articular structures or the joint itself.
articular anatomy with minimal potential complications As a result, there is an increased demand for postdoctoral
and is the gold standard for intra-articular joint evaluation. needle arthroscopy training for nonsurgeons and for needle
Arthroscopy is used to guide surgical intervention for most arthroscopy protocols that promote the safe and effective
intra-articular orthopedic pathology. Orthopedic surgeons evaluation of joint pathology. In-office needle arthroscopy
in the United States receive 4 years of residency training has been evaluated over more than 1400 cases and found
on arthroscopic surgical procedures.3 In 2013, the average to pose lower surgical risks than traditional arthroscopy.10
orthopedic surgery resident completed over 300 diagnostic We recommend that physicians in specialties where train-
and surgical arthroscopy procedures prior to graduation.4 ing and scope of practice do not include arthroscopic surgi-
The Arthroscopy Association of North America (AANA) cal procedures get advice from their state medical licensing
requires a minimum of 50 arthroscopic procedures a year boards and national board certifying organizations for any
for active membership.5 To obtain the sports medicine sub- requirements and consensus on the use of needle arthros-
specialty certification from the American Board of Orthope- copy in their specialties. Clinicians using needle arthroscopy
dic Surgery, a 1-year sports medicine surgical fellowship and should make sure that they have malpractice coverage for
a minimum of 75 arthroscopies must be completed in the surgical procedures, both for their own protection and their
year prior to application.6 Despite significant arthroscopic patients’ protection.
surgery training at the resident and fellowship levels, even In-office needle arthroscopy has a diagnostic accuracy
experienced arthroscopists will experience a learning curve equivalent to that of magnetic resonance imaging (MRI) or
when using needle arthroscopy in the office under local traditional arthroscopy when used to evaluate intra-articular
anesthesia. nonligamentous pathology.11 In-office needle arthroscopy
Traditionally, large-joint arthroscopy has been performed used as a diagnostic tool also involves potential financial
with an arthroscope 4 mm in diameter and 30 or 70 degrees savings compared with MRI and traditional arthroscopy.12
of visual offset. Technologic advances have led to the intro- Patient evaluation—including history, physical, and
duction of small-diameter disposable needle arthroscopes relevant imaging—is always done prior to considering
that can be used in the office setting under local anesthesia. needle arthroscopy. Often an in-office needle arthroscopy
Imaging can be done on a portable tablet and even com- substitutes for an MRI scan, especially if the primary clini-
bined with diagnostic ultrasound imaging on the same cal concern is an intra-articular derangement. We do not
tablet.7 Instrumentation has been further refined to allow feel that ordering an MRI scan prior to needle arthros-
for surgical procedures to be done in an operating room or copy is routinely necessary unless there is clinical concern

594
 CHAPTER 36 Needle Arthroscopy of the Knee, Shoulder, and Hip 595

for intraosseous, subchondral, popliteal, or extracapsular appropriate management prior to the procedure. In our
pathology. We do obtain plain radiographs prior to needle practice, we do not alter the patient’s anticoagulation regi-
arthroscopy to evaluate joint alignment and stability as well men since the bore of the arthroscope is not significantly
as bony anatomy and pathology. larger than the bore of a 14- to 18-gauge needle. We do
Our review of needle arthroscopy indications and tech- not typically give patients preoperative pain medications
niques is agnostic with regard to any particular needle or benzodiazepines, although that may be a consideration
arthroscopy system. in some clinical situations. Prior to beginning the proce-
dure, we follow the Joint Commission Universal Protocol
Indications for Needle Arthroscopy for Preventing Wrong Site, Wrong Procedure, and Wrong
Person Surgery.13
Common indications for using needle arthroscopy in the The surgical site is always isolated and draped, and sterile
knee: technique is observed. The skin is prepped with an effective
1. Diagnosing meniscal tears surgical prep such as povidone-iodine (Betadine) or chlorhex-
2. Diagnosing chondral pathology idine. Procedural anesthesia is usually obtained with a choice
3. Diagnosing anterior and posterior cruciate ligament of lidocaine 1% to 2% and/or bupivacaine (Marcaine) 0.25%.
pathology The addition of epinephrine may be considered, depending
4. Evaluating prior intra-articular procedures on physician preference. Other local anesthetics can also be
5. Guiding intra-articular injections. considered based on physician preference. It is important to
6. Identifying loose bodies wait 3 to 5 minutes after injecting the local anesthetic into the
7. Diagnosing patellofemoral tracking abnormalities portal sites before proceeding with the arthroscopy. Under
8. Staging osteoarthritis of the knee joint local anesthesia, the physician has 10 to 15 minutes of proce-
9. Patients unable to get an MRI scan dure time to evaluate the joint.
Common indications for using needle arthroscopy in the With all needle arthroscopy systems, normal saline is
shoulder: used to distend the joint. The volume of saline needed for
1. Diagnosing labral pathology needle arthroscopy is significantly less than the volume used
2. Diagnosing articular-sided rotator cuff pathology in standard arthroscopy. Usually no more than 30 to 50 mL
3. Diagnosing superior labrum, biceps tendon anchor of normal saline is used in the joint. The normal saline can
pathology (SLAP lesions) be injected using multiple small 10- to 30-mL syringes or
4. Diagnosing humeral head and glenoid bone loss with a larger bag of normal saline attached to the arthro-
5. Evaluating prior intra-articular procedures scope with intravenous tubing and a three-way stopcock.
6. Guiding intra-articular injections While the joint is being injected, the inflow of saline can
7. Identifying loose bodies also be used as a diagnostic tool to see whether structures
8. Staging osteoarthritis of the glenohumeral joint such as the labrum or meniscus are stable.
9. Patients unable to get an MRI scan
Common indications for using needle arthroscopy in the The Knee
hip:
1. Diagnosing labral pathology I. Setup
2. Diagnosing femoroacetabular impingement and CAM a. Tablet and ultrasound (US) (Fig. 36.1).
lesions II. Positioning
3. Diagnosis hip joint synovitis
4. Staging osteoarthritis of the hip joint
5. Guiding intra-articular injections
6. Evaluating prior intra-articular procedures
7. Diagnosing loose bodies
8. Patients unable to get an MRI scan

Needle Arthroscopy Technique

Preparation
Clinicians should obtain preoperative informed consent
prior to initiating needle arthroscopy. We typically do
not give pre- or post-procedure antibiotics because there
are no significant data suggesting that the extremely low
infection rates associated with needle arthroscopy would
be lowered further with antibiotic medications. If a patient • Fig. 36.1
Example of Patient, Ultrasound, and Tablet Positioning in
is on anticoagulation, the clinician should decide on its Preparation for the Procedure.
596 SEC T I O N I V Advanced

a. Seated: Patient is positioned on the edge of the exam V. US prep of procedure
table sitting upright with legs hanging off the edge of a. 10 mL of 1% lidocaine, 5 mL of 0.25% Marcaine,
the table. and 1 mL of epinephrine is infiltrated into soft tissue
b. Supine: Patient is positioned lying down on back with prior to insertion of the camera into the suprapatel-
a gel or foam “bump” under the knee to create flexion. lar pouch, lateral portal through Hoffa’s fat pad, and
III. Sterility medial portal through Hoffa’s fat pad.
a. Layout of the Mayo stand (Fig. 36.2) b. 30 mL of normal saline and 10 mL of 1% lidocaine
b. Drapes on the leg (Fig. 36.3) is used to infiltrate the joint capsule.
IV. Portal placement c. Additional syringes and normal saline are kept avail-
Suprapatellar pouch: 2 to 3 cm proximal to patella; able for extra flushing of the joint space to clear the
body habitus will determine how far anterior to pos- view for the camera.
terior the portal will be positioned; ultrasound makes d. Suprapatellar pouch—Authors’ tip: using US, infiltrate
this positioning easier and more accurate with spinal needle directed deep to the patella in anechoic
Medial: If the medial portal is being used, it will be 1 cm space between the quadriceps and prefemoral fat pads to
down and 1.5 to 2 cm medial from the inferior pole ensure expansion within the capsule of the joint.
of the patella. e. Optional US for the medial portal (Fig. 36.4).
Lateral: If the lateral portal is being used, it will be 1 cm f. Optional US for the lateral portal (Fig. 36.5).
down and 1 cm lateral from the inferior pole of the VI. Procedure (Most needle arthroscopy devices have a 0
patella. degree scope; thus visualization will differ compared
Note that portal placement for needle arthroscopy with a traditional arthroscopic camera.)
may differ from traditional arthroscopic portal If further visualization is required during the procedure,
placement. the physician can perform additional manipulation by
flexing the leg and/or applying varus or valgus force.
a. Placement in suprapatellar pouch (US recommended)
Be sure to be proximal enough in the pouch to allow for
the full range of the camera and needle (Fig. 36.6).
i. Patellar–trochlear articulation
ii. Lateral gutter
iii. Medial gutter.
b. Placement in lateral portal (aim toward medial femo-
ral notch/medial joint space)—US optional
i. Medial meniscus (valgus stress can be applied to
the knee to open the medial space)

• Fig. 36.2 Required Supplies Displayed on a Sterile-Covered Mayo

Stand.

• Fig. 36.4Utilization of Ultrasound (Optional) for Infiltration of the

• Fig. 36.3 Sterile Draping and Initial Positioning of the Leg. Medial Portal.
 CHAPTER 36 Needle Arthroscopy of the Knee, Shoulder, and Hip 597

•Fig. 36.5 Utilization of Ultrasound (Optional) for Infiltration of the

Lateral Portal.
• Fig. 36.7 Adjustment of leg into “figure four” position to allow for
opening of the lateral joint space, leading to improved visualization of
the structures within this compartment.

The Shoulder
Patients can be positioned either seated or in the lateral
decubitus position. With the seated position, it is help-
ful to have an assistant available to help with positioning
of the shoulder for dynamic evaluation. The physician is
positioned behind the patient, since the initial portal is the
posterior arthroscopy portal. In the lateral decubitus posi-
tion, it is helpful to have an assistant available to abduct
the shoulder. In the lateral decubitus position, an abduc-
tion bolster can also be helpful to abduct the shoulder and
mimic the positioning of the arm in traditional shoulder
arthroscopy with a shoulder holder.
The posterior shoulder is isolated and draped. If the phy-
• Fig. 36.6 Utilization of Ultrasound for Delivery of the Needle sician anticipates evaluating the joint from an anterior rota-
Arthroscope Into the Suprapatellar Pouch. Note in-plane visualiza- tor interval portal, the anterior shoulder should be prepped
tion of needle on ultrasound image. and draped as well before starting the procedure. Using the
local anesthetic mixture previously described, we inject 10
ii. Medial femoral condyle to 15 mL into the posterior portal site and along the needle
iii. Medial tibial plateau arthroscope path into the joint. The remaining 15 mL can
iv. Anterior cruciate ligament (ACL)/posterior cruci- be injected into the glenohumeral joint.
ate ligament (PCL) The primary shoulder portal to be used is the posterior
c. Placement in medial portal (aim toward lateral femo- portal. Its location is approximately 2 cm inferior and 1 cm
ral notch/lateral joint space)—US optional medial to the posterolateral edge of the acromion. Locating
i. Lateral meniscus (The lateral meniscus may be the proper placement with US guidance simplifies the pro-
visualized by placing the knee in a “figure four” to cedure and minimizes patient discomfort. With US guid-
open the lateral compartment.) (Fig. 36.7) ance, a 22-gauge spinal needle or the needle arthroscope is
ii. Lateral femoral condyle inserted via a posterior off-axis technique to minimize the
iii. Lateral tibial plateau distance to the joint and mimic the posterior portal used in
iv. ACL/PCL shoulder arthroscopy.
VII. Post-procedure The needle arthroscope is used to visualize shoulder
a. Use US to aspirate as much of the utilized intra-artic- anatomy just as with the traditional arthroscope. Nor-
ular normal saline as possible. mal saline is used sparingly to allow visualization. We
b. Clean and dress the wounds with simple adhesive recommend using a diagnostic protocol that mimics
bandages. the typical shoulder diagnostic evaluation. 14 A spinal
c. Compress with elastic bandage or compression sleeve. needle can be placed through the rotator interval and
598 SEC T I O N I V Advanced

used as a probe while watching from the posterior por- Conclusion

tal. However, it is rare that we have found the need to
use an anterior portal in our needle arthroscopy of the Needle arthroscopy has proven safety and utility as a diagnos-
shoulder joint. tic tool for intra-articular pathology in the knee, shoulder, and
A Band-Aid or Steri-Strip is used to cover the portal site. hip. The ability to convert diagnostic arthroscopy into a point-
Patients do not need to use a sling or change their activity of-care, same-day imaging modality benefits patients and clini-
level after the procedure. cians. Clinicians will be able to make better decisions sooner,
which will hopefully lead to better patient care. When all of the
costs associated with MRI scans and traditional surgical arthros-
The Hip
copy are considered, in-office needle arthroscopy presents dis-
Patients are positioned in the supine position. Unlike tradi- tinct advantages in terms of ease, cost, safety, and efficacy. As an
tional hip arthroscopy, needle arthroscopy of the hip does imaging modality, needle arthroscopy can also be used to guide
not require special tables or traction. Typically, the mid- surgical procedures, replacing the traditional larger arthroscope
anterolateral portal for hip arthroscopy is used for diagnos- in many situations. With its many orthopedic indications, nee-
tic needle arthroscopy. The mid-anterior hip portal can be dle arthroscopy is an excellent imaging modality that represents
identified via surface landmarks using previously described a technologic advancement in arthroscopy.
techniques.15 We prefer to use US to visualize the mid-ante-
rior hip portal, simplifying insertion of a 22-gauge spinal References
needle and placement of the needle arthroscope into the
joint. US guidance is also helpful in situations where bony 1. DeMaio M. Giants of orthopaedic surgery: Masaki Watanabe
landmarks are difficult to identify, and it eliminates the need MD. Clin Orthop Relat Res. 2013;471(8):2443–2448. https://
for fluoroscopy. doi.org/10.1007/s11999-013-3052-1.
The hip region is draped and prepped. Using the previ- 2. Jackson RW. The introduction of arthroscopy to North Amer-
ica. Clin Orthop Relat Res. 2000;374:183–186. https://doi.
ously described local anesthetic mixture, we inject 10 to 15
org/10.1097/00003086-200005000-00016.
mL at the site of the mid-anterior portal and along the path 3. Kanu O, et al. Do orthopaedic resident and fellow case logs accu-
of the needle arthroscope into the hip joint. The remaining rately reflect surgical case volume? J Surg Edu. 2018;75(4):1052–
10 to 15 mL can be injected into the hip joint. 1057.
The needle arthroscope is used to visualize hip anatomy 4. Hinds RM, et al. Trends in arthroscopic procedures performed
just as with the traditional arthroscope. We usually have during orthopaedic residency: an analysis of accreditation coun-
30 mL of normal saline available to insufflate the joint, cil for graduate medical education case log data. Arthroscopy: J
although this is used sparingly. As in other joints, normal Arthros Relat Surg. 2016;32(4):645–650.
saline inflow can also serve as a diagnostic tool to see if the 5. Arthroscopy Association of North America. (2019). http://
labrum or chondral surfaces are stable. Having an assistant www.aana.org.
available to internally and externally rotate the hip and to 6. American Board of Orthopedic Surgery. (2019). https://www-
.abos.org/subspecialties/orthopaedic-sports-medicine/.
flex the hip will maximize visualization of the femoral head
7. Trice Medical. The mi-eye2/mi-Ultra™; 2019. http://www.
and joint. At the end of the procedure, the saline is aspirated tricemedical.com.
from the joint. 8. ArthrexInc. The Nanoscope™ System; 2019. http://www.arthrex.com.
A Band-Aid or Steri-Strip is used to cover the portal site. 9. Visionscope Technologies, LLC. The Visionscope™; 2019.
Patients do not need to change their weight-bearing status http://www.visionscope-tech.com.
or activity level after the procedure. 10. McMillan S, et al. Risks and complications associated with intra-
articular arthroscopy of the knee and shoulder in an office setting.
Orthopaed J Sport Med. 2019;7(9): 2325967119869846.
Potential Complications 11. Gill TJ, et al. A prospective, blinded, multicenter clinical trial
Certain disadvantages and safety concerns deserve com- to compare the efficacy, accuracy, and safety of in-office diag-
ment. Unlike surgical arthroscopy, needle arthroscopy nostic arthroscopy with magnetic resonance imaging and sur-
gical diagnostic arthroscopy”. Arthroscopy: J Arthrosc Relat Surg.
does not allow for continuous irrigation of the joint.
2018;34(8):2429–2435.
Consequently, needle arthroscopy of joints containing an 12. McMillan S, et al. In-office diagnostic needle arthroscopy: under-
obscuring hemarthrosis may be less diagnostically accu- standing the potential value for the US healthcare system. Am J
rate. Additionally, bone pathology deep to the articular Orthop. 2017;46(5):252–256.
surface—such as marrow edema, sclerosis, or subchondral 13. The Joint Commission. (2019). https://www.jointcommission.or
cysts—would not be appreciated using needle arthros- g/en/standards/universal-protocol/.
copy. As with any minimally invasive manipulation of a 14. Buford Jr D, Snyder SJ. Diagnostic shoulder arthroscopy: the
joint, needle arthroscopy can place the patient at risk for 23-point arthroscopic evaluation with normal anatomivari-
joint infection, bleeding, or damage to nearby structures. ants and pathology. Atlas of Shoulder Arthroscopy. CRC Press;
However, prior studies evaluating the utility of needle 2003:82–91.
arthroscopy have reported no procedure- or device-related 15. Bond JL, et al. The 23-point arthroscopic examination of the hip:
basic setup, portal placement, and surgical technique. Arthros-
complications.
copy: J Arthrosc Relat Surg. 2009;25(4):416–429.
 S E C T I ON V Postprocedure Considerations

37
Rehabilitation Principles for
Interventional Orthopedics
and Orthobiologics
WALTER I. SUSSMAN, KEN MAUTNER, AND ABBY PERONE

