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Frequently asked questions about hip pain and injections

What hip conditions can be effectively managed with an ultrasound-guided injection?

What are the different ultrasound-guided treatments options available for hip pain?

The ultrasound-guided treatment options to help in the management of hip conditions include:

To find out more, please click on the relevant treatment option.

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Hip trochanteric bursitis

This is one of the common indications for ultrasound-guided steroid injections in our practice. In this condition, there is pain outside the hip due to inflammation of the trochanteric bursa. "The trochanteric bursa" is a thin fluid-containing sac found outside the hip, next to a bony prominence (called the greater trochanter), hence the condition's name. It is often associated with irritation of the tendons attaching to the greater trochanter (called the gluteal tendons); therefore, this condition is sometimes referred to as “gluteal tendonitis”. Trochanteric pain syndrome is an umbrella term for the different conditions that could affect this area. Please read our article about Trochanteric pain syndrome to find out more. The pain can be more severe after lying on the affected side and crossing the legs. To read more about this condition, please read our article about Hip trochanteric bursitis. The management of trochanteric bursitis starts with physiotherapy. An ultrasound-guided steroid injection can be very useful in management. Evidence also shows that there is a role for PRP (platelet-rich plasma) injections in the management of hip abductor tendinosis.

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Hip joint osteoarthritis

Hip osteoarthritis is a common cause of hip and groin pain, mainly affecting people over 50. It is usually a progressive condition due to wear and tear changes to the hip joint articular cartilage. This results in the loss of the protective, shock-absorbing function of the cartilage. If this progresses, there might be a complete loss of the articular cartilage, and the unprotected joint surfaces come into contact. This is called “bone on bone” and indicates severe osteoarthritis. Please read our article to find out more about the stages of hip arthritis. Ultrasound-guided hip joint steroid injections can be very useful in confirming the cause of symptoms and providing effective pain relief and anti-inflammatory effects. Please see our article to find out more about steroid injections around the hip. Hyaluronic acid injections are an alternative therapy for hip osteoarthritis with very good results, particularly in the mild and moderate forms of the disease.

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Iliopsoas bursitis/tendinosis

The iliopsoas tendon runs in front of your hip joint and the iliopsoas is the main muscle responsible for hip flexion (lifting up your hip and knee, like the movement you do to get out of the car). Iliopsoas tendonitis/tendinopathy refers to inflammation and irritation of the tendon. This tends to be an overuse injury when there is repetitive hip flexion (for example in running and cycling). It can be also seen in patients with hip replacement as this can cause iliopsoas tendon irritation. This condition can be associated with the accumulation of fluid between the tendon and the hip bone, within a small sac "called the psoas bursa". The condition is referred to as “iliopsoas bursitis”. To find out more, please read our article about iliopsoas bursitis/tendinosis. The main symptom of psoas bursitis/tendonitis is a feeling of pain at the front of the hip joint or in the groin. The pain usually worsens when performing activities that involve hip flexion, like getting out of the car, going upstairs and running. Managing the underlying condition along with an ultrasound-guided steroid injection is the usual management option.

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Ultrasound guided psoas tendon sheath injection

Proximal Hamstrings tendinosis/bursitis

The proximal hamstring tendon is attached to the ischial tuberosity (the sit bone, or the bone you sit on, deep to your buttock muscles). The hamstrings are a big group of muscles at the back of your thigh that are important for knee flexion and hip extension. The proximal hamstring tendon is prone to strains and injury as it undergoes much stress during sports and repetitive activity.  This can irritate and weaken the tendon, causing proximal hamstring tendonitis/tendinopathy. The condition can be associated with excess fluid build-up within a small sac (called a bursa) on top of the tendon. This is referred to as "Ischio-gluteal bursitis". To find out more, please read our article about Proximal Hamstrings tendinosis/tear.  Patients usually present with sharp pain deep to the buttock over the sitting bone. The pain is worsened with activity and improves with rest. It can also be worse after sitting or driving.
An
ultrasound scan is very useful for assessing the hamstring tendons. Furthermore, ultrasound is useful for administering a steroid injection into the Ischio-gluteal bursa. To learn more, please see our article about steroid injections around the hip. Other options include platelet-rich plasma (PRP) injections and tenotomy. In PRP injection, a blood sample is taken from the vein and put in a special centrifuge machine to separate its different components. The layer on the top is called “the plasma”, which contains platelets and other useful growth factors. This is injected into the tendon under ultrasound guidance to help stimulate healing. Please see PRP injections for more details. In tendon fenestration/tenotomy, a small needle is used to fenestrate the inflamed tendon multiple times under ultrasound guidance. This is thought to result in micro injury and the release of certain factors that help in tendon healing.

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Adductor tendinosis/Osteitis pubis

Osteitis pubis is an umbrella term that describes a few conditions, all causing pain around the pubic symphysis. The pubic symphysis is a small joint at the front of the pelvis in the midline of the body, immediately above the genitals. The two bones on each side of the joint (called the pubic bones) provide attachments to the muscles of the inner thigh and the abdomen and, therefore, can undergo stress due to sports or repeated activities. Osteitis pubis is more common in men, particularly if doing sports and in pregnant ladies.

This condition includes a few conditions and can be referred to by a few names, all resulting in groin pain.

  • It is sometimes called (athletic pubalgia) meaning groin pain in people who do athletic activities.

