Hip Injection Technique

Hip Injection can be used as a therapeutic or diagnostic technique for many pathologies of the hip joint.

Therapeutic hip injection with corticosteroids, hyaluronic acid, and plasma-rich platelets are the main treatment methods for non-surgical cases of the hip joint that failed to conservative treatment.

Equipment Needed

• Syringe: 5 ml
• Needle: Spinal, 22 gauge / 3.5 inches (90 mm)
• Kenalog 40: 40 mg
• Lidocaine: 4 ml, 1%
• Total volume: 5 ml

Related Anatomy

The hip joint capsule attaches to the base of the surgical neck of the femur, so if the needle is touching the neck, the solution will be deposited within the capsule. The greater trochanter is a triangular bone with a sharp angulation of the apex overhanging the neck. This part is difficult to palpate, especially on large patients, so allow at least a thumb’s width proximal to the most prominent part of the trochanter. The safest and easiest approach is from the lateral aspect.

Hip Injection Technique

• Patient lies on pain-free side, with lower leg flexed and upper leg straight, resting horizontally on a pillow.
• Palpate the triangular greater trochanter with thumb and middle finger of caudal hand, placed on either side of base, and identify dip at apex of bone with index finger.
• Place index finger of cephalic hand here while passively abducting leg.
• Insert needle perpendicularly about a thumb’s width proximal to the apex until it touches hard neck of femur.
• Inject solution as a bolus.

Gradually increase pain activity, maintaining the range with a stretching routine, but with limitation of weight-bearing exercise. During the early stages of the degenerative process, when the pain is localized with minimal night pain, elastic end feels and reasonably good function, physiotherapy can be effective.

Contraindications

Absolute contraindications to hip injection include:

1. Septic arthritis
2. Cellulitis at or near the skin entrance of the injection needle
3. Bacteremia
4. Acute fracture
5. Anaphylaxis/allergy to injected therapeutic agents

Notes

The lateral approach to the hip joint is simple, safe and is not painful; there is usually no sensation of penetrating the capsule and it is not essential to perform the technique under fluoroscopy. This injection is usually given to patients awaiting hip replacement, but should not be used in the run-up to surgery because this might increase the risk of postoperative infection; discuss with the surgeon before proceeding. It usually gives temporary pain relief and can, if necessary, be repeated at intervals of no less than 3 months if the patient is still awaiting or is unsuitable for surgery. An annual x-ray monitors degenerative changes.

For large patients, the total injection volume can be increased to 8 ml to 10 ml. Adcortyl (40 mg in a volume of 4 ml) might be preferred here, and a longer spinal needle may be required.

The proximity of the hip to important neurovascular structures, lack of palpable anatomic landmarks, and deep location of targets can make use of ultrasound guided hip injection ideal. The use of ultrasound guided hip injection has allowed for in-office image guidance with improved accuracy for more targeted and advanced procedures. 

Fluoroscopic guidance for injections helps in avoiding critical structures of the hip joint with enhanced needle guidance.

A systematic review found that intraarticular steroid injection in hip provided short term pain relief in patients affected by osteoarthritis-related pain. Data involving pain relief with hyaluronic acid and platelet-rich plasma vary, but also generally demonstrate efficacy.

References & More

1. Tafti D, Schultz D. Hip Joint Injection. [Updated 2022 Sep 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559023/
2. McCabe PS, Maricar N, Parkes MJ, Felson DT, O’Neill TW. The efficacy of intra-articular steroids in hip osteoarthritis: a systematic review. Osteoarthritis Cartilage. 2016 Sep;24(9):1509-17.
3. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P., American College of Rheumatology. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012 Apr;64(4):465-74.
4. da Costa BR, Reichenbach S, Keller N, Nartey L, Wandel S, Jüni P, Trelle S. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet. 2017 Jul 08;390(10090):e21-e33.
5. Lynch TS, Oshlag BL, Bottiglieri TS, Desai NN. Ultrasound-Guided Hip Injections. J Am Acad Orthop Surg. 2019 May 15;27(10):e451-e461. doi: 10.5435/JAAOS-D-17-00908. PMID: 30640742.
6. Bardowski EA, Byrd JWT. Ultrasound-Guided Intra-Articular Injection of the Hip: The Nashville Sound. Arthrosc Tech. 2019 Mar 11;8(4):e383-e388. doi: 10.1016/j.eats.2018.11.016. PMID: 31080722; PMCID: PMC6506808.
7. Knee vs hip single-joint intra-articular hyaluronic acid injection in patients with both hip and knee osteoarthritis: a pilot study – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/A-fluoroscopic-view-during-a-hip-joint-intra-articular-injection_fig1_24439956