Background The literature on prehabilitation is more limited in other

areas of orthopedics, but prehabilitation has been studied in
KEY POINTS anterior cruciate ligament (ACL) tears. Preoperative quadri-
• T he effects of prehabilitation in preparation for and ceps strength is a significant predictor of knee function even
rehabilitation after interventional orthopedic procedures 2 years after ACL reconstruction,9 and the enhancement of
have received little attention in the literature. quadriceps strength and function preoperatively has been
• Exercise is a cornerstone of management prior to and shown to improve surgical outcomes.10–13 In spinal surgery,
following many orthopedic and surgical procedures.
prehabilitation showed no statistically significant difference
   in pain or disability, but patients reported feeling more pre-
pared for surgery.14 These principles have not been studied
in interventional orthopedics, but it is reasonable to believe
Preprocedural Considerations that preconditioning could also have a beneficial effect after
the varied procedures outlined in this text.
Prehabilitation is the practice of training and enhancing Nutrition plays a role in healing, has been studied in the
the patient’s functional capacity to prepare for a major trauma literature15–17 and is a concern in chronic wound
procedure. Postoperative inactivity can lead to a decline in management.18 Proper nutrition is an essential parameter in
function, and the objective of prehabilitation is to help the musculoskeletal health, including the prevention and treat-
patient withstand the stress of this inactivity.1 ment of diseases.19 This is likely underrecognized in elderly
In total hip and knee arthroplasty, preoperative func- patients, and older adults may not have the same physi-
tional status is a significant predictor of postopera- ologic reserves of younger adults.20 Malnutrition is a risk
tive function.2–5 In fact, in one study, baseline pain and factor for wound chronicity.21 Given the prolonged would
function was the single best predictor of pain and func- healing process, nutrition should be considered as part of
tion at 6 months after a total hip or knee replacement.3 the presurgical or preprocedural assessment. Diagnostic
Patients may not report a perceived benefit from preha- markers of malnutrition remain elusive.22 The focus should
bilitation programs,2,4 but studies have shown functional be on basic nutrition and a healthy diet, including adequate
benefit.2 Even a 3-week preoperative strengthening pro- calories and protein supplies to support the increased energy
gram can increase lower extremity muscle strength prior demands of collagen synthesis, angiogenesis, fibroblast pro-
to surgery and improve the immediate postoperative liferation, tissue remodeling, and wound contraction during
course.2 The significant strength gains achieved in the 3- the healing process.23 Protein deficiency has been associated
to 6-week preoperative period suggest that the benefit of with impaired fibroblast proliferation and collagen synthe-
these short prehabilitation strength training programs is sis.22 Adequate hydration can help to promote tissue per-
increased neuromuscular coordination and not necessarily fusion, oxygenation, and waste removal,24 and macro- and
strength.6,7 Although there maybe short-term benefits to micronutrients may assist in enhancing the healing pro-
prehabilitation after arthroplasty, the longer-term benefits cess.22 In the literature on wound healing, there is evidence
are unclear.8 for supplementing vitamins A and C and—if there is a

599
600 SEC T I O N V Postprocedure Considerations

deficiency—supplementing arginine, glutamine, and zinc.22 Maturation phase

Proliferative phase
But the literature on orthobiologics is limited. Inflammatory phase
Malnutrition can take different forms; in addition to spe-
cific nutrient deficits, it can include inadequate intake and
overconsumption.25 There is evidence that obesity and asso-
ciated disorders can affect stem cell function. Obesity and
diabetes have been associated with abnormal cytokine sig-
naling, impaired tissue repair, and delayed wound closure.26 • Collagen
In rodent models of type 2 diabetes, endogenous mesen- accumulation
• Remodeling
chymal stem cells (MSCs) were less effective at mobilizing
to a site of injury than those in the nondiabetic controls,27 Inflammation
Granulation Wound
tissue contraction
and high levels of glucose were associated with the reduced
growth of mesenchymal progenitor cells.28 High glucose 0.1 0.3 1 3 10 30 100
concentrations have been shown to reduce the osteogenic Time (days)
and chondrogenic potential of adipose-derived mesenchy- • Fig. 37.1 Phases of Wound Healing. (Repoduced from Kumar V,
mal stem cells (ADSCs),29 and ADSCs had a reduced differ- Abbas A, Fausto N. Tissue renewal and repair: regeneration, healing,
entiation potential and a lower capacity for spontaneous or and fibrosis. In: Robbins and Cotran Pathologic Basis of Disease. 7th
therapeutic repair in patients who were obese and had meta- ed. Philadelphia, PA: Elsevier Saunders; 2005:87–118.)
bolic syndrome.30 In contrast, caloric restriction is known
to reduce inflammation and has been shown to increase the to trigger a healing response and stimulate the body’s own
proliferation of MSCs in mouse models31,32; moreover, the repair mechanism. Animal models of injury and repair are
restriction of glucose improved the self-renewal and antise- the primary means of understanding the fundamental pro-
nescence abilities of MSCs.33 Although the role of obesity cess of healing in tendon, ligament, and muscle tissue. In
or calorie restriction on clinical outcomes in orthobiologics a study by Virchenko and Aspenberg, rats with iatrogeni-
is unclear, the literature suggests that calorie restriction may cally injured Achilles tendons were injected with platelet-
improve stem cell function. rich plasma (PRP). Half of them received an intramuscular
Education has also been shown to have a positive impact injection of botulinum toxin A (Botox) into the calf mus-
on the outcomes of total knee and hip arthroplasty.34,35 cles to unloaded the tendon and had no effect from the
Being able to counsel patients regarding the expected post- PRP injection at 14 days compared with the control rats,
procedural course can help them to prepare for the proce- who were not treated with botulinum toxin and did show
dure. In theory, it could also affect the outcome after any neotendon development.38 The failure of the rats treated
interventional procedure. The following section outlines with botulinum toxin to develop neotendons suggests that
the expected postprocedure course of many orthobiologic mechanical stimulation is important in the early phases of
procedures. tendon regeneration. Ambrosio et al., in a mouse model,
demonstrated that stem cell transplantation into injured
Postprocedural Considerations Basic skeletal muscle proliferated and terminally differentiated
Science toward a myogenic lineage with daily treadmill running,
whereas the transplanted stem cells failed to divide rapidly
The healing potential following orthobiologic injections will in the absence of loading.39 Clinical studies have also sup-
vary depending on the tissue type (e.g., tendon, ligament, ported the role of rehabilitation. In a pilot study of PRP for
muscle, bone), underlying pathology (e.g., tendinopathy chronic patellar tendinopathy, Kon et al. found that sub-
vs. tear), and anatomic location (e.g., Achilles vs. rotator jects who did not follow the postprocedural stretching and
cuff). In general, healing of tendon, ligament, muscle, and strengthening program had poorer outcomes.40
bone injuries follows the normal wound-healing cascade— Further insight is needed into the molecular and cellular
a complex series of events that is typically divided into response to therapeutic exercises and stress after regenerative
three phases: inflammatory, proliferative and maturation therapies. Based science studies showing that the effects of
or remodeling. Some authors may describe a fourth phase, PRP are lost when tendons are unloaded mechanically, and
that of hemostasis, which is characterized by vasoconstric- one conclusion is that tendon healing may require a combi-
tion and the formation of a blood clot immediately after an nation of biologic and mechanical factors. The term mechano-
injury (Fig. 37.1). transduction is often used to describe the physiologic responses
There is limited evidence-based literature on the role of by which cells convert mechanical stimuli into structural
rehabilitation following orthobiologic or regenerative pro- adaptations.41–43 Mechanical stimuli or loads on a tendon are
cedures.36,37 Although rehabilitation is often encouraged for sensed by various cell surface receptors, integrins, stretch-acti-
the management of many orthopedic conditions to improve vated ion channels, and other mechanisms, triggering cell–
range of motion (ROM), strength, and functional activi- cell communication and changes in cellular biology within
ties, it may play a more specific role after orthobiologic pro- the cell nuclei.44 Eccentric exercises, with slow lengthening of
cedures. The objective of many regenerative procedures is the muscle-tendon unit while under load, have been shown
 CHAPTER 37 Rehabilitation Principles for Interventional Orthopedics and Orthobiologics 601

TABLE   General Principles of Rehabilitation may require even longer periods of unloading and protected
37.1 Prescription. weight bearing. The severity of pathology should also be
considered. For example, strengthening exercises after the
When rehabilitation after a regenerative procedure is
injection of PRP may be started later in high-grade partial
being initiated, the following considerations, which align
with the phases of the healing cascade, should be tendon tears as compared with tendinopathy.
considered with each phase: Guidance following a procedure must also be tailored to the
• Restrictions injectate or treatment. For example, rehabilitation following
• Which movements and activities are to be avoided an injection around a tendon (e.g., a high-volume injection
during the phase
between the Achilles tendon and the Kegar fat pad) will have
• Appropriate therapeutic exercise
• Appropriate exercises define the type and category a different expected postprocedural course than an intratendi-
of exercises for each phase nous procedure (e.g., PRP injected into the Achilles tendon).
• For example, early phases may consider partial or Likewise, an intra-articular knee injection of cortisone will
non–weight bearing, whereas later phases invite have a different course than an autologous cellular injection.
diverse planes of movement under varying loads
• Benchmarks to progress to next phase
• Benchmarks are objective goals to determine Phases of Rehabilitation and The Healing
preparedness to transition to the next phase of
rehabilitation Cascade
• For example, for a hip bone augmentation (see Table
37.6), patients may transition from phase I to phase Phase I of Healing—The Inflammatory Phase
II when they can “walk full weight bearing 50 ft with (0 to 5 Days)
minimal pain”
• Pain vs. time The inflammatory phase is the initial response to tissue
• The phases are not governed by the anticipated rate damage and generally occurs within the first 5 days after
of healing but are ultimately dictated by the patient’s
injury.49–52 This phase is initially characterized by hemo-
subjective pain and function
• For a patient to complete a phase and transition to stasis and “walling off” of the injured site, increased vas-
the next, the tasks of the current phase should be cular permeability, and an influx of inflammatory cells.
completed Platelets are among the first cells to respond to an injury;
they form a hemostatic plug and secrete chemokines (e.g.,
epidermal growth factor [EGF], fibronectin, fibrinogen,
histamine, platelet-derived growth factor [PDGF], sero-
tonin, and von Willebrand factor). These factors recruit
to stimulate a cellular response, including the activation and macrophages to the healing site, resulting in the scaveng-
proliferation of satellite stem cells.45 Heavy-slow resistance ing of debris and in phagocytosis to debride the wound
(HSR) training in which each repetition is performed slowly bed. Fibroblasts also migrate to the wound in this phase,
for more than 6 seconds for both the eccentric and concentric initiating the formation of granulation tissue and the tran-
phases has shown similar results to eccentric strengthening in sition into the proliferative phase.49 The specific cellular
long-term pain reduction. HSR has demonstrated normal- events will differ depending on the anatomy and physiol-
ization of tendon fibril morphology.46 There is also interest ogy of the given tissue.53
in low-load resistance training with blood flow restriction During this phase, patients may experience varying
(BFR), and recent studies have shown increased muscle pro- degrees of pain, swelling, redness, and limited ROM. Some
teins synthesis and proliferation of myogenic stem cells after patients’ symptoms are due primarily to laxity of the liga-
BFR training.47,48 ments; if such individuals are treated, the initial swelling
There are many translational questions about how to may sometimes actually cause a temporary improvement in
apply these principles to orthobiologic procedures. The topic perceived in stability and a reduction in symptoms, both of
of tissue repair and rehabilitation is vast, and this chapter is which dissipate once the swelling has gone down.
by no means exhaustive. The goal is to understand the basic
tenets of the healing process to help clinicians design reha- Phase II of Healing—The Repair Phase
bilitation programs, taking into consideration the patient
and his or her pathology (e.g., mechanism of injury, tissue (5 to 21 Days)
injured, severity, age of patient), the treatment (e.g., intra- The proliferative (granulation) phase is characterized by
articular vs. intraosseous or intratendinous vs. paratendi- “rebuilding” of the local tissue, and generally lasts for sev-
nous), and the different phases of healing (Table 37.1). eral weeks after injury.50–52 Granulation tissue formation,
Rehabilitation recommendations can vary depending collagen deposition, and angiogenesis create an extracellular
on the tissue treated. For example, tendons require load- matrix and network of blood vessels to supply the area. Neo-
ing in an earlier phase of rehabilitation in order to help vascularization helps to supply the wound bed with nutri-
support the development of tensile strength. Overall, the ents.49 Macrophages continue to supply growth factors, and
literature suggests that mechanical stress on the tendon is fibroblasts differentiate and produce collagen, depositing
needed to optimize outcomes.36 In contrast, osseous healing and remodeling the extracellular matrix.49
602 SEC T I O N V Postprocedure Considerations

Initially, migrating fibroblasts will begin to synthesize col- ligaments, fibroblasts produce collagen and form scar tissue
lagen around day 5, but by the fourth week, there is a notice- to bridge the gap between muscle fibers.64
able increase in the intrinsic proliferation of fibroblasts from
the endotenon. Initially the collagen fibers are randomly ori- Cartilage
ented, but as the tissue starts to mature, the collagen fibers
are increasingly oriented along the direction of force through Articular cartilage has poor intrinsic healing capacity and
the tendon, increasing the tensile strength of the tendon. By generally does not heal or heals only partially under certain
week 5, tenocytes become the main cell type.54 conditions.65 In most cases, surgical or biologic interven-
During this phase patients should feel a decrease in the tions are necessary to induce a repair response. Treatments
initial postinjury/procedural pain. Preprocedural symptoms include debridement, microfracture, and autologous tissue
may persist, slowly improve, or wax and wane. transplantation (e.g., autologous chondrocytes or MSCs).
Little is known about the histologic effects of cartilage
Phase III of Healing—The Maturation Phase healing after these procedures. In vitro studies have dem-
(21 Days to 12 Months) onstrated that mechanical stress can stimulate the differ-
entiation of MSCs into chondrocytes, extracellular matrix
The maturation or remodeling phase starts 3 weeks after an synthesis, and cytokine secretion,66 whereas excessive stress
injury and lasts up to 12 months or longer, with collagen may cause cell death and matrix degeneration.67
deposition by fibroblasts continuing for this entire period.51
Increased stability is acquired during the remodeling phase Bone
and is stimulated by continued use of the tendon. Mechani-
cal stress influences cell signaling and behavior; it contrib- Injured bone (e.g., fractured or necrotic bone) is resorbed
utes to remodeling of the collagen matrix and increases the and replaced by new bone following the three phases of
tensile strength of the tissue.55 As the maturation process healing. Macrophages and osteoclasts remove injured cal-
continues, the collage fibers continue to be reabsorbed and cified bone, and osteoblasts fill the fracture gap, forming
synthesized along the direction of force and cross-linking granulation tissue. Delayed bone formation and nonunion
of the collagen fibrils occurs, increasing the tendons’ ten- have been attributed to variations in the local inflammatory
sile strength. Along with this, there is increased deposition environment as well as the recruitment of muscle-derived
of type I collagen in preference to type III collagen.54,56 stromal cells and osteogenesis early in the healing process.68
The tensile strength is estimated to reach its maximum Bone repair follows two phases of healing: (1) the initial
at 3 months57,58 but never fully returns to its preinjury cartilaginous soft callus, followed by (2) remodeling and
strength.59 During this period, patients are usually notic- formation of a bony hard callus. Initially, the soft callus is
ing a consistent improvement in symptoms, although their formed when adjacent soft tissue and periosteum bridge the
condition will still often wax and wane as tissue transitions fracture site, stabilizing the fracture.69 Osteons travel along
from granulation tissue to scar formation. the cortical bone (by the Haversian system); they bridge the
fracture gap,70,71 and osteoblasts synthesize woven bone,
resulting in a hard callus.68,72,73 This irregular woven bone
Tissue-Specific Considerations callus remodels over months to years through continuous
Tendons and Ligaments osteoclast resorption, while osteoblasts replace the matrix
with lamellar bone to bring the bone back to its original
Healing of tendons and ligaments follows the three phases of shape, size, and strength/stability.74
wound healing that have already been detailed. In the initial
phase, blood clot and granulation tissue fill the gap between
the tendon and ligament fibers. In tendons, fibroblasts and Overview of Rehabilitation Guidelines per
tenocytes in the epitenon and paratenon are recruited and Phase of Healing
proliferate, bridging the injured gap and forming a stable
scar. In the early stages, the matrix is composed of increas- The objective of many traditional orthopedic injections,
ing amounts of type III collagen.60 After 10 weeks, a higher such as corticosteroids or ketorolac injections, is to address
proportion of collagen type I is synthesized and type III col- inflammation. The objective of orthobiologic procedures
lagen decreases, forming scarlike tendon tissue, a process in interventional orthopedics is different, and the aim is to
that will continue for years.61,62 reduce pain and improve function. This is often achieved
by stimulating a healing response by delivering growth fac-
Muscles tors to the target tissue (e.g., PRP, autologous stem cells) or
controlled microtrauma to convert a chronic injury into an
Muscle strains that cause a rupture of the myofibers also acute injury with healing potential (e.g., prolotherapy, per-
go through the three phases of healing. Satellite cells begin cutaneous needle tenotomy, Tenex ultrasonic debridement).
to proliferate and form new myoblasts, which fuse into The literature on rehabilitation after orthobiologic or
myotubes within a couple of days.63 Similar to tendons and interventional orthopedic procedures is limited, and many
 CHAPTER 37 Rehabilitation Principles for Interventional Orthopedics and Orthobiologics 603

