ultrasound guided interventional procedures in.5

REVIEWARTICLE

Ultrasound-Guided Interventional Proceduresin 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 emergingas a popular technique for pain intervention. It can be applied for the in-tervention procedures in the hip region. The objectives of this reviewarticle were to review the relevant anatomy and sonoanatomy of thehip joint and the trochanteric bursae, to describe the techniques forultrasound-guided injections, and to examine the efficacy and accuracyof 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 orpain specialist for injections. Osteoarthritis is the most commonjoint disorder in the United States and is the leading cause ofdisability in the elderly. Radiographic evidence of osteoarthritisof the hip is present in about 5% of the population older than65 years.3,4 However, not all patients with radiographic evidenceof osteoarthritis have symptoms. According to the National Centerfor Health Statistics, the Healthcare Cost and Utilization Projectestimated 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 patientpopulation in the primary care setting.7 The prevalence increasesin patients with musculoskeletal low-back pain and in women.6–9

This review focuses only on these 2 causes of hip pain, asthey reflect the common reasons for the referral to anesthesiol-ogists. The first objective of this review was to describe andsummarize the anatomy and sonoanatomy of hip structures rel-evant to these hip pain conditions. The second objective was toexamine the feasibility, accuracy, and effectiveness of the injec-tions to these structures as well as the injection techniques.

METHODSA 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, UniversityHealth 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: [email protected]).

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 PDFversions of this article on the journal’s Web site (www.rapm.org).

Copyright © 2013 by American Society of Regional Anesthesia and PainMedicine

ISSN: 1098-7339DOI: 10.1097/AAP.0b013e318291c8ed

264 Regional Anesthes

Copyright © 2013 American Society of Regional Anesthesia and Pain

terms “ultrasound,” “ultrasound-guided,” “pain management,”and different hip structures relevant to this review, such as “hip,”“hip joint,” “trochanteric bursa,” and “greater trochanter painsyndrome.” Only literature published in English was included.

DISCUSSION

AnatomyThe anatomy of the hip region has been detailed in many

excellent textbooks. In this review, we focus on the anatomythat is pertinent to the understanding of the injection of thehip joint and the pathophysiology of GTPS.

The hip is a synovial “ball-and-socket” joint formed by thearticulation 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 acetabulumand 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 andseveral powerful para-articular ligaments, this structural ar-rangement confers stability to the hip joint.

The joint capsule surrounds the outer surface of the labrumand inserts distally to the intertrochanteric region and posterioraspect of the femoral neck. The anterior joint capsule is com-posed of 2 layers, anterior and posterior, that are separated bythe anterior recess of the joint space (Fig. 2). Each layer is ofconsiderable thickness (2–4 mm) and lined by only a minute sy-novial membrane.11 The anterior layer runs caudally and insertson the intertrochanteric line, where it blends with the perios-teum. Many fibers are reflected upward, covering the femoralneck, to form the posterior layer of the joint capsule, which endsat the caudal edge of the articular cartilage of the femoral head.The trochanters (greater and lesser) and the lateral third of theposterior femoral neck are extra-articular.10

The capsule has several thickenings, including the longitu-dinally oriented iliofemoral, ischiofemoral, and pubofemoralextracapsular ligaments (Fig. 1). The ligamentum teres femoris,an intracapsular ligament, is attached to the acetabular notchand a depression on the femoral head called the fovea capitis.12

The structures in the anterior hip regions from medial to lateralare the following: pectineus muscle, femoral neurovascular bun-dle, iliopsoas muscle and tendon, and sartorius and rectusfemoris muscles (Fig. 3 and see Video, Supplemental DigitalContent 1, http://links.lww.com/AAP/A72, which shows layerby layer the muscles in the anterior hip region [reproduced withpermission from Ultrasound for Regional Anesthesia, Ultra-sound for Regional Anesthesia, www.usra.ca]).

