MSK Injection, Initial Assessment – Two Joints

Below you will find a list of MSK conditions suited to Ultrasound Guided Injections. This is not an exhaustive list and any of your ultrasound guided injection needs could be accommodated in direct consultation with the MSK Radiologist. Please call us on 02071013377.
Conditions which can be treated by ultrasound guided injections in Upper Limbs:
Hand & Wrist

• Carpal Tunnel Syndrome
• Tenosynovitis (Including De Quervain’s and Trigger finger)
• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Synovitis (Hand and Wrist joints)
• Ganglion aspiration

Elbow

• Cubital tunnel syndrome
• Golfer’s elbow (Medial Epicondylitis)
• Tennis elbow (lateral epicondylitis pain)
• Distal Biceps/Triceps tendinopathy
• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Olecranon Bursitis (Student’s Elbow)

Shoulder

• Impingement/Bursitis
• Adhesive Capsulitis/ frozen shoulder ( e.g. steroid injection or Hydrodilatation)
• Rotator cuff tendinopathy
• Calcific tendonitis ( e.g. for Barbotage)
• Biceps tendinopathy
• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis) in Glenohumeral joint or Acromioclavicular joint (ACJ)

Conditions which can be treated by ultrasound guided injections in Lower Limbs:
Ankle & Foot

• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Inter-metatarsal bursitis
• Morton’s Neuroma
• Plantar Fasciitis
• Retrocalcaneal bursitis
• Tenosynovitis
• Ganglion aspiration
• Sinus Tarsi syndrome

Knee Below you will find a list of MSK conditions suited to Ultrasound Guided Injections. This is not an exhaustive list and any of your ultrasound guided injection needs could be accommodated in direct consultation with the MSK Radiologist. Please call us on 02071013377.
Conditions which can be treated by ultrasound guided injections in Upper Limbs:
Hand & Wrist

• Carpal Tunnel Syndrome
• Tenosynovitis (Including De Quervain’s and Trigger finger)
• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Synovitis (Hand and Wrist joints)
• Ganglion aspiration

Elbow

• Cubital tunnel syndrome
• Golfer’s elbow (Medial Epicondylitis)
• Tennis elbow (lateral epicondylitis pain)
• Distal Biceps/Triceps tendinopathy
• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Olecranon Bursitis (Student’s Elbow)

Shoulder

• Impingement/Bursitis
• Adhesive Capsulitis/ frozen shoulder ( e.g. steroid injection or Hydrodilatation)
• Rotator cuff tendinopathy
• Calcific tendonitis ( e.g. for Barbotage)
• Biceps tendinopathy
• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis) in Glenohumeral joint or Acromioclavicular joint (ACJ)

Conditions which can be treated by ultrasound guided injections in Lower Limbs:
Ankle & Foot

• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Inter-metatarsal bursitis
• Morton’s Neuroma
• Plantar Fasciitis
• Retrocalcaneal bursitis
• Tenosynovitis
• Ganglion aspiration
• Sinus Tarsi syndrome

Knee

• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Baker’s cyst aspiration
• Bursitis e.g. Prepatellar (Housemaid’s knee), Infrapatellar (Clergyman’s knee)
• Chronic ligament sprain
• Patellar tendinosis

Hip

• Arthritis (Inflammatory and Degenerative i.e. Osteoarthritis)
• Greater Trochanteric (GT) pain syndrome (i.e. GT bursitis with Gluteal tendinopathy)
• Hamstring origin tendinopathy/ Ischial bursitis
• Iliopsoas bursitis

A) Corticosteroid injections

• Steroid is an important and effective treatment for some MSK conditions. Steroids are potent anti-inflammatory medications particularly used in inflammatory or degenerative arthritis (osteoarthritis) causing joint pain as well as inflammatory or mechanical soft tissue conditions and injury causing pain such as bursitis, tendonitis and neuritis.
• Steroid normally eases pain and increases patients’ mobility thereby improves the quality of life. The beneficial effect of steroid can last for days, weeks and/or sometimes several months. Local anaesthetics are typically injected at the same time to provide immediate temporary pain relief and make the procedure more comfortable. Steroid injections performed at London Private Ultrasound are very well tolerated by our patients.
• Please read our section for Steroid injection during Covid-19 pandemic.