of the rehabilitation protocols that have been proposed con- concern that immobilization may have a negative impact
stitute attempts to translate these would-be healing prin- on tendon healing. In animal models, loading the tendon
ciples into clinical practice.44,75–78 There is some variability resulted in neotendon development after a PRP injection
in the duration and overlap of the phases of wound healing versus when the tendon was unloading, there were no ben-
described in the literature,49–52 and progression through the eficial results.38 Prolonged immobilization has been associ-
rehabilitation process should be informed by clinical prog- ated with joint contractures and functional impairment,
ress through the program, and individualized, reflecting and early gentle active ROM is considered safe.75
the type of tissue undergoing recovery (e.g., tendon, bone,
ligament, muscle), severity of the underlying pathology, the Pain Management
patient’s preprocedural fitness level, her or his physical abili-
ties, and any existing comorbidities. Postprocedural pain can vary among patients and proce-
dures. For example, intra-articular injections are often less
painful than intratendinous or intraosseous injections. Peri-
Rehabilitation in the Inflammatory Phase procedural nerve blocks, when possible, can help with acute
of Healing (0 to 5 Days) postprocedural pain management. Longer-acting anesthet-
ics, such as ropivacaine, can extend the efficacy of these
The goal of rehabilitation in the inflammatory phase is typi- blocks. Alternative approaches to pain management and
cally one of protection, and care typically focuses on man- analgesia include cryotherapy and nonsteroidal antiinflam-
aging pain and postprocedural swelling. Management may matory drugs (NSAIDs).
vary, depending on the procedure, and tissue type (i.e. ten- There are different methods of cryotherapy, including
dons, ligament and bone/cartilage) but is typically achieved the use of crushed ice, ice bags, chemical or gel packs, and
with immobilization or bracing, ice, elevation, medications, commercially available cryotherapy devices that provide the
and gentle ROM exercises to activate the vasomotor pump.75 continuous circulation of ice water. However, there is evi-
dence that some of these methods are more effective than
Immobilization/Bracing others.80–82 There is some debate on the issue of limiting
cryotherapy in the acute phase after an orthobiologic pro-
In most cases, protected weight bearing is recommended for cedure.36,83 Cryotherapy has been shown to be effective for
pain control in the first 1 to 3 days. Most randomized con- managing pain in certain situations84 and is often accepted
trolled or prospective studies on orthobiologic procedures as an integral part of the treatment of acute soft tissue inju-
have prescribe a period of absolute or relative rest during ries despite the lack of a robust evidence base.85 In one
the acute inflammatory phase, although no prospective review of regenerative procedures for tendinopathy, 20%
studies have specifically studied these rehabilitation proto- of prospective randomized controlled studies prescribed
cols.36 Immobilization should not be prescribed owing to a cryotherapy for pain management.36 The theoretical con-
concern that the administered orthobiologic may disperse cern is that cryotherapy may reduce blood flow, which is
to other locations with movement. In a cadaveric model, important for healing. However, the literature is limited and
Achilles tendons that were injected with blue dye to simu- the effect of cryotherapy depends on a number of factors,
late a PRP injection were manipulated through 100 cycles including the temperature of the cooling device, the depth
of ankle dorsiflexion and plantarflexion, resulting in no sig- of the subcutaneous tissue, and the frequency and duration
nificant difference in the spread of the dye compared with of treatment.81,86–88 Studies have shown that cryotherapy
control specimens that were kept in a prone resting position can temporarily decrease microcirculatory perfusion when
for 15 minutes after the injection.79 This suggests that early measured at a depth of 2 to 8 mm,89,90 but they disagree
motion does not increase the spread or clearance of PRP on whether this decrease in blood flow persists following
from the target site. active cooling.90,91 There is limited literature on how the
Limitation of joint motion can help to reduce pain in the superficial effects of cooling affect the perfusion of deeper
associated area, and weight-bearing restriction or bracing structures, and skin temperature has been shown to be a
can be used for this objective. Avoiding any pain-provoking poor predictor of intramuscular temperature and may be a
activities is a common recommendation, but recommen- poor predictor of perfusion to deeper structures.92 In one
dations have varied across the literature, from avoiding all study of cryotherapy on the microcirculation of the mid-
physical activity to limiting only repetitive movements. portion Achilles tendon, the authors showed reduced blood
Crutches, a controlled-ankle-motion walking boot, or flow within the first minute of cryotherapy and return of
unloader braces can be used to limit motion or decrease capillary blood flow during recovery.91 Another theoretical
stress on a joint, bone, or tendon/ligament after treatment. concern is that cryotherapy may decrease platelet activation,
Any period of immobilization should be limited and guided but in vitro studies have shown that the temperature did not
clinically. In most randomized controlled or prospective affect platelet adhesion when tested at 0 and 37°C.93
studies that detailed postprocedure protocols, patients were The limitation of NSAIDs before and after an ortho-
usually instructed to restrict weight bearing or to immobi- biologic procedure is widely accepted across the literature.
lize the joint for 3 days to 2 weeks.36 However, there is a NSAIDs have been shown to inhibit platelet function and
604 SEC T I O N V Postprocedure Considerations

reduce the release of growth factors.94–96 In a study using a There is no overall effect on injuries prevention with SS
rat animal model of a surgically repaired rotator cuff ten- and PNF, but no data is available for DS on injury pre-
don, even initiating NSAIDs in the proliferative stage of vention.104 For tendinopathies specifically, it is inferred that
healing decreased the biomechanical strength of the repaired static stretching is the “safest” form of stretching due to its
tendon.97 slow and steady nature.75,104
Non-NSAID pain medications and prescription narcot-
ics are often prescribed for the first 72 hours. Over-the-coun- Strengthening
ter acetaminophen is often acceptable for pain control after
most procedures and does not demonstrate any antiinflam- Strengthening during the proliferative phase has also been
matory activity.96 Narcotics can be used for breakthrough evaluated after regenerative procedures in tendinopathy.40
pain following opioid-risk mitigation strategies, including This is typically started at 2 weeks in most published postpro-
patient education about opioids, clear instructions about cedure protocols,44,75–78 but timing varies across the litera-
when to use opioids (e.g., for moderate or severe pain only), ture.36 For joint injections, the strengthening program likely
and prescribing short-acting opioids at the lowest dose nec- can be start sooner than with tendons or ligaments. Most rec-
essary. In geriatric patients, doses should be decreased by at ommendations are to have a progressive strengthening pro-
least 50% if there is concern for cognitive impairment, risk gram. This is based on the progression of healing in tendons,
of falls, respiratory dysfunction, or renal insufficiency.98 where initially newly synthesized collagen fibers are oriented
randomly, but as the proliferative phase progresses, the col-
lagen fibers are increasingly oriented along the direction of
Rehabilitation in the Proliferative Phase of force, thus increasing the tensile strength of the tendon.54
Healing (5 Days to 6 Weeks) The safest type of contraction in this phase of healing
may be isometric, since joint motion is limited. Isometric
The objective of rehabilitation in the proliferative phase is contractions can decrease blood flow to the active tissues,
to gradually increase activity. There is no consensus on the but the effect is likely temporary.75 Isometric exercises have
optimal timing of a stretching or strengthening program, also been shown to be effective for short-term pain relief,
and most published study protocols do not specify the type and the authors typically will initially start with isometric
of strengthening recommended.36 Rehabilitation in this strengthening exercises after a regenerative procedure.105,106
phase is progressive and is typically governed by patient’s Eccentric contraction or heavy slow resistance training
tolerance. A good guideline is to limit any activity that may be the most beneficial type of exercise for long-term
increases the patient’s pain to greater than a 3/10 during or pain reduction and functional improvement in tendinopa-
after that activity. thy, but it has not specifically been studied after regenerative
Intraosseous, intraarticular, axial and injections of ten- injections.107 Limited literature guides the ideal timing to
dons and/or ligaments may all require different periods of initiate eccentric strengthening. There is some concern that
rest and activity modification.99,100 The literature on tendon if eccentric strengthening is started too soon, it may have
healing clearly suggests that early controlled loading influ- a hypovascular effect that attenuates the healing cascade,83
ences the early phases of tendon healing after regenerative and it has been suggested that eccentric exercises should be
injection or microtrauma (needle tenotomy)38,101 and that reserved for the late proliferative or remodeling phase.75
appropriate mechanical loading induces the differentiation There is also limited literature on open-chain versus closed-
of tendon stem cells (TSCs) into tenocytes.102 However, chain exercises after regenerative procedures.36,75
excessive loading can induce the differentiation of TSCs
into adipocytes, chondrocytes, and osteocytes.102 Concerns
about heterotopic ossification after PRP103, in theory may Rehabilitation in the Remodeling Phase of
stem from the failure of rehabilitation rather than the ortho- Healing (6 Weeks to 12 Months)
biologic injection.
The goal of rehabilitation in the remodeling, or maturation,
Stretching phase is the safe return to higher-level activities and sport.
At this stage, patients should have completed the early reha-
In the literature, the timing of a stretching program has bilitation protocols and have full ROM across the joint.
ranged from 24 hours postprocedure to 1 week.36 Studies Eccentric strengthening should be started in this phase, if
have been performed to determine if dynamic stretching not initiated earlier during the late proliferative stage, and
(DS), static stretching (SS), or proprioceptive neuromuscu- proprioceptive exercises should be added to the rehabilita-
lar facilitation (PNF) were superior; however, there is no tion program.75
consensus on the best form of stretching in early phases of The literature is limited to guide return-to-play decisions;
healing. The literature on DS, SS, or PNF in sport shows the timing should be individualized to the athlete. Initially,
a small to moderate effect on performance and a similar there should be a focus on the reintroduction of functional
improvement in ROM with all of the stretching approaches. activities specific to the athlete’s sport. Patients with lower
 CHAPTER 37 Rehabilitation Principles for Interventional Orthopedics and Orthobiologics 605

extremity injuries can start jogging and progress activity as frames at each stage of healing. Suggested rehabilitation
tolerated as long as the pain does not increase greater than a protocols are general guidelines (Table 37.1). Ultimately
3/10 on numeric rating scale. Sport-specific movements and the rehabilitation protocols will have to be individualized
activities should be included in a controlled setting before to best benefit each particular patient in terms of the spe-
progressing to a practice or game/competition setting. cific injury and treatment. Table 37.2 provides examples
of protocols for knee, intra-articular (Table 37.3), rota-
Conclusion tor cuff intratendinous (Table 37.4), ACL intraligament
(Table 37.5), and hip intraosseous (Table 37.6) orthobio-
Postprocedure recommendations are based on the underly- logic procedures.
ing physiology of the healing cascade and the relative time

TABLE
37.2   General Postprocedural Recommendations per Phase of Healing.

Phase of Healing Time Frame Restrictions/Rehabilitation

Phase I: Inflammatory Days 0–5 •  elative rest.
R
phase • Avoid excessive loading/stress and consider NWB or protected WB.
• Consider bracing to minimize ROM and provide protection.
• Avoid NSAIDs; use alternative pain management.
Phase II Day 5 to week 6 Early proliferative phase (day 4 through week 2)
• Full WB plus/minus protection.
• Active ROM.
• Initiate gentle stretching program.
• Avoid NSAIDs; use alternative pain management (e.g., acetaminophen, curcumin,
narcotics, limited cryotherapy, heat, laser therapy).
Late proliferative phase (day 4 through week 2)
• Full WB without protective device.
• Stretching program, adding “dynamic” stretching.
• Continue activity, passive ROM can be started.
• Progressive strengthening program, starting with high-repetition isometrics and
progressing to eccentric exercises closer to the end of this phase.
• Avoid NSAIDs; use alternative pain management.
Phase III Week 7 and after Weeks 7–12
• Proprioceptive training and sport-specific exercises.
Week 12
• Return to sport/activity.

NSAID, Nonsteroidal antiinflammatory drug; NWB, non–weight bearing; ROM, range of motion; WB, weight bearing.

TABLE
37.3   Medial or Lateral Compartment Osteoarthritis of the Knee (Example: Intra-Articular Rehabilitation).

Restrictions Therapeutic Goals/Exercises

Phase I (days 0–5) • W BAT. •  aily activities as tolerated.
D
• PWB or unloader bracing of joint if • Gentle active ROM as tolerated.
experiencing moderate to severe • Wound monitoring.
pain. • Pain management.
• Avoid NSAIDs.
Early phase II (day 5 • W BAT. • A ctivities as tolerated.
to week 2) • Avoid excessive loading of the joint. • Continue active ROM.
• Unloader brace with WB activity if • Enhance blood perfusion through modalities (infrared heat,
recommended by physician. moist heat, ultrasound, etc.).
• Avoid NSAIDs. • Begin isometric low-grade closed-chain program (e.g.,
• Avoid any activity that causes >3/10 start body weight partial squats and lunges).
pain during or after the activity. • Begin core activating exercises and postural therapy.
• Can start swimming and/or pool therapy and biking (low
resistance) on flat terrain.

Continued
TABLE
37.3   Medial or Lateral Compartment Osteoarthritis of the Knee (Example: Intra-Articular Rehabilitation).—cont’d

Restrictions Therapeutic Goals/Exercises

Late phase II • W BAT. • C ontinue active ROM and progress to passive ROM.
(weeks 2–6) • Unloader brace with weight-bearing • Can add resistance to closed-chain program. Start with
activity light weight and focus on form and increasing repetition.
• Avoid high-impact activities and Continue with isometric exercises and progress slowly to
heavy weightlifting to affected joint. concentric exercises.
• Avoid NSAIDs. • Can start light open kinetic chain exercises (e.g., start leg
• Avoid any activity that causes >3/10 curl/extension exercises with light weight).
pain during or after the activity. • Incorporate core, gluteal, postural, and alignment therapies.
• Continue modalities as needed
• Can continue pool therapy, swimming, biking, light walking
as tolerated.
Early phase III • D iscontinue unloader brace. • P rogress open kinetic chain exercises and functional
(weeks 7–12) • Avoid any activity that causes >3/10 exercise program.
pain during or after the activity. • Proprioception exercises, single limb stability exercises.
• May resume light aerobic activities such as hiking and light
agility training, and progress to jogging if able.
• Can increase biking resistance.
• Progress weightlifting/strength training as tolerated.
• Can start to add more activities in a stepwise fashion.
Late phase III (week • No specific restrictions. • S port and activity-specific training.
13 and thereafter) • Progress weightlifting/strength training.
• Return to full activities as tolerated.

NSAID, Nonsteroidal antiinflammatory drug; PWB, partial weight bearing; ROM, range of motion; WB, weight bearing; WBAT, weight bearing as tolerated.

TABLE
37.4   Rotator Cuff Tear (Example: Tendon Rehabilitation).

Restrictions Therapeutic Goals/Exercises

Phase I (days 0–5) • A void lifting, pushing, pulling. •  aily activities as tolerated.
D
• Avoid NSAIDs. • Gentle active ROM as tolerated three times daily.
• Avoid sling or immobilization. • Wound monitoring
• Pain management
Early phase II (day • A void lifting >5–10 lb. • C ontinue active ROM (e.g., add pendulum and pulley
5 to week 2) • Avoid overhead activity; no overhead lifting. exercises)
• Limit flexion/abduction to 90 degrees with • Enhance blood perfusion through modalities (e.g.,
palms up and extension to 0 degrees. infrared heat, moist heat, ultrasound)
• Avoid resistance exercise bands. • Strengthen inferior traps and rhomboids (e.g., rows,
• Avoid any activity that causes >3/10 pain extensions, abduction, triceps extensions) and forearms
during or after the activity. • Neck stabilization exercises
• Avoid NSAIDs.
Late phase II • A void repetitive overhead activity, no • Continue active ROM and progress to passive ROM
(weeks 2–6) overhead lifting. • B egin resistance training including gentle rotator
• Limit flexion/abduction to 90 degrees with cuff strengthening. Start with isometric exercises
palms up and extension to 0 degrees (e.g., with and progress to concentric exercises. Start with low
push-ups, keep hands shoulder width or closer). weight; focus on form and increase repetition instead of
• Avoid resistance exercise bands. increasing weight. Progress slowly.
• Avoid any activity that causes >3/10 pain • Continue to work on strength and flexibility, correcting
during or after the activity. poor biomechanics, asymmetry, scapular dyskinesia,
and postural restoration.
Phase III (weeks • C an start lightweight overhead activity but • P rogress strengthening exercises, adding eccentric
7–12) avoid repetitive overhead activity. exercises and progressing to a functional exercise program.
• Limit flexion/abduction to 90 degrees with • Proprioception exercises.
palms up and extension to 0 degrees (e.g., • Address strength asymmetry, flexibility, poor
with push-ups, keep hands at shoulder biomechanics, and scapular dyskinesia if present.
width or closer). • Return to full activities as tolerated.
• Avoid any activity that causes >3/10 pain • Can start to add more activities, including overhead, as
during or after the activity. tolerated and in a stepwise fashion.
Phase III (week 13 • No strict restrictions. • S port- and activity-specific training
and thereafter) • Progress weightlifting/strength training
• Return to full activities as tolerated

NSAID, Nonsteroidal antiinflammatory drug; ROM, range of motion.

 CHAPTER 37 Rehabilitation Principles for Interventional Orthopedics and Orthobiologics 607

TABLE
37.5   Anterior Cruciate Ligament (Example: Ligament Rehabilitation).

Restrictions Therapeutic Goals/Exercises

Phase I (days 0–5) • A CL or hinged knee brace (initial 4–6 • W ound monitoring.
weeks). • Pain management.
• No plyometrics, cutting movements, or
lateral movements. No running.
• Avoid NSAIDs.
Early phase II (day 5 to week • A CL or hinged knee brace (initial 4–6 • B egin active ROM in knee brace.
2) weeks). • Start stationary bike for ROM with minimal
• No plyometrics, cutting movements, or resistance.
lateral movements. No running. • Can start gentle isometric quad sets, hip
• Avoid any activity that causes >3/10 abductor and core strengthening.
pain during or after the activity. • Can start elliptical in brace and swimming.
• Avoid NSAIDs.
Late phase II (weeks 2–6) • A CL or hinged knee brace (initial • C ontinue stationary bike, elliptical in brace, and
4–6 weeks). Can discontinue brace swimming.
if recommended by physician at 4 • Can progress to pool jogging; chest depth, 30–45
weeks. min three to five times a week for 2 months. Can
• No plyometrics, cutting movements, or begin jogging on even terrain at 4–6 weeks if not
lateral movements. No running. painful.
• Avoid any activity that causes >3/10 • Progress to concentric strengthening (e.g., light
pain during or after the activity. squats, leg presses).
• Avoid NSAIDs. • Can start basic proprioceptive exercises in brace
(e.g., balance board exercises).
Early phase III (weeks 7–12) • C an discontinue brace. • P rogress strengthening and proprioceptive
• Avoid any activity that causes >3/10 exercises (e.g., ball toss on balance board).
pain during or after the activity. • Progress to eccentric strengthening (e.g., single
leg exercises, calf raises, squats, dead lifts).
• Address strength asymmetry, flexibility, poor
biomechanics.
• Objective ACL stability measurements at 12
weeks with Rolimeter/telos or KT 1000.
Late phase III (week 13 and • No strict restrictions. • C onsider repeating the MRI at 3 and 6 months.
thereafter) Pending results may consider repeat PRP or
bone marrow concentrate.
• Continue strength training, proprioceptive
exercises, single-leg stability exercises, landing
mechanics, neuromuscular control therapies.
• Progress to return to full sport at 3–9 months with
physician clearance after reviewing MRI, checking
objective stability, and demonstrating correct
neuromuscular control.
• Should demonstrate correct form (good knee,
hip, pelvic, and trunk stability) with step down,
drop jump, lateral shuffle, deceleration, triple
jump, and side step-cut tests before return to
cutting sports.
• Once the patient returns to sport, recommend
the Santa Monica Sports Medicine PEP (Prevent
Injury and Enhance Performance) program

ACL, Anterior cruciate ligament; MRI, magnetic resonance imaging; NSAID, nonsteroidal antiinflammatory drug; ROM, range of motion.
608 SEC T I O N V Postprocedure Considerations

TABLE
37.6   Hip Intraosseous (Example: Intraosseous Rehabilitation).

