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Hip and Pelvic InjectionsGeoffrey S. Van Thiel, MD, MBA,*,† Jaskarndip Chahal, MD, FRCSC,*,‡ Nathan Mall, MD,*Wendell Heard, MD,* Mark A. Jordan, BS,* and Shane J. Nho, MD, MS*,‡

Hip and pelvic disorders can be both functionally limiting and nonspecific. There are multipleoffending etiologies that often have significant cross over with regard to their symptoms. Animproved understanding and an increase in the treatment modalities have allowed physiciansto better identify and treat a wide range of ailments. Furthermore, the increase and availabilityof ultrasound has made evaluation and diagnosis of a multitude of conditions possible in anoffice setting. These advances in diagnosis have been followed by improved treatment options,including femoroacetabular impingement procedures and hip arthroscopy. However, the first-line treatment for the majority of hip and pelvic conditions consists of extensive conservativemanagement. Injections are a major part of the nonoperative treatment and can be an effectivediagnostic and therapeutic tool. This review describes injection techniques that can be used totreat a variety of hip and pelvic conditions, including bursitis, gluteus medius tendinosis,piriformis syndrome, hamstring pathology, labral tears, and osteoarthritis.Oper Tech Sports Med 20:142-153 © 2012 Elsevier Inc. All rights reserved.

KEYWORDS hip, pelvic, injections, trochanter

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Hip and pelvic pathology has gained significant attentionin contemporary orthopedics. The increase and avail-

bility of ultrasound has made evaluation and diagnosis of aultitude of conditions possible in an office setting. This has

een coupled with the fact that advances in hip arthroscopyave increased the treatment options we are able to offeratients. This increase in recognition and treatment of poten-ial pathologic conditions has also created a demand for newiagnostic and therapeutic options.The following review details the use of injections for the

iagnosis and treatment of a variety of hip and pelvic condi-ions, including bursitis, gluteus medius tendinosis, pirifor-is syndrome, hamstring pathology, labral tears, and osteo-

rthritis (OA).

BursitisGreater Trochanter BursitisTrochanteric bursitis is a term used to describe lateral hip painthat is most often accompanied by tenderness to palpation over-lying the lateral aspect of the hip. However, trochanteric bursitis

*Rush University Medical Center, Chicago, IL.†Rockford Orthopedic Associates, Rockford, IL.‡University of Toronto, Toronto, Canada.Address reprint requests to Shane J. Nho, MD, MS, Rush University Medical

Center, Midwest Orthopaedics at Rush, 1725 West Harrison Street, Suite

1063, Chicago, IL 60607. E-mail: shane.nho@rushortho.com

142 1060-1872/12/$-see front matter © 2012 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1053/j.otsm.2012.04.001

is now recognized as a member of a group of disorders oftenreferred to as the “greater trochanter pain syndrome.” The rea-son for this is lateral hip pain can be due to multiple othercauses, such as tendinitis, muscle tears, trigger points, and ili-otibial band disorders. Consequently, the exact etiology andpathology that are creating the patient discomfort is often diffi-cult to discern. There is no doubt that inflammation of the bursacan be a pain generator, but we are refining our diagnostic abil-ities to treat this condition more effectively.

In primary care settings, the incidence of greater trochantericpain is reported to be around 1.8 patients per 1000 per year.1 Itypically presents as chronic persistent pain in the lateral hipnd/or buttock that is exacerbated by lying on the affected side,ith prolonged standing or transitioning to a standing position,

itting with the affected leg crossed and with climbing stairs,unning, or other high impact activities.

There are specific physical examination criteria for tro-hanteric bursitis, as described by Ege Rasmussen Fanø,2

these include lateral hip pain with distinct tenderness aboutthe greater trochanter and one of the following:

1. Pain at the extreme of rotation, abduction, or adduction2. Pain on hip abduction against resistance3. Pseudoradiculopathy—pain radiating down the lateral

aspect of the thigh

However, it must be kept in mind that these symptoms arealso classic for greater trochanter pain syndrome, and a full

work-up should be completed.

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Hip and pelvic injections 143

Most cases of trochanteric bursitis are self limiting andtend to resolve with conservative measures, such as non-steroidal anti-inflammatories, ice, weight loss, physical ther-apy, and behavior modification that aim to improve flexibil-ity, muscle strengthening, and joint mechanics whiledecreasing pain. When conservative management fails, bursaor lateral hip injections with corticosteroid and local anes-thetics can provide effective long-term relief in 70%-85% ofpatients.3,4

Injection TechniqueThe greater trochanter is identified by palpating the lateralaspect of the proximal femur until a bony ridge is felt. Theappropriate site for the injection is the point of maximaltenderness in this area. At this point of maximal tenderness,a 22- or 25-gauge, 1“ and 1½” needle, is inserted perpendic-ular to the skin (Fig. 1). It is possible to use a longer needle inobese patients. The needle should then be inserted directlydown to bone, and then withdrawn 2-3 mm before injecting.A volume of 9 mL of a local anesthetic and 1 mL of steroid canthen be infused.Current Procedural Terminology (CPT) coding: Greater tro-chanter bursa injection-20,610.

