We use injections in sports medicine to reduce pain. Drugs injected include cortisone, hyaluronic acid, and platelet-rich plasma (PRP). In most cases, we perform these injections without direct vision. We simply direct the needle based on our knowledge of the position of bone, tendons, and joints. However, delivering an injection into a tendon or joint is not as easy as it sounds. For tendons, we need to inject them into the tendon sheath. Moreover, joint injections need to be administered into the joint rather than the surrounding soft tissue. Recently, doctors are using techniques to direct the needle to the right spot. Ultrasound injection allows us to see the needle directed to the target.

What are our options for guidance: X-ray or ultrasound injection?

Generally, we perform guided injections with either ultrasound or X-ray. Ultrasound-guided injections have many advantages compared to x-ray such as being cheaper and using no radiation. Previously, doctors used ultrasound infrequently due to the cost. Now, ultrasounds are portable and cheaper meaning that doctors can perform ultrasound-guided injections in their office rooms rather than a hospital saving time and money.

How do we perform an ultrasound injection?

Generally, we perform ultrasound injections like traditional injections. Firstly, sterile gel is placed onto the skin. Then, the ultrasound probe is placed close to the target. Finally, we direct the tip of the needle to the target site using an ultrasound picture. The video below shows a needle carefully directed to the shoulder bursa above the rotator cuff tendons. This injection is often used for rotator cuff tendonitis.

Is an ultrasound guided injection better?

Studies say that Ultrasound-guided injections are more accurate for most joint and soft tissue problems. For example, we perform ultrasound-guided knee joint injections with 100% accuracy compared to normal injections with only 75% accuracy. In addition, there is evidence that using ultrasound improves pain relief. Using ultrasound in carpal tunnel syndrome, rotator cuff tendonitis, and knee joint arthritis leads to greater pain relief.  Finally, there is evidence that using ultrasound is less expensive for knee and hip joint injections. This makes sense as greater pain reduction will mean that patients see their doctor less.

Moreover, Ultrasound-guided injections also reduce side effects of cortisone (such as skin thinning) and can give more information about the source of pain.

Overall, this paper summarises the evidence for ultrasound-guided injections in treatments.

Fluoroscopy vs ultrasound: which is better?

Most studies suggest that fluoroscopy vs ultrasound is the same regarding accuracy and effectiveness. However, we know that ultrasound is much cheaper. Also, most people preferred ultrasound to fluoroscopy. The primary reason for this preference is that we do an ultrasound in a clean office space and it takes less time. On the other hand, doctors do fluoroscopy in an operating theatre, which can take many hours. Moreover, fluoroscopy involves using radiation while ultrasound is radiation-free.

Can anyone perform an ultrasound injection?

Like any skill, it takes many years to learn how to do an ultrasound injection.

In the UK, doctors, physiotherapists, and podiatrists all perform a musculoskeletal ultrasound-guided injection. Overall, skill level can vary affecting the success of an injection. It is important that you have an injection performed by a practitioner who has excellent skills. In general, doctors have more training in ultrasound and ultrasound-guided injections than other practitioners.  You should ask your practitioner about experience and training before you have an injection.

While cost is an important factor, always be wary of non-doctor practitioners who charge less for injections. Some non-doctor practitioners in the UK who perform injections work in an unregulated environment with regards to ultrasound-guided injections. Conversely, doctors are tightly regulated by the government body called the CQC or Care Quality Commission, and General Medical council. Both of these bodies strive for safe and high health delivery services.

How do you know whether your practitioner is a specialist doctor? 

Check to see whether your practitioner is registered with the General Medical Council. Click here to search the DOCTOR register. Ideally, the doctor should be part of the specialist register although some general doctors also train in ultrasound and ultrasound-guided injections.

long head of biceps tendon injection

Final word from Sportdoctorlondon about an ultrasound injection

In summary, for joint and tendon injections, ultrasound is accurate and effective. Also, ultrasound reduces side effects. Most importantly, you should ask about the skill level of your practitioner. In general, doctors have excellent training and skill levels in performing ultrasound-guided injections. They are also regulated by the government body – CQC  and GMC- while other practitioners are not.

Dr Masci performs injections under ultrasound guidance. He has over 15 years of experience in using ultrasound to guide injections and teaches other doctors how to inject under ultrasound. He has developed an online ultrasound-injection course and has written scientific papers on ultrasound-guided injections.

More injection information:

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.

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