M u s c u l o s k e l e t a l I m a g i n g R ev i ew

Rowbotham and Grainger

Ultrasound-Guided Intervention in Hip Joint

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Musculoskeletal Imaging
Review

Ultrasound-Guided Intervention
Around the Hip Joint
Emma L. Rowbotham1
Andrew J. Grainger
Rowbotham EL, Grainger AJ

OBJECTIVE. The purpose of this article is to review some of the most common reasons
for ultrasound intervention around the hip joint, and describe the techniques involved.
CONCLUSION. Ultrasound alleviates the need for exposure to radiation and is already
the modality of choice for aspiration of the hip joint, an intervention that may be helpful in
guiding antimicrobial therapy and help avoid the need for surgical intervention. Ultrasound
can also be used to access the hip for diagnostic or therapeutic injection.

Keywords: greater trochanteric bursa, hip, iliopsoas

tendon bursa, ultrasound
DOI:10.2214/AJR.10.6344
Received December 14, 2010; accepted without revision
December 28, 2010.
1
Both authors: Department of Musculoskeletal
Radiology, Leeds Teaching Hospitals, Chapel Allerton
Hospital, Chapeltown Rd, Leeds, West Yorkshire LS7
4SA, United Kingdom. Address correspondence to
A. J. Grainger (andrew.grainger@leedsth.nhs.uk).

WEB
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ltrasound of the adult hip is a

commonly performed investigation that may be used to assess
for both intra- and extraarticular
pathology. Common findings include joint
fluid, bursitis, hematoma, and paralabral cyst
formation. Increasingly, ultrasound is being
used to guide intervention around the hip
joint for both diagnostic and therapeutic purposes. Ultrasound alleviates the need for exposure to radiation and is already the modality of choice for aspiration of the hip joint [1],
an intervention that may be helpful in guiding antimicrobial therapy and help avoid the
need for surgical intervention. Ultrasound
can also be used to access the hip for diagnostic or therapeutic injection [2]. Guided injection of the greater trochanteric bursa or
the iliopsoas tendon bursa may have enormous therapeutic benefits to the patient without the need for surgery or exposure to ionizing radiation. We review some of the most
common reasons for ultrasound intervention
around the hip joint: intraarticular injection,
aspiration of joint fluid for both therapeutic
and diagnostic purposes, injection of trochanteric or iliopsoas bursitis, and treatment
of the symptomatic snapping hip. We describe the techniques used at our institution
for these ultrasound-guided interventions,
along with tips to aid a successful procedure.
Intervention Technique
In many cases, diagnostic ultrasound will
be performed at the same appointment as
any appropriate intervention. With modern
equipment, a high-frequency linear probe

can be used to image the hip joint, typically

with frequencies around 915 MHz depending on patient body habitus. Occasionally, a
lower-frequency probe may be required if
the patient is obese.
Providing an aseptic environment is of
paramount importance in minimizing the introduction of infection, particularly when injecting into the joint itself. This essentially
involves using sterile gloves and probe covers; cleaning of the skin with an antiseptic
skin preparation, such as chlorhexidine solution; and ensuring the needle tip passes
through the cleaned area of skin, avoiding
any areas of broken skin or overlying infected areas. With the probe positioned over the
hip joint in the sagittal plane, the femoral
head is visualized and just superior to it, the
acetabular roof and acetabular labrum. The
labrum is a hyperechoic triangular structure
attached to the brightly hyperechoic bone of
the acetabulum (Fig. 1).
There are several important factors to
consider that will aid a successful ultrasound
guided procedure. Namely, always know
where the needle is, have a good knowledge
of the surrounding anatomy, and only inject
when the tip of the needle is visible. The crucial factor in keeping the needle visible on
the screen is to keep the probe and the needle in the same place throughout the procedure. However, it is important to realize that
the needle is best visualized when the needle
and probe face are parallel. With increasing
angle of insonation, the visualization of the
needle becomes less clear and may even become invisible due to the reflection of sound

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Ultrasound-Guided Intervention in Hip Joint

sity at 6 months when performed in vivo [3].
Consequently, we prefer the use of lidocaine
for anesthetizing the skin and bupivacaine
for intraarticular injection. The equipment
needed for injection of the hip is shown in
Figure 4.

