Ultrasound Guidance of Injections

  • Erik AdamsEmail author


Ultrasound guidance of injections allows a greater degree of accuracy and permits a greater variety of injections to be performed, compared to palpation guidance. The technique can also improve safety, in that neurovascular structures and articular cartilage can be visualized and avoided. Its successful implementation depends on a firm knowledge of the relevant anatomy and adherence to proper procedures. By no means should it be considered facile. This chapter reviews the current literature regarding injection accuracy, discusses issues of safety and technique, and describes a variety of injections of varying difficulty. It should be considered an adjunct to a more formal training program.


Articular Cartilage Ultrasound Guidance Tendon Sheath Tarsal Tunnel Flexor Retinaculum 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Cunnington J, Marshall N, Hide G, Bracewell C, Isaacs J, Platt P, et al. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum. 2010;62(7):1862–9.PubMedGoogle Scholar
  2. 2.
    Finnoff JT, Nutz DJ, Henning PT, Hollman JH, Smith J. Accuracy of ultrasound-guided versus unguided pes anserinus bursa injections. PM R. 2010;2(8):732–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Bianchi S, Zamorani MP. In: Bianchi S, Martinoli C, editors. Ultrasound-Guided Interventional Procedures. Berlin: Springer; 2007. p. 892.Google Scholar
  4. 4.
    Curtiss HM, Finnoff JT, Peck E, Hollman J, Muir J, Smith J. Accuracy of ultrasound-guided and palpation-guided knee injections by an experienced and less-experienced injector using a superolateral approach: a cadaveric study. PM R. 2011;3(6):507–15.PubMedCrossRefGoogle Scholar
  5. 5.
    Pekkafahli MZ, Kiralp MZ, Basekim CC, Silit E, Mutlu H, Oztürk E, et al. Sacroiliac injections performed with sonographic guidance. J Ultrasound Med. 2003;22(6):553–9.PubMedGoogle Scholar
  6. 6.
    Khosla S, Thiele R, Baumhauer JF. Ultrasound guidance for intra-articular injections of the foot and ankle. Foot Ankle Int. 2009;30(9):886–90.PubMedCrossRefGoogle Scholar
  7. 7.
    Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am. 2002;84-A(9):1522–7.PubMedGoogle Scholar
  8. 8.
    Wisniewski SJ, Smith J, Patterson DG, Carmichael SW, Pawlina W. Ultrasound-guided versus nonguided tibiotalar joint and sinus tarsi injections: a cadaveric study. PM R. 2010;2(4):277–81.PubMedCrossRefGoogle Scholar
  9. 9.
    Wiegerinck JI, Reilingh ML, de Jonge MC, van Dijk CK, Kerkhoffs GM. Injection techniques of platelet-rich plasma into and around the Achilles tendon. Am J Sports Med. 2011;39(8):1681–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Muir JJ, Curtiss HM, Hollman J, Smith J, Finnoff JT. The accuracy of ultrasound-guided and palpation-guided peroneal tendon sheath injections. Am J Phys Med Rehabil. 2011;90(7):564–71.PubMedCrossRefGoogle Scholar
  11. 11.
    Rutten MJ, Collins JM, Maresch BJ, Smeets JH, Janssen CM, Kiemeney LA, et al. Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol. 2009;19(3):722–30.PubMedCrossRefGoogle Scholar
  12. 12.
    Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y. Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg. 2011;20(7):1069–73.PubMedCrossRefGoogle Scholar
  13. 13.
    Luz KR, Furtado RNV, Nunes ICCG, Rosenfeld A, Fernandes ARC, Natour J. Ultrasound-guided intra-articular injections in the wrist in patients with rheumatoid arthritis: a double- blind, randomised controlled study. Ann Rheum Dis. 2008;67(8):1198.PubMedCrossRefGoogle Scholar
  14. 14.
    Sabeti-Aschraf M, Lemmerhofer B, Lang S, Schmidt M, Funovics PT, Ziai P, et al. Ultrasound guidance improves the accuracy of the acromioclavicular joint infiltration: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):292–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Reach JS, Easley ME, Chuckpaiwong B, Nunley II JA. Accuracy of ultrasound guided injections in the foot and ankle. Foot Ankle Int. 2009;30(3):239–42.PubMedCrossRefGoogle Scholar
  16. 16.
    Peck E, Lai JK, Pawlina W, Smith J. Accuracy of ultrasound-guided versus palpation-guided acromioclavicular joint injections: a cadaveric study. PM R. 2010;2(9):817–21.PubMedCrossRefGoogle Scholar