Restrictions Therapeutic Goals/Exercises

Phase I (days 0–5) • L imit WB activity as possible for 1 •  entle active ROM as tolerated.
G
week. PWB with crutches (first 3–5 • Wound monitoring.
days), then WBAT. • Pain management.
• Avoid NSAIDs. • Prevention of DVT: leg elevation while lying, ankle pumps,
(optional—compression socks when upright).
Early phase II (day 5 • W BAT. • C ontinue active ROM.
to week 2) • Once off crutches, walking no more • Can start stationary bike for ROM. If there is access to a
than 30 min at a time. pool, can start walking (chest depth, 30–45 min three to five
• Avoid any activity that causes >3/10 times a week).
pain during or after the activity. • Core stability exercises.
• Avoid NSAIDs. • Enhance blood perfusion through modalities (infrared heat,
moist heat, ultrasound, etc.).
• Can consider hyperbaric oxygen,108–110 PEMF therapy,
and/or low-intensity pulsed ultrasound if AVN or nonunion
fracture treatment.
Late phase II • W BAT. • S tart isometric low-grade closed-chain program (e.g., start
(weeks 2–6) • Avoid high-impact activities and body weight partial [mini] squats and lunges). Add pelvic
heavy weightlifting to affected joint. alignment exercises, hip abduction strengthening, and
• Avoid NSAIDs. core stabilization (e.g., plank, supine bridge) with therapist.
• Avoid any activity that causes >3/10 Progress to concentric exercises.
pain during or after the activity. • If there is access to a pool can start jogging in pool (chest
depth, 30–45 min three to five times a week) or add elliptical.
• Start proprioceptive exercises.
• Biking with low resistance.
Early phase III • A
 void any activity that causes >3/10 • S tart open kinetic chain exercises and functional exercise
(weeks 7–12) pain during or after the activity. program.
• Progress proprioception exercises
• Address strength asymmetry, flexibility, poor biomechanics.
• May start low- to moderate-impact activity at 2 months and
progress to biking with resistance, then jogging if able.
• Progress weightlifting/strength training as tolerated.
Late phase III (week • No specific restrictions. •  port and activity-specific training.
S
13 and thereafter) • Progress to running if able.
• Progress weightlifting/strength training.
• Return to full activities as tolerated.

AVN, Avascular necrosis; DVT, deep venous thrombosis; NSAID, nonsteroidal antiinflammatory drug; PEMF, pulsed electromagnetic field; PWB, partial weight
bearing; ROM, range of motion; WB, weight bearing; WBAT, weight bearing as tolerated.

References 5. Rodgers JA, Garvin KL, Walker CW, Morford D, Urban J,

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38
Advanced Imaging in
Interventional Orthopedics
RAHUL NAREN DESAI AND KATAR ZYNA IWAN

Regenerative musculoskeletal orthobiologics are a game- set by the practitioner.6 In many instances, imaging studies
changing and paradigm-shifting treatment option. They are misinterpreted because of the disconnect between physi-
require a new set of standards in terms of diagnosis, treat- cal exam and diagnostic imaging interpretation. The cause
ment regimen (moving from single joints or individual struc- for the patient’s pain or dysfunction, otherwise known as
tures to treatment of the entire kinetic chain), rehabilitation the diagnosis, is present on imaging but is not interpreted as
protocols, and expectations. These interventions and thera- critical or important or sometimes is simply not recognized.
peutic regimen afford physicians the ability to heal injured Another reason for the disconnect is the lack of interpreta-
tissues and return them to a more normal and, in some cases, tion skills of the treating physician, or solely relying upon the
a native uninjured state. In this manner, they have also set report of the radiologist who has never seen or evaluated the
new standards in preprocedural and postprocedural imaging. patient. The pressures on the radiologists to read high vol-
Regenerative therapies are powerfully compelling, but umes of cases and meet relative value units (RVU) quota fur-
consistently successful results require precision diagnosis, ther reduce the quality of imaging interpretations because the
and delivery with the use of image guidance (Fig. 38.1). priority becomes ruling out catastrophic findings (i.e., cancer,
There is clear and repeatable evidence that a precisely placed surgical emergencies) rather than finding subtle diagnoses.7
image-guided injection of regenerative materials, including The field has matured with the advent of improved
autologous cells, changes the tissue appearance back to a point-of-care ultrasound and postinjection-limited MRI.
more normal morphology.1–5 Physicians now can reimage patients after the procedure
In today’s practice, there are many conventional treatment and demonstrate healing of the tissue by delineating the
modalities that provide for improved function and reduce morphologic difference between injured tissue versus healed
pain. These include palliative treatments such as corticosteroid tissue. This can be best accomplished with the use of MRI,
injections, and nerve ablation. Surgeries are focused at remov- ultrasound, x-ray, and computed tomography (CT) scans,
ing the diseased tissues, whether it be a meniscus, labrum, which provide a detailed image of all structures and the abil-
or joint. However, the modalities all fail in regard to their ity to see regeneration of native tissue on a larger scale. This
ability to change the disease process of the injured tissues. is a major shift in thinking compared with orthopedic and
Orthobiologics have shifted the perspective from palliative to neurosurgical models, where the tissues are often severely
restorative, further confirmed as magnetic resonance imaging disrupted and where postoperative imaging is less than ideal
(MRI) and ultrasound evidence shows return to a normal tis- in demonstrating improvement. The tissue is often obscured
sue morphology. Follow-up imaging allows the clinician to by metallic artifacts; therefore the repaired tendon or tis-
correlate clinical success with structural tissue improvement, sues are poorly visualized. Artifacts may be related to screws,
further validating the source of pain and dysfunction. anchors, or even simply filings from shavers used during sur-
Most case reports, abstracts, and white papers in orthope- geries or arthroscopies. Postsurgical scarring involving the
dic, musculoskeletal, and regenerative medicine focus heav- soft tissues, epidural space, fat pad, and other areas are also
ily on pain scores and functional outcome measures such commonplace. In stark contrast, imaging in the regenera-
as the Oswestry Disability Index, visual analog scale (VAS) tive medicine setting can demonstrate resolution of tendon
score, and Knee injury and Osteoarthritis Outcome Score tears, reformation of ruptured ligaments, healing of annu-
(KOOS). Imaging has been used as an outcome measure to lar tears of discs, improved alignment of the spine, resolu-
a much smaller degree, but it is a crucial and highly objec- tion of joint effusions, and even reversal of bone marrow
tive measure of outcome. Imaging is a powerful modality lesions, cysts, and intraosseous edema (Figs. 38.2–38.10).
because it can be used in precisely defining injuries, inflam- Moreover, an updated imaging study prior to treatment
mation, and dysfunction, but this does require a specific skill is crucial because it focuses therapy to all the regions that

612
 CHAPTER 38 Advanced Imaging in Interventional Orthopedics 613

Successful Regenerative Medicine

Therapy

sis

Precision Biologics

Precisio
Precision

Diagno
Diagnosis Precision Delivery
History, physical exam Image-guided placement of

n
n
Diagnostic imaging and needle/therapy into injured

Delivery
Precisio
Injections tissues

Precision
Biologics
The best biologic for the
injury or disease process
• Fig. 38.1 Three-legged stool for successful regenerative medicine therapy comprises precision diagnosis,
precision biologics, and precision delivery into injured tissues.

A B

C D
• Fig. 38.2 Pretreatment magnetic resonance imaging (MRI) lumbar spine sagittal (A) and axial plane T2
(B) sequence demonstrates L4–L5 central, right-paracentral disc herniation with extrusion and caudal
migration. Posttreatment MRI (C, D) demonstrates complete resolution of the her-niation and extrusion.
614 SEC T I O N V Postprocedure Considerations

• Fig. 38.3 (Top images) Pretreatment magnetic resonance imaging (MRI) of right hamstring origin
demonstrates a large tear at the ischial tuberosity footprint, with fluid signal intensity filling the defect.
(Bottom images) One-year post stem cell injection therapy demonstrates complete resolution of the
defect, with normal appearing tendon origin. The patient’s symptom improvement strongly correlated with
these MRI findings.

• Fig. 38.4 (Top images) Pretreatment sagittal plane magnetic resonance imaging (MRI) through the pos-
terior horn of the medial meniscus demonstrating complex horizontal tear with extension through the
posterior peripheral base (blue arrow) and adjacent parameniscal cysts (orange arrow). (Bottom images)
Nine-month post-treatment MRI demonstrating resolution of the parameniscal cyst and coaptation and
healing of the meniscal tear. Patient is symptom free and has returned to running up to 6 miles 3 to 4 times
per week.

require intervention. In addition, it is most ideal to reimage dramatically reduce the extent of imaging required, scan
the patient at approximately 3 to 6 months and 12 months times, and costs and improve patient comfort. Imaging is
after orthobiologic therapy. Practitioners should use consis- beneficial in gauging the response of the injured tissue and
tent methods, imaging modalities, and imaging sequences. to document the outcome, both for documentation and for
Local imaging centers and radiology groups are usually able research purposes. It can also dramatically improve practi-
to offer discounted pricing for limited sequence exams that tioner and patient confidence that the treatments are work-
focus on the previously injured and treated tissues. This may ing toward their intended outcome.
 CHAPTER 38 Advanced Imaging in Interventional Orthopedics 615

• Fig. 38.5 Magnetic resonance imaging and ultrasound follow-up imaging of supraspinatus calcific tendi-
nitis after tenotomy calcium debridement combined with autologous fat injection therapy

• Fig. 38.6 (Left images) Magnetic resonance imaging demonstrating talonavicular arthritis, with large
areas of subchondral cyst formation with sclerotic walls, and extensive marrow edema extending to the
talar body. (Right images) Imaging post treatment at 6 months with stem cells shows dramatic improve-
ment of the subchondral edema, normal marrow signal, and structure occupying areas of previous cystic
change. The dense sclerotic walls have also resolved. (Bottom images) X-ray imaging demonstrates pre-
cision placement of Jamshidi needle, and contrast filling of cysts with reposition of needle into separate
discrete areas of injury. Contrast is seen filling the discrete cystic regions (top row, and right lower), as well
as flowing into the talar body with trabecular contrast depiction (lower right image).

In regenerative medicine, imaging is vital for identify- images with shorter acquisition times, minimal to no radia-
ing injured tissues and measuring the efficacy of treatment. tion dose, and assessment of structural and functional
Imaging bridges the gap between orthobiologic therapies improvement. In vivo imaging is a platform technology with
and outcomes, thus providing insight into healing, patho- the power to put function in its natural structural context.
physiology, and longitudinal restorative function. Regenera- Modalities such as elastography ultrasound can assess tensile
tive medicine aims to enhance the body’s intrinsic healing strength of tendons. With the drive to translate stem cell
capacity, although this therapy is still not covered by most therapies into preclinical and clinical trials, early selection
medical insurance carriers. Imaging technologies have of the right imaging techniques is paramount to success.
improved significantly in recent years and provide quality There are many instances in regenerative medicine where
616 SEC T I O N V Postprocedure Considerations

• Fig. 38.7 (Left image) Pretreatment magnetic resonance imaging demonstrates complete rupture of
anterior cruciate ligament (ACL). (Right image) Demonstrate progressive healing at 6 weeks and 3 months
post treatment with bone marrow aspirate concentrate.

• Fig. 38.8 (Top images) Pretreatment magnetic resonance imaging (MRI) on the top and posttreatment
MRI (bottom images) taken 2 years after treatment with intra-articular and subchondral bone marrow aspi-
rate concentrate for an osteo-chondral defect in the posterior lateral femoral condyle in a 38-year-old male
with posterior lateral knee pain for 3 years.
 CHAPTER 38 Advanced Imaging in Interventional Orthopedics 617

• Fig. 38.9 The left pretreatment T2-weighted coronal image of the left shoulder of a 63-year-old female
with a full-thickness rotator cuff tear measuring 1.4 cm treated with ultrasound-guided bone marrow aspi-
rate concentrate. The posttreatment T2 coronal magnetic resonance imaging done at 2 years post treat-
ment demonstrating significant healing and with patient-reported symptomatic improvement of 99%.

• Fig. 38.10(Top images) Pretreatment sagittal and axial T2-weighted sequence showing posterior disc
bulge and annular tear at L5–S1. (Bottom images) The posttreatment T2 MRI images demonstrating inter-
val improvement in disc bulge size and resolution of annular tearing.
618 SEC T I O N V Postprocedure Considerations

the biologic, biochemical, and biomechanical mechanisms 4. Buendía-López D, et al. Clinical and radiographic comparison of
behind the proposed function of stem cell therapies can a single LP-PRP injection, a single hyaluronic acid injection and
be elucidated by appropriate imaging.8,9 Imaging allows daily NSAID administration with a 52-week follow-up: a random-
providers and researchers to document objective outcome ized controlled trial. J Orthop Traumatol. 2018;19(1):3. https://
doi.org/10.1186/s10195-018-0501-3.
measures and further the integration of orthobiologic ther-
5. Kenmochi M, et al. Clinical outcomes following injections of leu-
apy into modern medicine. kocyte-rich platelet-rich plasma in osteoarthritis patients. J Orthop.
2019;18:143–149. https://doi.org/10.1016/j.jor.2019.11.041.
References 6. Centurion AJ, et al. Use of musculoskeletal ultrasound and re-
generative therapies in soccer. Am J Orthop (Belle Mead NJ).
1. Hurd JL, et al. Safety and efficacy of treating symptomatic, partial- 2018;47(10). https://doi.org/10.12788/ajo.2018.0093.
thickness rotator cuff tears with fresh, uncultured, unmodified, au- 7. Brady AP. Error and discrepancy in radiology: inevitable or
tologous adipose-derived regenerative cells (UA-ADRCs) isolated avoidable? Insights Imaging. 2017;8(1):171–182. https://doi.
at the point of care: a prospective, randomized, controlled first-in- org/10.1007/s13244-016-0534-1.
human pilot study. J Orthop Surg Res. 2020;15(1):122. https://doi. 8. Leahy M, et al. Functional imaging for regenerative medicine. Stem
org/10.1186/s13018-020-01631-8. Cell Research & Therapy. 2016;7(1 57). https://doi.org/10.1186/
2. Lychagin A, et al. Intraosseous injections of platelet rich plasma for s13287-016-0315-2.
knee bone marrow lesions treatment: one year follow-up. Int Or- 9. Li Q, et al. Advanced imaging in osteoarthritis. Sports Health.
thop. 2020 Apr 4. https://doi.org/10.1007/s00264-020-04546-5. 2016;8(5):418–428. https://doi.org/10.1177/1941738116663922.
3. Raeissadat SA, et al. MRI changes after platelet rich plasma injec-
tion in knee osteoarthritis (randomized clinical trial). J Pain Res.
2020;13:65–73. https://doi.org/10.2147/JPR.S204788.
Index

A Adhesive capsulitis (AC), 245b, 325b Adipose tissue harvesting (Continued)

A pulleys, 514 arthroscopic findings, 496 rehabilitation, 60
Abobotulinumtoxin A (ABO), 124 high-volume ultrasound-guided injection risks, 50
Absorbed dose, 32t (HVUGI) technique, 59–60
AC. See Adhesive capsulitis (AC) equipment, 498, 498f ADSC. See Adipose derived stem cells
Acellular allografts, 89–90 indications, 498 (ADSC)
Acetabulum, 323 needle orientation and technique, Allograft tissues
Acetic acid iontophoresis, 490–491 499–500, 499f advantages, 89
Achilles mid-portion tendinopathy, HVIGIs patient and clinician position, 499 cellular, 89
injectates, 507 patient selection, 498 cellular vs. acellular, 89–90
needle approach and transducer position, postprocedure complications, 500 culture-expanded, 91–92
510f–511f postprocedure protocol, 500 demineralized bone matrix
needle orientation, 507 transducer orientation, 499 (DBM), 95, 95f
patient and clinician position, 507 histopathologic appearance, 496 exosomes, 93–95
physiotherapy, 509 imaging, 497 mesenchymal stem cell, 90–91
post-injection management, 509 pathology, 496–500 placental-derived, 92–93
Achilles tendon, 2 risk factors, 496 Alpha-2 macroglobulin protein
Achilles tendon/paratenon injection treatment options (A2M), 74
anatomy, 438 capsular hydrodistention, 497–498 Amide local anesthetics, 43
pathology, 438 hydrodilation approach, 497–498 Amniotic tissue, 92, 93f
ultrasound-guided manipulation under anesthesia (MUA), Anesthetics
insertional, 439–440, 439f 498 adipose tissue harvesting, 58, 59t
mid-portion, 438–439, 439f orthobiologic treatments, 497–498 bone marrow procedures, 51–52
Achilles tendon scraping, 457–458, 457f, physical therapy, 497 Anisotropy, ultrasound, 15, 19f
458b Adipose derived stem cells (ADSC), 600 Ankle region injection techniques
Acromioclavicular (AC) joint caveats/side effects, 79 fluoroscopy-guided
anatomy, 259 clinical applications, 79 subtalar joint (sinus tarsi) anterior
fluoroscopic guidance, 268–270, 269f elderly patients, 78 approach, 460–462
osteoarthritis, 259 FDA regulations, 79–80 subtalar joint-posterior approach,
sprain and dislocations, 259 harvesting methods, 78 459–460
ultrasound-guided injections human and animal models, 77–78 talonavicular joint, 461
acromioclavicular joint intra-articular, mechanism of action, 79 tibiotalar joint, 458–459
259–260, 259f–260f systematic review, 78 ultrasound-guided
capsule, 260, 261f viability, 78 Achilles tendon scraping, 457–458,
conoid and trapezoid ligaments, vs. bone marrow aspirate concentrate 457f
260–262 (BMAC), 80 bursal injections, 454–456
Active release therapy (ART), 500 Adipose tissue harvesting joint injections, 428–429
Adductor longus (AL) tendinosis, 333f adipose processing, 59 ligament injections, 430–437
Adductor tendons anesthetics, 58, 59t perineural injections, 448–454
anatomy, 331 clear occlusive dressing, 59 tendon injections, 437–448
injury, 331 compressive garment, 59 Anterior ankle impingement, 545
pathology, 331 contraindications, 50 Anterior cruciate ligament injection
ultrasound-guided injection deployment, 60 anatomy, 411f–412f
equipment, 332 imaging, 58 fluoroscopy-guided injection,
injectates, 332 medications, 50–51 410–414
patient position, 332f–333f positioning, 58 rehabilitation, 607t
technique, 332 postprocedure, 60 ultrasound-guided injection, 390f

Note: Page numbers followed by ‘f’ indicate figures those followed by ‘t’ indicate tables and ‘b’ indicate boxes.

