Ultrasound Guided Procedures

• Ultrasound guided steroid injection
• Hyaluronic acid (Visco-supplement injections)
• Hydrodistention injection

How does steroid injection work?

Steroid injections (also known as cortisone injections) help to reduce inflammation, which is often the cause of pain. Pain and inflammation can delay healing by restricting movement and function. This leads to stiffness and often weakness of muscles around the painful area - which leads to further irritation and pain! Steroid injections help break the pain cycle. This gives a window to allow the patient to exercise so as to recover strength and function very quickly.

It follows, then, that before the effect of the steroid injection wears off, you should focus on the exercises prescribed by your physiotherapist. This way, when the effect diminishes, you will have gained better strength and function, which can be challenging to achieve when you are in pain.

What are the benefits of ultrasound guided steroid injections compared with those without ultrasound guidance?

Ultrasound allows precise needle placement, ensuring the injection reaches the exact spot required. This improves the success of injection and also reduces the dispersion of the medicine into areas where you might not need it.

How long is it before you can expect to feel an improvement?

Steroid injections are generally done in combination with local anaesthetic, which starts to work within a few minutes. The benefits of steroid's anti-inflammatory effect will be felt within 2-3 days, and the full effect can take 2-3 weeks.

How long does the effect of steroid injection last?

This depends on the underlying condition and also your lifestyle. Steroid injections will get rid of or significantly reduce the inflammation within 2-3 weeks. This improvement allows better movement and enhances your ability to exercise, which often can permanently address the problem. However, certain conditions cannot be fully reversed, such as arthritis. In this case, effects will depend on several variables, including the severity of the arthritis, your lifestyle, the strength and flexibility of the muscles around the joint, and the amount of strain placed on the joint with your daily activities. Therefore, the injection could last from a few weeks to several months. Understanding how to care for the underlying conditions can reduce the need for further injections, and your health professional can help to create a plan for this.

Are there any risks associated with steroid injections?

With any needle procedure, there is a small chance of infection (less than 1 in 10,000) or bruising at the site of injection. Please inform your clinician if you take any blood thinners.

There could be a risk of allergy. Please inform your clinician if you have any allergies. Some people experience a steroid flare, feeling more pain and swelling at the site of injection for 2-3 days. This is temporary and usually subsides. If you experience this, you can take a pain killer like paracetamol and apply ice.

Steroid can temporarily weaken the collagen in the soft tissues. Therefore, to prevent any damage to the tendon or ligaments, it is advised to avoid any strenuous/sporting activities for 2 weeks after the steroid injection and then gradually to build up after that.

Are there any precautions or restrictions after receiving a corticosteroid injection?

It is recommended to rest the joint that has been injected for 48 hours. After that you can do normal daily chores but avoid any high impact/repetitive movements for 2 weeks to lower the minor risk of tendon damage and also to optimise the therapeutic effect of injection.

How can I arrange an appointment if I want to have a steroid injection?

Please contact the clinic regarding booking the injection appointment. If you already have a confirmed diagnosis with another clinician in the NHS or privately, then please send us a copy of the consultation letter or reports from your investigation. Vikas will then call you to go through the pre-injection questionnaire. If appropriate we can then directly book you for the injection.

If you do not have a confirmed diagnosis, you will need to schedule an appointment for an assessment first, and then we can book the injection afterwards. Initial assessment session will also include physiotherapy treatment and advice regarding home exercises. If there is need for an Xray or a scan to confirm the diagnosis before the injection, this will also be discussed in the initial assessment session.

US guided injection may be performed for the following body parts:

• Shoulder - Subacromial impingement, AC joint, shoulder joint arthritis, hydrodilation (aka hydrodistension) of frozen shoulder
• 1st CMCJ - thumb arthritis
• Trigger finger
• DeQuervain's tenosynovitis
• Carpal tunnel syndrome
• Finger joints arthritis
• Trochanteric bursitis
• Gluteal tendinopathy and bursitis
• Ischial bursitis
• Hip joint
• Knee joint
• Anserine bursa
• Ankle joint
• Peroneal tendon
• 1st MTPJ- big toe arthritis
• Morton's neuroma
• Plantar fasciitis
• High volume saline injection in achilles tendon sheath

(We do not do spinal steroid injection)

Hyaluronic acid injection (Visco-supplement injection)

Visco-supplement injection is hyaluronic acid which is injected into synovial joints. Synovial joints (e.g. knees, hips and shoulders) have a layer of a membrane called synovial membrane around the joints. Where the two bones meet each other to form a joint, the ends of bones are covered with a thick rubbery cartilage. Synovial membrane produces synovial fluid which protects the joint cartilage by acting as a lubricant and shock absorber: and it helps in nutrition of the cartilage. Hyaluronic acid is the most important component of synovial fluid.

In a normal joint there is balance between the production and breakdown of hyaluronic acid. However, when there is osteoarthritis, breakdown happens faster than production which makes our synovial fluid less protective as it becomes more watery and loses its shock absorption properties. This makes our joint cartilage even more vulnerable to damage from impact and general use.

As the cartilage wears thin, the bone of our joint surfaces becomes directly exposed to impact which leads to damage within the bone. These changes are not reversible; hence people have to have a joint replacement.

How does visco-supplement injection help?

Visco-supplement injection like “Ostenil Plus” is a solution that has hyaluronic acid in its very pure form, specially manufactured for clinical use. Mannitol is added to Ostenil Plus which increases the efficacy of the hyaluronic acid, allowing it to work longer and more efficiently to protect the joint.

Are there any side effects of Visco-supplement injection?

There are no known serious side effects of this injection.

How long does it last and can it be repeated?

Effects of Visco-supplement injections vary depending on your activity level and the underlying condition of the joint. Generally, if you get more pain when weight bearing and less pain when resting then Visco-supplement injections tend to work well: but when pain is severe even at rest, it's an indication that joint could be badly inflamed. In this case, it is better to have a steroid injection first to ease the inflammatory flare up and then visco-supplement injection can be done a few weeks later to protect the joint from getting inflamed again from general use. The effects of visco-supplement injections can last for several months. Once the effect starts to wear off, you can have another injection as it is safe to repeat these injections.

Hydrodistension

Hydrodistension injections are done mainly for frozen shoulder or “adhesive capsulitis”. The shoulder joint is encapsulated by a layer of connective tissue, called the joint capsule. In frozen shoulder, the joint capsule thickens and tightens, leading to restriction in movement and also often quite severe pain. During the hydrodistension procedure, with the help of ultrasound guidance, a needle is precisely directed into the joint capsule. Along with steroid and local anaesthetic, a high volume of saline is injected into the joint capsule with the aim of stretching the joint capsule and joint adhesions. This helps in reduction of inflammation and pain.