A good knowledge of the anatomy of the lateral hip regionis instrumental to the understanding of the GTPS. The bony sur-face of the greater trochanter (GT) consists of 4 facets: anterior,

ia and Pain Medicine • Volume 38, Number 4, July-August 2013

Medicine. Unauthorized reproduction of this article is prohibited.

mailto:[email protected]

FIGURE 1. Front view of hip joint, the labrum (left), and the hipligaments. Ischiofemoral ligament cannot be seen from this viewbecause of the posterior location. Reproduced with permissionfrom Ultrasound for Regional Anesthesia, www.usra.ca.

FIGURE 3. Muscles (M) around hip joint. The femoral head andneck (in dotted line) and the schematic of femoral neurovascularbundle are shown here for reference. V indicates femoral vein;A, femoral artery; N, femoral nerve. Reproduced with permissionfrom Ultrasound for Regional Anesthesia, www.usra.ca.

Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013 Ultrasound in Pain Medicine/Hip

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 minimusand anterior and posterior tendons of the gluteus medius insertinto 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, thesubgluteal 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 summarizedin Table 1.

The superficial layer, from anterior to posterior, is formedby the tensor fascia lata and gluteus maximus muscle. The trian-gular interval between these 2 muscles is filled with fascia lataoverlying the gluteus medius muscle (Fig. 5). This superficiallayer is also called “deltoid of the hip joint,” reminiscent of

FIGURE 2. Figure shows the anterior synovial recess (***). Undernormal circumstances, the amount of synovial fluid in the recessis kept at a minimum. This figure shows a hip with effusion fordemonstration. Reproduced with permission from Ultrasoundfor Regional Anesthesia, www.usra.ca.

© 2013 American Society of Regional Anesthesia and Pain Medicine


the deltoid muscle of the shoulder. The iliotibial (IT) tract is athickening 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 posterolateralaspect of the thigh and inserts in the Gerdy’s tubercle of tibia.

The deep layer comprises gluteus medius and minimusmuscles. The anterior two-thirds of gluteus medius muscle des-cends distally and forms a tendon that inserts into the inferioraspect of the lateral facet of the GT. The posterior portion ofthe muscle gives rise to a strong tendon, which inserts into theposterosuperior facet (Fig. 4). The gluteus minimus tendoninserts onto the anterior facet of the GT. The tendons of gluteusminimus and medius can be considered the rotator cuffs of thehip 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 describedconsistently: the SMaB, the subgluteal medius bursa, and thesubgluteal minimus bursa.8,9,20,21 The function of the bursaeis to serve as a cushion against friction between tendons and fas-cia lata.

The SMaB is situated lateral to the GT, deep to the fascialata, gluteus maximus muscle, and its tendon. Contrary to thebelief of a single bursa, the SMaB is typically subdivided intoup to 4 separate bursae. The deep SMaB bursa, often referredas the “trochanteric bursa,” is the largest and most consistentamong these subdivisions (Fig. 6A and Video, SupplementalDigital Content 3, http://links.lww.com/AAP/A74, which showslayer by layer the 3 groups of subgluteal bursae in the lateralhip region [reproduced with permission from Ultrasound forRegional Anesthesia, www.usra.ca]). Other SMaBs are the su-perficial subgluteal maximus, secondary deep subgluteal maxi-mus, and gluteofemoral bursae (Fig. 6B). The subglutealmedius bursa is associated with the anterosuperior portion ofthe GT separating the gluteus medius tendon from either thedistal insertion of gluteus minimus and/or the lateral anteriorsurface 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

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

Peng Regional Anesthesia and Pain Medicine • Volume 38, Number 4, July-August 2013

insertion of the hip joint capsule into the base of the femoralneck (Fig. 6E; Video 3).

Patient SelectionIntra-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

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

Muscle Origin

Gluteus maximus Outer surface of ilium behind the posterior gluteadjacent posterior surface of the sacrum and csacrotuberous ligament

Tensor fascia lata Outer edge of the iliac crest between ASIS andGluteus medius Outer surface of ilium, between iliac crest and p

middle gluteal lineGluteus minimus Outer surface of ilium between middle and infe

ASIS indicates anterior superior iliac spine.

