REVIEW ARTICLE
Ultrasound-Guided Interventional Procedures
in Pain Medicine
A Review of Anatomy, Sonoanatomy, and Procedures. Part IV: Hip
Philip W.H. Peng, MBBS, FRCPC, Founder (Pain Medicine)
Abstract: Ultrasound-guided injection in pain medicine is emerging
as a popular technique for pain intervention. It can be applied for the in-
tervention procedures in the hip region. The objectives of this review
article were to review the relevant anatomy and sonoanatomy of the
hip joint and the trochanteric bursae, to describe the techniques for
ultrasound-guided injections, and to examine the efficacy and accuracy
of such injections.
(Reg Anesth Pain Med 2013;38: 264–273)
H ip pain can be a manifestation of a broad range of intra-
articular or extra-articular pathologies.1,2 Of those, osteoar-
thritis of the hip and greater trochanteric pain syndrome (GTPS)
are the 2 conditions commonly referred to an anesthesiologist or
pain specialist for injections. Osteoarthritis is the most common
joint disorder in the United States and is the leading cause of
disability in the elderly. Radiographic evidence of osteoarthritis
of the hip is present in about 5% of the population older than
65 years.3,4 However, not all patients with radiographic evidence
of osteoarthritis have symptoms. According to the National Center
for Health Statistics, the Healthcare Cost and Utilization Project
estimated that nearly 368,000 total hip replacements were per-
formed in 2004, costing the nation approximately $5.3 billion.5
Greater trochanteric pain syndrome affects approximately 18%
of the adults in community settings6 and 0.2% of the patient
population in the primary care setting.7 The prevalence increases
in patients with musculoskeletal low-back pain and in women.6–9
This review focuses only on these 2 causes of hip pain, as
they reflect the common reasons for the referral to anesthesiol-
ogists. The first objective of this review was to describe and
summarize the anatomy and sonoanatomy of hip structures rel-
evant to these hip pain conditions. The second objective was to
examine the feasibility, accuracy, and effectiveness of the injec-
tions to these structures as well as the injection techniques.
METHODS
A literature search of the MEDLINE database was per-
formed from January 1980 to December 2012 using the search
From the Department of Anesthesia and Pain Management, University
Health Network, University of Toronto, Toronto, Ontario, Canada.
Accepted for publication March 10, 2013.
Address correspondence to: Philip W. H. Peng, MBBS, FRCPC, Founder
(Pain Medicine), Department of Anesthesia and Pain Management,
University Health Network, University of Toronto, 399 Bathurst St,
Toronto, Ontario, Canada M5T 2S8 (e-mail: Philip.peng@uhn.on.ca).
Source of funding: Institutional.
The author received equipment support from SonoSite Canada.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.rapm.org).
Copyright © 2013 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0b013e318291c8ed
264 Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013
Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
terms “ultrasound,” “ultrasound-guided,” “pain management,”
and different hip structures relevant to this review, such as “hip,”
“hip joint,” “trochanteric bursa,” and “greater trochanter pain
syndrome.” Only literature published in English was included.
DISCUSSION
Anatomy
The anatomy of the hip region has been detailed in many
excellent textbooks. In this review, we focus on the anatomy
that is pertinent to the understanding of the injection of the
hip joint and the pathophysiology of GTPS.
The hip is a synovial “ball-and-socket” joint formed by the
articulation of the femoral head and the acetabulum. The ace-
tabular socket is formed at the junction of the ilium, ischium,
and pubis and is augmented by the acetabular labrum, a fibro-
cartilaginous ring attached directly to the rim of the acetabulum
(Fig. 1). This labrum increases the depth and surface of the ac-
etabular cavity, optimizing the congruity between acetabulum
and the femoral head. At any position of hip motion, approxi-
mately 40% of the articular surface of the femoral head is cov-
ered by the acetabulum.10 Along with the strong capsule and
several powerful para-articular ligaments, this structural ar-
rangement confers stability to the hip joint.
The joint capsule surrounds the outer surface of the labrum
and inserts distally to the intertrochanteric region and posterior
aspect of the femoral neck. The anterior joint capsule is com-
posed of 2 layers, anterior and posterior, that are separated by
the anterior recess of the joint space (Fig. 2). Each layer is of
considerable thickness (2–4 mm) and lined by only a minute sy-
novial membrane.11 The anterior layer runs caudally and inserts
on the intertrochanteric line, where it blends with the perios-
teum. Many fibers are reflected upward, covering the femoral
neck, to form the posterior layer of the joint capsule, which ends
at the caudal edge of the articular cartilage of the femoral head.
The trochanters (greater and lesser) and the lateral third of the
posterior femoral neck are extra-articular.10
The capsule has several thickenings, including the longitu-
dinally oriented iliofemoral, ischiofemoral, and pubofemoral
extracapsular ligaments (Fig. 1). The ligamentum teres femoris,