Iliopsoas Bursitis/TendinitisIliopsoas tendinitis or bursitis is another recognized source ofhip/groin pain. It is often seen in the setting of rheumatoidarthritis, acute trauma, overuse injury, or after total hip ar-throplasty.5-7 At presentation, patients may note pain withpecific sports-related activities, such as jogging, running, oricking. Pain can also be present with everyday activities thatequire hip flexion, including putting on shoes, going uptairs, getting up from a seated position, and fast walking/

Figure 1 Greater trochanter injection. This is to be done at the pointof maximal tenderness.

ogging. This discomfort will typically radiate down the an-

erior thigh toward the knee, and, occasionally, patients mayeport an audible snap or click in the hip.

Conservative management, including rest and stretching,s recommended as a first-line treatment in all cases, but inefractory cases, an anesthetic corticosteroid injection intohe tendon’s adjacent bursa can be both diagnostic and ther-peutic. Complete or near complete relief of the symptomsonfirms the diagnosis. More importantly, this injection mayrovide significant relief and help the patient avoid surgical

ntervention. By contrast, failure of the injection to provideelief may indicate an alternate cause for hip pain, such asabral degeneration or tear.

liopsoas Bursitis/Tendonitis Injection Techniquen iliopsoas injection is performed with the patient in aupine position. The tendon can be localized using a linearor curvilinear in larger patients) transducer placed in anblique orientation parallel to the femoral neck. The ili-psoas tendon is found in a deep eccentric position withinhe posterior and medial parts of the muscle belly and liesver the iliopectineal eminence. The iliopsoas bursa liesetween the tendon and the anterior capsule of the hip

oint; in normal states, it is collapsed and cannot be de-ected with ultrasound. Injection is then performed with a2- or 20-gauge spinal needle using a lateral approach athe level of the joint line (iliopectineal eminence) (Fig. 2).ocation can be confirmed by viewing the distention of theursa in real time (Fig. 3). Any combination of local anes-hetic and steroid is acceptable. We prefer a mixture of 4L of lidocaine, 4 mL of Marcaine, and 2 mL of steroid.he only potential immediate complication is a transient

emoral nerve palsy.PT Coding: Iliopsoas injection with ultrasound guidance-0,552 for 1 or 2 muscles.

Figure 2 Iliopsoas injection. Ultrasound probe is placed transverse

over the iliopsoas, and the needle is inserted in the long axis.

144 G.S. Van Thiel et al

Gluteus Medius TendonosisAs stated earlier in the text, lateral hip pain is often referred toas “greater trochanteric pain syndrome,” which is a clinicalsyndrome characterized by chronic pain localized to the lat-eral aspect of the hip. It has traditionally been associated withtrochanteric bursitis; however, recent studies suggest that it

Figure 4 Gluteus medius injection. Ultrasound probe is placed in acoronally oblique orientation, and the needle is inserted in the long

Figure 3 Ultrasound view of the iliopsoas. IP, iliopsoas muscle; IPT,iliopsoas tendon (arrow); A, acetabulum (arrow); Gray line, needletrajectory from lateral to medial in the long axis.

axis from anterior.

actually may be more often the result of gluteus medius ten-dinopathy.8-12

Gluteus medius tendinopathy involves tenderness to pal-pation of the gluteus medius muscle over the lateral aspect ofthe hip. This can be initiated by falls, prolonged weight bear-ing, overuse, and sporting activities. The most common pa-tient is the middle-aged woman that begins an exercise pro-gram with repetitive cardio. Initial presentation usuallyincludes transient pain that worsens over a period, a Tren-delenburg gait, and weakness. These symptoms can evenmore specifically affect runners, as there is tilting of the pelviswith running.

On physical examination, it can be difficult to distinguishbetween trochanteric bursitis and gluteus medius tendinitisdue to their proximity at the insertion site. A common way todifferentiate the 2 is that resistance to abduction will notaffect trochanteric bursitis but can cause pain at the posteriorinsertion of the gluteus medius onto the trochanter.