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radiographic evidence of osteoarthritis are symptomatic.4

Patients with osteoarthritis of the hip classically present withanterior or inguinal pain that increases with joint movementand is relieved, although incompletely, with rest. Although painarising from the osteoarthritis of the hip can occur at night, hippain at night may instead reflect tumors, infection, chronic in-flammatory arthritis, or crystal-induced arthropathies. Physicalexamination is important to rule out other causes of hip pain orpain referred from the spine. Patients indicated for intra-articular

egion

Insertion

al line,occyx and

Majority inserted into the IT band, some tothe gluteal tuberosity of the femur

the iliac tubercle IT bandosterior and Anterior tendon to lateral facet and posterior

tendon to superoposterior facet of GTrior gluteal line Anterior facet of GT



FIGURE 5. Figure shows the muscles and fascia in the lateral hipregion. Reproduced with permission from USRA.


injection are those with moderate to severe pain and disability,with poor response to conservative management, and those nota 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 withlateral 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 ofphysical signs that are highly specific to GTPS, and the specific-ity and sensitivity of these clinical features mentioned abovehave not been validated.9 Both magnetic resonance imaging andultrasound 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 anatomyTendonsBone attachmentImpingementBursa

Evidence supporting cuff disease as etiologyBursitis is secondary to initial pathology at tendinous attachments

Evidence of bursitis in GTPSPresence of tendinopathy or tendon tears in GTPS



Sonoanatomy and Injection Technique forHip Joint

The technique for revealing the anterior recess of hip jointis anterior oblique sagittal technique; that is, the transducer po-sition is aligned with the axis of the femoral neck.25 The patientis placed in supine position with the hip in neutral position,and the groin is exposed as medial as pubic symphysis. Eithercurvilinear or linear probe can be used, but the author prefersa curvilinear probe as it gives a panoramic view of the anteriorrecess and femoral neck even in an obese patient. The first scanis 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 howto obtain the sonoanatomy of the anterior recess [reproduced withpermission from Ultrasound for Regional Anesthesia, www.usra.ca]). In this view, the femoral head and acetabulum can usually beseen 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 thatthe following structures can be well defined: femoral head, neck,and joint capsule.

A 3.5-in, 22-gauge spinal needle is inserted in-planefrom lateral to medial direction. The target is the synovial re-cess underneath the joint capsule between the femoral headand neck (Fig. 8; Video, Supplemental Digital Content 5,http://links.lww.com/AAP/A76, which illustrates step-by-stepthe 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 advisableto survey the potential needle path with Doppler scan for any un-suspected vessel (Video 5). The needle is inserted until bone iscontacted and is then withdrawn 1 to 2 mm to avoid engagingthe needle tip in the posterior capsule. Monitoring the spread ofthe injectate real time throughout the injection is important to en-sure the injectate is spread within the joint space (Video 5). Themedication used is 5 mL of local anesthetic with steroid, suchas 2% lidocaine and 40 mg methylprednisolone acetate. Alterna-tively, 5 mL of VS can be injected.

Accuracy and Efficacy of Intra-articular Injectionof 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 werewithin 5 mm of the femoral nerve in 60% of the needle

Shoulder Hip

Supraspinatus Gluteus medius, gluteus minimusGreater tuberosity Greater trochanter

Coracoacromial arch Fascia lata, IT tractSubdeltoid, subacromial bursa Subgluteus maximus bursa

Rationale behind rotator cuff tendonitis,12,13 supported byradiological evidence14

Uncommon15–17

Very common17

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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 superficialSMaB; B, deep SMaB; C, secondary deep SMaB; D, gluteofemoral bursa; M, muscle. Reproduced with permission from Ultrasoundfor Regional Anesthesia, www.usra.ca.


insertions. In contrast, the accuracy of ultrasound-guided injectionwas 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 forneedle tip is the junction between the femoral head and neck.29

Five randomized controlled trials (RCTs) examining theanalgesic efficacy of intra-articular hip steroid injection havebeen published, and all injections were performed under imageguidance (fluoroscopy = 3, ultrasound = 2).30–35 Four are posi-tive trials with improvement in pain and functions.31–33,35 Onepossible explanation for the negative study34 is the potentialbias in the study design, as the patients were told that they