B) Aspiration of joint effusion, popliteal cyst (Baker’s cyst) and ganglion

 Joint aspiration means using a needle to remove fluid from a joint. Excess joint fluid (effusion) can increase stiffness and contribute to pain. Sometimes to improve the symptoms and efficacy of the steroid injection the radiologist would aspirate the joint prior to administering the steroid injection. The procedure would be considered as combined aspiration and steroid injection.

• During an aspiration, the fluid removed can be sent for testing to help with the diagnosis of your condition. For example, the fluid can be used to count the number of blood cells to see if there is an infection in the joint.
• Aspiration of a cyst for example from behind the knee (Popliteal cyst/Baker’s cyst) or in the hand/foot (Ganglion) can also be performed using a needle under ultrasound guidance to ease pain and pressure. This can also be combined with injection of steroid at the same time into the cyst cavity to reduce the chance of recurrence. The radiologist can discuss the options with you during your consultation.
• Note, joint effusion and ganglia can recur and may need repeated aspiration.

C) Platelet Rich Plasma (PRP) injections

• Platelet Rich Plasma (PRP) Therapy is an innovative, safe, non-surgical treatment option for tendon injuries and joint pain. It takes advantage of your own blood's natural healing properties by utilizing the proteins and growth factors of the platelets and plasma to restore injured cartilage, tendons, ligaments or muscles.

Plasma refers to the liquid component of blood and is mostly water but also includes proteins, nutrients, glucose, and antibodies, among other components. Platelets are tiny cells in your blood with a fundamental role in hemostasis (clot formation to stop bleeding) and are a natural source of growth factors.

• INDICATIONS:
• Tennis Elbow (lateral epicondylitis)
• Golfer’s Elbow (medial epicondylitis)
• Gluteal Tendinopathy
• Rotator cuff tear
• Plantar Fasciitis
• Runner’s Knee
• Patella Tendinopathy
• Achilles Tendinopathy
• Low Grade Muscle Tears
• Mild/moderate Arthritis
• During your appointment, one of our specialists will draw your blood into a collection tube. Spinning the tube in a centrifuge will isolate the platelets and a small volume of plasma. This Platelet Rich Plasma (PRP) will be injected into the injured area to promote healing.
• You will be asked to discontinue the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or high-dose aspirin for 5 days prior to your treatment. NSAIDs are asked to be discontinued because they impair platelet function, which may decrease the effectiveness of your PRP therapy. It is also recommended to refrain from smoking as this can cause increased inflammation and limit the success of your therapy.
• After the procedure you may experience some discomfort and/or mild swelling. Tendon therapies will generally cause more soreness than intra-articular injections. We recommend taking a pain reliever such as Paracetamol or Codeine as needed and using an ice pack if there is any swelling. Please do not take any NSAIDs until after you have finished your series of injections. You may return to daily activities and work at your own discretion.
• If your pain returns over time, you may benefit from follow-up PRP injections.

With ultrasound guidance the radiologist who is specifically trained in this field will ensure the needle is placed in the precise location to be treated. It has been proven through research that ultrasound guided injections achieve better outcomes compared with injections without ultrasound guidance, so called blind injections. The results are typically longer lasting with better pain relief and anti-inflammatory response which lead to faster improvement in the function of the injected area. Increased accuracy during injection reduces the risk of adverse events such as trauma to local tissues or misplacement of needle and medication.   Ultrasound guided injections therefore improve the safety and efficacy of the injections. Many patients have found ultrasound guided injections done at London Private Ultrasound to be more comfortable than their previous experiences.

Long lasting results of injections typically depend on the reason for the treatment, your overall health and severity of original condition. When you complete your treatment, your pain and inflammation of the affected joint should decrease. The beneficial effect of steroid can last for days, weeks and sometimes several months.