Injection Technique forGluteus Medius TendinopathyTo prepare the patient for the ultrasound injection, localanesthetic can be injected into the skin under sterile condi-tions, and the patient is placed in the lateral decubitus posi-tion. The ultrasound transducer is then positioned in anoblique coronal plane, and a 22-gauge spinal needle is fixedto a 10-mL syringe filled with local anesthetic is inserted viaan anterior approach in the long axis (Fig. 4). Using contin-uous ultrasound imaging, the needle is advanced while in-jecting a small amount of local anesthetic (Fig. 5). This injec-tion technique allows a deeper local anesthesia to be obtainedfor the comfort of the patient and gives a better image of thelocation of the tip of the needle. The fascia lata is traversedwith the needle, and the tip is positioned at the lateral part ofthe gluteus medius tendon at its insertion to the greater tro-chanter. A mixture of 4 mL of local anesthetic and 1 mL of acorticosteroid is then injected and monitored under real-time

Figure 5 Ultrasound view of the gluteus medius injection. GM, glu-teus medius; GT, greater trochanter.

ultrasound.

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Hip and pelvic injections 145

CPT coding: gluteus medius injection with ultrasound guid-ance-76,942.

Lateral FemoralCutaneous Nerve SyndromeCompression of or injury to the lateral femoral cutaneousnerve is also known as Meralgia Paresthetica. It is a syndromeof paresthesia and pain in the lateral and anterolateral thighthat is most commonly seen in middle-aged individuals, butit can occur at all ages. Compression usually occurs at theinguinal ligament, and it can result from intrapelvic, ex-trapelvic, or mechanical causes. Intrapelvic causes includepregnancy, abdominal tumors, uterine fibroids, diverticuli-tis, or appendicitis. Extrapelvic etiologies are more commonand include direct trauma to the nerve (commonly the resultof a seat belt injury), tight garments, or belts. Mechanicalfactors can include prolonged sitting, standing, or repetitiveflexion of the hip.

Symptoms include anterior and lateral thigh burning, tin-gling, and/or numbness. Standing, walking, or hip extensioncan exacerbate the symptoms, and patients will often have anincrease in discomfort when lying prone. The symptoms usu-ally improve with sitting and are almost always unilateral.Physical examination findings include hyperesthesia over thelateral thigh, and pain can be reproduced by pressure justmedial to the anterior superior iliac spine (ASIS). A positiveTinel sign can also be present directly over the nerve withpercussion.

Diagnosis is based on clinical symptoms, but can be con-firmed with relief following a localized injection. Conserva-tive treatment and time will relieve the symptoms in mostpatients; however, for those who continue to have discom-fort, a therapeutic injection of anesthetic and steroid can be

Figure 6 Lateral femoral

performed.

Lateral Femoral Cutaneous Nerve InjectionA lateral femoral cutaneous nerve injection can be performedwith a 22- or 25-gauge needle. A local anesthetic is placed inthe skin approximately 1.5 cm caudal to the anterosuperioriliac spine just below the inguinal ligament. A deeper injec-tion of 1-2 cm is then performed at an angle of approximately60° to the skin with 4 mL of local anesthetic and 1 mL ofsteroid (Fig. 6).13

CPT coding: lateral femoral cutaneous nerve injection (ante-rior thigh) 64,450.

Piriformis SyndromePiriformis syndrome is increasingly recognized as a potentialcause of buttock and posterior leg pain. The tight piriformismay become tender and contracted or may cause compres-sion of the surrounding structures, including the sciaticnerve and blood vessels. There are a multitude of conditionsthat would be included in the differential diagnosis of piri-formis syndrome, including sciatica, hip pain, and hamstringpathology. In fact, piriformis syndrome is more often a diag-nosis of exclusion after all other potential causes have beenruled out.

The major clinical symptom is buttock pain, with or with-out posterior thigh pain, which is aggravated by sitting oractivity. Physical examination may demonstrate tendernessto palpation at the greater sciatic notch or over the piriformismuscle belly. Diagnostic tests, such as magnetic resonanceimaging (MRI), computed tomography, and electromyogra-phy (EMG), are used to rule out other sources of pathology;unfortunately, there is no classic diagnostic test for piriformissyndrome.

Initial treatment for piriformis syndrome is always conser-vative, and patients will respond well to stretching tech-niques. The stretching will relax a tight piriformis and help to

eous nerve injection.13

relieve any associated nerve compression. Stretches can be

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146 G.S. Van Thiel et al

done in both the standing and supine positions, and involvehip and knee flexion, hip adduction, and internal rotation ofthe thigh. However, there are patients who do not respond tothese stretching techniques, and are then good candidates fora therapeutic injection.