an intracapsular ligament, is attached to the acetabular notch
and a depression on the femoral head called the fovea capitis.12
The structures in the anterior hip regions from medial to lateral
are the following: pectineus muscle, femoral neurovascular bun-
dle, iliopsoas muscle and tendon, and sartorius and rectus
femoris muscles (Fig. 3 and see Video, Supplemental Digital
Content 1, http://links.lww.com/AAP/A72, which shows layer
by layer the muscles in the anterior hip region [reproduced with
permission from Ultrasound for Regional Anesthesia, Ultra-
sound for Regional Anesthesia, www.usra.ca]).
A good knowledge of the anatomy of the lateral hip region
is instrumental to the understanding of the GTPS. The bony sur-
face of the greater trochanter (GT) consists of 4 facets: anterior,
Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013
FIGURE 1. Front view of hip joint, the labrum (left), and the hip
ligaments. Ischiofemoral ligament cannot be seen from this view
because of the posterior location. Reproduced with permission
from Ultrasound for Regional Anesthesia, www.usra.ca.
lateral, superoposterior, and posterior (Fig. 4 and Video, Sup-
plemental Digital Content 2, http://links.lww.com/AAP/A73,
which shows the 4 facets in the GT in a 3-dimensional view
[reproduced with permission from Ultrasound for Regional An-
esthesia, www.usra.ca]).13 The tendons of the gluteus minimus
and anterior and posterior tendons of the gluteus medius insert
into the anterior, lateral, and superoposterior facets, respec-
tively. There is no tendon attached to the posterior facet. Be-
tween the posterior facet and gluteus maximus muscle, the
subgluteal maximus bursa (SMaB) can be found.
The muscles in the lateral region are divided into 2 layers.
The origins and the insertions of those muscles are summarized
in Table 1.
The superficial layer, from anterior to posterior, is formed
by the tensor fascia lata and gluteus maximus muscle. The trian-
gular interval between these 2 muscles is filled with fascia lata
overlying the gluteus medius muscle (Fig. 5). This superficial
layer is also called “deltoid of the hip joint,” reminiscent of
FIGURE 2. Figure shows the anterior synovial recess (***). Under
normal circumstances, the amount of synovial fluid in the recess
is kept at a minimum. This figure shows a hip with effusion for
demonstration. Reproduced with permission from Ultrasound
for Regional Anesthesia, www.usra.ca.
© 2013 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Ultrasound in Pain Medicine/Hip
FIGURE 3. Muscles (M) around hip joint. The femoral head and
neck (in dotted line) and the schematic of femoral neurovascular
bundle are shown here for reference. V indicates femoral vein;
A, femoral artery; N, femoral nerve. Reproduced with permission
from Ultrasound for Regional Anesthesia, www.usra.ca.
the deltoid muscle of the shoulder. The iliotibial (IT) tract is a
thickening of the fascia lata commencing at the level of GT,
where three-fourths of gluteus maximus muscle and tensor fas-
cia lata insert into it. The IT tract passes along the posterolateral
aspect of the thigh and inserts in the Gerdy’s tubercle of tibia.
The deep layer comprises gluteus medius and minimus
muscles. The anterior two-thirds of gluteus medius muscle des-
cends distally and forms a tendon that inserts into the inferior
aspect of the lateral facet of the GT. The posterior portion of
the muscle gives rise to a strong tendon, which inserts into the
posterosuperior facet (Fig. 4). The gluteus minimus tendon
inserts onto the anterior facet of the GT. The tendons of gluteus
minimus and medius can be considered the rotator cuffs of the
hip joint, analogous to the shoulder joint. In both situations,
the tendons are covered with bursa against friction (Table 2).
The similarities between the 2 regions are important in the un-
derstanding of the pathophysiology of GTPS.14–19
In the lateral hip region, 3 groups of bursae are described
consistently: the SMaB, the subgluteal medius bursa, and the
subgluteal minimus bursa.8,9,20,21 The function of the bursae
is to serve as a cushion against friction between tendons and fas-
cia lata.
The SMaB is situated lateral to the GT, deep to the fascia
lata, gluteus maximus muscle, and its tendon. Contrary to the
belief of a single bursa, the SMaB is typically subdivided into
up to 4 separate bursae. The deep SMaB bursa, often referred
as the “trochanteric bursa,” is the largest and most consistent
among these subdivisions (Fig. 6A and Video, Supplemental
Digital Content 3, http://links.lww.com/AAP/A74, which shows
layer by layer the 3 groups of subgluteal bursae in the lateral
hip region [reproduced with permission from Ultrasound for
Regional Anesthesia, www.usra.ca]). Other SMaBs are the su-
perficial subgluteal maximus, secondary deep subgluteal maxi-
mus, and gluteofemoral bursae (Fig. 6B). The subgluteal
medius bursa is associated with the anterosuperior portion of
the GT separating the gluteus medius tendon from either the
distal insertion of gluteus minimus and/or the lateral anterior
surface of the GT (Figs. 6C, D; Video 3). The subgluteus mini-
mus bursa lies deep to the gluteus minimus insertion on the an-
terior aspect of the GT, in close proximity to the inferior
265
Peng Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013