  • Osteitis pubis refers to increased stress upon the pubic bone, which provides attachments to important tendons and ligaments in this area, or if there is instability of the pubic symphysis joint (the joint between the two pubic bones).

  • Adductor tendonitis refers to Inflammation/irritation of the adductor tendons that attach to the pubic bone.

  • Sometimes, the condition is referred to as a “sports hernia”.  Although there is no actual hernia here, the nomenclature reflects that the condition is more common in a sports person and results in groin pain (the same site of pain when there is a true hernia).

  • To find out more, please see our article about adductor tendinosis/tear.

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Should hip injections be done under ultrasound guidance?

Yes. This is our routine practice, as plenty of evidence supports ultrasound guidance when performing joint injections. Doing hip injections under ultrasound/imaging guidance allows for direct visualisation of the needle to ensure accurate placement into the area of pain/inflammation (like a bursa, an arthritic joint or an inflamed tendon sheath). Ultrasound guidance results in more accurate, less painful and faster procedures, with better outcomes than these injections without guidance. Ultrasound guidance avoids sensitive structures (like nerves and vessels) during the procedure.

What is a hip cortisone injection?

Corticosteroid (cortisone) is a potent anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis, arthritis and tendinosis). A cortisone injection will reduce inflammation in the injected area (like the hip joint or trochanteric bursa) and allow you to manage the condition, usually by undergoing physiotherapy. To learn more, please read our article Steroid injections around the hip.

Do I need a hip cortisone injection?

Generally, the management of most hip conditions starts with physiotherapy treatment and progressive rehabilitation. The duration of this depends on the condition. If the response from the above is poor or not satisfactory, then an ultrasound-guided hip treatment option may be considered. Injection therapy can be very useful in reducing pain and improving function, allowing for more effective rehabilitation. We always advise performing hip injections under ultrasound guidance by an experienced doctor to ensure accurate medicine delivery to the targeted area.

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Are hip cortisone injections safe?

Yes, generally these injections are very safe and routinely done in our practice. There is a very small risk of infection (about 1:10.000). The procedure will be explained to you in detail during your appointment and all your questions will be addressed. To find out more about cortisone injection in general, please see our FAQs.

What are the commonly used steroid medicines in hip injections?

The commonly used types of steroid injections for musculoskeletal conditions are triamcinolone (Kenalog) and methylprednisolone (Depo-medrone). These preparations are long-acting steroid injections that normally take a few days to start working.

How long will the effect of a hip cortisone injection last?

Current evidence suggests that cortisone can improve pain and function for up to 3 months, but in some cases, it can last longer. The injections usually also contain a local anaesthetic that provides immediate pain relief lasting a few hours.

How soon will a hip steroid injection start to work?

A steroid injection usually takes a few days (1-3) before you notice the effect, although sometimes the pain relief can start on the same day. The injected area will often feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection. Other injections like PRP and intra-articular Hyaluronic acid injections can take a few weeks (2-5 weeks) before noticing any results.

What is the benefit of imaging in patients with hip pain?

Imaging is vital in establishing the correct diagnosis, assessing the condition's severity and deciding the best treatment options. To get the correct diagnosis, you must be assessed by an experienced practitioner (a hip specialist doctor or an experienced physiotherapist). In most cases, imaging will be needed to confirm the diagnosis and assess the severity of the condition. A hip x-ray is the most common initial imaging assessment performed, mainly when there is suspicion of hip joint osteoarthritis (wear and tear changes to the joint).  Ultrasound is useful to assess the superficial soft tissues around the hip (ligaments and tendons), like the gluteal tendons. It is also useful to assess for any fluid build-up within or around the hip joint (like joint effusion, which refers to fluid within the joint or an iliopsoas bursa). It is also extremely useful to guide injection therapy around the hip joint. MRI is more valuable for assessing the deep structures (the labrum and the articular cartilage). An experienced musculoskeletal radiologist doctor would be most suited to interpret the various imaging studies mentioned above.​

Do hip steroid injections just hide/mask the pain?

Steroid injections do not just mask or hide the pain but they act by reducing the inflammation in the targeted area, thus providing a strong and local anti-inflammatory effect to help control the symptoms and allow the patient to manage the condition, usually by undergoing effective rehabilitation.

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How many hip injections can I have?

We advise reducing the number of cortisone hip injections if possible, by combining any injection therapy with an effective physiotherapy programme to address the underlying cause. Repeated steroid injections into the same area should be avoided if the previous injection was less than 3-4 months ago.​

Are hip injections painful?

Pain is very subjective and people have different pain thresholds. Generally, hip injections are well-tolerated and the majority of patients experience very little discomfort during the procedure. The corticosteroid is usually mixed with a local anaesthetic (numbing medicine) to enhance pain relief. We use ultrasound guidance to ensure the procedure is quick and efficient. Ultrasound ensures needle visualisation to choose the safest path for the injection and avoid any important or sensitive structures.

How long should I rest after a hip injection?

Usually, we advise patients to rest for 48-72 hours after having a hip injection. This can vary depending on the type of treatment and severity of the condition. Usually, patients who have a trochanteric bursa corticosteroid injection are usually advised to rest for 48 hours, while patients who had a more advanced procedure like PRP injection into the gluteal tendons may be advised to rest for 5-7 days.

Sub-specialist Consultant Musculoskeletal Radiologist Doctor with extensive experience in image-guided intervention

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The Musculoskeletal Ultrasound & Injections clinic

169 Richmond Road, Kingston upon Thames

KT2 5DA

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