Steroid injection +/- Aspiration Risks are small and every precaution will be taken to ensure preventable risks are minimal. Most recognised and serious risks of steroid injections are:

• Post-injection flare (swelling and more pain several hours after the injection which usually subsides within several days)
• Bruising or bleeding especially if on blood thinning medication
• Allergic reactions to the medicines injected, equipment (latex, plaster) or aseptic solutions used to clean the skin at the site of the injection.
• Infection at the site of injection (extremely rare)
• De-pigmentation (paler skin at the site of injection - this may be permanent)
• Local fat atrophy (thinning of the skin at the injection site)
• Tissue damage (e.g. tendon rupture or cartilage damage from repeated injection)
• Increased blood sugar for few days if diabetic
• Increased blood pressure for few days if hypertensive
• Temporary irregularity in menstrual cycle

PRP injection Since PRP therapy only utilizes your body’s own healing properties there is no risk of allergic reaction or rejection of treatment by the body. However, since the growth factors trigger a complex cascade of healing, swelling and discomfort is expected for up to a week after receiving PRP treatment. Because of this expected ‘healing discomfort’, you should plan to have a friend or family member drive you home from the appointment.

At London Private Ultrasound the injections are done by an experienced, highly skilled radiology consultant whose expertise and accuracy in performing the procedure will ensure maximum comfort and efficacy. All our patients have very well tolerated their injections and when required have had no hesitation to return to us for their repeat injections. This is especially reassuring for patients with prior unpleasant encounters with injections elsewhere and those with fear of needles (needle phobia). Please call us on 02071013377 if you have any questions or concerns.

You will need someone to drive you home after the examination. Driving is hazardous for around 6 hours after the injection because of the local anaesthetic. After you have had a joint injection, you need to rest the affected area for 24 hours and avoid strenuous activity for several days. For the first 4-6 hours after the injection the area injected will be numb. This is because of the local anaesthetic. It is important that you monitor and keep a record of any changes in your pain during this time. Resolved pain during this short period can indicate that the site injected was contributing to your symptoms (diagnostic value of the injection). This information will be useful the next time you see your consultant. Once the local anaesthetic wears off in a minority of patients worsening of symptoms may occur (steroid flare up) which is temporary and self-limiting. You are welcome to take pain killers to help overcome the flare up. You can expect to notice the effect of steroid between 2-5 days after the injection but the full benefit may not be felt until 6 weeks later. After PRP therapy you may experience some discomfort and/or mild swelling. Tendon therapies will generally cause more soreness than intra-articular injections. We recommend taking a pain reliever such as Paracetamol or Codeine as needed and using an ice pack if there is any swelling. Please do not take any NSAIDs until after you have finished your series of injections. Only do minimal activity after the procedure and resume light activity after a week.  You may return to work as soon as you feel able - usually within a few days after the procedure. If your job involves manual work, stay off work for about a week.

PRECAUTIONS:

• Repeated injections into the same joint/site are not advisable in a short period of time. Please discuss alternative treatment with your doctor.
• Steroid injection should not be done if there is any infection at the affected area or anywhere else in the body. Injection should be postponed to at least 7 days after completion of antibiotic treatment and resolution of infection.
• In the case of history of serious allergy to the medications and substances used for injection, such injection should not be given. Please discuss with your own doctor or the radiologist for alternative treatment.
• Certain medications might interfere with steroids. If you have any health conditions that you have to take medication for, you need to let our doctor know.
• If you are taking blood thinning medication such as Warfarin you should consult your specialist first and obtain their advice before having an injection. You may also require a blood test prior to your injection with adjustment of your medication. This is to make sure that your blood is not too thin to cause any bleeding at the site of injection.
• It is recommended to allow at least 2 weeks between any dose of Covid-19 vaccination and a steroid injection.