There are multiple different techniques and injectionsavailable. The injections include local anesthetic, corticoste-roid, botulinum toxin, or any combination. Lidocaine andcorticosteroid have been shown in a large study to providesymptomatic improvement when combined with physicaltherapy.14 Botulinum toxin has also received significant at-ention recently in the treatment of piriformis syndrome andas been shown to be effective.15 One large study comparedotox with steroid and found that Botox provided a higheregree of pain relief at 60 days.16 Regardless, both steroid andotox have been shown to provide relief when combinedith physical therapy.A variety of techniques have been described using EMG,

uoroscopy, ultrasound, and computed tomography. Ourreferred technique is to use either fluoroscopy or ultra-ound; however, the technique is described in the followingection.

Piriformis Injection TechniqueUltrasonographic GuidancePlace a curvilinear probe horizontally between the greatertuberosity and the ischial tuberosity (Fig. 7). Find the sciaticnerve as a hyperechoic structure. The piriformis muscle canthen be seen moving with its attachment site on the greatertrochanter with internal and external rotations of the hip anda flexed knee (Fig. 8).17 The probe is then directed parallel tohe piriformis, and the needle is inserted in the long axis viewhrough the gluteus maximus from medial to lateral into theiriformis (Fig. 9).17

Figure 7 Piriformis injection. Ultrasound is inline with the pirifor-

mis, and the needle is placed in the long axis from medial to lateral.

To avoid injury to the sciatic nerve, advance the needleslowly and have the patient report any neurologic symptoms(numbness, tingling, electrical impulse, etc). If these signs dooccur, slowly pull the needle back and redirect it more later-ally. If the injection is placed too close to the nerve, thepatient may experience postinjection weakness in that leg.They should be counseled that this is transient, and thestrength will return.CPT coding: piriformis injection with ultrasound guidance-76,942.

Figure 8 Ultrasound view of the piriformis. G MAX, gluteus maxi-us; PIR, Piriformis; GT, greater trochanter.17

Figure 9 Injection of the piriformis. Needle in the long axis frommedial to lateral. (A) Arrows illustrate the needle. (B) Fluid is shown

by the black line/area. PIR, piriformis.17

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Hip and pelvic injections 147

Hamstring InjectionsHamstring strains of the mid and distal hamstring myotendi-nous complex are common athletic injuries. These injuries caninclude partial tears, full tears, inflammatory reaction, and ten-don degeneration. The initial presenting symptoms will mostoften include the acute or subacute onset of deep buttock andthigh pain with activity. Patients with grade I injuries will usuallyrecover quickly and do not seek medical attention. However,grade II and III strains report acutely with pain, loss of strength,transient sciatica, and posterior thigh tenderness.

Physical examination in the prone position will reveal anarea slightly swollen, tender, and possibly ecchymotic. Painis exacerbated with 90 degrees of hip flexion or resisted kneeflexion. It has been reported that the more proximal the in-jury, the longer the recovery process.18 If there is a significant

amstring rupture, a palpable knot or defect can be felt alonghe posterior thigh.

In the absence of a large defect, initial treatment shouldonsist of conservative measures and physical therapy. Rest,ce, compression, and elevation are the mainstay of initialamstring strain treatment. This helps to decrease hemor-hage and the inflammatory process. After a couple days ofest, physical therapy can be initiated for range of motion andradual strengthening. If these conservative measures fail torovide symptomatic improvement, and MRI can then berdered to further evaluate the hamstring tendon. A large tearan be addressed operatively in the symptomatic patient.

However, in the setting of a symptomatic partial tear orprain that has failed conservative management and operativentervention is not indicated, an injection can be considered.evine et al19 reported good results of corticosteroid injec-

tions in National Football League football players.

Hamstring Injection TechniqueThe technique is rather simple. The hamstring myotendinouscomplex is palpated along its length on the posterior thigh withthe patient in the prone position. The point of maximal tender-ness is identified, and a mixture of anesthetic and corticosteroidis injected intramuscularly (Fig. 10). The senior authors do notuse it, but ultrasound can also be used to isolate the hamstringtendon at the insertion to the ischial tuberosity.

Complications are related to intramuscular injection andinclude hemorrhage and pain. However, these are infre-quent. Patients are usually restricted from activity for 48hours, and then they are allowed a gradual return with phys-ical therapy, focusing on initial range of motion.

