- December 19, 2019
The basics of ultrasound guided injections are knowing your anatomy. Any type of injection you do whether it’s a shoulder a hip and knee or whatever it may be if you don’t know the anatomy you probably shouldn’t be injecting it. And that’s why we don’t do spinal injections. We know the anatomy but we don’t do the anatomy. so spinal injections are done by pain management and spine profession. They’re experts even though we’ve all done spine surgery we don’t feel like we’re good enough to do that. So if you don’t do this on a somewhat regular basis you might not feel comfortable doing a lot of these, so practice. You’ve got to get on it. Know your anatomy first become familiar with using an ultrasound before you try to do an ultrasound and a needle. Please do that. It’ll save you the pain and agony it’ll save your patient pain and agony and a lot of sweat and tears. Because if you start out day one with a probe and a needle. Bad things are going to happen.
. Use the ultrasound a lot. Get comfortable with that then talk about using an injection. Have an assistant available. I don’t do this. I don’t have an assistant available in my room because I’m moving and I have all my stuff kind of planned out but the worst thing in the world is to have your probe on a patient the needle on the patient and realize you forgot something. Because then you’re your stuck. You’re going to take out the needle and come back and pe them again. I mean it can become very problematic. So have a system available. Make sure your patient is comfortable. They need to be seated on the edge of the bed whatever it is support whatever’s hurting them cover whatever they’re modest about.
Make them comfortable and relaxed exude confidence. If you walk in, you’re like I never done this I don’t know what is it the Geico commercials or something where the guy walks in he’s like What. You know. So make sure the patient is comfortable. But make sure you’re comfortable too. I don’t ever do shots unless they’re in the position that I want him to be in. Like if you can’t get up on this on the bed, I’m liable to say sorry I can’t give you a shot you know I mean it’s one of those things where this is what I’m good at and I’m good at it in this environment. So like when I go to the hospital and I try to try to do a shot it’s like a two second process in my office when I go to the hospital and the patients all in a weird position in a bed it makes my really easy job really hard.
So make it the same for you every time. Make yourself comfortable. If the patient’s way across the bed have them come closer to you don’t reach in. Get your hands all extended. Make sure your needle is long enough when you’re doing ultrasound guided injections you need to have a longer needle because you need to have a path that’s parallel to your ultrasound waves. The shorter your needle is the more acute angle you have to take to get where you’re going. And then you lose the ability to see the needle because it becomes more angled away from your probe. Right. The more parallel it is to your probe the more exogenous into you’re gonna have. So when you’re back there injecting into the phantom’s we have little phantoms for you to inject to see what it los like when you put your needle down at an angle and then see what it los as you drop your angle and bring it more parallel to your probe.
You’ll get a lot more feedback from that. So because of that two inches minimum for me the basics on this. So in plain is longitudinal. So if you’re parallel to your probe you’re in plain if you’re perpendicular to your probe you’re out of plane you’re on axis . You always want to do things in the longitudinal injection always in the plane of the ultrasound because then you get this nice idea of the length of your needle and where the end of it is. if you do out of plane where you’re doing perpendicular to your probe it’s gonna be a dot. Is it this dot. Is it that dot. Is that this dot and then where’s the end of your dot. so you don’t know the depth of your penetration. The only time I recommend you out of plane injection is the AC joint.
It’s almost impossible to get enough of an angle to be in plane and be in the AC joint. The good news though is when you inject your material, you’ll see the AC joint fill up and you can actually see the Kenalog which is what I use. You’ll see that material floating around and it’s almost like a little R in the shoulder it’s almost like a little dust storm you’ll see the material. It’s actually echogenic. So everything you can do longitudinal so you’ll get a whole length of the needle. Depending on the pathology that you’re treating that is going to depend on patient positioning. So I would like to say that every time it’s at the end of the bed. But it depends on what I’m treating. So what is their pathology is that the biceps is that the cough is at the joint.