619
620 Index

Anterior inferior tibiofibular ligament Bevel rotation, 28t Bone spurs (Continued)
(AITFL) injection Biceps tendon radiographs, 544–545
anatomy, 434 anatomy, 256 sonographic findings, 544–545
pathology, 434 pathology, 256 treatment options, 545, 545f
ultrasound-guided ultrasound-guided injection ultrasound-guided percutaneous excision
equipment, 435f equipment, 256 and cheilectomy
injectates, 435 long head of biceps tendon (LHBT), complications, 549–550, 550f
technique, 435, 435f–436f 257f equipment, 546
Anterior intermeniscal ligaments, 419 pearls and pitfalls, 258b injectates, 546
Anterior longitudinal (ALL) ligament short head of biceps tendon (SHBT), Jamshidi trocar and cannula, 545f, 547,
injuries, 585b 258, 258f 547f–548f
Anterior meniscofemoral ligaments, 419 Blood anticoagulants needle orientation, 547–549
Anterior talofibular ligament (ATFL) chemical composition, 66–67 patient and clinician position, 546
injections glucose concentration, 67 patient selection, 545–546
anatomy, 431 heparin, 66–67 post procedure, 548–549
ultrasound-guided mesenchymal stem cell (MSC) Tenex TX-Bone (TXB) Micro Tip
equipment, 431 proliferation, 67 Device, 545f, 547–548, 548f
injectates, 431 Blood flow restriction (BFR), 600–601 transducer orientation, 546–547
pathology, 431 BMAC. See Bone marrow aspirate Bony debris, 549–550
technique, 432, 432f concentrate (BMAC) Bony exostosis, 544
Anterolateral knee joint injection, 368f Bone grafts, 95 Bony proliferation, 544
Anterolateral ligament (ALL) Bone healing, 602 Botulinum toxin (BTX)
anatomy, 394 Bone marrow aspirate concentrate (BMAC), administration techniques, 124–125
pathology, 394 554–555 adverse effects, 129–130
ultrasound-guided injection, 394, 395f vs. adipose tissue stem cells (ASCs), 80 chronic exertional compartment
Anteromedial (AM) bundle, 410 caveats/side effects, 76–77 syndrome (CECS), 126
Anxiety, 51 cell components, 75–76 clinical effectivenes, 124–125
Apley Scratch test, 498 centrifugation, 75 dosing, 124
Arterial puncture, 65 clinical applications, 76 entrapment syndromes, 128–129
Arthropathies, subtalar joint, 459–461 clinical efficacy, 76 indications, 125
Articular cartilage, 4, 4f composition, 75–76 intra-articular applications, 127–128,
Aseptic technique, ultrasound, 24 contraindications, 76–77 128t
As low as reasonably achievable (ALARA) FDA regulations, 77 lateral epicondylitis, 127
principle, 33, 34t mechanism of action, 76 mechanism of action, 124
Athletic pubalgia, 331 non-cultured, 75 myofascial pain syndrome, 125–126
Atlanto-occipital and atlanto-axial surface markers, 75 piriformis syndrome, 129
interventions, 150–152 Bone marrow aspiration plantar fasciitis, 126–127
Atrophy, medial calcaneal and inferior anesthetics, 51–52 popliteal artery entrapment syndrome,
calcaneal nerve, 468 anticoagulation, 52 129
Attritional-type tears, plantar plate, 479 contraindications, 50 reconstitution, 124
Autologous iliac crest bone graft, 95 fluoroscopy parallel, 54–55 supplies utilized for, 124–125, 125t
Autologous mesenchymal stem cell, 90–91 fluoroscopy perpendicular, 53–54, 55f tendon and fascia applications, 126–127,
Autologous orthobiologics hemorrhage complications, 51 127t
adipose tissue stem cells (ASCs), 77–80 iliac sectors for, 53f thoracic outlet syndrome (TOS),
alpha-2 macroglobulin protein (A2M), 74 medications, 50–51 128–129
bone marrow aspirate concentrate needles, 52, 55f Bursal injections, ankle region
(BMAC), 75–77 patient preparation, 51 retro-Achilles bursa injection, 456, 456f
cultured cellular injectates, 80–82 perpendicular approach, 51, 53f retro-calcaneal bursa injection, 454–455,
interleukin-1 receptor antagonist protein, processing, 58 455f
74–75 risks, 50 Bursitis
platelet lysate (PL), 73–74 site and positioning, 51 iliopsoas, 333
platelet-rich plasma (PRP), 70–73 syringe, 52–53 sclerotherapy
Autologous tissue harvesting techniques. See ultrasound-assisted parallel, 57–58, 57f–58f patient selection and management,
Platelet-rich plasma (PRP) ultrasound-guided perpendicular, 55–57, 120–121
Avascular necrosis (AVN), 7, 556f 56f–57f theory and clinical evidence, 118–119
Axillary nerve hydro-dissection, 264, 265f Bone marrow lesions treatment, 553 Butterfly needle system, 63f
Bone pathology, 6–7
B Bone spurs C
Bankart lesions, 253 minimally invasive arthroscopic and Caclcaneofibular ligament (CFL) injection
Baxer’s neuritis, 451 endoscopic resection, 545 anatomy, 432
Beam steering, 28t open versus minimally invasive pathology, 432–433
Beam-width artifact, ultrasound, 18 cheilectomy, 550 ultrasound-guided
 Index 621

Caclcaneofibular ligament (CFL) Carpal tunnel syndrome (CTS) (Continued) Cervical intradiscal injection (Continued)
injection (Continued) patient position, 539–541, 540f equipment, 587
equipment, 433 post procedure management, 540 lateral fluoroscopic view, 591f
injectates, 433 technique, 539, 540f neck pain, 586–587
technique, 433 transducer orientation, 539 needle position, 588–590, 590f
Calcaneocuboid joint Carpometacarpal (CMC) joint injection, pathology, 587–592
anatomy, 479–480 315–317 patient position, 587
fluoroscopy-guided injection, 480, 481f fluoroscopy-guided, 320f, 319–320 technique, 158–162
pathology, 479 ultrasound-guided, 316f, 315–317, transducer and C-arm position, 588,
Calcific tendonitis 315b–316b 589f–590f
calcific stage, 489 Cartilage healing, 602 Cervical plexus blocks
clinically relevant anatomy, 489–491 Cartilage injury anatomy, 144
clinical presentation, 490 fibrocartilage, 5 pathology, 144
clinical symptoms, 490 hyaline cartilage, 4–5 ultrasound-guided injection, 144–146
epidemiology, 490 Caudal angulation, 147 Cervical plexus location, 105f
formative phase, 489 Caudal epidural injection Cervical spine discs anatomy, 587, 588f
imaging, 490, 491f fluoroscopy guided, 233–235, 234f–235f Cervical supraspinous and interspinous
pathophysiology, 489–490 ultrasound-guided, 231f, 230 ligaments
postcalcific stage, 489–490 CECS. See Chronic exertional compartment anatomy, 136, 136f
precalcific stage, 489 syndrome (CECS) nuchal ligament, 136, 137f
resorptive phase, 489 Cellular allografts, 89–90 pathology, 136
resting phase, 489 Center for Biologics Evaluation and ultrasound-guided injection, 136, 137f
treatment options Research (CBER), 73 CFL injection. See Caclcaneofibular
conservative management, 490 Cephalic vein, 62 ligament (CFL) injection
open/arthroscopic surgical excision, Cervical anterior longitudinal ligament CHLs. See Coracohumeral ligaments
491 injection, 585–586 (CHLs)
risk factors, 490 AP fluoroscopic view, 587f Chronic anterior pelvic instability, 327
shockwave lithotripsy, 491 lateral fluoroscopic view, 586f–587f Chronic exertional compartment syndrome
ultrasound-guided barbotage/lavage set up, 586f (CECS)
technique ultrasound needle trajectory, 586f activity modification, 527
clinical trials, 492 Cervical injection techniques botulinum toxin (BTX), 126
clinician position, 492 fluoroscopy-guided botulinum toxin-A injections, 527
double-needle technique, 494–495 atlanto-occipital and atlanto-axial differential diagnosis, 524–525
equipment, 492 interventions, 150–152 intracompartmental pressure testing
injectates, 492 cervical interlaminar epidural, 148–150 equipment, 525
patient position, 492 cervical intradiscal technique, 158–162 needle entry sites, 525, 525f
single-needle technique, 493–494 cervical radiofrequency neurotomy, patient and clinician position, 525
transducer position, 492 medial branches, 156–158 protocol, 525–526
ultrasound guidance, 492f C2-3 to C7-T1 facet joints, 152–156, neurologic symptoms, 524
Calcium, 70 154f open surgical fasciotomy, 527
Capsular distention, adhesive capsulitis, facet joints, 150–164 pathology, 524–525
325b stellate ganglion block, 162 Pedowitz criteria, 525t
Capsuloligamentous complex (Turf Toe) transforaminal cervical epidural ultrasound-guided (USG) fasciotomy
injuries, 479 injections, 146–150 anterior compartment, 527–528
Carpal tunnel (CT), anatomy, 535, 536f ultrasound-guided complications, 529
Carpal tunnel injection cervical, 134–135 equipment, 528
equipment, 302 cervical facets, 138–140 lateral compartment, 528
pathology, 302 cervicalplexus blocks, 144–146 local anesthesia, 528
technique, 302–303 cervical supraspinous and interspinous meniscotome position, 528–529, 529f
Carpal tunnel syndrome (CTS) ligaments, 135–137 patient and clinician position, 528
botulinum toxin (BTX), 128 greater and lesser occipital nerve block, pitfalls, 529–530
endoscopic carpaltunnel release (ECTR), 137–138, 137f post-procedure instructions, 529
538–539 interscalene brachial plexus block, skin closure, 529
pathophysiology/diagnosis, 537–538 140–142 transducer position, 528–530
platelet-rich plasma, 72 supraclavicular brachial plexus block, V-shaped meniscotome, 527–528
sonographic evaluation/findings, 538 142–144 Chronic nerve compression injuries, 8
treatment options, 538 Cervical interlaminar epidural injections, Collagen molecules, 2
ultrasound-guided release, 538–539 148–150 Color Doppler ultrasound, 18–19
clinician position, 539 Cervical intradiscal injection Common extensor tendon
complete release, 540 anteroposterior (AP) fluoroscopic view, anatomy, 276–277, 276f
complications, 540–541 591f pathology, 276
equipment, 539 clinician position, 588 ultrasound-guided injection, 277, 277f
622 Index

Common flexor tendon Deeper nerves/ganglion/plexi (Continued) Dextrose prolotherapy (DPT) (Continued)
anatomy, 277–278 thoracic spine/upper to mid back, 106 tissue proliferation, 102
pathology, 278 wrist/hand, 110 training and protocols, 103
ultrasound-guided injection, 278, 278f Deep peroneal nerve injection Diabetes, 600
Common peroneal nerve (CPN), 528 anatomy, 450 Digital nerve block, 319f, 318
Compression fracture, 576 pathology, 450 Discitis, 161b–162b
Compressive neuropathies, 8 ultrasound-guided, 450–451, 451f Distal biceps femoris injection/tenotomy,
Conoid and trapezoid ligaments, 260–262, Degenerative changes 386–387, 387f
262f common extensor tendon, 276 Distal biceps tendon
Conventional treatment modalities, 612 common flexor tendon, 278 anatomy, 279–280
Coracohumeral ligaments (CHLs), 244, 496 Degenerative plantar fasciopathy, 465b pathology, 279
Coronary ligaments, 372, 418 Deltoid ligament complex injection ultrasound-guided injection
Corticosteroid injections (CSIs) anatomy, 435–436, 436f anterior approach, 279–280, 279f
axial spine injections, 42–43 pathology, 436–437 equipment, 279
benefits, 41 ultrasound-guided, 437, 437f posterior approach, 280, 280f
cellular transcription, 41 Demineralized bone matrix (DBM), 90, Distal carpal rows, 308, 309f
complications, 43 95, 95f Distal iliotibial band bursa and
intra-articular injection, 41–42 De Quervain tenosynovitis peritendinous injection, 382–383
long-term systemic, 41 pathology, 519 Distal quadriceps tendon
risks associated, 41 treatment options, 519 anatomy, 377, 378f
short-term systemic, 41 ultrasound-guided release ultrasound-guided injection
soft tissue, 43 complications, 522 equipment, 377
Corticosteroids, 50–51, 342b de Quervain release, 520–522, 521f injectates, 378
Costochondral joints equipment, 519–520 technique, 378, 378f
pathology, 169 nerve block, 520 Distal radial ulnar joint ultrasound-guided
ultrasound guided thoracic injections, post-procedure, 521–522 injection, 292, 292f
170, 170f technique, 520 Distal semimembranosus tendon, 388–389
Costo transverse joint injection ultrasound imaging findings, 519 Distal volar forearm, transverse ultrasound, 19f
anatomy, 176 Dextrose injection Dorsal compartments, wrist injection
fluoroscopy, 176, 176f perineural injection therapy, 103–104 anatomy, 295–297, 296f
pathology, 176 prolotherapy, 102–103 pathology, 297
Cryotherapy, 603 regional injection approaches ultrasound-guided
CSIs. See Corticosteroid injections (CSIs) ankle/foot, 113–114 equipment, 297
CTS. See Carpal tunnel syndrome (CTS) cervical spine/neck, 105 injectates, 297
Cubital fossa, anterior view, 63f elbow, 107–109 technique, 297–298, 297f–298f
Cultured cellular injectates, 80–82 head/facial region, 104–105 Dorsal radioulnar joint injection
Culture-expanded allografts hip/pelvic area, 110–112, 113f–114f fluoroscopy-guided, 306
clinical evidence, 92 knee, 112–113 ultrasound-guided, 292
isolation, 91 lumbosacral area, 110 Dorsal root ganglion (DRG) stimulation, 574
neonatal tissues, 91 shoulder girdle, 106–107 Dorsal wrist
three-dimensional (3D) culture systems, thoracic spine/upper to mid back, ganglion cyst aspiration/injection, 299f
91–92 105–106 wrist ligament injection, 293f
umbilical cord blood, 91 wrist/hand, 109–110 Dose equivalent, 32t
Dextrose prolotherapy (DPT) Double-needle barbotage technique, 494–495
D clinical research, 103 Doxycycline, 121t
DBM. See Demineralized bone matrix hypertonic dextrose, 102
(DBM) in vivo rabbit model, 103 E
Deep branch radial nerve mechanism of action, 102–103 Eccentric exercises, 600–601
anatomy, 283 regional injection approaches Eccentric strengthening, 604
pathology, 283 ankle/foot, 113–114 Ecchymosis, phlebotomy, 64
ultrasound-guided perineural injection, cervical spine/neck, 105 ECTR. See Endoscopic carpal tunnel release
283, 284f elbow, 107–109 (ECTR)
Deep cervical plexus block, 144b head/facial region, 104 Elbow injection techniques
Deeper nerves/ganglion/plexi, 111 hip/pelvic area, 110–111 fluoroscopy injections, 287
ankle and/or foot, 114 knee, 112 ultrasound-guided
cervical spine/neck, 105 lumbosacral area, 110 joint injections, 272
elbow, 109 shoulder girdle, 106 ligament injections, 274
head/facial region, 105 thoracic spine/upper to mid back, median nerve, pronator teres, 283
hip/pelvic area, 111 105–106 olecranon bursa, 282
knee, 113 wrist/hand, 109–110 perineural injections, 282
lumbosacral area, 110 strength of recommendation (SOR) tendon injections, 276
shoulder girdle, 107 criteria, 103 ulnar nerve, cubital tunnel, 286
 Index 623

Endoscopic carpal tunnel release (ECTR), Facet joint injections (Continued) Flexor digitorum profundus (FDP), 514, 535
538–539 fluoroscopy-guided technique, 210–211 Flexor digitorum superficialis (FDS), 514, 535
Endosomes stage, exosome biogenesis, 94 pitfalls, 187b, 211b Flexor hallucis longus (FHL) tendon/tendon
Endotenon, 2 ultrasound-guided technique, 186–187 sheath injection
Entheses, 111–112 ultrasound-guided thoracic injection anatomy, 447
ankle and/or foot, 114 clinician and patient position, 168 pathology, 447
cervical spine/neck, 105 equipment, 168 ultrasound-guided, 448, 448f
elbow, 109 injectate volume, 168–169 Flexor pollicis longus (FPL), 535
head/facial region, 105 needle position, 168, 169f Flexor tendons and pulleys, 515f
hip/pelvic area, 111–112 pathology, 168 Fluoroquinolones, bone marrow aspirate and
knee, 113 transducer position, 168 adipose tissue harvesting, 50–51
lumbosacral area, 110 FDP. See Flexor digitorum profundus (FDP) Fluoroscopy
shoulder girdle, 107 FDS. See Flexor digitorum superficialis active radiation dosimetry monitoring, 38
thoracic spine/upper to mid back, 106, (FDS) C-arm system, 32, 33f
108f Femoral head IO infiltration, 560 contrast media, 34–37
wrist/hand, 110 Femoral neurovascular bundle, 323 iodinated contrast agents (ICAs), 37
Enthesopathy, lateral cord of the plantar Femoroacetabular joint injection orthobiologics, 37
fascia (LCPF), 465 anatomy, 323 documentation, 34
Enthesophytes, 544 fluoroscopy-guided facility, 38
Entrapment neuropathy, medial calcaneal anterior approach, 353, 354f flat-panel detector systems, 32
and inferior calcaneal nerve, 468 equipment, 353 fluoroscopes, 32
Entrapment syndromes, botulinum toxin injectates, 353 history and background, 31–33
(BTX), 128–129, 129t lateral approach, 353, 355f interventional orthopedic procedures,
Epidermal growth factor (EGF), 71t posterior approach, 353–355, 356f 38–39
Epidural corticosteroid injections (CSIs), 42 pathology, 323 joint injections, 31
Ethyl alcohol, 121t ultrasound-guided injection lead protective aprons, 37–38
Exogenous activator, 70 anterior approach, 323–326, 325f lead protective eye wear, 38
Exogenous hyaluronic acid (HA), 44–45, 45t equipment, 323 nonstochastic effects, 34
Exosomes injectates, 323 protective lead gloves, 38
biogenesis, 94 lateral approach, 326 radiation dose, 33–34, 35t
biologic capabilities, 94–95 pearls and pitfalls, 325b regenerative medicine practice, 34
formation and mechanism, 94f posterior approach, 326, 327f stochastic effects, 34
function and composition, 94 Femoroacetabular labrum injection thin film transistor technology, 32
isolation, 94 anterior approach, 362, 362f three-dimensional (3D), 33
legal considerations, 95 fluoroscopy-guided thyroidshields, 38
off-the-shelf product, 94 equipment, 362 vs. ultrasound, 22
size, 94 injectates, 362 X-rays
therapeutic application, 94–95 lateral approach, 363–364, 363f ALARA principle, 33
Extensor digitorum brevis (EDB) muscle, Femorotibial joint injection harmful effects, 32
441 medial and lateral joint compartments, risk reduction, 34t
Extensor digitorum longus (EDL) tendon/ 404–405, 404f–405f Focal zone depth, ultrasound, 15
tendon sheath injection patella facets, 406–408 Food and Drug Administration (FDA)
anatomy, 441 weightbearing femoral chondral surface, regulations
pathology, 441 405–406, 406f adipose tissue stem cells (ASCs), 79–80
ultrasound-guided, 442f FFI. See Foot Function Index (FFI) alpha-2 macroglobulin protein (A2M), 74
Extensor Retinaculum, 519f Fibrin agents, sclerodesis, 119 bone marrow aspirate concentrate
Extracorporeal shock wave (ECSW) therapy, Fibrin glue, 121t (BMAC), 77
plantar fasciitis, 127 Fibroblast growth factor-2 (FGF-2), 71t interleukin-1 receptor antagonist protein
Extracorporeal shock wave therapy (ESWT), Fibrocartilage, 5 (IRAP), 75
491 Fixed fluoroscopes, 32 platelet lysate (PL), 74
Flat-panel display (FPD) systems, 32–33 platelet-rich plasma (PRP), 73
F Flexor carpi radialis tendon and sheath Foot and Ankle Outcome Score (FAOS),
Facet joint injections injection, 300–301, 301f 113–114
cervical Flexor carpi ulnaris injection/aspiration, Foot Function Index (FFI), 113–114
anatomical model, 138f–139f 301, 302f Foot injection techniques
anatomy, 138 Flexor digitorum accessory longus (FDAL), fluoroscopy-guided
C2-3 facet joint scan, 140f 446 calcaneocuboid joint, 479–481
pain provocation patterns, 138f Flexor digitorum longus (FDL) tendon intercuneiform joints, 481–486
pathology, 138 injection interphalangeal (IP) joints, 486–488
ultrasound image, 139f anatomy, 446 metatarsophalangeal joints, 485
lumbar pathology, 446 naviculocuboid (cuboideonavicular)
anatomy, 210 ultrasound-guided, 446–447, 447f joint, 481
624 Index