• Steroid injections are currently considered on a case-by-case basis, when all other options have been exhausted and after careful consideration between the doctor and patient.
• COVID infection can be very serious and potentially life threatening. To date there is no conclusive scientific data but some information suggests there may be an increased risk of contracting COVID-19 or possibly more severe or drawn-out infectious process following steroid injections.
• Steroid medications have immunosuppressive effects. This may potentially increase the risk of acquiring infection with worsening or protracted disease course. This effect is believed to be smaller in joint and soft tissue injections compared to oral or intravenous preparations.
• The current WHO guidance for COVID-19 is to avoid the routine use of systemic corticosteroids unless indicated for another reason. The use of alternatives to steroids must always be considered. If steroids are needed, the lowest possible dose should be used for the shortest possible time.

• Steroid injection of multiple body parts on the same day/appointment should be avoided. Another appointment must be arranged 2 weeks (14 days) after the first injection.
• Although children and young adults are thought to be at lower risk from coronavirus, this guidance also applies to adult, young adult and children.
• Some will be at greater risk. Higher risk individuals need careful consideration and should only have an injection after all other options have been exhausted, with careful risk versus benefit assessment performed.
•  Higher risk people include:
  • 70 year or older (regardless of medical conditions)
  • Younger than 70 years with an underlying health condition listed below (i.e. anyone instructed to get a flu jab as an adult by their GP):

1. Lung diseases e.g. asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
2. Heart disease e.g. heart failure or previous heart attacks
3. Kidney disease (with reduced function or needing dialysis)
4. Liver disease, such as “hepatitis” or liver failure
5. Diabetes
6. Splenic problems e.g. sickle cell disease or spleen removed
7. Neurological conditions e.g. Parkins (MS)
8. Weakened immune system e.g. HIV and AIDS, taking medicines such as steroid or immunosuppressive tablets for inflammatory joint conditions (Arthritis) or organ transplant recipient (Lung, Kidney etc.).
9. Cancer patient including if on chemotherapy or radiotherapy
10. Any cancers of the blood or bone marrow e.g. leukaemia
11. During pregnancy
12. Clinically Overweight (a body mass index (BMI) of 40 or above

• Current guidelines state single steroid injection does NOT mean the patient has to “shield” but they should minimise the risk as much as possible as per NHS advice.
•  Patients should not come into hospital if they or anyone of their household develops symptoms that might be related to Covid-19 including high temperature, new continuous cough or loss or change to your sense of smell or taste.
• If the patient thinks they have the COVID-19 symptoms they should follow the latest government guidelines found on the following website https://www.gov.uk/coronavirus and if unsure use the NHS 111 online service: https://111.nhs.uk/service/COVID-19 or Call NHS 111.
• It is recommended to allow at least 2 weeks between any dose of Covid-19 vaccination and the steroid injection.

Reference: Management of patients with musculoskeletal and rheumatic conditions who are on corticosteroids - require initiation of oral/IV corticosteroids -require a corticosteroid injection. 16 June 2020 Supported by the British Society for Rheumatology, British Association of Orthopaedics, British Association of Spinal Surgeons, Royal College of General Practitioners, British Society of Interventional Radiology, Faculty of Pain Medicine, British Pain Society and Chartered Society of Physiotherapy) https://mskphysioclinic.co.uk/wp-content/uploads/2020/06/MSK_rheumatology_corticosteroid_guidance.pdf

• Consultation
• Diagnostic ultrasound scan
• Ultrasound-guided injection if appropriate
• A detailed report of your scan findings and the performed treatment

If within this process, you decided that injection therapy is not the appropriate treatment plan for you, you will be given a full explanation of the findings and the most appropriate management plan. In that case you will be charged for the ultrasound scan only.

To book your appointment for injections, you should book an initial assessment with our musculoskeletal intervention radiologist consultant, prior to your injection. The cost of this initial assessment will be a part of the total payment that should be paid for the injection. Injections are not given to any person of age 16 or younger without a specialist referral.

1. MSK Injection Initial Assessment (One Joint)- £220/part                  Book Now
2. MSK Injection Initial Assessment (Two Joints) - £330/part                  Book Now
3. Steroid injection - £445/part                  Book Now
4. Aspiration combined with steroid injection - £595/part                  Book Now
5. Barbotage (Shoulder) - £595/part                  Book Now
6. Hydrodilatation (Shoulder) - £595/part                  Book Now