US-guided injection of joints

James Collins, Robin Smithuis and Matthieu Rutten

Department of Radiology of the Medical Center, Leeuwarden, the Rijnland Hospital,
Leiderdorp and the Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands

This article describes the application of

Ultrasound guidance for diagnostic and
therapeutic joint injections.

Ultrasound is a valuable alternative to

procedures performed either blind or under
fluoroscopic or CT guidance.

Shoulder

Glenohumeral joint

Anterior approach

In the anterior approach the patient is lying

supine with the extended arm externally
rotated (figure).

The transducer is placed ventrally parallel

to the long axis of the subscapular tendon.

The grey line on the side of the transducer

indicates the long axis.

Local anaesthetics are not needed if

needles are used with a diameter of 21-
gauge or thinner.

For joint aspirations one may need to use a

larger bore needle due to high viscosity of
the aspirate. In such cases local
anaesthetics are indicated.

To facilitate injection of medication or

contrast, one may use a connection tube in
between the needle and the syringe, the
latter being held and managed by an
assistant.
 A 22-gauge, 50mm needle is used
connected to a syringe containing the
contrast media, held by an assistant who
upon proper needle position injects 15-20
mL of the contrast medium.

The needle is advanced perpendicular to

The landmarks one should look for are the the medial edge of the humeral head,
medial contour of the humeral head and medial
to this the coracoid process (C)
penetrating the subscapular tendon.

If one hits the cartilage of the humeral

head, the needle should be pulled back 1
or 2 mm, slightly angled by about 15◦ and
then advanced tangentially to the head into
the joint with the bevel of the needle facing
into the joint (figure).

No resistance to injection should be felt

and one should see the contrast flow freely
into the joint and if present into the
subscapular recess.

Posterior approach

A. The needle is in the intra-articular

position with the tip underneath the
infraspinatus tendon (ISP) and posterior
labrum (L) and bordering the hyaline
cartilage (asterisks) of the humeral head.

B. Corresponding cadaver section showing

US-image showing a long axis view of the
supraspinatus tendon (SSP). The advancing
the optimal needle track (white line).
needle under real-time US-guidance has entered
the subacromial bursa between the deltoid and C. Sonogram after injection of 15 mL
SSP-muscle. Dilatation of the subacromial– contrast. The correct intra-articular position
subdeltoid bursa after injection of 5 mL fluid of the needle can be visualized real-time
(blue arrows). during injection, but is also confirmed by
the 'comma'-like configuration of the
Subacromial bursa posterior labrum (arrowheads), which is
lifted by the intraarticularly injected fluid.
The subacromial-subdeltoid bursa is a
synovial lined space, which contains no
observable or only a minimal amount of
fluid.

The bursa consists of two bursal leaves.

The outer and inner leaves are fused with
the deltoid muscle fascia and rotator cuff,
respectively. The bursal leaves can easily
glide over each other, thus facilitating the
range of movement of the shoulder.

Blind subacromial injection of drugs into

the subacromial bursa is a frequently
performed therapy by general practitioners
and orthopedic surgeons. The incidence of
injections that miss the subacromial bursa
range from 12% to 70%.

Elbow

For injection of the elbow the patient is

supine with the arm in 90◦ flexion, raised
and resting on a cushion. The joint space
between the radial head and the capitulum
is easily palpated. The hand is pronated or
may be turned into the thumb up position,
which is necessary to open the joint
maximally.

The transducer is placed over the joint

visualizing the joint space. The needle (22
gauge, 30 mm) is directed at a slight
craniocaudal angle on the dorsolateral side
of the joint toward the joint space aiming
toward the articular surface of the radial
head.

When seen to have entered the joint and

upon feeling the cartilage of the radial
head, the needle is slightly pulled back to
ensure that the bevel is free from the
cartilage and facing into the joint.

5-8 mL of contrast media is injected. No

resistance to injection should be felt.

Wrist and hand

Radiocarpal joint

The patient is supine with the wrist resting

flexed over a 45◦ sponge or a rolled-up
towel.

In some cases it may be helpful to hold the

wrist in ulnar deviation in order to open the
joint space even more.

The space between the radius and the

scaphoid is identified on ultrasound.

A 23-25-gauge, 30 mm needle is advanced

under ultrasound guidance into the joint
directed toward the articular surface of the
radius until one feels contact with the
radius.

After ensuring that the tip of the needle is

free from the radial cartilage 2-4 mL
contrast is injected.

The bevel of the needle is facing toward

the joint space and the contrast is seen to
flow into the joint.