Is it any whatever part of the body it is. What is the patient’s anatomy like? Are they going to be able to sit in the position I need? Am I going to get to the position I need? It’s amazing the variability of the human species. I’ll see a patient that has that weighs 80 pounds and the very next patient will weigh 400 pounds. Very different way you need to treat those two patients. Make sure that that patient can cooperate with your exam if they’re super dramatic and tearful and real jumpy might not be the best patients to do this on. And that’s for any type of injection if I have somebody that I can’t calm down and is grabbing my hand and stuff like that not doing an injection. Done. That’s it for me. Make sure you know your anatomy again you have to know your anatomy on exam. You have to know your anatomy on your ultrasound and you have to know your anatomy where your needle is going.
And I think that’s pretty much it.
These are my tools everyone always asks me what do you use when you inject. There’s no right way. This is Dr. Baker’s way. I use betadine. I like this little ampule because it gets in this little pouch. I squeeze the vial it goes down to the cotton. I can rub it on the patient I don’t have to open that little zip pouch and have all these probes in the end they get my hands all dirty. This is self-contained. I put it right back in there. I’ll then use one alcohol swab and I’ll dab the area after I’ve prepped it. I’ll use ethylchloride to numb the skin just to remove that kind of initial anxiety of that pin prick. I used to not do this when I got into private practice I did because people want to want to not have any pain with it. I use a single four by four here. I’m very adamant about this because I’ll have my girls give me like a stack of them going to be like fifty-four by fours I just need one. I’m just gonna put pressure on after I inject them.
One Band-Aid. 21 gauge needle – you want to make sure if you’re going to use a safety needle that it has enough length to it. I don’t think we should be using safety needles I personally think it makes them more unsafe because now you’re capping these things. So I use a two 2 inch safe needle, everybody uses it gets a five CC syringe. I think it’s really important that you use the same needle and the same syringe for almost all injections and the reason is that part of my injection and my injection is the feedback that my thumb feels if I’m pushing and I feel a lot of resistance. I’m in the wrong spot whereas if I go to a smaller needle and a larger syringe you have to push hard to get that large volume through that small needle .anyway so whatever your combo is that you like make sure it’s the same every time so you get an idea of what that feels like. The one it makes it hard is the visco so when you do Visco supplementation you go from a nice liquid material to a very thick discus material and now it feels different as you’re injecting it so it gets a little bit tougher to know. I use 2 CCs 1% lidocaine two CCs of quarter percent Marcaine, and then one quarter and then forty milligrams of Kenalog, and depending on your mix that may be a half CC or a full CC.
Now Dr. Yi has a different mix. Dr. Gasser has a different mix probably this is what I think is the most effective in my hands when I did this the research on this catalog was very gentle on the soft tissues seem to be less toxic when you start to mix more things together lidocaine, Marcaine, Kenalog. Everything you add to that it becomes more toxic to your cartilage and your soft tissues or whatever it may be there is no 100 percent safe material to inject it’s all the lesser of evils right. So if you’re trying to inject the tendinitis it’s probably a pretty safe thing to do. You’re not trying to inject that tendon. You know we’re not trying to inject the tendon itself.
Ultrasound guided injections again you need all of your pieces in a row. If you don’t have a mobile unit to set up then you’re not going to be comfortable where you’re at because you’re you’re it’s gonna be on a chair, it’s gonna be on a desk or something. It’s not going to be at a height that you’re used to and accustomed to. So I really recommend using the stand for that patient positioning. All right. So we’ll start with the biceps tendon. So biceps tendon injection. I like to do mine with the patient’s supine. The reason for this the patient is number one comfortable. The patient is number two controlled. What I do is I find their tendon on the on the short axis first all then lo at the biceps tendon and the long axis and I’ll center it wherever it is where it’s centered so my hand is a straight up and down.