Hip Osteoarthritis/Labral PathologyRheumatologic and recent orthopedic literature differs whendiscussing primary hip OA. Although many rheumatologistsand primary care physicians believe hip OA is a primarydisorder, many hip surgeons believe that the incidence ofidiopathic OA of the hip is rare and that it can be typically

attributed to some underlying process or deformity.20-23 Hip

ysplasia of varying severity, hip impingement (Cam or Pin-er), acetabular retroversion, coxa profunda, prior Legg-alvé-Perthes disease, prior slipped capital femoral epiphy-

is, infection, neuropathy, avascular necrosis, or trauma canach lead to OA. Obesity also seems to play a role in theevelopment of hip OA, and although it may or may not be airect cause, it likely accelerates the process or worsens theffects of the underlying deformity. Regardless of the cause, hipain is a common presentation to both the primary carehysician and orthopedic specialist. A recent systematiceview using radiographs to diagnose hip OA found arevalence ranging from 0.9% to 27% in the general adultopulation.24

Labral pathology has been increasingly recognized in ayounger patient population. Scientific studies are ongoing todescribe the exact role of the hip labrum, but we do know that itprovides a “suction seal” for the hip joint and may assist in thecontact mechanics during hip loading. In differentiation to OA,these patients are younger with different symptoms.

In arthritic hips, patients often complain of a grindingsensation in the groin, decreased range of motion, and in-creasing difficulty of activities of daily living, including put-ting on their shoes or socks. Often patients will complain of adeep pain that worsens with weight bearing. Certain findingsin the history should alert the physician to search for anothercause of the patient’s pain. Hip OA does not typically causeradicular or shooting pain. Pain over the greater trochanter ordeep posterior pain is not typically caused by hip OA directly,but trochanteric bursitis or posterior tendinoses can be foundconcomitantly with OA of the hip. In younger patients with asuspected labral tear, some will complain of a traumatic eventthat initiated their hip pain, but the majority will describe aninsidious onset of anterior/groin pain with activities that re-quire hip flexion.

Physical examination findings that typically accompany

Figure 10 Hamstring injection.

both hip OA and labral tears are limitation of motion and

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148 G.S. Van Thiel et al

pain localized to the groin. Typically, patients will have re-duced hip flexion and hip flexion with internal rotation. De-pending on the severity of the arthritis, more limitations inmotion can occur. Any examination of the hip should beginwith a general observation of the patient’s posture and gaitpattern. A Trendelenburg gait can clue the physician regard-ing hip abductor weakness, whereas an antalgic gait may beseen with pain causing limited motion. A careful examinationof the lumbar spine should be included as part of the hipexamination.

A standard standing anterior-to-posterior (AP) pelvis ra-diograph, AP of the affected hip, and cross table or frog-leglateral radiographs should be obtained in patients complain-ing of hip pain, especially when localized to the groin. MRI orother advanced imaging should not be needed for the diag-nosis of hip arthritis and should be reserved for patients aged�60 years with no radiographic evidence of OA and physicalexamination findings suggestive of intra-articular hip pathol-ogy. MRI arthrogram is more reliable at detecting intra-artic-ular hip pathology than MRI alone, and local anesthetic withor without corticosteroid can be injected at the same time asa diagnostic and potentially therapeutic injection.

Treatment of hip OA includes similar treatment to otherforms of OA, which include weight reduction, anti-inflam-matory medications if not contraindicated, and activity mod-ification. Intra-articular injections can be used for diagnosticand therapeutic purposes. The ultimate treatment is a totalhip arthroplasty, which offers patients a high success rate anddramatic improvements in pain and functional scores. How-ever, as with any surgery complications exist, such as infec-tion, fracture, prosthesis failure, prosthesis wear, squeaking(with some implant materials), and dissatisfaction.

The treatment of labral tears also includes initial conserva-tive measures with avoidance of offending activities, physicaltherapy, and nonsteroidal antiflammatories. If these mea-sures fail, hip arthroscopy can provide effective relief ofsymptoms and return to activity.

Indication for InjectionIntra-articular hip injection can be performed for therapeuticor diagnostic purposes. The physician can confirm a diagno-sis of an intra-articular process using a diagnostic injection oflocal anesthetic, which can be combined with corticosteroidfor a therapeutic effect. Corticosteroid may be avoided in theyoung patient in whom the injection may be used to helpdiagnose a labral tear; however, when there is subtle to severeOA, corticosteroid can be used if there are no contraindica-tions. Intra-articular steroid injections can help the cliniciandifferentiate between intra-articular hip pain or pain radiat-ing from the lower back.25 A recent study of 40 patients with

onolateral severe hip OA undergoing a series of 3 plateletich plasma injected during a 3-week period demonstratedignificant reductions in Visual Analog Scale, Western On-ario and McMaster Universities Arthritis Index, and Harrisip subscores for pain and function both at 7 weeks and 6

onths. Fifty-eight percent of patients achieved at least a

0% reduction in their pain scores, which was deemed thelinically significant difference.26

Injection TechniqueTypically, the most reliable and comfortable method of per-forming a hip injection is performed in the supine position,with the needle directed from anterolateral (Fig. 11). Withthe patient lying supine on a radiolucent table, the ASIS ispalpated and marked. A line is then drawn down the longaxis of the femur from this spot. Needle placement shouldstay lateral to this line to avoid risk to the femoral nerve andvessels. The femoral vessels can typically be palpated and canbe marked for further assurance. Radiographic guidance canthen be used beginning at a point approximately 2.5 cmdistal to the ASIS, and fluoroscopy can verify using a ra-diopaque instrument that this location is in line with thefemoral head. The entrance site it then marked, and localanesthetic, typically 1% lidocaine, is used to anesthetize theskin and subcutaneous tissues after sterile preparation.