Fig. 1Hip anatomy.

A, Radiograph shows normal anatomy of hip in healthy subject. Plane of transducer (blue) is parallel to
femoral neck.
B, Sonogram in 28-year-old man shows hip joint with transducer placed in oblique axial plane along femoral
neck (F) and corresponding normal anatomy of hip joint. Hyperechoic labrum is seen covering superior aspect
of femoral head (blue arrow). There is small joint effusion seen at this hip joint (white arrow).

Fig. 2Greater trochanteric bursa in 68-year-old woman.

A, Normal radiograph from healthy subject (provided for comparison) shows probe position (blue) is placed
along lateral aspect of hip in plane parallel to lateral surface of greater trochanter.
B, Needle parallel to probe. Image shows needle (arrow) being introduced into soft tissues toward greater
trochanter (GT) in plane parallel to transducer. This is optimal angle and entire needle is easily seen.

away from the probe (Fig. 2). Careful planning of the needle path will allow exquisite
visualization of the needle during the procedure. Marking of the skin at the chosen entry point before injection is a valuable step in
the procedure (Fig. 3). This allows the needle to be positioned into the subcutaneous
tissues first without the need for also holding the transducer. The transducer can then
be brought over the needle tip and the position confirmed before advancing the needle
into the desired location. A 22-gauge needle
is usually used for injections around the hip.

A larger bore needle, such as a 16 or 18 gauge

may be needed for aspiration, particularly if
the fluid is infected.
With all the described injections, a combination of local anesthetic and steroids is
used to maximize symptom relief. The steroid used in our institution is 40 mg triamcinolone and the local anesthetic is 1% lidocaine, usually in a volume of 5 mL. A recent
study comparing the chondrocyte-damaging
properties of local anesthetics used in joint
injections has shown that 0.5% bupivacaine
resulted in a reduction in chondrocyte den-

Ultrasound-Guided Aspiration
of the Hip
One of the most common indications for
ultrasound of the adult hip is the detection
and aspiration of a joint effusion. Pain in the
groin or medial thigh, pain aggravated by lying on the side, decreased extension or internal rotation or abduction or flexion, painful
external rotation, and pain on palpation in
the groin showed a significant relation (adjusted for age and radiologic osteoarthritis of
the hip) with ultrasonic hip joint effusion [4].
The most common reason for aspiration in
the hip is for the diagnosis of infection. However, reliance on the ultrasound appearance
of the effusion is not sufficient to distinguish
between infection and a simple effusion. Pus
can appear anechoic, and a complex appearance to the effusion does not reliably indicate
sepsis (Fig. 5). The presence of a joint effusion is confirmed by an increased volume
of fluid in the anterior recess. This is usually measured in the oblique sagittal plane
along the line of the femoral neck and should
be compared with a measurement from the
contralateral side (Fig. 6). The normal distance from femoral neck to the capsule has
been described as between 4 and 10 mm. It
can sometimes be difficult to differentiate
thickened synovium from joint effusion because both have similar appearances on ultrasound. If this is the case, asking the patient to move the hip is helpful because this
will disperse an effusion around the joint,
whereas synovial thickening would remain
constant in appearance. Aspiration of joint
effusion is not always necessary and should
be confined to patients in whom there is a
high clinical suspicion of sepsis.
Ultrasound-Guided Injection
Injection of the hip joint is undertaken for
a variety of reasons. Inflammatory arthritides
may be treated with direct injection of cortisone into the hip. Similarly, symptomatic relief of osteoarthritis may also be achieved.
Frequently, it is unclear whether a patients
symptoms are due to hip pathology, for instance if the patient has both hip osteoarthritis and degenerative change in the spine. In this
situation, a diagnostic injection of long-acting