FIGURE 4. Figure shows the 4 facets of great trochanter. Reproduced with permission from Ultrasound for Regional Anesthesia,
www.usra.ca.

insertion of the hip joint capsule into the base of the femoral
neck (Fig. 6E; Video 3).
Patient Selection
Intra-articular hip injection is considered for the manage-
ment of a wide variety of hip disorders, including osteoarthritis,
rheumatoid arthritis, and acetabular labral tears.22,23 Osteoar-
thritis is the most common joint disorder. Not all patients with
radiographic evidence of osteoarthritis are symptomatic.4
Patients with osteoarthritis of the hip classically present with
anterior or inguinal pain that increases with joint movement
and is relieved, although incompletely, with rest. Although pain
arising from the osteoarthritis of the hip can occur at night, hip
pain at night may instead reflect tumors, infection, chronic in-
flammatory arthritis, or crystal-induced arthropathies. Physical
examination is important to rule out other causes of hip pain or
pain referred from the spine. Patients indicated for intra-articular

TABLE 1. Origin and Insertion of the Muscles in the Lateral Hip Region

Muscle Origin Insertion

Gluteus maximus Outer surface of ilium behind the posterior gluteal line, Majority inserted into the IT band, some to
adjacent posterior surface of the sacrum and coccyx and the gluteal tuberosity of the femur
sacrotuberous ligament
Tensor fascia lata Outer edge of the iliac crest between ASIS and the iliac tubercle IT band
Gluteus medius Outer surface of ilium, between iliac crest and posterior and Anterior tendon to lateral facet and posterior
middle gluteal line tendon to superoposterior facet of GT
Gluteus minimus Outer surface of ilium between middle and inferior gluteal line Anterior facet of GT
ASIS indicates anterior superior iliac spine.

266 © 2013 American Society of Regional Anesthesia and Pain Medicine

Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013
FIGURE 5. Figure shows the muscles and fascia in the lateral hip
region. Reproduced with permission from USRA.
injection are those with moderate to severe pain and disability,
with poor response to conservative management, and those not
a surgical candidate either because of age or comorbidity.4,23
Injected medications may include corticosteroids, local anes-
thetics, and viscosupplements (VSs).
Evaluation of the patient with GTPS reveals patient with
lateral hip pain, distinct tenderness about the GT (jump sign),
Trendelenburg sign, positive Ober test, and Patrick-Faber test
(flexion, abduction, and external rotation). There is a paucity of
physical signs that are highly specific to GTPS, and the specific-
ity and sensitivity of these clinical features mentioned above
have not been validated.9 Both magnetic resonance imaging and
ultrasound are very useful in the evaluation of the gluteal ten-
dinopathy, tendon tears, or presence of bursitis.8,9,24
TABLE 2. GTPS: A Bursitis or Rotator Cuff Disease
Similarity between shoulder and hip anatomy
Tendons
Bone attachment
Impingement
Bursa
Evidence supporting cuff disease as etiology
Bursitis is secondary to initial pathology at tendinous attachments
Evidence of bursitis in GTPS
Presence of tendinopathy or tendon tears in GTPS
© 2013 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Ultrasound in Pain Medicine/Hip
Sonoanatomy and Injection Technique for
Hip Joint
The technique for revealing the anterior recess of hip joint
is anterior oblique sagittal technique; that is, the transducer po-
sition is aligned with the axis of the femoral neck.25 The patient
is placed in supine position with the hip in neutral position,
and the groin is exposed as medial as pubic symphysis. Either
curvilinear or linear probe can be used, but the author prefers
a curvilinear probe as it gives a panoramic view of the anterior
recess and femoral neck even in an obese patient. The first scan
is to locate the femoral neurovascular bundle in the infraingu-
inal region (Fig. 7A; Video, Supplemental Digital Content 4,
http://links.lww.com/AAP/A75, which shows step-by-step how
to obtain the sonoanatomy of the anterior recess [reproduced with
permission from Ultrasound for Regional Anesthesia, www.usra.
ca]). In this view, the femoral head and acetabulum can usually be
seen underneath the iliopsoas muscle and its tendon. The trans-
ducer is then rotated to a position coaxial to the femoral neck
(Fig. 7B; Video 4). The scan is then optimized in a way such that
the following structures can be well defined: femoral head, neck,
and joint capsule.
A 3.5-in, 22-gauge spinal needle is inserted in-plane
from lateral to medial direction. The target is the synovial re-
cess underneath the joint capsule between the femoral head
and neck (Fig. 8; Video, Supplemental Digital Content 5,
http://links.lww.com/AAP/A76, which illustrates step-by-step
the injection technique for intra-articular injection of hip [repro-
duced with permission from Ultrasound for Regional Anesthe-
sia, www.usra.ca]). Before the needle insertion, it is advisable
to survey the potential needle path with Doppler scan for any un-
suspected vessel (Video 5). The needle is inserted until bone is
contacted and is then withdrawn 1 to 2 mm to avoid engaging
the needle tip in the posterior capsule. Monitoring the spread of
the injectate real time throughout the injection is important to en-
sure the injectate is spread within the joint space (Video 5). The
medication used is 5 mL of local anesthetic with steroid, such
as 2% lidocaine and 40 mg methylprednisolone acetate. Alterna-
tively, 5 mL of VS can be injected.
Accuracy and Efficacy of Intra-articular Injection
of Hip
Depending on whether the approach is anterior or lateral,
the accuracy of the landmark-based technique ranged from 52%
to 80%.26,27 In addition to the low accuracy, Leopold et al27 dem-
onstrated that the risk of piercing the femoral nerve from the
“blind” anterior approach was 27%, and the needle tips were
within 5 mm of the femoral nerve in 60% of the needle
Shoulder Hip
Supraspinatus Gluteus medius, gluteus minimus
Greater tuberosity Greater trochanter
Coracoacromial arch Fascia lata, IT tract
Subdeltoid, subacromial bursa Subgluteus maximus bursa
Rationale behind rotator cuff tendonitis,12,13 supported by
radiological evidence14
Uncommon15–17
Very common17
267
Peng Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013

