Psoas Bursa Injection

Chronic bursitis

Equipment:
Syringe - 5ml
Needle - 22G 3.5 inches (90mm) spinal
Kenalog 40 - 20 mg
Lidocaine - 4 ml 1%
Total volume - 4.5 ml

Causes and findings:
• Overuse - especially sports or activities involving repeated hip flexion movements, e.g. hurdling, ballet, javelin throwing, football
• Pain in groin
• Painful: passive flexion, adduction, abduction and possibly extension resisted flexion and adduction scoop test - passive semicircular compression of femur from full flexion to adduction
• End-feel normal

Anatomy:
The psoas bursa lies between the iliopsoas tendon and the anterior aspect of the capsule over the neck of the femur. It is situated deep to three major structures
in the groin - the femoral vein, artery and nerve, lying at the level of the inguinal ligament. For this reason, careful placement of the needle is essential. Following the instructions below ensures that the needle will pass obliquely beneath the neurovascular bundle.

Technique:
• Patient lies supine
• Identify femoral pulse at mid-point of inguinal ligament. Mark a point three fingers distally and three fingers laterally. The entry point lies in direct line with the anterior superior iliac spine and passes through the medial edge of the sartorius muscle
• Insert needle at this point and aim 45° cephalad and 45° medially. Visualize the needle sliding under the three major vessels through the psoas tendon until point touches bone on anterior aspect of neck of femur
• Withdraw slightly and inject as bolus deep to tendon

Aftercare:
Absolute avoidance of the activities that irritated the bursa must be maintained for at least 1 week, then stretching of hip extension and musclebalancing programme is initiated.

Comments:
Although this injection might appear intimidating to the clinician at the first attempt, the approach outlined above is safe and effective. Very occasionally it is possible to catch a lateral branch of the femoral nerve and temporarily lose power in the quadriceps. If the patient complains of a tingling or burning pain during the process, reposition the needle before depositing solution. Differential diagnoses include local lesions such as hip joint pathology, adductor strain, hernia, abdominal muscle sprain, cutaneous nerve entrapment, pubic symphysitis, testicular disease, fracture and referred symptoms from lumbar spine, sacroiliac joint and genitourinary organs. Suspicion of any of these should be maintained until the clinician is satisfied of the cause of the symptoms. If in doubt, a diagnostic injection of local anaesthetic alone is advisable.

Alternative approaches:
For large individuals, a longer spinal needle might be required.