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ultrasound guided injections

Understanding Diagnostic and Therapeutic Ultrasound-Guided Injections

News / 9/16/2020

If you suffer from musculoskeletal pain, injections may be part of a management plan to minimize that pain so you can return to daily life. Dr. Moore utilizes ultrasound guidance when performing musculoskeletal injections, this makes injections more accurate ensuring you receive the best results with less complications. 

Dr. Moore, a PM&R physician at APEX Orthopedics & Sports Medicine, specializes in diagnostic and therapeutic ultrasound-guided injections into the joint or around a structure like a tendon, fascia, or nerve. From her experience at Mayo Clinic, she has found success in alleviating pain and discomfort that stems from a variety of conditions, including osteoarthritis, tendinopathy, and sports-related injuries. 

Read on to learn more about ultrasound-guided injections and how they can help you manage musculoskeletal pain.

How does ultrasound technology work?

hand moving buttons on an ultrasound machine in kansas city

Ultrasound is a unique imaging modality that uses sound waves instead of ionizing radiation to create live, real time images. It is an exceptionally safe and well tolerated imaging modality. In musculoskeletal imaging, ultrasound can show very fine detail of soft tissue structures including muscles, tendons, ligaments and nerves. 

An ultrasound machine consists of a computer that sends electrical signals to a transducer (or probe). The transducer then turns the electrical signals into sounds waves that transmit through the soft tissues in front of it. The sounds waves reflect back to the probe in varying degrees, and those reflections (or echoes) are then reformatted into an image in real time showing the structures you are looking at. This process is very similar to how boats and submarines use sonar technology for travel. 

Ultrasound can be used for imaging alone (meaning evaluating anatomical structures for abnormalities, injury, disease) and to help guide procedures like joint injections, tendon procedures, or even carpal tunnel releases. While palpation guided (or blind) injections are the most common way most injections are done word wide, there are many benefits to using ultrasound to guide injections. 

With ultrasound guidance you see the needle or procedural device in real time as you direct it to your target (e.g. specific joint space, peritendinous area, perineural area). This allows the provider to be confident that the injection is accurately placed where it is intended to be. This increased accuracy optimizes the potential results of an injection for the patient & allows us to better interpret your response to the injection. For instance, if someone had a palpation guided injection with good benefit, it was probably injected into the right area. On the other hand, if a palpation guided injection did not work, it is unclear whether the lack of benefit was due to  the “destiny” of the injection (e.g. pain was not coming from that target, or the medicine was never going to work for that person) or if the injection simply did not accurately get to the target. 

Ultrasound can also enhance the safety of injection by limiting unintended injury to nearby nerves/vessels/structures during the procedure. For certain patient populations, like people on blood thinners who are at higher risk for bleeding complications, limiting unintended injury is critical. For certain procedures, like injections around nerves where the difference between ideal injection placement versus unintentionally hitting the nerve is a hair breadth apart, ultrasound provides precision and safety. 

All of these reasons are why Dr. Moore thinks using ultrasound-guidance for injections is so important–the instant feedback through dynamic viewing, the reduction in human error while injecting the area, the ability to use a smaller needle making the procedure more comfortable, the mitigation of procedural risks, and the ability to more confidently interpret the outcome of the injection to best guide future management.

Determining candidacy for ultrasound guided injections

To determine who is a good candidate for ultrasound-guided injections, Dr. Moore looks at the “who, what, and where.” It is important to consider these factors before determining whether a diagnostic and/or therapeutic injection is needed. 

In simple terms, a diagnostic injection is an anesthetic-only injection used to verify the source of the pain. If the pain goes away after the injection, it is a good indication that the target was the pain generator. Normally anesthetic injections only last for hours, and are not meant to provide long-term pain benefit. You can think of these injections as another way to evaluate or confirm the suspected pain generator, much like your provider may recommend getting an X-Ray or MRI to get more information about your condition and pain. Based on a clinical evaluation, Dr. Moore determines whether a diagnostic injection will be beneficial to gain more insight in order to guide the pain management process. 

Therapeutic injections, on the other hand, are injections with the goal of providing more long-standing pain relief and management. There are a variety of substances one can inject for therapeutic reasons, including steroids (cortisone), viscosupplementation (hyaluronic acid), or orthobiologic injections (platelet-rich plasma, etc). 

With steroid injections, we often include anesthetic medication in the same syringe that is injected, and that can provide both diagnostic information (meaning did your pain get better during the anesthetic time period in the hours post procedure) and therapeutic relief (long-term pain relief on the order of weeks to months to longer).

So when looking at the “who, what, and where,” Dr. Moore starts with the “who.” The “who”, meaning you as a patient, requires expert detail to your medical history, specific circumstances, goals, etc. She needs to make sure that an injection aligns with your lifestyle and can meet your needs to return to your daily activities. 

