Hip injection technique

Hip injections can be used as either a therapeutic or diagnostic procedure for a range of hip joint conditions.

Therapeutic hip injections using corticosteroids, hyaluronic acid, and platelet-rich plasma are the main non-surgical treatment options when conservative management has failed.

Required Equipment

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

Relevant Anatomy

The hip joint capsule attaches at the base of the femoral neck. When the needle contacts the neck, the solution is deposited within the capsule. The greater trochanter is a triangular bone with a sharp, angled tip that projects beyond the neck. This part can be difficult to palpate, especially in larger patients. Therefore, insert at least one thumb’s width proximal to the most prominent part of the trochanter. The safest and simplest approach is from the lateral side.

Hip Injection Technique

• The patient lies on the pain-free side, with the lower leg bent and the upper leg straight, resting horizontally on a pillow.
• Palpate the triangular greater trochanter using the thumb and middle finger of your caudal hand, placing them on either side of its base. Use your index finger to identify the depression at the tip of the bone.
• Position the index finger of your cephalad hand at this spot while passively abducting the leg.
• Insert the needle perpendicularly, approximately one thumb’s width proximal to the tip, until it contacts the hard femoral neck.
• Inject the solution as a bolus.

Gradually increase pain-related activity and maintain the area with a stretching routine, but limit weight-bearing exercises. In the early stages of degeneration, when pain is localized with minimal night pain, an elastic end feel, and reasonably good function, physical therapy can be effective.

Contraindications

Absolute contraindications for a hip injection include:

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

Notes

The lateral approach to the hip joint is simple, safe, and generally painless. There is usually no sensation of penetrating the capsule, and it is not essential to perform the technique under fluoroscopy. This injection is often given to patients awaiting hip replacement. However, it should not be used immediately before surgery, as this may increase the risk of postoperative infection. Discuss this with the surgeon before proceeding. It typically provides temporary pain relief and can be repeated at intervals of at least 3 months if the patient is still waiting for surgery or is not a suitable candidate. Annual X-rays monitor degenerative changes.

In larger patients, the total injection volume can be increased to 8 ml or 10 ml. In such cases, Adcortyl (40 mg in a 4 ml volume) may be preferred and a longer spinal needle might be required.

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

Fluoroscopic guidance for injections helps avoid critical structures of the hip joint through improved needle navigation.

A systematic review found that intra-articular steroid injection into the hip provided short-term pain relief for patients with osteoarthritis-related pain. Data on pain relief with hyaluronic acid and platelet-rich plasma vary, but generally also show effectiveness.

References and Further Reading

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. Single-joint intra-articular hyaluronic acid injection in knee vs. hip in patients with hip and knee osteoarthritis: a pilot study – Scientific Figure on ResearchGate. Available at: https://www.researchgate.net/figure/A-fluorscopic-view-during-a-hip-joint-intra-articular-injection_fig1_24439956