Now that may mean that that patient’s arm is against their own belly. It may mean that their arm is externally rotated and resting against my belly here. But I know where it’s going to be based on where I did when I when I examined initially so I’ll put my probe on. I’ll rotate their arm till it’s straight up and down where my I want my biceps to be that way I know where I want their arm to be. The elbows bet that 90 degrees to control that rotation. so I don’t want it at their side because patients invariably move. I want it here so I can control that rotation. I’ll then put the transducer in the opposite hand because I want to inject from the bottom up. You could do it from the top down but going across the acromion and stuff like that in the anterior subscapularis can be a little bit tough. I find a lot easier to come from the bottom up. So it’s always being injected by the ipsilateral hand on the on the biceps tendon. So this is a little video.
Here we go. So all of this so. So this patient has had shoulder pain. It’s directed anterior to the aspect of her shoulder identifying the bicycle groove there and I just make a little imprint with my my fingernail. I never liked the idea of marking the skin because when I prep it that Mark is always still there. So how did I clean it if it’s still there. I never I’ve never understood that. So he’s marked with an imprint of my finger then put my betadine blot there. I’ll put a Band-Aid where I can reach it. Easily my four by four is either on the patient or on the bed behind them. Then blot it with the alcohol swab. I’ll then use the ortho chloride and then I’ll get my probe and put it into position. And this is where it’s handy to have an assistant. I’m going to go until I find my groove. There’s greater tuberosity. I went past lesser.
This is the top of the bicycle groove. Her biceps tendon is very degenerative so it’s kind of the length of it is kind of bad. You can see the biceps are the needle coming in as you go through this when there is bicycle tendonitis. The tendon itself is really thick and boggy. So you’re not going to get a perfect like nice line right away but as I do that you actually start to see the biceps tendon on basically outlining it and I’m going a little bit in the cybercriminal space and then a little bit in the device a little groove and then back and forth. I’m just not I don’t want to inject it directly into her tendons. I’m going back and forth slightly so I can fill that fluid up around the tendon chief and you can see the patient’s not moving around or writhing in pain this is a relatively easy injection to do. If you’re going to do them, I think it from a hands skill I think is probably the easiest injection to do to get started with next to the AC joint but you don’t get a lot out of doing the AC joint.
Other than just kind of figuring out your hands. So I think biceps tendon injections are a pretty straight way of doing that. Does that make sense. Any questions on that before move on the next one. All right subacromial injections. Now this you can really kind of do whatever you want. There’s there’s three or four different ways to do this. You can do it from the back you do it from the front. I prefer to generally do it from the side. In this case I do like to stand behind the patient. Believe it or not I think they like to watch it a little bit. So this is one where they can see all then put the probe over the lateral aspect of the tuberosity. If you want to have them come out this way you can. I prefer not to do that because it tightens the tissue over the supraspinatus. So I like the arm to be relaxed with their hand at their side or in their lap. I’ll do the longitudinal view of the supraspinatus. I’ll then introduce that that needle and watch it go into the subacromial space. What’s interesting on this one this guy actually was a little bit difficult. Let me see if I just hit click. No this guy was a little bit difficult to get into his space actually thought about redoing one but we’ll show you what it’s like sometimes even for me all right.
So first thing we do is identify the supraspinatus. So we have greater tuberosity. We have deltoid tuberosity. We have supraspinatus in here. You can see this patient actually has significant bursitis. So this little black stripe between the supraspinatus. So this is the bicipital tendon, excuse me supraspinatus tendonitis here. supraspinatus is here. Deltoid fascia here. And that black stripe is actually bursitis. That’s a lot of bursitis and you’ll see this if you do enough, you’ll see lots of rip roaring bursitis. But this is a great view here. Greater tuberosity, humeral head, supraspinatus tendon, and then tendinitis. This one just because of the positioning because I had two girls recording this. I went ahead and did it from the standing from the front. It doesn’t really matter wherever you’re comfortable with you can do. So again, I find my spot. I Marker with my fingernail all them prepped with betadine and alcohol and then I’ll give the alpha chloride.