Using sterile technique, a 22-gauge spinal needle with a10-mL syringe filled with air attached is then introduced intothe skin and directed toward the center of the femoral headon the AP radiograph. Once the needle reaches the center ofthe femoral head on radiograph, the air in the syringe isinjected, and a fluoroscopic radiograph is taken of the airarthrogram to confirm intra-articular placement of the needle(Fig. 12). We then attach a separate syringe of 2 mL of 1%lidocaine, 2 mL of 0.5% Marcaine, and 1 mL of 40 mg Depo-Medrol. This is injected into the joint by keeping the needledirectly on the femoral neck and pulling back only enough toallow the medication to flow freely.

Injection After CareIce to the injection site is typically recommended. Refrainingfrom strenuous activity the day of the injection is also typi-cally advised. Otherwise, there are no limitations following

Figure 11 Hip injection. Location of needle.

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Hip and pelvic injections 149

ComplicationsPotential complications include a rise or irregularity in bloodsugars in poorly controlled diabetic patients, intravascularinjection of local anesthetics, and improper placement of themedication (inability to inject into the joint).

CPT and ICD-9 Code76,942 Ultrasonic guidance for needle placement.20,610 Arthrocentesis, aspiration, and/or injection; majorjoint or bursa.77,002 fluoroscopic guidance for needle placement (modi-fier 26 if do not own the X-ray machine-professional compo-nent only).715.5 osteoarthrosis—hip.

Osteitis PubisSports-related groin injuries occur with an incidence of0.5%-6.2%,27 with even higher rates in soccer players. The

ifferential diagnosis for groin pain in an athlete includessteitis pubis, sports hernia, referred low back pain or geni-ourinary pain, intra-articular hip pathology, stress fractures,nd musculotendinous strains. Osteitis pubis is defined as aainful inflammatory process of the pubic symphysis andurrounding structures.

Urological and gynecologic procedures, rheumatologi-al conditions, trauma, pregnancy, and athletics are pre-isposing factors thought to contribute to the develop-ent of osteitis pubis. Pain is caused and worsened by

printing, kicking, twisting, and cutting, and thus partic-

Figure 12 Hip injection fluoroscopy. Left image shows tgram to confirm the intra-articular location.

pants in sports, such as soccer, football, ice hockey,

ugby, and running, are at higher likelihood of developinghis condition.28

On physical examination, there is tenderness to palpationof the pubic symphysis. Resisted strength testing of the ad-ductor muscles as well as the lower abdominal muscles oftenelicits pain due to their pull on the pelvis. Adductor stretch-ing by hip abduction can also cause pain. There is significantoverlap between this and other disorders causing chronicgroin pain in the athlete.

Radiographs are typically the first diagnostic modality or-dered as irregularity at the symphysis can sometimes be seenon this inexpensive test, especially in chronic cases. MRIwould likely be the next most informative test, as this candemonstrate edema in the bone. A bone scan or a taggedwhite blood cell scan can be used to differentiate from osteo-myelitis if the clinical picture is indistinct.

Treatment typically starts with anti-inflammatory med-ications (NSAIDs) and physical therapy. Some authors de-scribe use of compression shorts as additional therapy.Results of a systematic review of the treatment of osteitispubis demonstrated that physical therapy and NSAID usewere more beneficial, and return to play was faster theearlier the diagnosis was made and treatment was initi-ated.29 Therapy should be directed at core stability, glutealnd adductor strength, and endurance.

Indication for InjectionThe indication for injection in this population would be inathletes who have failed conservative treatment. Studies ex-amining corticosteroid use for osteitis pubis demonstrate a

le entering the joint. Right image shows an air arthro-

he need

58.6% success rate and over 20% that had no response.29

150 G.S. Van Thiel et al

This may be related to the fact that injections were reservedfor athletes who did not respond to other treatments. Onestudy noted that 3 patients who underwent acute injection allwere able to return to sport within 2 weeks from the injec-tion, indicating there may be a role for immediate injection inthe acute period.28 Prolotherapy has been performed in 1study, with �90% of athletes returning to sport at a mean of9 weeks from the first injection. None of these studies wererandomized controlled trials and thus the indications for in-jection following the diagnosis of osteitis pubis need furtherexamination.