FIGURE 6. Figures show the bursae in the lateral hip region layer by layer. Panel B is a close up of panel A. A indicates superficial
SMaB; B, deep SMaB; C, secondary deep SMaB; D, gluteofemoral bursa; M, muscle. Reproduced with permission from Ultrasound
for Regional Anesthesia, www.usra.ca.

insertions. In contrast, the accuracy of ultrasound-guided injection
was 97% to 100%.25,28 In those studies, contrast-enhanced fluo-
roscopy25 or computed tomographic scan28 was used as the vali-
dation tools. For ultrasound-guided injection, the ideal site for
needle tip is the junction between the femoral head and neck.29
Five randomized controlled trials (RCTs) examining the
analgesic efficacy of intra-articular hip steroid injection have
been published, and all injections were performed under image
guidance (fluoroscopy = 3, ultrasound = 2).30–35 Four are posi-
tive trials with improvement in pain and functions.31–33,35 One
possible explanation for the negative study34 is the potential
bias in the study design, as the patients were told that they
would be given priority for surgery if their pain worsened after
injection. Current data from available RCTs and other uncon-
trolled studies30–36 demonstrate strong evidence that steroid in-
jection can provide a short-term (1–3 months) reduction in pain.
The analgesic efficacy of VS was recently examined in a
systematic review.37 Although the experience from the 14 case
series including 1094 patients supported the analgesic efficacy
of VS in patients with arthritic hip pain, the results from the ran-
domized trials were different. Of 5 randomized trials, 3 included
saline as the control,32,35,38 1 compared VS with local anes-
thetic only,39 and another compared 2 preparations of VS of dif-
ferent molecular weights.40 All of the 3 studies comparing VS

268 © 2013 American Society of Regional Anesthesia and Pain Medicine

Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013
FIGURE 7. A, Sonoanatomy of the infrainguinal hip region. The position of the transducer is shown in the insert. A indicates femoral
artery; V, femoral vein. B, Sonoanatomy of the anterior hip region when the transducer is placed in the long axis of the femoral
neck. The arrowheads indicate the anterior recess. The position of the transducer is shown in the insert. Reproduced with permission
from Ultrasound for Regional Anesthesia, www.usra.ca.
with saline did not find a difference in the analgesic efficacy
between the treatment groups. Therefore, the authors concluded
that VS could not be recommended as standard therapy in pa-
tients with hip osteoarthritis for wider populations, and there-
fore the indications remained a highly individualized matter.
Five retrospective studies have examined the increased in-
fection risk of hip replacement following a prior intra-articular
hip injection (Table 3).41–45 The earliest publication41 revealed
that the rates of superficial and deep infection were 30% and
10% compared with 7.5% and 0% of the matched cohort (pa-
tients with total hip arthroplasty without prior intra-articular
steroid injection). However, subsequent publications did not
confirm the increased risk from intra-articular injection. One
study suggested that an interval of less than 6 weeks between
the injection and hip replacement was a risk factor for deep
infection.43
Sonoanatomy and Injection Technique for GTPS
The patient is placed in lateral decubitus position with the
injection site as the nondependent side. A linear ultrasound
probe is preferred unless the patient is of very high body mass
index. The key landmark structures are GT (anterior, lateral, and
posterior facet), IT band, gluteus medius, and minimus tendons.
FIGURE 8. Ultrasonography shows the anterior recess (*) as the
target. Small arrows outline the joint capsule, and arrowheads
indicate the needle. The insert shows the position of the
transducer and the needle. Reproduced with permission from
Ultrasound for Regional Anesthesia, www.usra.ca.
© 2013 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Ultrasound in Pain Medicine/Hip
The first scan is to obtain a transverse view of the GT
and the insertion of the gluteus medius tendon (lateral and
posterolateral facets) and gluteus minimus tendon (anterior
facet). A sharp-pointed ridge separates the anterior and lat-
eral facets (Fig. 9; Video, Supplemental Digital Content 6,
http://links.lww.com/AAP/A77, which shows step-by-step how
to obtain the sonoanatomy of the target for peritendinous injec-
tion of gluteus medius and minimus tendons [reproduced with per-
mission from Ultrasound for Regional Anesthesia, www.usra.ca]).
The transverse view is useful to differentiate the gluteus ten-
dons, but the long-axis view is valuable in revealing the space
between the IT band and the gluteus medius tendon. The IT
band is a well-defined hypoechoic layer superficial to the glu-
teus medius tendon (Fig. 9; Video 6). Careful examination of
the gluteus medius tendon may demonstrate radiological fea-
tures suggestive of pathology such as hypoechogenicity, loss of
fibrillary pattern, tear, and the presence of enthesophytes or calci-
fications.46,47 For the gluteus minimus tendon, the transverse view
is sufficient to reveal the superficial and deep aspect of the tendon
(Fig. 9; Video 6).
Most of the GTPS is related to the pathology of gluteus
medius tendon, and the target is between the IT band and the
gluteus medius tendon.47 After obtaining a long-axis view of
the gluteus medius tendon and IT band, a 22-gauge, 3.5-in spi-
nal needle is inserted in-plane toward the caudal direction
(Fig. 10). Hydrolocation with normal saline should show the
injectate spread between the IT band and gluteus medius ten-
don. The injectate is 3 mL of local anesthetic with steroid, such
as 0.25% bupivacaine and 40 mg methylprednisolone acetate.
Alternatively, a transverse view is obtained, and the needle is
inserted in-plane from posterior to anterior. The potential ad-
vantage of the latter method is that it allows peritendinous injec-
tion of both the anterior and posterior tendons of the gluteus
medius muscle. For the gluteus minimus peritendinous injec-
tion, the needle is inserted in-plane from posterior to anterior
after a transverse view of the tendon is obtained (Fig. 10).
Accuracy and Efficacy of Injection for GTPS
The landmark-based technique was validated once in the
literature.48 Using bursagram under fluoroscopy as the validation
tool, the GT was contacted by the needle in only 78%, and the lo-
cation of the needle tip was correct in 45% of cases on the
first needle placement.48 One of the major criticisms is that the
bursa is defined by soft-tissue plane. Previous study using x-ray
269
Peng Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013

