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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 intervention 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 efcacy and accuracy
of such injections.

DISCUSSION
Anatomy

(Reg Anesth Pain Med 2013;38: 264273)

ip pain can be a manifestation of a broad range of intraarticular or extra-articular pathologies.1,2 Of those, osteoarthritis 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 performed 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.69
This review focuses only on these 2 causes of hip pain, as
they reect the common reasons for the referral to anesthesiologists. The rst objective of this review was to describe and
summarize the anatomy and sonoanatomy of hip structures relevant to these hip pain conditions. The second objective was to
examine the feasibility, accuracy, and effectiveness of the injections to these structures as well as the injection techniques.

METHODS
A literature search of the MEDLINE database was performed 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 journals Web site (www.rapm.org).
Copyright 2013 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0b013e318291c8ed

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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.

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 acetabular socket is formed at the junction of the ilium, ischium,
and pubis and is augmented by the acetabular labrum, a brocartilaginous ring attached directly to the rim of the acetabulum
(Fig. 1). This labrum increases the depth and surface of the acetabular cavity, optimizing the congruity between acetabulum
and the femoral head. At any position of hip motion, approximately 40% of the articular surface of the femoral head is covered by the acetabulum.10 Along with the strong capsule and
several powerful para-articular ligaments, this structural arrangement 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 composed 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 (24 mm) and lined by only a minute synovial membrane.11 The anterior layer runs caudally and inserts
on the intertrochanteric line, where it blends with the periosteum. Many bers are reected 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 longitudinally 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 bundle, 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, Ultrasound 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 surface of the greater trochanter (GT) consists of 4 facets: anterior,

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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, Supplemental 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 Anesthesia, 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, respectively. There is no tendon attached to the posterior facet. Between 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 supercial layer, from anterior to posterior, is formed
by the tensor fascia lata and gluteus maximus muscle. The triangular interval between these 2 muscles is lled with fascia lata
overlying the gluteus medius muscle (Fig. 5). This supercial
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 uid in the recess
is kept at a minimum. This gure shows a hip with effusion for
demonstration. Reproduced with permission from Ultrasound
for Regional Anesthesia, www.usra.ca.
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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 fascia lata insert into it. The IT tract passes along the posterolateral
aspect of the thigh and inserts in the Gerdys tubercle of tibia.
The deep layer comprises gluteus medius and minimus
muscles. The anterior two-thirds of gluteus medius muscle descends 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 understanding of the pathophysiology of GTPS.1419
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 fascia 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 supercial subgluteal maximus, secondary deep subgluteal maximus, 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 minimus bursa lies deep to the gluteus minimus insertion on the anterior aspect of the GT, in close proximity to the inferior

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Peng

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 management of a wide variety of hip disorders, including osteoarthritis,
rheumatoid arthritis, and acetabular labral tears.22,23 Osteoarthritis 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 reect tumors, infection, chronic inammatory 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
Gluteus maximus

Tensor fascia lata


Gluteus medius
Gluteus minimus

Origin

Insertion

Outer surface of ilium behind the posterior gluteal line,


adjacent posterior surface of the sacrum and coccyx and
sacrotuberous ligament
Outer edge of the iliac crest between ASIS and the iliac tubercle
Outer surface of ilium, between iliac crest and posterior and
middle gluteal line
Outer surface of ilium between middle and inferior gluteal line

Majority inserted into the IT band, some to


the gluteal tuberosity of the femur
IT band
Anterior tendon to lateral facet and posterior
tendon to superoposterior facet of GT
Anterior facet of GT

ASIS indicates anterior superior iliac spine.

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Ultrasound in Pain Medicine/Hip

Sonoanatomy and Injection Technique for


Hip Joint

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 anesthetics, 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
(exion, abduction, and external rotation). There is a paucity of
physical signs that are highly specic to GTPS, and the specicity 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 tendinopathy, tendon tears, or presence of bursitis.8,9,24

The technique for revealing the anterior recess of hip joint


is anterior oblique sagittal technique; that is, the transducer position 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 rst scan
is to locate the femoral neurovascular bundle in the infrainguinal 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 transducer 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 dened: 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 recess 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 [reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca]). Before the needle insertion, it is advisable
to survey the potential needle path with Doppler scan for any unsuspected 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 ensure 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. Alternatively, 5 mL of VS can be injected.

Accuracy and Efcacy 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 demonstrated 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

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

Shoulder

Hip

Supraspinatus
Greater tuberosity
Coracoacromial arch
Subdeltoid, subacromial bursa

Gluteus medius, gluteus minimus


Greater trochanter
Fascia lata, IT tract
Subgluteus maximus bursa

Rationale behind rotator cuff tendonitis,12,13 supported by


radiological evidence14
Uncommon1517
Very common17

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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 supercial
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 uoroscopy25 or computed tomographic scan28 was used as the validation 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 efcacy of intra-articular hip steroid injection have
been published, and all injections were performed under image
guidance (uoroscopy = 3, ultrasound = 2).3035 Four are positive trials with improvement in pain and functions.3133,35 One
possible explanation for the negative study34 is the potential
bias 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 after


injection. Current data from available RCTs and other uncontrolled studies3036 demonstrate strong evidence that steroid injection can provide a short-term (13 months) reduction in pain.
The analgesic efcacy of VS was recently examined in a
systematic review.37 Although the experience from the 14 case
series including 1094 patients supported the analgesic efcacy
of VS in patients with arthritic hip pain, the results from the randomized trials were different. Of 5 randomized trials, 3 included
saline as the control,32,35,38 1 compared VS with local anesthetic only,39 and another compared 2 preparations of VS of different molecular weights.40 All of the 3 studies comparing VS
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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 nd a difference in the analgesic efcacy