Distal radioulnar joint (DRUJ)

A linear array transducer is axially

positioned dorsally over the distal radius
and ulna. Along the short axis of the
transducer a 23-25- gauge, 30 mm needle
is inserted being directed from proximally
to distally in a caudal direction. A total
amount of 0.5-1 mL is injected according
to rising pressure during injection.

Carpal, carpometacarpal and

interphalangeal joints

Physicians and specialists routinely perform

intra-articular punctures and injections on
small wrist and finger joints to relieve joint
effusion or to inject drugs.

The failure rate and frequency of

occurrence of peri-articular injections are
high: 15% - 32%, especially with the joints
of the little finger and the DIP joints.

Unintended peri-articular drug injection

moreover may affect the surrounding
ligaments or tendons, leading to serious
complications.

A dorsal approach using a 23-25-gauge

needle is preferable. Although high-
frequency linear array transducers with
frequencies from 18 to 12 MHz are often
used for scanning the superficial soft tissue
structures of the wrist and hand, a small
footprint transducer may allow better
access to the small peripheral joints.

Generally, 0.5-1 mL of contrast material is

instilled after confir- mation of correct
needle placement.
 Sacroiliac Joint

The sacroiliac joint has been implicated as

a source of low back and lower extremity
pain, which is thought to be caused by
sacroiliitis.

Treatment consists of intra-articular

injection of corticosteroids. Diagnostic
injections or blocks are frequently
performed, to distinguish between the
probable causes of low back pain, because
in 15-25% this is generated by the SI joint.

Upper level SI joint injection

The axially orientated transducer is moved

from the level of the fifth lumbar vertebra
caudally, depicting the dorsal surface of the
sacrum with the median and lateral sacral
crest, the gluteal surface of the ilium, and
the first posterior sacral foramen.

The needle is inserted along the short axis

of the transducer into the hypoechoic cleft
located between the surface of the sacrum
and the contour of the ilium. Angulations of
needle insertion are adjusted to the
orientation of the hypoechoic cleft of the SI
joint, which presents cranially a more
medial to lateral orientation, and caudally a
more vertical orientation.

Lower level SI joint injection

From the upper level the transducer is

moved downward by delineation of the
median and lateral sacral crest, at the
dorsal surface of the sacrum and the
gluteal surface of the ilium until the second
posterior sacral foramen is visualized.

As with the upper level, the needle is

inserted into the hypoechoic cleft between
the sacrum and ilium.

Hip
The patient is placed supine. The leg is
held in slight endorotation and abduction
thereby reducing tension on the capsular
structures and moving the iliopsoas tendon
and bursa medially out of the intended
needle path.

Preferably a 5-3.5 MHz curved array

transducer is used, which provides the
necessary penetration depth.

Usually a 21 gauge needle with a length of

9 cm is used for the average adult. In
smaller adults or children a 23-gauge, 5 cm
hypodermic needle might be used.

Local anaesthetic may be injected prior to

the main injection but this entails extra
manipulation as well as non-contrast fluid
(anaesthetic) in the joint leaving less room
for the contrast in the limited joint space as
well as possibly 2 punctures.

The needle may inadvertently be

withdrawn from the joint after anaesthetic
injection during the switch to connect the
syringe with contrast. This could be
avoided by using a three-way connector
between the two syringes containing the
anaesthetic and the injection fluid (contrast
or medication).

The needle is advanced at a caudo-cranial

angle along the long axis of the transducer
aiming for the anterior recess near the
junc- tion of the femoral neck with the
femoral head (Fig. B and C).

The bevel of the needle should be facing

toward the joint.

When the needle makes contact with the

femoral head-neck junction it is slightly
retracted.

If one sees that it is within the joint

capsule, 10-15 mL contrast or medication
is injected and one sees the anterior recess
swell with fluid confirming the intra-
articular positioning.

Knee
 Indications for CT or MR arthrography of
the knee are evaluation of the post-
operative meniscus, query intra-articular
bodies, evaluation of the stability of
osteochondral lesions and evaluation of
articular cartilage. One may also be
requested to inject medication such as
corticosteroids and/or a local anaesthetic.

For injection we do not use ultrasound

guidance but use the standard "blind"
procedure introducing the needle (21-
gauge, 50 mm) behind the patella using a
lateral midpatellar approach.

The patella is lateralized and the needle

introduced from the mid lateral side aiming
toward the centre of the patella indicated
by the left forefinger.