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would be given priority for surgery if their pain worsened afterinjection. 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 asystematic review.37 Although the experience from the 14 caseseries including 1094 patients supported the analgesic efficacyof VS in patients with arthritic hip pain, the results from the ran-domized trials were different. Of 5 randomized trials, 3 includedsaline 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



FIGURE 7. A, Sonoanatomy of the infrainguinal hip region. The position of the transducer is shown in the insert. A indicates femoralartery; V, femoral vein. B, Sonoanatomy of the anterior hip region when the transducer is placed in the long axis of the femoralneck. The arrowheads indicate the anterior recess. The position of the transducer is shown in the insert. Reproduced with permissionfrom Ultrasound for Regional Anesthesia, www.usra.ca.


with saline did not find a difference in the analgesic efficacybetween the treatment groups. Therefore, the authors concludedthat 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-articularhip injection (Table 3).41–45 The earliest publication41 revealedthat the rates of superficial and deep infection were 30% and10% compared with 7.5% and 0% of the matched cohort (pa-tients with total hip arthroplasty without prior intra-articularsteroid injection). However, subsequent publications did notconfirm the increased risk from intra-articular injection. Onestudy suggested that an interval of less than 6 weeks betweenthe injection and hip replacement was a risk factor for deepinfection.43

Sonoanatomy and Injection Technique for GTPSThe patient is placed in lateral decubitus position with the

injection site as the nondependent side. A linear ultrasoundprobe is preferred unless the patient is of very high body massindex. The key landmark structures are GT (anterior, lateral, andposterior facet), IT band, gluteus medius, and minimus tendons.

FIGURE 8. Ultrasonography shows the anterior recess (*) as thetarget. Small arrows outline the joint capsule, and arrowheadsindicate the needle. The insert shows the position of thetransducer and the needle. Reproduced with permission fromUltrasound for Regional Anesthesia, www.usra.ca.



The first scan is to obtain a transverse view of the GTand the insertion of the gluteus medius tendon (lateral andposterolateral facets) and gluteus minimus tendon (anteriorfacet). 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 howto obtain the sonoanatomy of the target for peritendinous injec-tion of gluteusmedius andminimus tendons [reproducedwith per-mission fromUltrasound 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 spacebetween the IT band and the gluteus medius tendon. The ITband is a well-defined hypoechoic layer superficial to the glu-teus medius tendon (Fig. 9; Video 6). Careful examination ofthe gluteus medius tendon may demonstrate radiological fea-tures suggestive of pathology such as hypoechogenicity, loss offibrillary pattern, tear, and the presence of enthesophytes or calci-fications.46,47 For the gluteus minimus tendon, the transverse viewis 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 gluteusmedius tendon, and the target is between the IT band and thegluteus medius tendon.47 After obtaining a long-axis view ofthe 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 theinjectate spread between the IT band and gluteus medius ten-don. The injectate is 3 mL of local anesthetic with steroid, suchas 0.25% bupivacaine and 40 mg methylprednisolone acetate.Alternatively, a transverse view is obtained, and the needle isinserted 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 gluteusmedius muscle. For the gluteus minimus peritendinous injec-tion, the needle is inserted in-plane from posterior to anteriorafter a transverse view of the tendon is obtained (Fig. 10).

Accuracy and Efficacy of Injection for GTPSThe landmark-based technique was validated once in the

literature.48 Using bursagram under fluoroscopy as the validationtool, the GTwas contacted by the needle in only 78%, and the lo-cation of the needle tip was correct in 45% of cases on thefirst needle placement.48 One of the major criticisms is that thebursa is defined by soft-tissue plane. Previous study using x-ray

