Let me start by saying that I’ve been practising injections therapy since 1996 which is when it became part of physiotherapy scope of practice. And yes, after undertaking extensive training, I’ve been injecting using anatomical landmarks to guide my technique. I have also led the SOMM injection course since 2001 and trained about 2000 physiotherapists and doctors since. 

Over the past few years, we have seen the use of USS guided injection techniques grow massively. At the same time, the evidence appears to suggest that the clinical outcome from USS guided or non-USS guided techniques is pretty much the same. So why should we bother with USS?

Well, curiosity got the better of me and so off I went and started training in diagnostic USS and USS guided injections. It has been a fascinating journey. Here are my top 10 observations so far:

  1. No substitute – USS is not a substitute for strong clinical and anatomical knowledge and is best learned after core anatomical and injection skills are in place. 
  2. Gold standard – an USS guided technique for a significant list of injections (sub-acromial, hip joint, GTPS to name a few) is unquestionably the ‘Gold standard’ approach in terms of accuracy and safety (although we should remember the thousands of patients who have been getting better for years without USS guided procedures). 
  3. Improved patient compliance  – patient confidence and compliance appears to be greatly enhanced when they can see the lesion and injection treatment in real time (my observation only).
  4. Not always better – it is sometimes more complex choosing to do an USS guided injection with questionable benefit in terms of accuracy or outcome (e.g. ACJ, 1st MTP) – that is not to say that some clinicians might prefer doing it that way. 
  5. Broadens scope of treatment – USS opens up the prospect of treating structures that without guidance we might shy away from (e.g. Achilles lesions/hip joint)
  6. Removes uncertainty – diagnostic ultrasound can inform our clinical reasoning and ultimately determine whether an injection is a good idea or not. Think particularly any injection around an enthesis…
  7. Cost-benefit analysis – no doubt someone will come up with these figures which are always going to land in favour of not using USS guidance – not that that is a great argument in itself but there would have to be a very large disparity in outcome to justify recommending USS guided techniques only. And think of the waiting lists…  
  8. More comfortable – this all about technique but visualisation adds to the needle proprioception skills a good injector possesses and adds a feature that may make the injection more comfortable. The narrower gauge needles favoured for use in USS guided injections no doubt helps too
  9. Needs a helping hand – as a novice using USS guidance, having an extra hand would be useful – anyone know what i’m talking about?! 
  10. And the future is…? – stay up to date with evidence, skill yourself with training in anatomical knowledge and good technique (USS guided or not) and use injection therapy judiciously based on strong clinical reasoning. 

It’s been a steep learning curve but well worth it. USS provides so much extra information to the MSK clinician and it is a great resource to have access to. When it comes to using injection therapy – it seems perfectly sensible to me to have both options at your disposal – and that’s exactly what I’ll be doing.

Paul Hattam
Module Leader, Theory & Practice of Injection Therapy
The Society of Musculoskeletal Medicine

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