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Rowbotham and Grainger

Fig. 3Photograph shows hip injection skin marking in 32-year-old woman. Marking of skin before injection
allows accurate placement of needle into tissues and then placing probe back onto skin to guide final
positioning. This image shows marking of skin before hip joint injection with probe in axial plane.
A and B, Axial ultrasound image (B) shows corresponding normal anatomy with probe in axial plane as in A.
Labrum is indicated with blue arrow and psoas muscle overlying femoral head (F) is indicated with white arrow.

Fig. 5Complex hip effusion in 74-year-old woman.

There is large amount of complex fluid (arrow) seen
within hip joint in patient who has had dynamic
hip screw inserted into femoral headneck after
fractured neck of femur (F). Hip aspirate revealed
frank pus within joint and patient was taken to theater
for washout of septic joint.

Fig. 4Photograph shows injection equipment.

Chlorhexidine cleaning sticks are now used for
all procedures at our institution, and 1% lidocaine
is usually adequate for subcutaneous analgesia.
Duraprene manufactured by Allegiance Healthcare.

the needle to be introduced almost parallel

to the probe face. This technique also means
the skin puncture is made laterally, well away
from the medially located neurovascular bundle. This enables the operator to place the needle and then confirm position with the sterile probe. For aspiration, the needle should be
placed into the deepest pool of fluid within the
joint and aspirated into a sterile syringe. Samples should be sent for culture and sensitivity.
Aspiration should be as complete as possible
to maximize relief of symptoms.
As with aspiration of the hip, we prefer an
axial approach to the hip joint for injection.
The femoral head is identified and the probe is
then positioned to obtain an axial view through
the head. Sweeping the probe distally identifies the junction of the femoral neck and head

in the axial plane, which is the point targeted

for the injection. The needle is introduced from
the lateral side along the long axis of the probe
and as parallel to the probe face as is feasible.
When the needle is seen (and felt) to contact the
bone, it will lie within the joint on the anterolateral aspect of the headneck junction (Fig.
7). A sterile technique is again of paramount
importance, and marking the skin at the appropriate needle entry point before preparing
the sterile equipment is helpful. A combination
of local anesthetic and steroids should be prepared in the same syringe. The injectate should
be placed into the anterior recess at the femoral
headneck junction (Fig. 8). Unless the examination is being undertaken for arthrography,

anesthetic into the hip can help make the distinction. We also make use of ultrasound guidance for the injection of contrast material for
MRI arthrography. In this instance, the technique is essentially the same as for therapeutic
injection, with contrast medium instilled into
the joint as opposed to local anesthetic and steroids. The introduction of contrast material for
arthrography can be combined with diagnostic
anesthetic injection if required.
Aspiration and Injection Technique
For both injection into the hip joint and aspiration of the hip joint the patient should be
positioned supine and the transducer placed in
the longitudinal oblique plane along the axis
of the femoral neck to examine the anterior
recess and confirm the presence of effusion
(Fig. 6). Intervention can be performed either
in the axial or sagittal plane. In our institution,
the axial plane is preferred because it allows

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Fig. 6Axial oblique approach to hip joint in 82-year-old woman.

A, Photograph shows transducer placed in axial oblique plane along femoral neck and needle placed into soft
tissues along line of transducer.
B, Sonogram shows hip effusion (arrow). In this case, effusion has been measured (calipers) in anteroposterior
direction and measurement was compared with contralateral side to confirm presence of effusion.

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Ultrasound-Guided Intervention in Hip Joint

gluteus medius and gluteus minimus muscles have been described in the literature as
the rotator cuff of the hip, and tendinopathy
or tears of these two muscles have also been
shown to be present in most patients presenting with trochanteric bursitis [5].