Foot injection techniques (Continued) Glenohumeral joint capsule Heavy-slow resistance (HSR) training,
naviculocuneiform joints, 483 ligaments (Continued) 600–601
tarsometarsal joints, 484 inferior glenohermal ligament, Hemolysis, platelet-rich plasma (PRP)
ultrasound-guided, 465 250–253, 252f quality, 65–66, 66f
great toe sesamoid injection, 475–476 middle glenohumeral ligament Hemostasis, 549
intersection syndrome, 470 (MGHL), 251f Heparin, bone marrow aspiration, 52
Lisfranc joint, 472–473 superior glenohumeral ligament Higher-frequency linear array transducer, 15
medial calcaneal and inferior calcaneal (SGHL), 250 High platelet content platelet-rich plasma
nerve, 467 Glenohumeral joint labrum (Hi-PRP), 67
metatarsophalangeal joint, 474 anatomy, 253 High-volume image-guided injections
midfoot joints, 470 fluoroscopy guided (HVIGIs)
neuroma-bursal complex anterior-inferior labrum, 268 Achilles mid-portion tendinopathy
injection, 477 equipment, 268 injectates, 507
plantar fascia, 465 superior labrum, 268 needle approach and transducer
plantar plates, 479 pathology, 253 positioning, 510f–511f
Functional popliteal artery entrapment ultrasound-guided injection needle orientation, 507
syndrome (FPAES), 129 biceps tendon, 255–258 patient and clinician position, 507
C-arm position, 254–255 physiotherapy, 509
G equipment, 253 post-injection management, 509
Ganglion cysts injection, 298b posterior labrum and capsule, 255, 256f chronic tendinopathies, 507
anatomy, 298 superior glenohumeral labrum, 253, 254f corticosteroids, 507, 508t
dorsal wrist ganglion cyst aspiration/ Glial cells, 7 equipment, 507
injection, 299f Greater and lesser occipital nerve block local anesthetics, 507, 508t
equipment, 300 anatomy, 137 patient selection, 507b
injectates, 300 pathology, 137 saline volumes, 508t
pathology, 300 ultrasound-guided injection, 137, 137f success rate, 507
proximal tibiofibular joint, 370 Great toe sesamoid injection Hip capsular ligaments
technique, 300 anatomy, 475–476 anatomy, 328–329
volar wrist ganglion cyst aspiration/ pathology, 476 fluoroscopy-guided injection
injection, 298, 299f ultrasound-guided anterior approach, 360–361
Ganglion impar injection, 239–240, equipment, 476 lateral approach, 361, 361f
239f–240f injectates, 476 posterior approach, 361–362, 361f
Gate control theory, 573b–574b technique, 476, 476f–477f pathology, 329
Gel stand-off technique, 26–27, 27f Growth factor concentration, allograft ultrasound-guided injection
Genicular nerve block tissue, 90 anterior approach, 329, 330f
anatomy, 400 equipment, 329
pathology, 400–401 H injectates, 329
radiofrequency ablation, 421–424 Haglund deformity, 438, 454 posterior approach, 330, 330f
ultrasound-guided injection Hamstring muscles, 337 Hip dysplasia, 358
equipment, 401 Hand injection techniques Hip injection techniques
injectates, 401 fluoroscopy-guided injection fluoroscopy-guided
technique, 401–403 metacarpal, proximal and distal capsular ligaments, 360–362
Glenohumeral joint (GHJ), 496 interphalangeal joint, 319f, femoroacetabular joint, 352
anatomy, 242, 243f 320–322 femoroacetabular labrum, 362–364
intra-articular fluoroscopy-guided thumb carpometacarpal joint, 318f, ligamentum teres and transverse
injection, 264–265 319–320 acetabular ligament, 357–358
intra-articular ultrasound-guided injection hand pulley system anatomy, 314f pubic symphysis, 355–356
anterior approach, 244, 245f ultrasound-guided ultrasound-guided
equipment, 242 A1 pulley injection, 318f, 318f, external rotators, 342–347
posterior approach, 242–244, 244f 317–318 femoroacetabular joint, 323–326
pathology, 242 carpometacarpal capsular ligaments, gluteal attachments, 339–341
Glenohumeral joint capsule ligaments 317f, 315–317, 316b–317b hip capsular ligaments, 328–330
anatomy, 249–250 carpometacarpal (CMC) joint, 316f, joints, 323–328
fluoroscopyguided, 266–267 315–317, 315b–316b perineural injection, 347–352
anterior capsule approach, 266–267, digital nerve block, 319f pubic symphysis, 326–328
267f interphalangeal joint, 313–315 tendons and bursae, 330–352
equipment, 266 metacarpophalangeal (MCP) joint, Hip instability, 329
pathology, 250 315f, 313–315 Hip intraosseous rehabilitation, 608t
ultrasound-guided injection scaphotrapeziotrapezoid (STT) Hip, needle arthroscopy, 598
coracohumeral ligament (CHL), 250 joint injection, 315f, 315–317, Hip osteoarthritis and avascular necrosis
equipment, 250 315b–316b fluoroscopic guidance
glenohumeral joint labrum, 253–255 volar and dorsal targets, 314f acetabulum IO infiltration, 561, 563f
 Index 625

Hip osteoarthritis and avascular Iliotibial band (ITB), 383 Interleukin-1 receptor antagonist protein
necrosis (Continued) IMGN. See Inferomedial genicular nerve (IRAP) (Continued)
equipment, 559 (IMGN) osteoarthritis (OA), 74
femoral head IO infiltration, 560–561 Impingement syndrome, 245b recombinant forms, 74–75
ultrasound guidance Incobotulinumtoxin A, 127 Intermetatarsal bursa, 477
acetabulum IO infiltration, 566, 566f Inferior calcaneal nerve (ICN) injection International Society for Cellular Therapy
equipment, 565–566 anatomy, 468 (ISCT), 75
femoral head IO infiltration, 565, 566f pathology, 468–469 Interphalangeal joint injection, 313–315
Hip range-of-motion (ROM) techniques, ultrasound-guided, 468–469, 469f fluoroscopy-guided injection, 320–322,
325b Inferior calcaneo navicular ligament (ICNL), 486–488
Hockey-stick transducers, 15 436 ultrasound-guided, 313–315
Hoffa’s fat pad hydrodissection, 379b Inferior glenohermal ligament (IGHL), Interscalene brachial plexus block
Horner’s syndrome, 142b, 146b 250–253, 252f anatomy, 140–141, 143f
Humeral olecranon joint injection Inferior tibiofibular ligaments (ITFL) pathology, 141
fluoroscopy, 289f injection ultrasound-guided injection, 141–142
HVIGIs. See High-volume image-guided anatomy, 434 Intersection syndrome injection,
injections (HVIGIs) pathology, 434–435 470, 471f
Hyaline cartilage, 4–5 ultrasound-guided Interspinous process devices (IPDs), 580
Hyaluronic acid (HA) equipment, 434–435 Interspinous spacer implantation, 580–582
exogenous, 44–45 injectates, 435 Intervertebral disc, 5
glycosaminoglycan structure, 44 technique, 435, 435f–436f Intra-articular corticosteroid injections,
knee osteoarthritis, 45 Inferolateral genicular nerve (ILGN) 41–42
tendinopathies, 45 anatomy, 400 Intra-articular subtalar joint pathology,
viscosupplementation, 44 ultrasound-guided injection, 403, 404f 429
Hydrodissection, 104 Inferomedial genicular nerve (IMGN) Intradiscal injection
anatomy, 400 anatomy, 213
I fluoroscopy-guided injection, 424, 424f fluoroscopy-guided lumbar injection
ICAs. See Iodinated contrast agents (ICAs) ultrasound-guided injection, 401, 403f contraindication, 213
IGHL. See Inferior glenohermal ligament Inflammatory phase, healing cascade, 601 equipment, 213
(IGHL) immobilization/bracing, 603 indication, 213
Iliofemoral ligament, 329 pain management, 603–604 pitfalls, 215b
Iliolumbar intertransverse ligaments Infrapatellar fat pad impingement, 379 technique, 214–215
anatomy, 195 Infrapatellar superficial/deep bursal injection Intraosseous (IO) injections
fluoroscopy-guided lumbar injection anatomy, 381 acromial bone, 567f
C-arm position fluoroscopy, 217 pathology, 381 ankle tibia and talus intraosseous needle,
needle position, 217 ultrasound-guided 568f
patient and clinician position, 217 equipment, 381 glenoid, 570f
pitfalls, 217b injectates, 381–382 hip osteoarthritis and avascular necrosis,
targets, 217 technique, 382, 382f 559–561
pathology, 195–196 Infraspinatus tendon, 490 fluoroscopic guidance, 559–561
ultrasound-guided lumbar injection Infraspinatus/teres minor tendons, 248 ultrasound guidance, 565–566
equipment, 196 In-office needle arthroscocy, 594 knee osteoarthritis
injectates, 196 Insertional Achilles tendon injection, 439f fluoroscopic guidance, 555–557
needle position, 196 Insertional peroneus brevis tendon/tendon ultrasound guidance, 563–565
patient and clinician position, 196 sheath injection lateral fibula, 569f
pearls and pitfalls, 196b anatomy, 443 medial cuneiform, 571f
transducer position, 196 pathology, 444 medial tibia plateau, 568f
Iliolumbar syndrome, 216 ultrasound-guided, 444, 444f proximal humeral head, 570f
Iliopsoas bursitis, 333 Intercostal nerve block, fluoroscopy guided proximal scaphoid, 572f
Iliopsoas tendinosis, 333 thoracic injection, 183–184, 184f sesamoid, 569f
Iliopsoas tendon and bursa Intercuneiform joints subchondral bone, 553, 554f–555f
anatomy, 332–333 anatomy, 481–482 toe magnetic resonance imaging, 571f
pathology, 333 fluoroscopy-guided injection, 482, 482f treatment options and published studies,
ultrasound-guided injection pathology, 482 553–555
distal iliopsoas injection, 333–334, Interdigital nerve, 477 Intraosseous lesions, sclerotherapy, 120
335f Interdigital (Morton’s) neuroma, 477 Intrathecal injection, 148b
equipment, 333 Interleukin-1 receptor antagonist protein Intravascular injection, 142b, 146b
lateral approach, 334–336, 336f (IRAP) Iodinated contrast agents (ICAs), 37
patient and clinician position, 333, clinical applications, 75 Iohexol, 37
334f clinical efficacy, 75 Iopamidol, 37
transducer position, 333 FDA regulations, 75 IRAP. See Interleukin-1 receptor antagonist
Iliopsoas tendon impingement, 333 mechanism of action, 75 protein (IRAP)
626 Index

Ischiogluteal bursa Knee joints (Continued) Ligament injections (Continued)

anatomy, 338 parameniscal cyst aspiration/injection, knee
pathology, 338 376–377 anterior cruciate ligament injection,
ultrasound-guided injection, 338–339 popliteal/Baker’s cyst injections, 371–372 389, 390f
Isometric exercises, 604 suprapatellar recess, 366b, 368f anterolateral ligament injection,
ITFL injection. See Inferior tibiofibular weightbearing trochlea groove chondral 393–394, 395f
ligaments (ITFL) injection surfaces, 369, 370f lateral (fibular) collateral ligament and
Knee osteoarthritis bursa injection, 392–393
J fluoroscopic guidance medial and lateral patella ligament
Jogger’s foot, 451 equipments, 555 injection, 395–396
Joint injections lateral femoral condyle, 557 medial collateral ligament and bursal
ankle region MFC IO infiltration, 556–557, 558f injection, 391–392
subtalar joint injection, 429–430, 430f patellar IO infiltration, 557, 559f posterior cruciate ligament injection,
tibiotalar joint injection, 428–429, subchondral bone injection locations, 389–390
429f 557f wrist
elbow tibial plateau IO infiltration, 556, 557f scapholunate ligament (SLL), 292–297
anatomy, 272 ultrasound guidance volar ligaments, 294
fluoroscopy-guided, 287–289 equipments, 563 Ligament injury, 3–4
pathology, 272 femoral condyle IO infiltration, Ligamentum teres
ultrasound-guided, 272–274, 273f–274f 564–565, 565f anatomy, 357–358
foot injection techniques, fluoroscopy- preparation, 563–565, 563f fluoroscopy-guided injection
guided, 479 tibial plateau IO infiltration, 563–564, equipment, 358
hip injection, 323–328 564f–565f injectates, 358
knee. See Knee joints Knobology, ultrasound, 15, 16f technique, 358, 359f
wrist pathology, 358
anatomy, 291f L Lisfranc joint injection
distal radial ulnar joint, 292 Lateral collateral ligament (LCL) anatomy, 472
midcarpal joint injection, 292 anatomy, 274–275, 392 pathology, 472
radiocarpal joint, 290–292 pathology, 274, 392 ultrasound-guided
J-style bone marrow manual aspiration ultrasound-guided injection equipment, 472
needle, 52, 55f equipment, 392 injectates, 472–473
injectates, 274, 392 technique, 473, 474f–475f
K pearls and pitfalls, 275b Local anesthetics
Ketorolac, 44 technique, 275, 392–393, 394f amide, 43
Knee injection techniques Lateral epicondylitis, botulinum toxin antiinflammatory action, 43
fluoroscopy-guided (BTX) injection, 127 chondrotoxic effects, 43
anterior cruciate graft, 414–415 Lateral femoral condyle, 557, 558f lidocaine, 43
anterior cruciate ligament, 410–414 Lateral patellofemoral ligament (LPFL) membrane-stabilizing effect, 43
genicular nerve radiofrequency pathology, 395 Long head biceps tendon (LHBT), 250,
ablation, 421–424 ultrasound-guided injection, 395, 397f 254f, 256–258, 257f
joints, 403–406 Leukocyte infiltration, platelet-rich plasma, anatomy, 256
meniscus, 418–421 71 Long radiotriquetral ligament (LRLL)
patella facets, 406–408 Leukocyte-poor platelet-rich plasma injection, 294
posterior cruciate ligament, 415–418 (LP-PRP), 71 Long-term systemic corticosteroid use, 41
tibiofibular joint, 409–410 LHBT. See Long head biceps tendon Low back pain, 1–2
ultrasound-guided (LHBT) Lower-frequency curvilinear array
joint injections, 366–377 Lidocaine, 43 transducer, 15
ligaments, 389–396 Ligament injections Low platelet platelet-rich plasma (Lo-PRP), 67
perineural injections, 396–403 ankle region L5 Pars injection, 214f–215f
tendon injections, 377–389 anterior talofibular ligament (ATFL), LPFL. See Lateral patellofemoral ligament
Knee joints 430–432 (LPFL)
anatomy, 366 caclcaneofibular ligament (CFL), Lumbar discography, 216f
bony landmarks, 367f 432–433 Lumbar injection techniques
fluoroscopy, 403–406 deltoid ligament complex injection, fluoroscopy-guided
pathology, 366 435–437 intradiscal injection, 213–215
ultrasound-guided injection inferior tibiofibular ligaments injection, lumbar interlaminar epidural injection,
anterolateral approach, 367 434–435 201–206
equipment, 366 posterior talofibular ligament (PTFL), lumbar ligaments, 215–219
injectates, 366 433–434 lumbar transforaminal epidurals,
medial and lateral menisci, 372–375 elbow 198–201
medial/lateral directed knee joint lateral collateral ligament complex, 274 medial branch block, 209
injection, 367–369, 369f medial ulnar collateral ligament, 275 pars interarticularis defect, 211–213
 Index 627