between the treatment groups. Therefore, the authors concluded
that VS could not be recommended as standard therapy in patients with hip osteoarthritis for wider populations, and therefore the indications remained a highly individualized matter.
Five retrospective studies have examined the increased infection risk of hip replacement following a prior intra-articular
hip injection (Table 3).4145 The earliest publication41 revealed
that the rates of supercial and deep infection were 30% and
10% compared with 7.5% and 0% of the matched cohort (patients with total hip arthroplasty without prior intra-articular
steroid injection). However, subsequent publications did not
conrm 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.

The rst 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 lateral 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 injection of gluteus medius and minimus tendons [reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca]).
The transverse view is useful to differentiate the gluteus tendons, 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-dened hypoechoic layer supercial to the gluteus medius tendon (Fig. 9; Video 6). Careful examination of
the gluteus medius tendon may demonstrate radiological features suggestive of pathology such as hypoechogenicity, loss of
brillary pattern, tear, and the presence of enthesophytes or calcications.46,47 For the gluteus minimus tendon, the transverse view
is sufcient to reveal the supercial 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 spinal 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 tendon. 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 advantage of the latter method is that it allows peritendinous injection of both the anterior and posterior tendons of the gluteus
medius muscle. For the gluteus minimus peritendinous injection, the needle is inserted in-plane from posterior to anterior
after a transverse view of the tendon is obtained (Fig. 10).

Accuracy and Efcacy of Injection for GTPS


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

The landmark-based technique was validated once in the


literature.48 Using bursagram under uoroscopy as the validation
tool, the GT was contacted by the needle in only 78%, and the location of the needle tip was correct in 45% of cases on the
rst needle placement.48 One of the major criticisms is that the
bursa is dened 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
Kaspar and de V de Beer41
Sreekumar et al42
McIntosh et al43
Chitre et al44
Sankar et al45

Study Period

Matching
Cohort

THR With
Previous Injection

Location of
Procedure

Infection

19951998
19972004
19982002
19962000
20022009

Yes
Yes
Yes
No
No

40
66
217
36
40

XR
XR
XR
OR
OR

Overall: 30 vs. 7.5% Deep: 10 vs. 0%


NS
NS supercial and deep
Supercial-1
Superifcial-1

THR indicates total hip arthroplasty; XR, radiological suite; OR, operating room; NS, no signicant difference.

to conrm the location of contrast in the subacromial bursa suggested 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 uoroscopy-guided and blind steroid injection for the GTPS
did not show any analgesia advantage of the image-guided technique over the blind technique.50 In contrast, ultrasound is a valuable tool in dening the anatomy and pathology of the gluteal
muscles and tendons in the trochanteric region.46,51,52 At present, 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 rst-line approach is
to perform the injection for GTPS with landmark-based technique with the following exceptions: history of previous failed
response to landmark-based injection, inability or difculty to dene the GT by palpation, or when gluteal minimus tendon is the
main pathology.
A number of investigations examining the effect of injection 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.

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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 randomized 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 symptom 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 uoroscopy guided
against blind injection without any placebo or nontreatment
control.50 By dening success with a positive categorical outcome (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 refractory unilateral GTPS sequentially assigned to 1 of the following groups: a home training program (group A), a single
local corticosteroid injection (group B), or a repetitive lowenergy radial shock wave treatment (group C).54 The response
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Ultrasound in Pain Medicine/Hip

was measured on a 6-point Likert scale, and the treatment success was dened as either completely recovered or much improved. Subjects underwent outcome assessments at baseline
and at 1, 4, and 15 months. At 1 month, corticosteroid injection (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 conrmed the shortterm analgesic effectiveness of steroid injection, treating physicians should be aware of the other conservative measures that
could be of benet to those with refractory symptoms from GTPS.
Finally, a recent pragmatic, multicenter, open-label randomized clinical trial evaluated the effect of corticosteroid
injections compared with expectant treatment (usual care, ie,
physiotherapy and analgesic) in patients with GTPS in a primary care setting.55 One hundred twenty patients were randomly 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 patients in the usual care group had recovered (dened as totally
or strongly recovered) compared with 55% in the injection
group (adjusted odds ratio = 2.38; 95% condence interval
[CI], 1.145.00; 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, 0.312.05) and in pain with activity of 1.30 (95%
CI, 0.322.29). The secondary outcomes (Western Ontario and
McMaster Universities Arthritis Index pain and function measures) 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 supercial pain at the site of the injection, no differences in adverse events were found.
In conclusion, both the case series and randomized trials
supported the safety and short-term analgesic efcacy (3 months)
of steroid injection for GTPS.

CONCLUSIONS
Intra-articular injection of the hip can be reliably performed with ultrasound guidance, targeting the anterior synovial 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 efcacy of intra-articular steroid injection is strong. However, controlled 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 modestly accurate, it offers an easy bedside method. Ultrasoundguided technique emerges as a rational technique allowing the
denition of the soft tissue involved. However, more studies
evaluating the feasibility and efcacy are required.
ACKNOWLEDGMENTS
The author would like to thank Lucy Zhang and Bonnie
Tang for their work on the illustrations.
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