Fig. 7Hip injection video in 71-year-old man. This

animation shows needle entering tissues distal to
hip joint and then being guided to hip joint before
injecting mixture of local anesthetic and steroid into
joint space under ultrasound guidance. For this
video, see Figure S7 in supplemental data at www.
ajronline.org.

Fig. 8Sagittal sonogram of hip joint in 68-year-old

woman shows femoral head (F) and needle within
hip joint (arrow) immediately before injection. (See
also Fig. S8, cine loop, in supplemental data at www.
ajronline.org.)

it is helpful to inject a little air at the start of

the injection. This is easily seen on ultrasound
and confirms the intraarticular location of the
injection. If the patient is to undergo MRI arthrography, the presence of air is to be avoided
because it may be confused for pathology, such
as intraarticular loose bodies.
The patient should be warned that there
might be an aching sensation in the hip in
the 24 hours after injection and, when cortisone has been injected, that the maximal
therapeutic benefit may not be experienced
for several days after the procedure.
Ultrasound-Guided Injection of
the Greater Trochanteric Bursa
Trochanteric bursitis is a relatively common condition affecting physically active pa-

tients and usually presenting with pain to the

lateral aspect of the hip, particularly on walking. This condition either occurs secondary to
an injuryusually overuse injuryor more
rarely as a manifestation of rheumatoid arthritis. Traumatic injury includes bursal irritation as a result of the iliotibial band moving over the bursa repetitively and is usually
seen in athletes. The trochanteric bursa is best
thought of as a bursal complex with bursae
present between the gluteal tendons. The trochanteric bursa itself is often described as being situated between the iliotibial tract and the
gluteal tendons (Fig. 9). In addition there is
a subgluteus medius bursa beneath the gluteus medius tendon, and similarly, a subgluteus
minimus bursa. Inflammation of any of these
bursae will present with lateral hip pain. The

Greater Trochanteric
Bursa Technique
The trochanteric bursae are best approached
with the patient lying on the side in the lateral
decubitus position with the symptomatic side
uppermost (Fig. 9A). The bursae are relatively
superficial structures and therefore readily accessible. The superficial position also makes
keeping the probe face and needle track parallel relatively easy. Both axial and sagittal imaging will show fluid within the bursa, provided
not too much pressure is applied with the transducer, which may compress the inflamed bursa. As in assessment of joint effusion, comparison with the contralateral side is useful when
findings are equivocal. Again, sterile conditions are essential. A combination of local anesthetic and steroids (typically 40 mg triamcinolone) should be prepared and injected into the
fluid collection (Fig. 10).
Ultrasound-Guided Treatment
of Iliopsoas Pathology
When the patient moves the hip through certain positions, snapping of the iliopsoas tendon
over the iliopectineal eminence may cause an
audible snap or click that can be painful and
felt anteriorly. This condition may occur secondary to previous trauma or injury, particularly overuse injury [6]. The iliopsoas muscle
functions as a hip flexor and arises from the

Fig. 9Trochanteric bursitis injection position in 57-year-old woman.

A, Photograph shows position of transducer in longitudinal plane with relation to greater trochanter. Position of proximal end of transducer has been marked before
injection.
B, Trochanteric bursa (blue arrow) is thickened in this axial image and shows echo-poor line immediately adjacent to bone cortex, in keeping with trochanteric bursitis.
Gluteus medius bursa is also thickened in this example (white arrow). GT = greater trochanter.
C, Further more florid example of trochanteric bursitis (arrow) is shown in this longitudinal image. GT = greater trochanter.

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Rowbotham and Grainger

bundle. The patient is best positioned in the
supine position. A combination of local anesthetic and steroids is again required. The
approach is similar to that used to inject the
hip in the axial plane. By positioning the
probe over the bursa or tendon, the needle
can be advanced in the lateral side of the
thigh, parallel to the probe face, maintaining exquisite visualization. Injection typically comprises 40 mg of triamcinolone mixed
with a small amount of lidocaine.
A

Fig. 10Needle position in greater trochanteric bursa in 68-year-old woman.