Lumbar injection techniques (Continued) Medial branch block (Continued) Mesenchymal stem cells/stromal cells
radiofrequency ablation, 210 thoracic (MSCs) (Continued)
suboptimal flow patterns, 206–209 anatomy, 177–178 explicit criteria, 91t
zygapophyseal or facet joint injections, fluoroscopy-guided injection, 179, 179f FDA regulations, 82
210–211 pathology, 178 human trials, 91
ultrasound-guided radiofrequency ablation, 179–180, 180f sources, 90
facet joints, 186–187 Medial collateral ligament (MCL), 391 tissue sample evaluation, 90
iliolumbar intertransverse ligaments, and bursal injection Metacarpophalangeal (MCP) joint
195–196 anatomy, 391 injection
multifidus muscles, 190–193 equipment, 392 fluoroscopy-guided injection, 321f,
quadratus lumborum (QL), 196–197 injectates, 392 320–322
supraspinous and interspinous pathology, 391–392 ultrasound guided, 315f, 313–315
ligaments, 187–190 technique, 392, 393f Metatarsophalangeal joint injection
thoracodorsal fascia, 194–195 Medial/lateral compartment osteoarthritis, anatomy, 474, 485
Lumbar interlaminar epidural injection knee intra-articular rehabilitation, fluoroscopy-guided injection, 485, 485f
anatomy, 202, 204f 605t–606t pathology, 474–477, 485
fluoroscopy-guided injection Medial/lateral directed knee joint injection, ultrasound-guided
equipment, 202 367–369, 369f equipment, 474–475
fluoroscope position, 205f–206f Medial patellar facet, 408 injectates, 474
injectates, 203 Medial patellofemoral ligament (MPFL), technique, 475, 475f–476f
needle position, 205–206, 207f 395 Metatarsosesamoid injection, 486–487, 487f
pitfalls, 206b anatomy, 395 Microdiscectomy, 584b
technique, 204–206 pathology, 395 Micro-fragmented adipose tissue (MFAT),
pathology, 202 ultrasound-guided injection, 395–396, 59, 60f
Lumbar transforaminal epidurals 396f Microvascular imaging mode, ultrasound, 19
anatomy, 198 Medial patellomeniscal ligament (MPML), Midcarpal joint injection, wrist, 292
fluoroscopy-guided injection 395 Middle glenohumeral ligament (MGHL),
equipment, 198 Medial patellotibial ligament (MPTL), 395 249, 251f, 267
infraneural transforaminal epidural Medial ulnar collateral ligament (MUCL) Midfoot joints
approach, 200–201 injection anatomy, 470–471
injectates, 198 anatomy, 275–276 pathology, 470–471
subpedicular approach, 198–200 pathology, 275 risk structures, 470
pathology, 198 ultrasound-guided synovial compartments, 470
Lumbosacral pelvis ligamentous anatomy, equipment, 275 ultrasound-guided injection, 473f
187f injectates, 275 Midpatella lateral approach, 366b
Lunotriquetral ligament (LTL) injection, pearls and pitfalls, 276f, 276b Mid-portion Achilles tendon injection,
292–297 technique, 276 438–439, 439f
Median nerve, elbow Minimally invasive lumbar decompression
M anatomy, 283–286 (MILD)
Magnetic resonance imaging (MRI) pathology, 283 anatomy, 578
adhesive capsulitis (AC), 497 ultrasound-guided perineural injection epidural steroid injections (ESI), 578
avascular necrosis, 556f equipment, 285 equipment, 579
calcific tendonitis, 490, 491f injectates, 285 fluoroscopy position, 579
toe, metatarsal intraosseous injection, 571f pearls and pitfalls, 286b injectates, 579
vs. ultrasound, 22 technique, 285–286, 285f needle position
Malnutrition, 599–600 Median nerve hydrodissection, 303f bone Rongeur, 580f
Maturation phase, healing cascade, 602 Medical calcaneal nerve (MCN) injection epidurogram, 579f
Mechanotransduction, 600–601 anatomy, 468 trochar placement, 580f
Medial and lateral menisci pathology, 468–469 pathology, 578–579
anatomy, 372, 374f ultrasound-guided, 468–469, 469f patient and clinician position, 579
meniscal tears, 372 Meniscal injuries, 5–6 Mini-open carpaltunnel release (mOCTR),
ultrasound-guided injection Meniscal ligaments, 373f 538
equipment, 373 Meniscus MLLs. See Morel-Lavallee lesions (MLLs)
injectates, 373 anatomy, 418–419 Mobile fluoroscope, 32
posterior medial meniscus and capsule, lateral, 421 Morel-Lavallee lesions (MLLs), 119
376f medial, 419, 420f–421f sclerotherapy
technique, 374–375, 375f Mesenchymal stem cells/stromal cells patient-oriented, resource-
Medial branch block (MSCs), 75, 600 conscientious steps, 121
lumbar adipose tissue, 81–82 theory and clinical evidence, 119
anatomy, 209 allogenic, 90–91 Morton’s neuroma, 477
fluoroscopy-guided injection, 209 autologous, 90–91 MPFL. See Medial patellofemoral ligament
radiofrequency ablation, 210 bone marrow, 80–81 (MPFL)
628 Index

MSC. See Mesenchymal stem cells/stromal Neurogenic inflammation, 103–104 Osteoarthritis (OA) (Continued)
cells (MSCs) Neuroma-bursal complex injection, 477 midfoot joints, 470b
MUCL injection. See Medial ulnar collateral Neuroma, perineural injection, 448b pathophysiology, 553
ligament (MUCL) injection Neuromuscular junction (NMJ), 8–9 treatment strategies, 5
Multifidus muscles Neuromusculoskeletal structures, Osteoconductivity, 95
anatomy, 190 ultrasound, 19t Osteophytes, 544
functional stabilization, 191 Neuropathies, medial calcaneal and inferior Over-the-counter acetaminophen, 604
pathology, 191 calcaneal nerve, 468 Overuse injuries
ultrasound-guided injection, 135f, 191 Neuropeptides, 103–104 pes tendon and bursa, 384
Multivesicular bodies (MVBs) stage, Nociceptors tendonpathology, 379
exosome biogenesis, 94 ankle/foot, 114
Muscle fibers, 9 cervical spine/neck, 105, 106f–107f P
Muscle healing, 602 elbow, 109 Pain, phlebotomy, 64
Muscle injury, 8–9 head/facial region, 104–105 Palliative treatment, 612
Musculoskeletal injections hip/pelvic area, 110–112 Palmar cutaneous nerve, 537
contraindications, 41 knee, 113 Palmaris longus (PL) muscle, 537
corticosteroid injections (CSIs), 41–43 lumbosacral area, 110 Parameniscal cyst aspiration/injection
hyaluronic acid (HA), 44–45 shoulder girdle, 107 anatomy, 376
ketorolac, 44 thoracic spine/upper to mid back, 106, pathology, 376
local anesthetics, 43 108f–109f ultrasound-guided
Myelin, 7 wrist/hand, 110 equipment, 376
Myocytes, 8 Nonionic iodinated contrast agents (ICAs), injectates, 376–377
Myo-enthesis, 2 37 technique, 377, 377f
Myofascial pain syndrome, botulinum Nonsteroidal antiinflammatory drugs Paresthesia, 65
toxin-A (BTX-A) injections, 125–126, (NSAIDs), 50–51, 73, 603–604 Pars interarticularis defect
126t Non-traumatic subluxation, peroneus anatomy, 211, 214f
longus/brevis, 442 fluoroscopy-guided lumbar injection
N equipment, 211
Narcotics, 604 O injectates, 211
Naviculocuboid (cuboideonavicular) joint, OA. See Osteoarthritis (OA) needle position, 212
481 Obesity, 600 patient position, 212
Naviculocuneiform joint injection, 483, Obliquus capitis inferior (OCI) muscle pitalls, 213b
483f injection, 135f–136f pathology, 211
Needle arthroscopy Obliquus capitis superior (OCS) injection, Partial-thickness Achilles tendon tears, 438
hip, 598 135f Patella, 406, 407f
indications, 595 Occipital neuralgia, 137b Patella facets
in-office, 594 Olecranon bursitis anatomy, 406
knee anatomy, 282 fluoroscopy-guided injection
patient positioning, 595–596 pathology, 282 equipment, 407
patient, ultrasound, and tablet ultrasound-guided injection, 282, 282f injectates, 407
positioning, 595f Onabotulinumtoxin A (ONA) lateral patella facet injection, 408,
portal placement, 596 dosing, 124 408f–409f
postprocedure, 597 lateral epicondylitis, 127 medial patellar facet, 408
procedure, 596, 597f myofascial pain syndrome, 126 technique, 407–408, 408f
sterility, 596, 596f piriformis syndrome, 129 pathology, 407
US prep, 596, 596f–597f popliteal artery entrapment syndrome, vascular supply, 406, 407f
large-joint arthroscopy, 594 129 Patellofemoral joint, 406
normal saline, 595 reconstitution, 124 Pedowitz criteria, 525t
patient evaluation, 594–595 thoracic outlet syndrome, 128–129 Pelvic large neurovascular and bony
postdoctoral, 594 vial containing, 125f anatomy, 324f
preparation, 595 Open discectomy, 584b Percutaneous disc decompression, 584–585
shoulder, 597–598 Oregon Radiation Protection Services, 34 Percutaneous needle tenotomy/fenestration,
surgical intervention guide, 594 Osgood-Schlatter disease, 545 440b
surgical site preparation, 595 Osteitis pubis, 327 Perineural injections
video imaging device, 594 Osteoarthritis (OA), 4 ankle
Needle tracking techniques, 28t acromioclavicular joint, 259 deep peroneal nerve, 450–451
Nerve axon terminals, 8–9 hip. See Hip osteoarthritis and avascular saphenous nerve, 452–453
Nerve block, 520 necrosis superficial peroneal nerve, 449–450
Nerve compression pathology cascade, 7f intra-articular botulinum toxin (BTX), sural nerve, 454
Nerve injury, 7–8 127–128 tibial nerve, 451–452
Neural foramen, 167f intraosseous injections. See Intraosseous elbow, 282, 284f
Neural impingement, 202 (IO) injections knee
 Index 629

Perineural injections (Continued) Plantar fasciitis, botulinum toxin (BTX) Popliteal/Baker’s cyst injections
common peroneal nerve injection, 398 injection, 126–127 anatomy, 371
genicular nerve block, 400–403 Plantar plates equipment, 372
saphenous nerve injection, 399–400, anatomy, 479 injectates, 372
400f–401f pathology, 479 pathology, 371
tibial nerve injection, 396–397 ultrasound-guided injection, 479 technique, 372, 373f
mechanism/clinical research, 103–104 Plasma-rich protein (PRP), 37 Posterior acoustic shadowing, ultrasound, 17
training and protocols, 104 Plasma type platelet-rich plasma (P-PRP), Posterior cruciate ligament injection
ultrasound-guided, 531 67 anatomy, 389, 415–416, 416f
Peripheral nerve Platelet-derived growth factor (PDGF), 71t fluoroscopy-guided injection
anatomy, 531 Platelet lysate (PL) equipment, 416
pathology, 531–532 advantages, 73 injectates, 416
scanning and image optimization, 531, caveats/side effects, 74 technique, 416–418, 417f–418f
532f clinical applications, 73 pathology, 416f
ultrasound-guided injections clinical efficacy, 73–74 ultrasound-guided injection
equipment, 532 FDA regulations, 74 equipment, 389
indications, 532 growth-promoting effects, 73 injectates, 390
post-injection scanning, 533 mechanism of action, 73 technique, 390, 391f
principles, 532–533, 533f preparation, 73 Posterior inferior glenohumeral ligament
Peripheral nerve stimulation (PNS), Platelet-rich plasma (PRP), 506 (PIGHL), 253
583–584 caveats/side effects, 73 Posterior inferior tibiofibular ligament
Peritendinous corticosteroid injections, 339b classification, 70 (PITFL) injection
Persistent media artery (PMA), 537 clinical applications, 72 anatomy, 434
Pes anserinus snapping syndrome, 384 clinical efficacy, 72 pathology, 434–435
Pes tendon and bursa commercial kit, 70 ultrasound-guided
anatomy, 384 device grouping, 67–68 equipment, 435
pathology, 384 dosing and blood volume, 67 injectates, 435
ultrasound-guided injection, 385, 386f electron microscopic scanning, 65f technique, 435, 436f
Phlebotomy exogenous activator, 70 Posterior meniscofemoral ligament, 372, 419
adverse events and complications Food and Drug Administration (FDA) Posterior superior iliac spine (PSIS)
arterial puncture, 65 regulations, 73 approach, bone marrow aspiration, 51
infection, 64–65 formulation, 70 Posterior talofibular ligament (PTFL)
pain and ecchymosis, 64 high platelet content, 67 injection, 433–434
paresthesia, 65 homemade protocol, 67 Posterolateral (PL) bundle, 410
aseptic technique, 63 isolation, 70 Postprocedural pain
blood aspiration, 64, 64f leukocyte infiltration, 71 cryotherapy, 603
contaminated materials, 64 low platelet content, 67 intra-articular injections, 603
kit, 63f mechanism of action, 71–72 nonsteroidal antiinflammatory drugs
tourniquet, 63 phlebotomy, 62–64 (NSAIDs), 603–604
vein assessment, 62 adverse events and complications, Power Doppler ultrasound, 18–19
venipuncture, 63, 64f 64–65 Prehabilitation
Phrenic nerve block, 142b, 146b aseptic technique, 63 anterior cruciate ligament (ACL) tears,
Piriformis syndrome, botulinum toxin blood aspiration, 64, 64f 599
(BTX), 129 contaminated materials, 64 education, 600
PITFL injection. See Posterior inferior kits, 63f malnutrition, 599–600
tibiofibular ligament (PITFL) tourniquet, 63 total hip and knee arthroplasty, 599
injection vein assessment, 62 3-week preoperative strengthening
PL. See Platelet lysate (PL) venipuncture, 63, 64f program, 599
Placental-derived allografts plasma type (P-PR), 67 Pre-patella bursitis, 379b
amniotic tissue, 92, 93f platelet concentration, 71 Prepatellar bursal injection
umbilical cord blood, 93 preparations, 9 anatomy, 380
Wharton jelly, 93 preparation kit, 62, 63f pathology, 380
Placental-derived products, 90 quality, factors influencing ultrasound-guided
Plantar fascia blood draw site and time, 65 equipment, 380
anatomy, 465–466, 466f hemolysis, 65–66, 66f injectates, 380
ultrasound-guided shear stress, 65 technique, 380, 381f
equipment, 465–466 randomized controlled trials (RCTs), 72 Proliferative phase, healing, 604
injectates, 465–466 Platelets, 62 Pronator tunnel syndrome, 283
lateral cord of the plantar fascia Pneumothorax, 142b, 144b, 161b–162b Propionibacterium acnes, 253b
(LCPF), 466, 468f Polidocanol injection, 119, 121t Proprioceptive neuromuscular facilitation
LAX In-Plane Approach, 466, 467f Popliteal artery entrapment syndrome, (PNF), 500
SAX In-Plane Approach, 467f botulinum toxin (BTX), 129 Protein deficiency, 599–600
630 Index

Proximal carpal rows, 309–310, 310f Radioscapholunate ligament (RSLL) Remodeling phase, rehabilitation, 604–605
Proximal hamstring tendon injection, 294 Retinaculum of Weitbrecht dissection, 323,
anatomy, 337–338 Randomized controlled trials (RCTS), 324f
pathology, 338 botulinum toxin-A (BTX-A) injections, Retro-Achilles bursa injection, 456, 456f
ultrasound-guided injection 125–126 Retro Achilles bursitis, 456
equipment, 338 Rectus capitis posterior major (RCPM), Retro-calcaneal bursa injection
injectates, 338 ultrasound-guided injection, 135f anatomy, 454
technique, 338–339, 338f–339f Rectus femoris/sartorius tendons pathology, 454
Proximal iliotibial band injection, 336–337 anatomy, 330 ultrasound-guided
Proximal tibiofibular joint (PTFJ) pathology, 330 equipment, 454
anatomy, 370 ultrasound-guided injection injectates, 454
nerve supply, 370 equipment, 330 technique, 455, 455f
pathology, 370 injectates, 330 Retro-calcaneal bursitis, 454, 454b
ultrasound-guided injection pearls and pitfalls, 331b Retrodural space of Okada, 206–207
equipment, 370 technique, 331, 331f fluoroscopic image, 207f–208f
injectates, 370 Regenerative growth factors, 71t magnetic resonance imaging, 208f
technique, 371, 371f Regenerative injection, 2 Retro-malleolar peroneus brevis and/longus
vascular supply, 370 Regenerative medicine, 33–34, 50 tendon/tendon sheath injection
PRP. See Platelet-rich plasma (PRP) Regenerative procedures, 600–601 anatomy, 442
PTFJ. See Proximal tibiofibular joint (PTFJ) Regenerative therapies pathology, 442
Pubic symphysis elastography ultrasound, 615–618 ultrasound-guided
anatomy, 326 imaging studies, 612 equipment, 442
fluoroscopy-guided injection magnetic resonance imaging (MRI) injectates, 442–443
equipment, 355 ACL rupture, 616f technique, 443, 443f
injectates, 355 full-thickness rotator cuff tear, 617f Reverberation artifacts, ultrasound, 18
pearls and pitfalls, 356b intra-articular and subchondral bone Rimabotulinumtoxin B, 124
technique, 355–356, 357f marrow aspirate, 616f Rotational three-dimensional (3D)
pathology, 327 lumbar spine, 613f fluoroscopy, 33
ultrasound-guided injection medial meniscus, 614f Rotator cuff, 489
anterior ligaments, 328, 329f posterior disc bulge and annular tear, Rotator cuff injections
equipment, 327 617f full-thickness, 246b
injectates, 327 supraspinatus calcific tendinitis, 615f pathology, 247
technique, 327–328 talonavicular arthritis, 615f rehabilitation, 606t
transducer position, 328f postsurgical scarring, 612–614 ultrasound-guided injection
Pubofemoral ligament, 328–329 three-legged stool, 613f equipment, 247
Pudendal nerve, 229b Rehabilitation infraspinatus/teres minor tendons, 248
cartilage, 602 pearls and pitfalls, 249b
Q evidence-based literature, 600 subscapularis tendon, 248
Quadratus femoris pathology, 345b healing cascade supraspinatus tendon, 247–248
Quadratus lumborum (QL) bone, 602 Rotator interval (RI), 496, 497f
anatomy, 196–197 cartilage, 602
pathology, 197 inflammatory phase, 601, 603–604 S
ultrasound-guided lumbar injection maturation phase, 602 Sacral insufficiency fractures (SIFs),
equipment, 197 muscles, 602 575–576
injectates, 197 repair phase, 601–602 Sacrococcygeal injection techniques
needle position, 197 tendons and ligaments, 602 fluoroscopic procedures
patient and clinician position, 197 literature, 602–603 caudal epidural injection, 233–235
pearls and pitfalls, 197b muscles, 602 ganglion impar injection, 239–240
transducer position, 197 phases sacroiliac joint, 235–237
Quadrilateral space syndrome (QSS), 264 healing potential, 600 sacroiliac joint radiofrequency ablation,
mechanotransduction, 600–601 237–239
R osseous healing, 601 S1 transforaminal epidural, 231
Radiation, 31–33, 32t platelet-rich plasma (PRP), 600 ultrasound-guided procedures
Radiation Protection Services, 34 therapeutic exercise, molecular and caudal epidural, 230
Radioactivity, 32t cellular response, 600–601 sacrococcygeal joint, 226
Radiocapitellar joint lateral approach prehabilitation, 599–600 sacroiliac joint, 224–226
fluoroscopy, 288f principles, 601t sacrotuberous and sacrospinous
Radiofrequency ablation proliferative phase, 604 ligaments, 229–230
lumbar medial branch, 210 recommendations, 605t short and long dorsal sacroiliac
sacroiliac joint injection, 237–239 remodeling phase, 604–605 ligament, 227
Radioscaphocapitate ligament (RSCL) tendons and ligaments, 602 superficial posterior sacrococcygeal
injection, 294 tissue-specific considerations, 602 ligament, 227–229
 Index 631