TABLE 3. Risk of Injection Following Hip Arthroplasty With Previous Intra-articular Steroid Injection

Matching THR With Location of

Authors Study Period Cohort Previous Injection Procedure Infection
Kaspar and de V de Beer41 1995–1998 Yes 40 XR Overall: 30 vs. 7.5% Deep: 10 vs. 0%
Sreekumar et al42 1997–2004 Yes 66 XR NS
McIntosh et al43 1998–2002 Yes 217 XR NS superficial and deep
Chitre et al44 1996–2000 No 36 OR Superficial-1
Sankar et al45 2002–2009 No 40 OR Superifcial-1
THR indicates total hip arthroplasty; XR, radiological suite; OR, operating room; NS, no significant difference.

to confirm the location of contrast in the subacromial bursa sug-
gested that x-ray was unreliable in locating a bursa when the
result was validated with cadaver dissection.49 Not surprisingly,
a subsequent multicenter randomized controlled study comparing
the fluoroscopy-guided and blind steroid injection for the GTPS
did not show any analgesia advantage of the image-guided tech-
nique over the blind technique.50 In contrast, ultrasound is a valu-
able tool in defining the anatomy and pathology of the gluteal
muscles and tendons in the trochanteric region.46,51,52 At pres-
ent, literature on the ultrasound-guided injection for GTPS is
scant, let alone the validation study. Given the simplicity of
the landmark-based technique and the lack of literature on the
ultrasound-guided technique, the author's first-line approach is
to perform the injection for GTPS with landmark-based tech-
nique with the following exceptions: history of previous failed
response to landmark-based injection, inability or difficulty to de-
fine the GT by palpation, or when gluteal minimus tendon is the
main pathology.
A number of investigations examining the effect of in-
jection as the primary treatment modality for GTPS have been

FIGURE 9. A, Ultrasonography shows the junction (*) between the anterior and lateral facets of the GT (dotted line). The position of
the transducer is shown in the insert. B, Ultrasonography shows the gluteus medius tendon in short axis. The position of the transducer
shown in the insert is posterior to that shown in A. C, Ultrasonography shows the SMaB. Note that the axis of the transducer is aligned
with the long axis of the IT band as shown in the insert. D, Ultrasonography shows the gluteus minimus tendon. Note that the position
of the transducer is anterior to that shown in A. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