Injection TechniqueThe patient is brought to a room with fluoroscopic capabili-ties. The patient lies supine on a radiolucent table. The phy-sician typically can palpate the pubis, and often the symphy-sis. If the symphysis is not palpable an AP fluoroscopic imagecan be taken to localize the needle. After prepping the pa-tient, sterile technique is used to inject local anesthetic (typ-ically 1% lidocaine) using a 25 gauge by 1.5 needle in the skininitially and then through the subcutaneous tissues down tothe level of the symphysis (Fig. 13). Then, a 22-gauge needlecan be inserted into the symphyseal cleft. This is performed byfeeling the needle meet some resistance, which will indicate theouter margins of the joint, and then advancing an additional 1cm. The feel of puncturing the fibrocartilaginous disk is de-scribed as similar to that of puncturing an intervertebral disk.30

Once in the disk, 1 mL of nonionic contrast material can beinjected to ensure appropriate placement of the needle, outlinethe disk, and determine if there is disk degeneration, and poten-tially provoke symptoms similar to a spinal diskogram.30 Oncethe contrast material is injected, a fluoroscopic AP radiographshould be obtained to evaluate the disk morphology. Followingthe radiograph, a 3-mL solution of 1 mL 0.5% Marcaine, 1 mL of1% lidocaine, and 1 mL of 40 mg Depo-Medrol is injected.Other local anesthetics and steroid medications can be substi-tuted. The patient should then be reexamined, and prior posi-tive findings should be eliminated or reduced in severity.

Injection After CareIce to the injection site is typically recommended followingthe injection. The patient should refrain from strenuous ac-tivity the day of the injection, however, can return to normalactivities of daily living.

ComplicationsNo reported complications were noted in any of the studiesevaluating cortisone and prolotherapy for osteitis pubis. The-oretic risks include bladder puncture, infection (especiallywith repeated injections), and intravascular injection of localanesthetic, as this is a highly vascular area. Localizationshould be performed with either direct palpation, ultrasoundguidance, or fluoroscopy. The latter 2 would allow the phy-sician to evaluate the depth of the needle to ensure bladderpenetration does not occur.

CPT and ICD-9 Code76,942 Ultrasonic guidance for needle placement.20,610 Arthrocentesis, aspiration, and/or injection; major

joint or bursa.

77,002 fluoroscopic guidance for needle placement (modi-fier 26 if do not own the X-ray machine-professional compo-nent only).733.5 Osteitis pubis.843.8 Sprain/strain hip or pelvis.

Sacroiliac JointThe sacroiliac (SI) joint is a diarthrodial joint that receivesinnervation from lumbosacral nerve roots. Fluoroscopicallyguided contrast-enhanced injections have shown that the SIjoint is a source of primary low back pain and/or lower ex-

Figure 13 Osteitis pubis injection. A, the insertion of the needle, andB, the injection of contrast and the confirmation of location withfluoroscopy.

tremity pain in approximately 15% of patients with low back

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Hip and pelvic injections 151

pain.31,32 The most common cause of SI joint pain is idio-athic and occurs acutely or because of cumulative trauma.auses of the pain have been suspected to include ligamen-

ous or capsular tension, extraneous compression or shearorces, hypomobility or hypermobility, aberrant joint me-hanics, and myofascial or kinetic chain imbalances leadingo inflammation and pain.33 Additionally, SI joint pain can beaused by infection, OA, malignancy, insufficiency fracture,racture of the SI joint after major trauma, ligamentousprain, and stress fracture. Inflammation in the SI joint can beaused by metabolic, traumatic, or arthritic processes. Nearly00% of patients with ankylosing spondylitis will developacroiliitis.34 Metabolic processes, including calcium pyro-hosphate crystal deposition, gout, ochronosis, hyperpara-hyroidism, renal osteodystrophy, and acromegaly, can prog-ess to early degeneration, inflammation, and pain.33 In

pregnancy, the release of relaxin and estrogen can cause loos-ening of the soft-tissue support structure around the SI jointand lead to pain, particularly in the third trimester. Patientswho have had previous lumbar spine fusion or hip arthrode-sis may transfer added stress to the SI joints. There is nouniversally accepted gold standard for the diagnosis of lowback pain stemming from the SI joint.35