Sacrococcygeal joint injection Shoulder injection techniques (Continued) Stress fractures, great toe sesamoid injection,
anatomy, 226b glenohumeral joint, 264–265, 266f 476
pathology, 226b glenohumeral joint capsule ligaments, Stretching program, 604
ultrasoun-guided injection, 226f, 226b 266–267 Stromal vascular fraction (SVF), 78
Sacroiliac joint injection glenohumeral joint labrum, 267–268 Stylet movement, 28t
anatomy, 224b ultrasound guidance Subacromial bursa injections
fluoroscopy-guided injection, 235–237, acromioclavicular (AC) joint, 259–262 anatomy, 245
236f axillary nerve, quadrilateral space, 264 pathology, 245
pathology, 224b glenohumeral joint, 242–244 ultrasound-guided
radiofrequency ablation, 237–239, 239f glenohumeral joint capsule ligaments, equipment, 245
ultrasound-guided 249–253 lateral approach, 245–246, 246f
equipment and technique, 224b, 225f rotatorcuff tears, 246–248 pearls and pitfalls, 246b
pearls and pitfalls, 225b subacromial bursa injections, 245–246 Subarachnoid injection, 142b
Sacropelvic ligaments, 324f suprascapular nerve, 262–263 Subchondral bone injections, joint
Sacroplasty, 575–576 Shoulder, needle arthroscopy, 597–598 osteoarthritis, 557f
Sacrotuberous and sacrospinous ligaments, SIFs. See Sacral insufficiency fractures (SIFs) Subgluteus maximus bursitis, 341b
229–230 Single-needle barbotage technique, 493–494 Subscapularis tendon, 248
Saphenous nerve injection Sinus tarsi, 460 Subtalar joint injection
anatomy, 452–453 SLGN. See Superolateral genicular nerve anatomy, 429, 459
pathology, 453 (SLGN) fluoroscopy-guided
ultrasound-guided, 453, 453f Small-footprint linear array transducers, 15 anterior approach, 460–462
Sarcomere, 8 SMGN. See Superomedial genicular nerve posterior approach, 459–460, 460f
Scapholunate ligament (SLL) injection, (SMGN) pathology, 429, 459
292–297 Sodium morrhuate, 121t ultrasound-guided
Scaphotrapezio trapezoid (STT) joint Soft tissue corticosteroid injections (CSIs), 43 equipment, 429
injection, 315–317 Solid-state flat-panel display (FPD) systems, injectates, 429
Schwann cell, 7 32–33 pitfalls, 430b
Sciatic nerve, 338, 348b Spinal cord stimulation (SCS) technique, 430
Sciatic tunnel syndrome, 347b burst stimulation, 573b Superb microvascular imaging (SMI), 19
Sclerotherapy high-frequency stimulation, 573b Superficial cervical plexus block, 144b
bursitis, 118–120 microglia and astrocytes targeting, Superficial nerves/penetrators, 104, 111
indications, 118–120 573–574 ankle and/or foot, 114
intraosseous lesions, 120 NEVRO system, 573 cervical spine/neck, 105
Morel-Lavallee lesions and seromas, 119, pathology, 574 elbow, 109
121 pitfalls, 575b head/facial region, 104
olecranon and patellar bursitis, 120 SENZA-RCT trial, 573 hip/pelvic area, 111
sclerosing agents spinal cord stimulator (SCS) therapy, knee, 113
administration techniques, 121–122 573b lumbosacral area, 110
and dosing, 121t temporary lead insertion, 574 shoulder girdle, 107
tendinosis and tenosynovitis, 119–120 traditional spinal cord stimulation, 573b thoracic spine/upper to mid
Scoliosis, 216 Spine fracture therapies back, 106
“Scotty dog” sign, 211 cervical spine, 577 wrist/hand, 110
SCS. See Spinal cord stimulation (SCS) lumbar spine, 576–577 Superficial peroneal nerve (SPN), 528
Secretomes, 94 sacroplasty, 575–576 Superficial peroneal nerve injection
Septic bursitis thoracic spine, 577 anatomy, 449
olecranon bursitis, 282 Statins, bone marrow aspirate and adipose pathology, 449
pre-patella bursa, 381b tissue harvesting, 50–51 ultrasound-guided, 449–450, 449f
SGHL. See Superior glenohumeral ligament Stenosing tenosynovitis, 297, 514 Superficial posterior sacrococcygeal
(SGHL) Sternoclavicular joints, ultrasound guided ligament, 227–229, 228f
SHBT. See Short head of biceps tendon thoracic injections, 171–175, 171f Superficial radial nerve hydrodissection/
(SHBT) Sternocostal joints block, 305–306, 307f
Shear stress, platelet-rich plasma (PRP) anatomy, 170 Superion device implantation, 582, 583f
quality, 65 pathology, 170 Superion implant, 582
Shockwave lithotripsy, 491 ultrasound-guided thoracic injections Superior glenohumeral ligament (SGHL)
Short head of biceps tendon (SHBT), 258, equipment, 170 fluoroscopy-guided injection, 267
258f injectate volume, 170 ultrasound-guided injection, 250
Short radiolunate ligament (SRLL) technique, 170, 170f Superior labral anterior-posterior (SLAP)
injection, 294 StimuBlast, 95f tear, 253
Short-term systemic corticosteroid use, 41 S1 transforaminal epidural injection, 232f Superolateral genicular nerve (SLGN)
Shoulder injection techniques Strengthening program, 604 anatomy, 400
fluoroscopic guidance Strength of recommendation (SOR) criteria, fluoroscopy-guided injection, 424, 424f
acromioclavicular joint, 268–270 prolotherapy, 103 ultrasound-guided injection, 401, 402f
632 Index

Superomedial calcaneonavicular ligament Tendinopathy (Continued) Tendon injections (Continued)

(SMCNL), 436 extensor digitorum longus (EDL) tendon tibialis posterior tendon/tendon sheath
Superomedial genicular nerve (SMGN) sheath injection, 441, 442f injection, 444–445
anatomy, 400 flexor digitorum longus (FDL) tendon, distal semimembranosus tendon
fluoroscopy-guided injection, 423 446 injection/tenotomy, 388–389, 388f
ultrasound-guided injection, 401, 402f flexor hallucis longus tendon, 448b elbow
Superspinous and interspinous ligament insertional peroneus brevis, 444 common extensor tendon, 276
injection, 175f, 182–183 intervertebral disc, 5 common flexor tendon, 277
Supraclavicular brachial plexus block intrinsic and extrinsic factors, 506 distal biceps tendon, 279
anatomy, 142 ligament injury, 3–4 triceps tendon, 280
pathology, 142 meniscal injuries, 5–6 knee
ultrasound-guided injection, 142–144 muscle injury, 8–9 distal biceps femoris injection/
Suprapatella bursa injection, 368f nerve injury, 7–8 tenotomy, 386–387
Suprascapular nerve injection pathology, 502 distal iliotibial band bursa and
anatomy, 262 tendon pain, 2–3 peritendinous injection, 382–383,
ultrasound-guided tibialis anterior tendon/tendon sheath, 383f
equipment, 263 440 distal quadriceps tendon injection,
pearls and pitfalls, 264b treatment options, 502–503 377–378
superior approach, 263 high-volume image-guided injections infrapatellar superficial/deep bursal
Supraspinatus tendon, 247–248 (HVIGIs). See High-volume injection, 381–382
Supraspinous and interspinous image-guided injections (HVIGIs) patellar tendon injection and tenotomy,
ligaments platelet-rich plasma (PRP) injections, 379, 380f
anatomy, 166–168, 187f–188f, 188 506 pes tendon and bursa injection, 384–385
fluoroscopy-guided lumbar injection, ultrasound-guided needle tenotomy/ popliteus tendon/tendon sheath
215–219 fenestration, 503 injection/tenotomy, 383–384, 385f
pathology, 168, 188 ultrasound-guided tenotomy and prepatellar bursal injection, 379–380
thoracic injections debridement, TX system Tendon stem cells (TSCs), 604
fluoroscopy guided, 182–183 Achilles calcification, 504f Tenex TX-Bone (TXB) Micro Tip tool,
ultrasound guided, 168, 168f cutting energy, 503–504 502–504, 503f
ultrasound-guided lumbar injection incision, 503 Tenoblast, 2
clinician position, 189 patient selection and rationale, 504–505 Tenosynovitis, 297
equipment, 188 post-procedure care and rehabilitation, flexor hallucis longus tendon, 447
injectate, 188 504 sclerodesis, 119–120
in-plane short-axis injection, 191f ultrasound imaging findings, 506 sclerotherapy theory and clinical evidence,
needle position, 190 Tendinosis 119–120
out-of-plane injection, 190f, 192f Achilles tendon, 438 Tenotomy
patient position, 189 peroneus longus/brevis, 442 distal biceps femoris tendon, 386–387
pearls and pitfalls, 190b sclerodesis, 119–120 distal quadriceps tendon, 377–378
transducer position, 189–190 sclerotherapy theory and clinical evidence, distal semimembranosus tendon,
Suralnerve injection, ultrasound guided, 454 119–120 388–389
Sustentaculum tali (ST), 470 Tendon patellar tendon, 379
Syndesmophytes, 544 healing, 602 popliteus tendon, 383–384
Synovial folds, 323 hierarchy, 3f Tensor fascia lata (TFL) tendon injection,
structure, 2 336–337
T Tendon injections Thenar motor branch (TMB), 537
Talonavicular arthritis, 615f ankle region Therapeutic injection, 1
Talonavicular joint injection Achilles tendon/paratenon injection, Thin film transistor technology, 32
anatomy, 461 437–440 Thoracic costotransverse joints, 169, 169f
fluoroscopy-guided, 462 extensor digitorum tendon/tendon Thoracic injection techniques
pathology, 461 sheath injection, 441–442 fluoroscopy
Tarsal tunnel syndrome, 451 flexor digitorum longus tendon/tendon epidural approach, 172
Tarsometarsal joints sheath injection, 446–447 intercostal nerve block, 183–184, 184f
anatomy, 484 flexor hallucis longus tendon/tendon interlaminal epidural (IL) paramedial
fluoroscopy-guided injection, 484, 485f sheath injection, tarsal tunnel, approach, 172–175, 174f
pathology, 484 447–448 intra-articular facet joint injection, 177
Tearing, muscle tissue, 9 insertional peroneus brevis tendon/ intradiscal approach, 180–181, 181f
Tegaderm, 59 tendon sheath injection, 443–444 medial branch blockade, 177–180
Tendinopathy retro-malleolar peroneus brevis and/ sternoclavicular and sternocostal joints,
Achilles tendon, 438 longus tendon/tendon sheath 175, 175f
cartilage injury, 4–5 injection, 442–443 superspinous and interspinous ligament
diagnosis, 506 tibialis anterior tendon/tendon sheath injection, 182–183
etiology, 2 injection, 440 thoracic rib facets, 176
 Index 633

Thoracic injection techniques (Continued) Tibiotalar intra-articular loose bodies, 428 Ultrasound (US)
transforaminal infraneural approach, Tibiotalar joint injection accuracy, 21
172, 173f anatomy, 428, 458 adhesive capsulitis (AC), 497
ultrasound-guided fluoroscopy, 166–170 fluoroscopy-guided, 458–459 advantages, 20–21, 21t
costochondral joints, 169, 170f anterior, 458–459, 458f anechoic structure, 15
sternoclavicular joints, 171–175 equipment, 458 artifacts
sternocostal joints, 170 injectates, 458 anisotropy, 15, 19f
supraspinous and interspinous posterior, 459, 459f beam-width artifact, 18
ligaments, 166, 168f pathology, 428, 458 posterior acoustic enhancement, 17–18
thoracic costotransverse joints, 169, ultrasound-guided posterior acoustic shadowing, 17
169f equipment, 428 reverberation artifacts, 18
thoracic facet joints, 168 injectates, 428–429 aseptic technique, 24
thoracic spine anatomy, 166, 167f needle position, 429 blood flow visualization, 18–19, 20f
Thoracic interlaminal epidural (IL) patient and clinician position, 428 calcific tendonitis, 490, 491f
paramedial approach, 172–175, 174f transducer orientation, 428–429 Color Doppler, 18–19
Thoracic intra-articular facet joint injection Time gain compensation (TGC), 15 vs. computed tomography (CT), 22
anatomy, 177 Traction spur, 544 cost, 22–23
fluoroscopy, 177, 178f Traditional image-intensifier based C-arm direct vs. indirect guidance, 23–24
pathology, 177 fluoroscopy system, 32, 33f efficacy, 21
Thoracic intradiscal approach Transducer, ultrasound, 14–15, 15f ergonomics, 23
anatomy, 180 Transforaminal cervical epidural injections, vs. fluoroscopy, 22
fluoroscopy-guided injection, 180–181, 146–150 hyperechoic structure, 15, 18f
181f Transforaminal endoscopic spine discectomy, image echogenicities, 15
pathology, 180 584b image optimization, 14–15
Thoracic outlet syndrome (TOS), botulinum Transverse carpal ligament (TCL) knobology, 15, 16f
toxin (BTX), 128–129 nerve and tendons, 535 transducer selection, 14–15, 15f
Thoracic spine anatomy, 166, 167f proximal portion, 535 interventional orthopedic procedures
Thoracic transforaminal epidural Trauma fracture, pars interarticularis, 211 contraindications, 21–22
fluoroscopy, 172, 173f Triangular fibrocartilage complex (TFCC) injection accuracy, 21
Thoracodorsal fascia injection, 293, 293f needle placement indications, 19–20
anatomy, 194 Triceps tendon ultrasound guidance indications, 21
pathology, 194 anatomy, 280–281 isoechoic structure, 15
ultrasound-guided lumbar injection intratendinous injection, 281f local anesthesia, 24
clinician position, 194 pathology, 281 vs. magnetic resonance imaging (MRI),
equipment, 194 Trigger finger 22
needle position, 194–195 inflammation, 514 microvascular imaging mode, 19
patient position, 194 injection, 318f needle approach
pearls and pitfalls, 195b Quinnell grading system, 514 in-plane approach, 24–25
transducer position, 194 treatment options, 515 needle trajectory, 25
Three-dimensional (3D) fluoroscopy, 33 ultrasound-guided A1pulley release out-of-plane approach, 24–25
Tibialis anterior tendon/tendon sheath complications, 517 needle selection, 24
injection equipment, 515 needle visualization
anatomy, 440, 440f injectate volume, 515 continuous visualization, 25
pathology, 440 needle orientation, 515 gel stand-off technique, 26–27, 27f
ultrasound-guided, 440, 441f patient and clinician position, 515, needle tracking techniques, 27, 28t
Tibialis posterior tendon/tendon sheath 517f transducer manipulation, 25, 26t, 27f
injection pearls and pitfalls, 515–517 neuromusculoskeletal structures, 19t
anatomy, 444 post-procedure, 517 patient information and labeling, 23
pathology, 444–445 ultrasound imaging findings, 514–515, physics, 14
ultrasound-guided, 445, 445f–446f 516f power Doppler, 18–19
Tibial nerve injection preprocedural scan, 23
anatomy, 451 U principles, 14–19
ultrasound-guided Ulnar capsular ligament injection, 315f safety, 21
equipment, 451 Ulnar nerve, elbow technical considerations, 23–27
injectates, 451 anatomy, 286 Ultrasound-guided carpaltunnel release
technique, 452, 452f pathology, 286 (USCTR)
Tibial plateau IO infiltration ultrasound-guided injection anatomic variants, 537
bone trocar, 557f–558f equipment, 286 clinician position, 539
subchondral bone injection locations, pearls and pitfalls, 286b complete release, 540
557f perineural injection, 286, 287f complications, 540–541
Tibial sesamoid bone, 475 Ulnar nerve hydrodissection, 303–305, 306f equipment, 539
Tibiofibular joint injection, 409–410, 410f Ulnar neuropathy, 286 patient position, 539–541, 540f
634 Index

Ultrasound-guided carpaltunnel release Vertiflex/superion procedure (Continued) Wrist injection techniques (Continued)
(USCTR) (Continued) pathology, 582 flexor carpi radialis tendon and sheath
post procedure management, 540 spinous process fracture, 581 injection, 300–301, 301f
technique, 539, 540f Volar wrist ganglion cyst aspiration/ flexor carpi ulnaris tendon lavage, 301,
transducer orientation, 539 injection, 298, 299f 302f
Umbilical cord blood, 91, 93 ganglia injection, 298–300
W joint injections, 290
V Wharton jelly, 93 ligament, 292–297
Vascular endothelial growth factor (VEGF), World Anti-Doping Agency (WADA), 73 superficial radial nerve hydrodissection/
71t Wrist injection techniques block, 305–306
Venipuncture, 63, 64f fluoroscopic-guided ulnar nerve hydrodissection, 303–305,
Vertebral augmentation, 575b distal carpal rows, 308, 308f–309f 306f
Vertebroplasty, 575b dorsal radioulnar joint injection, 306
Vertiflex/superion procedure proximal carpal rows, 309–310, 310f X
equipment and technique, 582 ultrasound-guided X-rays
interspinous process devices (IPDs), 580 carpal tunnel injection, 302–303 discovery, 31–32
interspinous spacer devices, 581 dorsal compartments, 295, 296f harmful effects, 32
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