270 © 2013 American Society of Regional Anesthesia and Pain Medicine

Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013
FIGURE 10. A, Ultrasonography shows the target for the
peritendinous injection for gluteus medius. The dashed arrow
shows the path of the needle inserted in-plane from cephalad
to caudal direction. The insert shows the ultrasound probe
position. B, Ultrasonography shows the target for the
peritendinous injection for gluteus minimus. The dashed arrow
shows the path of the needle in plane from posterior to anterior
direction. The insert shows the ultrasound probe position.
Reproduced with permission from Ultrasound for Regional
Anesthesia, www.usra.ca.
published.9,53 Most of them are case series, and only 3 are ran-
domized trials.50,54,55 In those case series, most of the patients
received only a single injection, and the visual analog pain scale
was not even used as the outcome measure. The case series
showed favorable short-term outcome (3 months) with symp-
tom resolution, and the ability to return to activity ranged from
49% to 100% with steroid injection as the primary treatment
modality.53
One randomized trial examined a fluoroscopy guided
against blind injection without any placebo or nontreatment
control.50 By defining success with a positive categorical out-
come (≥50% pain relief and satisfaction with the results), the
outcomes at 3-month assessment were comparable in both
groups (41% vs 47% in x-ray and blind group, respectively).
Complication is rare and minor.
Another large quasi-RCT recruited 229 patients with re-
fractory unilateral GTPS sequentially assigned to 1 of the fol-
lowing groups: a home training program (group A), a single
local corticosteroid injection (group B), or a repetitive low-
energy radial shock wave treatment (group C).54 The response
© 2013 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Ultrasound in Pain Medicine/Hip
was measured on a 6-point Likert scale, and the treatment suc-
cess was defined as either completely recovered or much im-
proved. Subjects underwent outcome assessments at baseline
and at 1, 4, and 15 months. At 1 month, corticosteroid injec-
tion (group B) resulted in the best improvement (success rates
were 7%, 75%, and 13% for groups A, B, and C, respectively).
However, the success rate of the injection group declined with
time and was subsequently superseded by the other 2 groups at
4 and 15 months (success rates were 41%, 51%, and 68% at
4 months and 80%, 48%, and 74% at 15 months for groups A,
B, and C, respectively). Although this study confirmed the short-
term analgesic effectiveness of steroid injection, treating physi-
cians should be aware of the other conservative measures that
could be of benefit to those with refractory symptoms from GTPS.
Finally, a recent pragmatic, multicenter, open-label ran-
domized clinical trial evaluated the effect of corticosteroid
injections compared with expectant treatment (usual care, ie,
physiotherapy and analgesic) in patients with GTPS in a pri-
mary care setting.55 One hundred twenty patients were ran-
domly allocated to receive either local corticosteroid injections
(n = 60) or usual care (n = 60). All patients were followed
up for 12 months. At the 3-month follow-up, 34% of the pa-
tients in the usual care group had recovered (defined as totally
or strongly recovered) compared with 55% in the injection
group (adjusted odds ratio = 2.38; 95% confidence interval
[CI], 1.14–5.00; number needed to treat = 5). Reduction in pain
severity at rest and on activity was greater in the injection
group, with the adjusted difference in pain at rest of 1.18
(95% CI, 0.31–2.05) and in pain with activity of 1.30 (95%
CI, 0.32–2.29). The secondary outcomes (Western Ontario and
McMaster Universities Arthritis Index pain and function mea-
sures) showed a greater decrease in pain in the injection group
as well. At the 12-month follow-up, differences in outcome
were no longer present. Aside from a short period with super-
ficial pain at the site of the injection, no differences in ad-
verse events were found.
In conclusion, both the case series and randomized trials
supported the safety and short-term analgesic efficacy (3 months)
of steroid injection for GTPS.
CONCLUSIONS
Intra-articular injection of the hip can be reliably per-
formed with ultrasound guidance, targeting the anterior syno-
vial recess. In contrast, the landmark-based technique is
unreliable and subjects the patient to risk of soft-tissue or nerve
injury. The evidence supporting the short-term analgesic effi-
cacy of intra-articular steroid injection is strong. However, con-
trolled trials did not support the use of VS for hip osteoarthritis.
Because current evidence suggests that GTPS is associated
with pathology of gluteus medius and minimus tendons, it is
rational to direct the steroid injection to the tendons involved.
Although the current landmark-based technique is at most mod-
estly accurate, it offers an easy bedside method. Ultrasound-
