Hip Joint Injection

Acute capsulitis

Causes and findings:
• Osteoarthritis, rheumatoid arthritis or traumatic capsulitis with night pain and severe radiating pain no longer responding to physiotherapy
• May be on waiting list for surgery
• Buttock, groin and/or anterior thigh pain
• Painful limitation in capsular pattern - most: loss of medial rotation; less: loss of flexion and abduction; least: loss of extension
• Hard end-feel on passive testing

Equipment:
Syringe - 5ml
Needle - 22G 3.5 inches (90mm) spinal
Kenalog 40 - 40 mg
Lidocaine - 4 ml 1%
Total volume - 5 ml

Anatomy:
The hip joint capsule attaches to the base of the surgical neck of the femur. Therefore, if the needle is inserted into the neck, the solution will be deposited
within the capsule. The safest and easiest approach is from the lateral aspect. The greater trochanter is triangular in shape with a sharp angulation
inwards or the apex overhanging the neck. This part is difficult to palpate, especially on patients with excessive adipose tissue, so insert needle at least a thumb's width proximal to the most prominent part of the trochanter.

Technique
• Patient lies on pain-free side with lower leg flexed and upper leg straight and resting on pillow so that it lies horizontal
• Identify apex of greater trochanter with finger while passively abducting patient's upper leg
• Insert needle perpendicularly about a thumb's width proximal to palpable apex of trochanter until it touches the neck of femur
• Inject solution as a bolus

Aftercare:
Patient gradually increases pain-free activity maintaining range with a home stretching routine but limits weight-bearing exercise.

Comments:
The lateral approach to the hip joint is both simple and safe. It is not necessary to do the technique under fluoroscopy and the procedure is not painful. There is usually no sensation of penetrating the capsule. This injection is usually given to patients who are on a waiting list for surgery, but the joint should not be
injected within at least 6 weeks of surgery because reduced immunity could result in greater possible risk of infection. It is usually successful in giving temporary
pain relief and can, if necessary, be repeated at intervals of no less than 3 months. An annual X-ray monitors degenerative changes.

Alternative approaches:
For large patients the total volume can be increased to 8-10 ml. Forty mg Adcortyl, giving 4 ml of volume, might be the preferred steroid here. For large individuals, a longer spinal needle might be required. During the early stages of the degenerative process, when the pain is local, there is minimal night pain and end feels are still elastic with reasonably good function, physiotherapy can be effective.