SI joint pain is referred to an area just inferior to the ipsi-lateral posterior superior iliac spine, which is common toother sources of spinal pain. Only 4% of patients with SI painmark pain drawings above the level of L5.34 The referral of

ain to the lower extremity does not rule in or rule out SIoint pain. Slipman et al36 confirmed SI joint symptoms in 54atients using intra-articular blocks; 94% of patients haduttock pain, 48% thigh pain, 28% lower leg pain, 13% footr ankle pain, 14% groin pain, and 2% had pain in the ab-omen.No specific physical examination maneuvers that identify

I joint pain have been validated. The physical examinationhould include a neurologic examination, including straighteg raise and thoracolumbar spine range of motion evalua-ion. It should be noted that a false-positive straight leg raiseay occur when the affected leg is elevated to approximately

0° because false dural tension symptoms are caused by SIoint motion at this degree of elevation. A hip examinationhould also be performed. Typically, patients with SI jointain will be neurologically intact and may show nonderma-omal extremity sensory loss. Provocative tests (Patrick andaenslen tests), motion demand tests, true and functional leg

ength determinations, ligament tension tests, sacral sulcusenderness, Gillet test, and hip rotation tests lack scientificalidity.33

Treatment goals aim to decrease pain and increase func-tion. This is accomplished by improving joint kinematics,correcting lumbopelvic hip mechanics, establishing lum-bopelvic and lower extremity muscular length and strengthbalance, and addressing soft-tissue irritability. Additionally,establishing a preventive program is important for long-termsuccess. Physical therapy treatments follow the general prin-ciples of rehabilitation. Education and training regarding

proper body mechanics and posture, aerobic conditioning,

correction of flexibility and strength deficits, and early mo-bilization are all important in the treatment of SI joint pain.

Radiofrequency neurotomy of the L5 dorsal ramus, itsbranches to the SI joint, and the lateral branches of the S1-S3dorsal rami may be performed for chronic joint pain, but onlyafter less invasive treatment options have been attempted. Asan absolute last line of treatment, arthrodesis of the SI jointcan be performed.

Diagnostic anesthetic blocks offer an excellent way to con-firm the diagnosis of SI joint pain as well as provide a thera-peutic intervention to help improve function.

Injection TechniqueSI joint injections performed without the use of imaging as-sistance show poor target specificity and should be avoided.37

Rupert et al38 performed a systematic review of the literaturend concluded that the use of SI joint injections for diagnos-ic use is moderately supported, whereas the effect of thera-eutic SI joint injections is not sufficiently proven. Mosttudies show that intra-articular SI joint corticosteroid injec-ions provide therapeutic benefit for sacroiliitis in patientsith spondyloarthropathy39-43; however, there are no con-

rolled trials that show benefit for other causes of SI jointain.Typically, patients tolerate the procedure with local anes-

hetic, and premedication with anxiolytics or analgesics is noteeded. The patient is placed prone on the fluoroscopy table,nd the SI joint is viewed fluoroscopically. It will be necessaryo either position the patient in an oblique position or useuoroscopic equipment that permits rotation so the appro-riate view of the SI joint can be obtained. The SI joints arengled 10-30° posteriorly relative to the coronal plane and0-20° medially relative to the sagittal plane. When prone,he posterior joint is medial, and the anterior joint is lateral. Aephalad angling of the fluoroscopy tube by 20°-25° can helpifferentiate the posteroinferior SI joint by moving it in aaudal direction. The target for needle entry is in the inferiorspect of the joint, as the superior portion is fibrous. The skinntry site is found using a metal object with the aid of fluo-oscopy and is marked with a marking pen.

The skin is prepared in standard sterile manner. The skin isppropriately anesthetized, and a 22-gauge spinal needle isnserted through the anesthetized skin, aiming toward thearget area. There will be a decrease in resistance once theosterior longitudinal ligament is punctured. Fluoroscopyonfirms appropriate needle placement, which can be furtheronfirmed with radio-opaque contrast dye (Fig. 14). Theharmaceutical agents are then injected. A typical injectionay consist of 40 mg of methylprednisolone acetate with 2-3L of 0.5% bupivacaine hydrochloride, although numerous

teroid and anesthetic combinations are possible. The sciaticerve is just anterior to the piriformis muscle. Large amountsf local anesthetic or improper needle placement may causeransient lower extremity weakness.

ICD-9 Codes724.6 Disorders of the sacrum.

847.3 Sprain/strain of the sacrum.

3

152 G.S. Van Thiel et al

CPT Codes27,096: Injection procedure for SI joint, arthrography,and/or anesthetic/steroid. Code to be used only with imageconfirmation of intra-articular needle position.77,003: Fluoroscopic guidance and localization of needle orcatheter tip for spine or paraspinous diagnostic or therapeu-tic injection procedures. Use if formal arthrography is notperformed and recorded, and a formal radiographic report isnot issued.

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