guided technique emerges as a rational technique allowing the
definition of the soft tissue involved. However, more studies
evaluating the feasibility and efficacy are required.
ACKNOWLEDGMENTS
The author would like to thank Lucy Zhang and Bonnie
Tang for their work on the illustrations.
REFERENCES
1. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint.
Arthroscopy. 2008;24:1407–1421.
271
Peng Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013
2. Blankenbaker DG, Tuite MJ. The painful hip: new concepts. Skeletal
Radiol. 2006;35:352–370.
3. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the
prevalence of arthritis and selected musculoskeletal disorders in the
United States. Arthritis Rheum. 1998;41:778–799.
4. Lane NE. Osteoarthritis of the hip. N Engl J Med. 2007;357:1413–1421.
5. Merrill C. (Thomson Healthcare) and Elixhauser A (AHRQ). Hospital
stays involving musculoskeletal procedures, 1997–2005. HCUP
Statistical Brief #34. July 2007. Agency for Healthcare Research and
Quality, Rockville, MD. Available at: http://www.hcup-us.ahrq.gov/
reports/statbriefs/sb34.pdf. Accessed February 10, 2013.
6. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain
syndrome: epidemiology and associated factors. Arch Phys Med
Rehabil. 2007;88:988–992.
7. Lievense A, Bierma-Zeinstra S, Schouten B, Bohnen A, Verhaar J, Koes
B. Prognosis of trochanteric pain in primary care. Br J Gen Pract.
2005;55:199–204.
8. Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome.
Sports Med Arthrosc Rev. 2010;18:113–119.
9. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of
anatomy, diagnosis and treatment. Anesth Analg. 2009;108:1662–1670.
10. Martinoli C, Bianchi S. Hip. In Baert AL, Knauth M, Sartor K, eds.
Ultrasound of the Musculoskeletal System. Heidelberg, Germany:
Springer; 2007:551–610.
11. Robben SGF, Lequin MH, Diepstraten AFM, den Hollander JC,
Entius CAC, Meradji M. Anterior joint capsule of the normal hip and
in children with transient synovitis: US study with anatomic and
histologic correlation. Radiology. 1999;210:499–507.
12. Petersilge CA. Chronic adult hip pain: MR arthrography of the hips.
RadioGraphics. 2000;20(suppl):S43–S52.
13. Pfirrmann CWA, Chung CB, Theumann NH, Trudell DJ, Resnick D.
Greater trochanter of the hip: attachment of the abductor mechanism
and a complex of three bursae—MR imaging and MR bursography in
cadavers and MR imaging in asymptomatic volunteers. Radiology.
2001;221:469–477.
14. Gordon EJ. Trochanteric bursitis and tendinitis. Clin Orthop.
1961;20:193–202.
15. Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue
rheumatology. III: trochanteric bursitis. J Clin Rheum. 2004;10:123–124.
16. Kingzett-Taylor A, Tirman PF, Feller J, et al. Tendinosis and tears of
the gluteus medius and minimus muscle as a cause of hip pain.
Am J Roentgenol. 1999;173:1123–1126.
17. Karpinski MR, Piggott H. Greater trochanteric pain syndrome. J Bone
Joint Surg Br. 1985;67:762–763.
18. Silva F, Adams T, Feinstein J, Arroyo RA. Trochanteric bursitis: refuting
the myth of inflammation. J Clin Rheumatol. 2008;14:82–86.
19. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation
of magnetic resonance imaging and physical examination findings in
patients with greater trochanteric pain syndrome. Arthritis Rheum.
2001;44:2138–2145.
20. Woodley SJ, Mercer SR, Nicholson HD. Morphology of the bursae
associated with the greater trochanter of the femur. J Bone Joint Surg
Am. 2008;90:284–294.
21. Dunn T, Heller CA, McCarthy SW, et al. Anatomical study of the
“trochanteric bursa.” Clin Anat. 2003;16:233–240.
22. McCarthy J, Noble P, Aluisio FV, Schuck M, Wright J, Lee JA.
Anatomy, pathologic features, and treatment of acetabular labral tears.
Clin Orthop Relat Res. 2003;406:38–47.
23. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for
the management of hip and knee osteoarthritis, Part II: OARSI
evidence-based, expert consensus guidelines. Osteoarthritis Cartilage.
2008;16:137–162.
272
Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
24. Ege Rasmussen KJ, Fano N. Trochanteric bursitis. Treatment by
corticosteroid injection. Scand J Rheumatol. 1985;14:417–420.
25. Smith J, Hurdle MFB, Weingarten TN. Accuracy of sonographically
guided intra-articular injections in the native adult hip. J Ultrasound
Med. 2009;28:329–335
26. Dobson MM. A further anatomical check on the accuracy of
intra-articular hip injections in relation to the therapy of coxarthritis.
Ann Rheum Dis. 1950;9:237–240.
27. Leopold SA, Battista V, Oliverio JA. Safety and efficacy of intraarticular
hip injection using anatomic landmarks. Clin Orthop Relat Res.
2001;391:192–197.
28. Pourbagher MA, Ozalay M, Pourbagher A. Accuracy and outcome of
sonographically guided intra-articular sodium hyaluronate injections
in patients with osteoarthritis of the hip. J Ultrasound Med.
2005;24:1391–1395.
29. Kantarci F, Ozbayrak M, Gulsen F, Gencturk M, Botanlioglu H,
Mihmanli I. Ultrasound-guided injection for MR arthrography of the