Next comes the “what.”  What kind of injections are out there and which one will work best for you? Common injectates include: 

  • Anesthetic-only injections (e.g. diagnostic injections): used in complex cases to rule in or rule out a structure as a potential musculoskeletal pain generator 
  • Steroid injections (e.g. cortisone): anti-inflammatory medication that can help improve pain from arthritis (osteoarthritis, inflammatory arthritis), tendinopathies/fasciopathies (rotator cuff tendinopathy, plantar fasciopathy), and certain nerve pathology (carpal tunnel syndrome)
  • Viscosupplementation (hyaluronic acid injection): acts as a lubricant to help alleviate pain from osteoarthritis, currently primarily covered for knee osteoarthritis, but can be beneficial for other regions 
  • Orthobiologics (e.g. PRP or BMAC): “regenerative medicine” treatments meant to optimize your body’s own healing response, used commonly for osteoarthritis, tendinopathy, fasciopathy, and nerve injuries.  

From there, Dr. Moore looks at the “where,” focusing on using ultrasound guidance for accurate injection placement to optimize your results with the injection while limiting injury to unintended nearby structures that could increase pain or cause unwanted side effects. 

Therefore, to truly understand whether or not you are a candidate for diagnostic and/or therapeutic ultrasound-guided injections, you must visit a physician. That way, they can understand your condition, goals, and decide the best next steps toward a solution. 

What to expect when receiving an ultrasound-guided injection

ultrasound technology used on an orthopedic patient in kansas city

You may be referred to Dr. Moore specifically for an injection only (meaning you saw another physician who recommended and ordered an injection and that physician will continue to follow your care afterwards) or if you are seeing Dr. Moore for clinical evaluation she may recommend doing one herself.

Before the injection is performed we discuss the risks, benefits, alternatives, and ensure you agree to the procedure. During this process we also review your allergies to ensure there are no contraindications to the procedural medications. Ultrasound injections are generally exceedingly safe. The most common risk is increased pain the night of or day after the injection, which can generally be managed quite well with ice and over-the-counter pain medications. Infection is a rare risk of any injection; this risk is further reduced by using sterile technique during the injection procedure and ensuring you do not have any systemic signs of infection like fever, chills, or rash the day of the procedure. Any time something is injected into you there is a possibility of having an allergic reaction; this is also rare, and we use medications that generally are well tolerated.  

We then prescan the injection area with the ultrasound to ensure the procedural approach and other procedural considerations are all planned out. The skin at the site of the planned injection is then cleansed with surgical cleaning solution. The medications are drawn up, and the injection is performed under sterile guided technique. If a larger needle is required to appropriately reach the target, local anesthetic will be used to numb the skin and superficial soft structures prior to the procedural needle. Generally, the injection itself is the quickest part of the injection appointment. 

After the injection we will discuss any specific post-procedure restrictions or guidelines. For most injections, we ask you to refrain from submerging the injection site underwater for 48 hours to further reduce infection risk, but showering is OK. If we are doing a diagnostic injection, you may be provided a pain diary to write down your pain response in the hours following the injection. With steroid injections, we generally recommend taking it relatively easy for 2-3 days after the procedure (meaning no heavy exercise). The night of or day(s) after the injection it can be normal to have some mild soreness in the injection area, this is generally well managed with ice or over-the-counter pain medications like acetaminophen or non-steroidal anti inflammatories (pending you are able to take and tolerate these medications normally).

It is always important for you as the patient to know what to expect with pain relief following an injection. The expected outcomes should be something you discuss with your provider before agreeing to proceed with an injection. In general, anesthetic-only injections start to work in minutes and last hours; steroid injections start to work in days up to two weeks and may last on the order of weeks to months (though it can be much longer as well); viscosupplement injections start to work in 4 to 6 weeks and may last around six months; orthobiologic injections start to work in weeks with full affect taking up to 12 weeks and may last for a year or more. Oftentimes, injections are not used in isolation, but rather as part of a multifocal management plan. 

Get to know Dr. Moore at APEX Orthopedics & Sports Medicine

Dr. Moore is our newest addition to the APEX team and one of the only two sports-fellowship trained PM&R physicians in the Kansas City area. With subspecialties in sports medicine and musculoskeletal ultrasound, Dr. Moore has the credentials and tools to treat anything from acute injuries to chronic overuse.

Her time at Mayo Clinic has ingrained the importance of using an evidence-based approach while remaining on top of the curve on cutting-edge medical advancements. In her practice, she utilizes therapeutic and diagnostic ultrasound-guided injections, regenerative and orthobiologic treatments, and advanced, minimally invasive tendon procedures such as Tenex. 

The core of her success lies in accurate diagnosis. An appointment with Dr. Moore includes the highest quality technology to pinpoint a patient’s underlying musculoskeletal conditions. From there, she can better understand which treatment option would be the best solution. 

For a thorough evaluation with Dr. Moore, call us at 913-642-0200 or schedule an appointment today.

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