I’m going to try to parallel the probe and you see how flat My hand is. The flatter I am the better I’m going to be able to see that needle. This is all like unedited. I haven’t edited anything when you’re in this and you have this Bursa.
I don’t want to inject these tendons. That’s a really good thing about doing these under ultrasound guidance is if you’re injecting cortisone into the tendon you’re going to cause a rupture at some point I mean it is definitely a degradative enzyme or excuse me a steroid. So I’m kind of going back and forth trying to find my way. He’s thin so it actually makes a little bit harder a little bit softer more soft tissue makes a little bit easier.
Some kind of I want to make it perfect as I’m recording it for you guys. So I to my time and probably made it worse. So but again you can see the length of the needle. I can see where I’m injecting the material and you’ll see at some point I finally get my my position where I where I really want to be and then I’ll really fill up that area. You can actually see here I’m actually filling up the bursa itself before I was above the bursa. And now you can see I’m really filling that thing up nicely and that’s only 5 CCs. I partner that, do 10 CCs. This is why I don’t do 10 CCs. clearly that’s a lot of volume in there I just don’t think it’s necessary. You’re just trying to depolarize the nerves with the with the lidocaine and then the Kenalog generally 40 milligrams is enough. So that’s a subacromial injection. Any questions on that at all.
All right intramuscular injection are probably where we should be doing them more. Actually, don’t do them very much here because I think I’m good at blind injections. Intraarticular injections can you again be done in many ways from the front from the back. Again, what’s up. What’s comfortable for you what’s comfortable. Very patient. That’s really how you have to guide this. So the way I like to do it is from the back I think going through from the front hurts any of you guys that I’ve ever had an MRI arthrogram. Every patient that I ever get that gets one of those done says it hurts and it’s really a terrible experience. So because of that I’ve always gone from the back. And I’ll show you kind of what we do. So we’re finding that posterior point twelve. Like we looked at earlier.
Second time. So we’re going to find the human head and that’s here the enforcement aid us is here. Soon as I get my hand right, we’ll show you that annoyed. So this is the glenoid down here. Keep moving and then the labrum is that triangle there. So that’s what I’m talking about there. So labrum, glenoid, humeral head, infraspinatus and I’m just showing the angle that I want this needle to go in if you try to go in from this direction which technically you could you can see you’re enough to traverse that tendon and it’s very tough to hit that angle. So it’s better to go from medial to lateral so you can kind of dead end right at that infraspinatus.
So again, I’m marking with my fingernail I’m not going to put the probe down and I’m going to prep the betadine on first I’m just squeezing a capsule. Prep it. I’ll put my Band-Aid on. And this is just my routine you never forget anything if you do your routine. People are always like Don’t forget the freezy spray and I don’t because it’s my routine.
So then alcohol then I mean get my pro back in a position you know technically you could go and put you know the sterile lube and you could use the guy there the cover that goes over the end of the probe and sterile gloves and all that stuff. Or you could just be sterile you know practice sterile technique and not touch the area you’re trying to inject and yet that’s the way I go with this. So again, I’m finding my position first. Then I’m gonna take a little pe in the skin and then you can see I’m just slightly out of place. I move those tissue somebody use my probe to find my position. There’s my needle coming in and this one you really have to make sure that you get a long needle because you could be out but I’m going right to the joint surface there’s nowhere that I could be but in the joint when I get there. So as I inject that you can see it filling that up to make sure that you’re deep enough that you’re not just filling up your infraspinatus and then as we keep going here we’ll basically see a nice stripe going around the whole humeral head. And again, it’s only five CCs in the whole humerus you’re not going to see a huge balloon distension but you could do more if you wanted to and that’s how I do my intra-articular injections. I don’t go for this. All. Right.