The needle is introduced horizontally

aiming posterior to the centre of the patella
until one makes contact with the lateral
patellar facet or the lateral femoral condyle
and when felt to be in the joint 40 mL
contrast media is injected.

Prior to CT or MR one can choose to apply

a tight bandage above the patella thereby
forcing contrast from the suprapatellar
recess into the joint space proper.

Ankle and foot

Tibiotalar joint

CT or MR arthrography may be used to

query ligamentous, osteochondral or
chondral injury, eval- uation for free bodies
or query stability of ostechondral lesions.

For injection of the ankle (tibiotalar joint)

the patient is supine with the foot in slight
plantar flexion.

The medial side of the tibiotalar joint is

investigated anteriorly with ultrasound to
The foot is slightly plantar flexed. The long axis deter- mine a suitable place for injection,
of the transducer is indicated by the grey line on at the same time checking for any
the side, being in a sagittal plane. excessive joint fluid.

We use a small curved array 8 MHz

transducer but if preferred one can use an

Sonogram showing the needle (arrow) and the
needle tip (arrowhead) and the injected contrast
media in the tibiotalar joint.
18-12 MHz linear array transducer. The
long axis of the probe is held in a sagittal
plane.
The needle, usually 22-gauge (length: 30
mm), is introduced in line with the long
imaging axis of the transducer on the
medial side of the anterior joint space,
medial to the anterior tibial ligament,
avoiding ligaments and vessels.
One should identify the talar dome and the
overhanging anterior tibial lip. The needle
is angled caudo-cranially into the joint
under the ventral lip of the distal tibia
aiming for the articular surface of the distal
tibia.
Contact is felt and once again one ensures
that the needle tip is free from the tibial
cartilage and that the bevel is facing into
the joint.
8-10 ml of contrast is injected into the
tibiotalar joint and one sees the anterior
capsule swells up with the fluid.
There should be no resistance to injection
or pain experienced by the patient.
Posterior subtalar joint
The subtalar or talocalcaneal joint is
composed of 3 facets: a broad posterior
facet representing the primary articulating
surface, a medially located middle facet in
which the sustentaculum tali articulates
with the medial process of the talus, and
an anterior facet. Subtalar arthrography
may be performed via an anterolat- eral,
posterolateral or posteromedial approach.
2-4 ml of contrast material is injected into
the posterior subtalar joint.
Volumes of injection
 1.
Sinus tarsi

The sinus tarsi is a cone-shaped cavity that

courses in a postero- medial to
anterolateral direction. It is located in the
lateral aspect of the foot between the neck
of the talus and the anterosuperior surface
of the calcaneus.

The tarsal sinus continues medially as the

tarsal canal, which is a funnel-shaped
space between the talus and the calcaneus.
Schematic drawing in a coronal view of the right
sinus tarsi. Displayed are the course and
It contains fat, an arterial anastomosis,
attachment sites of the cervical ligament (1);
the interosseous talo- calcaneal ligament (2); joint cap- sules, nerve endings, and five
and the medial (3), intermediate (4), and lateral ligamentous structures-the medial,
(5) roots of the inferior extensor retinaculum. intermediate, and lateral roots of the
inferior extensor retinaculum; the cervical
ligament; and the interosseous
talocalcaneal ligament (figure).

This space can be the cause of foot pain in

the sinus tarsi syn- drome. The first step in
treatment is infiltration of the sinus tarsi
with a mixture of Depomedrol and local
anaesthetic (Lidocaine). This can be
challenging for the surgeon in a non-guided
approach but is reasonably easily and
accurately achieved with ultrasound
guidance.

US-guided injection of the sinus tarsi at the

right-hand side with a lateral approach.
The transducer is held in a coronal oblique
plane. The needle is introduced along the
long axis of the transducer.

The sinus tarsi can easily be visualized

using ultrasound.

The patient turns onto the contralateral

side laying the foot to be treated with its
medial surface against the table top, the
lateral side of the foot being uppermost.

The transducer is held in a coronaloblique

plane with regards to the foot.

US-guided injection of the upper and lower

extremity joints.
by Collins JM, Smithuis R, Rutten MJ. Eur J Radiol.
2012 Oct;81(10):2759-70
The sinus tarsi is identified as a triangular
space between the anterior process of the
calcaneus and the talar neck.

The tip of the needle (arrow head) is seen

within the cone shaped sinus tarsi, which is
bordered by the talus (T) and calcaneus
(C).

Depending on the degree of inflammation

there may be hyperemia of the space and
there may be intervening vessels visible,
which one wishes to avoid. This is relatively
easy, especially with colour doppler