A and B, Sonograms show start (A) and end (B) positions of needle as it is positioned into greater trochanteric
bursa as shown in video Figure S10A (available in supplemental data at www.ajronline.org).A shows needle
(blue arrow) entering tissues proximal to greater trochanter (GT) and greater trochanteric bursa (white arrow),
and B shows final position of needle in trochanteric bursa immediately before injection. Needle (blue arrow) is
seen clearly with tip in bursa (white arrow).

Fig. 11Snapping iliopsoas tendon in 27-year-old man.

A and B, Sonograms show start (A) and end (B) of snapping iliopsoas tendon (IP) (blue arrow) as it flips across
iliopectineal eminence of pelvis. (See also Fig. S11A in supplemental data at www.ajronline.org).

anterior inferior iliac spine and inserts into the

lesser trochanter of the femur. A similar sensation is produced by the iliotibial band snapping over the greater trochanter but is felt in
a lateral position and usually felt as the hip
moves from extension to flexion. Iliopsoas tendinopathy is a recognized complication in patients who have had hip replacement surgery
[7]. It may be possible to show impingement of
the iliopsoas tendon on a prominent aspect of
the hip arthroplasty. It is important to exclude
other pathology that may present with similar
symptoms, such as labral tears, cartilage defects, and intraarticular loose bodies.
Ultrasound can be used to show the iliopsoas muscle flipping over the iliacus muscle
to confirm the diagnosis of snapping iliopsoas
(Fig. 11), and in many cases an associated ilio-

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psoas bursitis will also be visualized. Iliopsoas

bursitis may also be seen be seen in isolation
and is treated the same way.
In some cases, surgical intervention is necessary to alleviate symptoms, but a combination of
local anesthetic and corticosteroid injection can
often provide symptomatic relief and avoid the
need for surgery. The injection is performed into
the iliopsoas bursa or, in the absence of a bursa,
deep to the iliopsoas tendon. Failure of the injection to provide symptomatic relief suggests that
an alternative pathology may be responsible for
the patients hip or groin pain.
Iliopsoas Technique
With the probe oriented along the femoral head and neck, the iliopsoas tendon can
be seen to lie lateral to the neurovascular

Complications of Ultrasound-Guided
Intervention Around the Hip Joint
Complications after ultrasound-guided intervention at the hip are not common. However, as with every interventional procedure,
complications do occasionally occur. The most
common include infection both at the puncture site and of the hip joint itself, bleeding into
the joint, and injury to the femoral nerve. Allergy to the local anesthetic may present with
systemic symptoms of headache, dizziness,
circumoral numbness and tachycardia, or local symptoms related to nerve damage, such as
paraesthesia or prolonged anesthesia.
Introducing infection into the joint is rare,
but if it occurs it may have long-term consequences in terms of damage to the joint.
Patients should be informed of this potential
complication when giving consent for the
procedure to be performed. Aseptic conditions minimize this risk, but patients should
be aware that ongoing or worsening symptoms accompanied by redness and swelling
around the joint may be a sign of infection.
Bleeding into the joint is minimized by
ensuring the international normalized ratio is below 1.5. Patients on anticoagulation
therapy should be advised to stop the therapy
before the procedure is performed.
Injury to the femoral nerve is rare but is
documented in the literature [8]. This is usually temporary and results in diminished sensation over the anterior thigh and inability to
flex the hip or put weight on the extremity.
One of the major advantages of ultrasound
guidance over fluoroscopy for intervention
around the hip is that the femoral nerve and
other neurovascular structures are well visualized and therefore injury is minimized.
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Ultrasound-Guided Intervention in Hip Joint

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F O R YO U R I N F O R M AT I O N

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