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

Authors Study PeriodMatchingCohort

THRWithPrevious Injection

Location ofProcedure 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 NSMcIntosh et al43 1998–2002 Yes 217 XR NS superficial and deepChitre et al44 1996–2000 No 36 OR Superficial-1Sankar 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 theresult was validated with cadaver dissection.49 Not surprisingly,a subsequent multicenter randomized controlled study comparingthe fluoroscopy-guided and blind steroid injection for the GTPSdid 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 glutealmuscles and tendons in the trochanteric region.46,51,52 At pres-ent, literature on the ultrasound-guided injection for GTPS is

FIGURE 9. A, Ultrasonography shows the junction (*) between the anthe transducer is shown in the insert. B, Ultrasonography shows the gshown in the insert is posterior to that shown in A. C, Ultrasonography swith the long axis of the IT band as shown in the insert. D, Ultrasonograof the transducer is anterior to that shown in A. Reproduced with permi

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scant, let alone the validation study. Given the simplicity ofthe landmark-based technique and the lack of literature on theultrasound-guided technique, the author's first-line approach isto perform the injection for GTPS with landmark-based tech-nique with the following exceptions: history of previous failedresponse to landmark-based injection, inability or difficulty to de-fine the GT by palpation, or when gluteal minimus tendon is themain pathology.

A number of investigations examining the effect of in-jection as the primary treatment modality for GTPS have been

terior and lateral facets of the GT (dotted line). The position ofluteus medius tendon in short axis. The position of the transducerhows the SMaB. Note that the axis of the transducer is alignedphy shows the gluteus minimus tendon. Note that the positionssion from Ultrasound for Regional Anesthesia, www.usra.ca.



FIGURE 10. A, Ultrasonography shows the target for theperitendinous injection for gluteus medius. The dashed arrowshows the path of the needle inserted in-plane from cephaladto caudal direction. The insert shows the ultrasound probeposition. B, Ultrasonography shows the target for theperitendinous injection for gluteus minimus. The dashed arrowshows the path of the needle in plane from posterior to anteriordirection. The insert shows the ultrasound probe position.Reproduced with permission from Ultrasound for RegionalAnesthesia, 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 patientsreceived only a single injection, and the visual analog pain scalewas not even used as the outcome measure. The case seriesshowed favorable short-term outcome (3 months) with symp-tom resolution, and the ability to return to activity ranged from49% to 100% with steroid injection as the primary treatmentmodality.53

One randomized trial examined a fluoroscopy guidedagainst blind injection without any placebo or nontreatmentcontrol.50 By defining success with a positive categorical out-come (≥50% pain relief and satisfaction with the results), theoutcomes at 3-month assessment were comparable in bothgroups (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 singlelocal corticosteroid injection (group B), or a repetitive low-energy radial shock wave treatment (group C).54 The response



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 baselineand at 1, 4, and 15 months. At 1 month, corticosteroid injec-tion (group B) resulted in the best improvement (success rateswere 7%, 75%, and 13% for groups A, B, and C, respectively).However, the success rate of the injection group declined withtime and was subsequently superseded by the other 2 groups at4 and 15 months (success rates were 41%, 51%, and 68% at4 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 thatcould 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 corticosteroidinjections 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 followedup for 12 months. At the 3-month follow-up, 34% of the pa-tients in the usual care group had recovered (defined as totallyor strongly recovered) compared with 55% in the injectiongroup (adjusted odds ratio = 2.38; 95% confidence interval[CI], 1.14–5.00; number needed to treat = 5). Reduction in painseverity at rest and on activity was greater in the injectiongroup, 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 andMcMaster Universities Arthritis Index pain and function mea-sures) showed a greater decrease in pain in the injection groupas well. At the 12-month follow-up, differences in outcomewere 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 trialssupported the safety and short-term analgesic efficacy (3 months)of steroid injection for GTPS.

CONCLUSIONSIntra-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 isunreliable and subjects the patient to risk of soft-tissue or nerveinjury. 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 associatedwith pathology of gluteus medius and minimus tendons, it isrational 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 thedefinition of the soft tissue involved. However, more studiesevaluating the feasibility and efficacy are required.

ACKNOWLEDGMENTSThe author would like to thank Lucy Zhang and Bonnie

Tang for their work on the illustrations.

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