hip: comparison of two different techniques. Skeletal Radiol.
2013;42:37–42.
30. Kruse DW. Intraarticular cortisone injection for osteoarthritis of
the hip. Is it effective? Is it safe? Curr Rev Musculoskelet Med.
2008;1:227–233.
31. Lambert RGW, Hutchings EJ, Grace MGA, Jhangri GS,
Conner-Spady B, Maksymowych WP. Steroid injection for osteoarthritis
of the hip. A randomized, double-blind, placebo-controlled trial.
Arthritis Rheum. 2007;56:2278–2287.
32. Qvistgaard E, Christensen R, Torp-Pedersen S, Bliddal H. Intra-
articular treatment of hip osteoarthritis: a randomized trial of hyaluronic
acid, corticosteroid, and isotonic saline. Osteoarthritis Cartilage.
2006;14:163–170.
33. Kullenberg B, Runesson R, Tuvhaq R, Olsson C, Resch S. Intraarticular
corticosteroid injection: pain relief in osteoarthritis of the hip?
J Rheumatol. 2004;31:2265–2268.
34. Flannagan J, Thomas TL, Casale FF, Desai KB. Intraarticular injection
for pain relief in patients awaiting hip replacement. Ann R Coll Surg
Engl. 1988;70:156–157.
35. Atchia I, Kane D, Reed M, Isaacs JD, Birrell F. Efficacy of a single
ultrasound guided injection for the treatment of hip osteoarthritis.
Ann Rheum Dis. 2011;70:110–116.
36. Micu MC, Bogdan G, Fodor D. Steroid injection for hip osteoarthritis:
efficacy under ultrasound guidance. Rheumatology. 2010;49:1940–1944.
37. Colen S, Haverkamp D, Mulier M, van den Bekerom MP. Hyaluronic
acid for the treatment of osteoarthritis in all joints except the knee.
What is the current evidence? BioDrugs. 2012;26:101–112.
38. Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in
symptomatic hip osteoarthritis: a multicenter, randomized,
placebo-controlled trial. Arthritis Rheum. 2009;60:824–830.
39. Migliore A, Massafra U, Bizzi E, et al. Comparative, double-blind,
controlled study of intra-articular hyaluronic acid (Hyalubrix) injections
versus local anesthetic in osteoarthritis of the hip. Arthritis Res Ther.
2009;11:R183
40. Tikiz C, Unlű Z, Sener A, et al. Comparison of the efficacy of lower and
higher molecular weight viscosupplementation in the treatment of hip
osteoarthritis. Clin Rheumatol. 2005;24:244–250.
41. Kaspar S, de V de Beer J. Infection in hip arthroplasty after previous
injection of steroid. J Bone Joint Surg. 2005;87-B:454–457.
42. Sreekumar R, Venkiteswaran R, Raut V. Infection in primary hip
arthroplasty after previous steroid infiltration. Int Orthop.
2007;31:125–128.
43. McIntosh AL, Hanssen AD, Wenger DE, Osmon DR. Recent
intraarticular steroid injection may increase infection rates in primary
total hip arthroplasty. Clin Orthop Relat Res. 2006;451:50–54.
© 2013 American Society of Regional Anesthesia and Pain Medicine
Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013
44. Chitre AR, Fehily MJ, Bamford DJ. Total hip replacement after
intra-articular injection of local anaesthetic and steroid. J Bone Joint
Surg. 2007;89-B:166–168.
45. Sankar B, Seneviratne S, Radha S, Rajeev A, Banaszkiwwicz P.
Safety of total hip replacement following an intra-articular steroid hip
injection—an audit. Acta Orthop Belg. 2012;78:183–186.
46. Connell DA, Bass C, Sykes CJ, Young D, Edwards E. Sonographic
evaluation of gluteus medius and minimus tendinopathy. Eur Radiol.
2003;13:1339–1347.
47. Labrosse JM, Cardinal É, Leduc BE, et al. Effectiveness of
ultrasound-guided corticosteroid injection for the treatment of gluteus
medius tendinopathy. AJR. 2010;194:202–206.
48. Cohen SP, Narvaez JC, Lebovits AH Stojanovic MP. Corticosteroid
injections for trochanteric bursitis: is fluoroscopy necessary? A pilot
study. Br J Anaesth. 2005;94:100–106.
49. Mathews PV, Glousman RE. Accuracy of subacromial injection:
anterolateral versus posterior approach. J Shoulder Elbow Surg.
2005;14:145–148.
© 2013 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2013 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Ultrasound in Pain Medicine/Hip
50. Cohen S, Strassels S, Foster L, et al. Comparison of fluoroscopically
guided and blind corticosteroid injections for greater trochanteric
pain syndrome: multicentre randomised controlled trial. BMJ.
2009;338:986–988.
51. Fearon AM, Scarvell JM, Cook JL, Smith PN. Does ultrasound correlate
with surgical or histologic findings in greater trochanteric pain
syndrome? A pilot study. Clin Orthop Relat Res. 2010;468:1838–1844.
52. Kong A, van der Vliet A, Zadow S. MRI and US of gluteal tendinopathy
in greater trochanteric pain syndrome Eur Radiol. 2007;17:1772–1783.
53. Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of
trochanteric bursitis: a systematic review. Clin J Sport Med.
2011;21:447–453.
54. Rompe J, Segal N, Cacchio A, Furia JP, Morral A, Maffulli N. Home
training, local corticosteroid injection, or radial shock wave therapy for
greater trochanteric pain syndrome. Am J Sports Med. 2009;37:1981–1990.
55. Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections
for greater trochanteric pain syndrome: a randomized controlled trial
in primary care. Ann Fam Med. 2011;9:226–234.
273