While the ultrasound-guidance of injections is only necessary in certain circumstances requiring greater precision, it remains that it is extremely valuable in those circumstances — which include but are not limited to:

  • difficult targeted injections of the plantar fascia,
  • the targeting of stump neuromas and multilocuated cysts, intra-articular injections,
  • intra-lesional injections,
  • biopsies of deep masses and abscesses,
  • and the aspiration of fluid-filled masses not fully palpable.

Only through live, ultrasound guidance can injections requiring this kind of precision be delivered accurately. Without ultrasound guidance, such procedures are very often (literally) hit or miss.

The Procedure

The method for using ultrasound to guide an injection is straightforward enough.

  1. You simply establish an image at an appropriate position and angle for you to see where you will be making the injection,
  2. You have a nurse or an assistant take over holding the probe for you (maintaining the same pressure and angle on the probe),
  3. And then, with your hands free, you administer the injection as normal.
  4. After watching the injection take place, you take out the needle, you press “Freeze,” and you scroll the trackball to the left, backing up in time, to find the frame that shows the injection with the greatest clarity.
  5. You press the letter “A” on your keyboard to pull up an arrow, use the trackball (and the “Value” knob) to position it where it points at the location of the injection, and press “Enter” to stick it on the image. You then press “TEXT” and give the image a title (e.g., Left Plantar Fascia Injection) and you label the arrow with the letters “Inj.”
Optional approach …

You can also try it this way if you prefer: Have your nurse or assistant handle the cold spray and be ready to press the Freeze button on the ultrasound after the injection is complete, while you handle the probe in one hand and the needle in the other. This may give you greater control over the process. (Try both approaches and see which you prefer.)

A few general tips …
  • It goes without saying, it’s best to wear sterile gloves when delivering any injection.
  • It’s also best to use sterile ultrasound gel. This comes in single-application packets and works out to about $1.50 per procedure — about 1/100th of the reimbursement.
  • It’s possible (though less common) to cover the probe itself with a protective sleeve invisible to ultrasound, or to lay an acoustic couplant sheet over the area to be injected (basically a sterile wound dressing that ultrasound can pass through). This is a more elaborate measure, to be sure, but you may feel more comfortable with this approach under some circumstances.
  • Avoid having your patients watch the screen while you do your first two or three guided injections. This removes some of the stress when you are first learning to perform the procedure. After that, though, when you feel comfortable with it, definitely turn the monitor so that the patients can watch while you execute the injection. They love seeing it.

Note: if you would like to get a box of sterile ultrasound gel packets, or if you would like to order some probe covers or sterile acoustic couplant sheets, just let us know. Write: info [at] fisherbiomedical.com.

Note on seeing the needle in the image …

With a normal needle you may or may not see it. Just depends on the gauge of the needle, the angle it’s at, how much of it is even coming within view of the ultrasound probe, how deep you’re penetrating, etc. What you’re looking for is the dark bloom of the liquid going in. That’s what you’re watching for and documenting with your image.

(They actually make special needles that are particularly echogenic and easier to visualize on the monitor. You may want to get some of these for your ultrasound-guided procedures. Unfortunately, the ones we have found so far are rather large. We are working to find a company that can manufacture them in the 27 to 30 gauge range. If we find those, we will be sure to post the supplier here. The ones we have found so far are listed below …)


Notes on fascial band injections …

When you are injecting the fascia with a steroid, two approaches are commonly seen. One approach involves delivering the injection transverse at the insertion of the plantar fascia, where the needle is run medial to lateral. The other approach (typical when only the medial band is to be injected) is to deliver the injection from the posterior aspect of the calcaneus, where the needle runs parallel to the probe longitudinally, passing from the posterior aspect of the heel to the insertion of the medial band.

Notes on intra-articular injections of the 1st MTPJ …

In this procedure, the injection is delivered dorsally, traveling along the plantar aspect. You want to hold the probe longitudinal, medial to the 1st MTPJ.

Notes on injections of neuromas …

When injecting a neuroma, you will normally hold the probe along the bottom of the patient’s foot, spanning the metatarsals, and you will inject from the top of the foot, introducing the needle into the interspace, watching for the dark, hypoechoic plume of the injected liquid to push the neuroma.

A few words on billing for guided injections …

My suggestion when it comes to insurance billing (as always) is to try to fly under the radar as much as possible and use ultrasound to guide only the injections where you really think it aids in your accuracy. I am not a doctor, and I am not an insurance specialist, but if it were me, and I had an average-sized practice … I think I would probably keep my ultrasound-guided injections down to 2 or 3 (maybe 4) per day, and those in situations where it seems reasonably justified.

You certainly want to use your ultrasound for guiding injections. But you want to be responsible when it comes to how often you do so. A conservative approach to the number of guided injections you bill out for will prove less apt to throw up any red flags, and if you only use the ultrasound to guide select injections, and your images are well-annotated and your reports sound, you should not have anything to worry about.

Some situations seem perfect for ultrasound guidance: stump neuromas, biopsies of deep masses and abscesses, injections to a tendon sheath, and cases involving the aspiration of a fluid-filled mass not fully palpable. But this isn’t to say that other procedures might not also benefit from ultrasound guidance. Two such instances are mentioned often by our clients:

  • When treating Calcaneal Bursitis, ultrasound-guided pinpoint trigger injections just below the calcaneal tuberocity can thicken up the bursae, and a procedure such as this is common in many practices.
  • A series of plantar fascia injections might also benefit from ultrasound guidance, depending on the patient and the treatment being provided. (Indeed, there is even an article in support of one such procedure, recently published by ScienceDaily.)

In the end you must use your discretion and make use of ultrasound in guiding those injections where you think it appropriate and fit. In general, however, it’s almost always best to err on the side of caution. Better to bill out fewer guided injections and throw up no red flags … than to bill out too many and draw unneeded attention from an insurance provider. (You can read more on billing suggestions by clicking here.)