AC joint this is the one that I I said you can do out of plane you would basically view it from the superior position you would basically palpate where that divot is between the AC joint and then go from front to back and inject material. Now blind injections are the majority of what I do. So again in order to do blind injections you got to know your anatomy. The patient has to be comfortable. You have to be comfortable. Move quickly and accurately but don’t stab or swipe. The problem that I feel or that that I see people make mistakes on is they’ll put the needle in and then they’ll move that needle is stuck in the tissue. So as you move you’re just bending that needle in their tissues. So if you need to move the needle you need to move your hand all the way out and then go back in and whatever direction you want.
So it should be all linear movements. Patients come to me all the time and like all God I’ve had in the injection it was terrible I’m never doing it again I’m like they didn’t do it right. I mean if you do it correctly and you move swiftly and you’re not moving your needle around or you’re not injecting a tissue that doesn’t have a space then it shouldn’t really hurt if you’re injecting a knee space or a subacromial space or an intra-articular space you’re filling up a void so it shouldn’t hurt to inject that now frozen shoulder sometimes we’ll be a little uncomfortable because there’s very stiff. And as you expand that tissue that can hurt a little bit. But for the most part these things really shouldn’t hurt. Again, apply steady pressure to your plunger you’re going to know what that feels like when you do your injection.
Then if you’re getting resistance don’t push harder. Change your hand. So you’ll see every injection that I do I’m moving my hand back and forth slightly to make sure I’m getting that smooth steady flow as I’m injecting the material. So it’s not a mistake that I move my hand that’s on purpose. Subacromial injections and other thing that I find people do wrong on a regular basis. If you lo at the scapula wide view of the of the shoulder basically if we take this bone and turn it 90 degrees. So we’re looking into the glenoid. This is the acromion with the subacromial type B or C’s spur. This is your coracoid. And then this is the scapula body. This is where we’re trying to inject that that material. Almost everyone has an upward slope from the back of the acromion to the front of the acromion.
Now every once in a while, you’ll have somebody who has really bad posture or bad kyphosis in their shoulders or slope down so that that is the one time where this changes. But the key is to put your hands on the patient feel the back of the acromion and feel the acromion to know what their slope is. So if you’re injecting this patient that angle is all wrong you’re just putting it right into the back of their shoulder. So you’re basically injecting that into their into their infraspinatus. All right. That’s going to hurt them. It’s not going to do what you want. And it may cause a rupture if we’re trying to get into this space just underneath that acromion. So if you’re going at that angle you’re not going to make that patient better most likely drop your hand and inject from the bottom up and that’s where you’re going to want to go. So you’ll see on all my patients I always impress, Hold the acromion and then parallel my fingers.
So don’t do it that way. So this is an injection of the acromion. You can see the lateral acromion posterior acromion. Got my Band-Aid in position. I’ve just outlined it for for everyone to see here. We’ll prep it with the alcohol. And again, you can see my little thumbnail print there give the freezy spray.
Then I’m going to grab the arm I can feel my front of my coming on my back I’m dropping my hand and I’m paralleling that position I’m going in and out because it’s a thick bursa. I want to spread that tissue and she has no pain. She’s doing totally fine with this. She was scared to have it done but she volunteered to do it for a video and she still didn’t have any jumping or craziness into articular injections you can go from three different spots. You can go from the front the back or from the top. I was trying to go from the top. We did some studies of C.T. guided excuse me fluoroscopic guided injections and we seem to be more accurate going from the visitor’s portal. This might be a little advanced but it’s a good way of kind of getting an idea of where anatomy is. Our goal is to go behind the AC joint and into the joint itself. So looking at your pre op X or your pre injection x ray to have an idea of what those and at anatomical endpoint endpoints are is helpful. So as we lo at this guy’s shoulder we have the acromion here.