Suggested Reading

  1. Checa A, Chun W, Pappu R. Ultrasound-guided diagnostic and therapeutic approach to Retrocalcaneal Bursitis. J Rheumatol. 2011;38(2):391–2.PubMedCrossRefGoogle Scholar
  2. Chen CP, Lew HL, Tsai WC, Hung YT, Hsu CC. Ultrasound-guided injection techniques for the low back and hip joint. Am J Phys Med Rehabil. 2011;90(10):860–7.PubMedCrossRefGoogle Scholar
  3. Choudur HN, Ellins ML. Ultrasound-guided gadolinium joint injections for magnetic resonance arthrography. J Clin Ultrasound. 2011;39(1):6–11.PubMedCrossRefGoogle Scholar
  4. Collins JM, Smithuis R, Rutten MJ. US-guided injection of the upper and lower extremity joints. Eur J Radiol. 2012;81(10):2759–70.PubMedCrossRefGoogle Scholar
  5. Elkousy H, Gartsman GM, Drake G, Sola W Jr, O’Connor D, Edwards TB. Retrospective comparison of freehand and ultrasound-guided shoulder steroid injections. Orthopedics. 2011;34(4):270.Google Scholar
  6. Finnoff JT, Hurdle MF, Smith J. Accuracy of ultrasound-guided versus fluoroscopically guided contrast-controlled piriformis injections: a cadaveric study. J Ultrasound Med. 2008;27(8):1157–63.PubMedGoogle Scholar
  7. Gilliland CA, Salazar LD, Borchers JR. Ultrasound versus anatomic guidance for intra-articular and periarticular injections: a systematic review. Phys Sportsmed. 2011;39(3):121–31.PubMedCrossRefGoogle Scholar
  8. Hashiuchi T, Sakurai G, Sakamoto Y, Takakura Y, Tanaka Y. Comparative survey of pain-alleviating effects between ultrasound-guided injection and blind injection of lidocaine alone in patients with painful shoulder. Arch Orthop Trauma Surg. 2010;130(7):847–52.PubMedCrossRefGoogle Scholar
  9. Hartung W, Ross CJ, Straub R, Feuerbach S, Schölmerich J, Fleck M, et al. Ultrasound-guided sacroiliac joint injection in patients with established sacroiliitis: precise IA injection verified by MRI scanning does not predict clinical outcome. Rheumatology (Oxford). 2010;49(8):1479–82.CrossRefGoogle Scholar
  10. Hurdle MF, Wisniewski SJ, Pingree MJ. Ultrasound-guided intra-articular knee injection in an obese patient. Am J Phys Med Rehabil. 2012;91(3):275–6.PubMedCrossRefGoogle Scholar
  11. Kayhan A, Gökay NS, Alpaslan R, Demirok M, Yılmaz İ, Gökçe A. Sonographically guided corticosteroid injection for treatment of plantar fasciosis. J Ultrasound Med. 2011;30(4):509–15.PubMedGoogle Scholar
  12. Lee DH, Han SB, Park JW, Lee SH, Kim KW, Jeong WK. Sonographically guided tendon sheath injections are more accurate than blind injections: implications for trigger finger treatment. J Ultrasound Med. 2011;30(2):197–203.PubMedGoogle Scholar
  13. Mandl P, Naredo E, Conaghan PG, D’Agostino MA, Wakefield RJ, Bachta A, et al. Practice of ultrasound-guided arthrocentesis and joint injection, including training and implementation, in Europe: results of a survey of experts and scientific societies. Rheumatology (Oxford). 2012;51(1):184–90.CrossRefGoogle Scholar
  14. Mulvaney SW. Ultrasound-guided percutaneous neuroplasty of the lateral femoral cutaneous nerve for the treatment of meralgia paresthetica: a case report and description of a new ultrasound-guided technique. Curr Sports Med Rep. 2011;10(2):99–104.PubMedGoogle Scholar
  15. Peck E, Finnoff JT, Smith J, Curtiss H, Muir J, Hollman JH. Accuracy of palpation-guided and ultrasound-guided needle tip placement into the deep and superficial posterior leg compartments. Am J Sports Med. 2011;39(9):1968–74.PubMedCrossRefGoogle Scholar
  16. Sabeti-Aschraf M, Ochsner A, Schueller-Weidekamm C, Schmidt M, Funovics PT, V Skrbensky G, et al. The infiltration of the AC joint performed by one specialist: ultrasound versus palpation a prospective randomized pilot study. Eur J Radiol. 2010;75(1):e37–40.PubMedCrossRefGoogle Scholar
  17. Sibbitt Jr WL, Peisajovich A, Michael AA, Park KS, Sibbitt RR, Band PA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36(9):1892–902.PubMedCrossRefGoogle Scholar
  18. Smith J, Finnoff JT, Levy BA, Lai JK. Sonographically guided proximal tibiofibular joint injection: technique and accuracy. J Ultrasound Med. 2010;29(5):783–9.PubMedGoogle Scholar
  19. Smith J, Hurdle MF, Weingarten TN. Accuracy of sonographically guided intra-articular injections in the native adult hip. J Ultrasound Med. 2009;28(3):329–35.PubMedCrossRefGoogle Scholar
  20. Smith J, Finnoff JT, Santaella-Sante B, Henning T, Levy BA, Lai JK. Sonographically guided popliteus tendon sheath injection: techniques and accuracy. J Ultrasound Med. 2010;29(5):775–82.PubMedGoogle Scholar
  21. Smith J, Wisniewski SJ, Finnoff JT, Payne JM. Sonographically guided carpal tunnel injections: the ulnar approach. J Ultrasound Med. 2008;27(10):1485–90.PubMedGoogle Scholar
  22. Soh E, Li W, Ong KO, Chen W, Bautista D. Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review. BMC Musculoskelet Disord. 2011;12:137.PubMedCrossRefGoogle Scholar
  23. Ucuncu F, Capkin E, Karkucak M, Ozden G, Cakirbay H, Tosun M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain. 2009;25(9):786–9.PubMedCrossRefGoogle Scholar
  24. Yoong P, Guirguis R, Darrah R, Wijeratna M, Porteous MJ. Evaluation of ultrasound-guided diagnostic local anaesthetic hip joint injection for osteoarthritis. Skeletal Radiol. 2012;41(8):981–5.PubMedCrossRefGoogle Scholar
  25. Zufferey P, Revaz S, Degailler X, Balague F, So A. A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine. 2012;79(2):166–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Midwest Sports Medicine InstituteMiddletonUSA

Personalised recommendations