We had the posterior spine AC joint. The humeral head is always slightly anterior unless they have bad posterior arthritis. The head’s actually anterior which I think is commonly misunderstood. The coracoid process you can see here and I’m gonna go just behind the AC joint and I’m a prep theory I’m going to go right down usually angling about maybe 20 or 30 degrees interior and then lateral from that position as I put my injection and I’m feeling the joint lined with my index finger and my thumb so I’m feeling the rounded part of the humerus head and can actually shift it kind of back and forth to feel where that joint is and then all I’m doing is aiming between my fingers until I hit the head and basically is going straight to the soft tissues until you get that well then inject that you can see I can remove my hand it doesn’t bother him at all it’s totally supported by a shoulder that injections is sitting there he has no pain whatsoever from this we’re gonna inject the material hold pressure on the injection site and then put her Band-Aid on and just to show that this is.
Again something that you can do. Quickly and comfortably and I’m going slow on these videos because I’m talking, I’m trying to narrate them but this is kind of two views to give you an idea. We have the clavicle lateral acromion. Then the posterior spine. I’m feeling that AC joint just behind the AC joint there’s a soft spot. I’m going to feel the joint line I’m going to move her arm just a little bit. I’m in a feel where the humeral head is moving and where that moving stops becomes the glenoid. And I’m going to feel that the entire through the entire of the injection with my right hand. And I’m gonna be aiming between my two fingers it seems difficult but it’s actually very easily tolerated and pretty quickly on prepped with my betadine.
Get my Band-Aid ready you only forget those things one time and then you never forget them again because you’ve got a needle in the patient or they’re bleeding dabbled with the alcohol given their freezy spray. Gonna grab that joint line again. I’m going to place my needle into position go until it stops. Inject the fluid. I’ll move in and out slightly. As long as it’s going in easily. Then I’ll leave my hand then and inject the rest of material. She’s talking I’m asking her are you in any pain she says nope don’t really feel anything and then we’re done.
One four by four for a little bit of pressure there and she man it. Adhesive capsulitis is the most common reason we’re doing those shots. AC joint can be a little bit tricky actually and I think the patient that I show you here was actually hard to find. This patient is gonna be a lot easier to inject than this patient. lo at the anatomy of the AC joint. Sometimes they’re very sloped this direction. Sometimes they’re slope this direction. Sometimes they’re almost fused. So I prepare the patient to know that they’re going to feel me moving I’ll push down until I hit bone. I’ll come up I’ll change my angle a little bit and you’ll see me do this in the video. They don’t hurt. It’s for them. Prep them that you know what you’re doing and you’re not doing in an accident that is just trying to find the spot. The position of where to put it is usually pretty straightforward between the anterior middle heads of the deltoid usually at the end of the trapezius. Yes you can see it very easily on her. Maybe a little tougher on him but you can almost always palpate it. So this guy again volunteered for a injection for us. And I’ve already prepped and put my thumbprint where I think that that joint is.
So I feel the interior AC joint, lateral posterior just so I know where I’m at.
I’m feeling in the posterior soft spot on advisor’s portal there. Already prepped with my betadine, Band-Aids in place. Going to dab it with our alcohol, freezy spray and again you’ll notice as I do this hopefully, I rest the owner aspect of my hands. My hand is stabilized.
I’ll then get it there I’ll give a little bit. I’ll move a little bit move and then I’m going to realize that I’ve gone too far. Now I’m I come back the other direction because I’m not finding his space. There’s a reason he has pain because he has a very narrow space here. And then I’m going to fall into that space so you can see there I’m going up and down I’m actually going a little bit through the AC joint there. There you go see I went all the way through the joint and I’m putting a little bit in the sub criminal space.
These can hurt a little bit. I mean this is the only one I do less fluid. I do 3 CCs pf this which is probably still way too much so I do a little bit underneath the joint a little bit above the joint for my AC joint injections. Questions on shots.
I’m done talking. I know it’s been a long long time I’ve been sitting down. All right so let’s go to the back if you have a tank top or something like that and you’re not too shy to take off your shirt. That would be helpful and we’ll start examining some shoulders. While I’ll be around to help out and you can ask any types of questions on any of this material that you want. Thanks guys.