Musculoskeletal Ultrasound Injection – non-steroid – Patient Information

What is a musculoskeletal injection?

A musculoskeletal injection is an injection into joints (articular) or in soft tissue structures around joints (per-articular) to relieve pain, reduce inflammation, and improve mobility. Until recently, a radiologist would inject a corticosteroid (and some local anaesthetic) to reduce inflammation and alleviate pain. Most common sites for these injections are shoulders, elbows and knees.

What is an ultrasound guided musculoskeletal injection?

An ultrasound scan is where sound waves are used to build pictures of the body when reflected back of different structures. The sound waves travel through a hand-held sensor which is moved over your skin with the aid of some gel. Therefore, ultrasound is used to guide the radiologist to the exact point where the injection is needed to ensure accuracy.

What has changed with the injection and why?

Routinely, locally injected steroid was used. However, recently it has been found that a steroid can temporarily supress your immune system. In the current era of COVID 19, with a presumed extended period of the virus remaining in the wider community, this induced immunosuppression could potentially increase the risk of infection with COVID 19. Therefore, the use of non-steroidal anti-inflammatory drugs (NSAID) are being offered as an alternative injection. The NSAID that will be used is called Ketorolac.

What are the benefits of having a non-steroid injection?

The main benefit of using a non-steroid injection is the reduced chance your immune system will be supressed. Many of these injections have proven to have similar or equivalent outcomes when compared to previous steroid injections, such as a substantial decrease in the pain and increase the range of motion of the joint.

Are there any risks or contraindications of the NSAID injection?

Some risks of any injection include:

• Infection – there is always a risk of infection with any injection but this is minimized by following a sterile procedure
• Allergic reaction
• No benefit – the injection may not help your symptoms at all

Ketorolac, the NSAID used can cause ulcers in your gastrointestinal tract, however this all depends on the dose and duration of treatment. Some contraindications of NSAID are:

• active or previous stomach ulcer, stomach bleeding, or intestinal bleeding;
• a bleeding or blood-clotting disorder;
• a closed head injury or history of bleeding into the brain;
• bleeding from a recent surgery;
• severe kidney disease or dehydration;
• a history of asthma or severe allergic reaction after taking aspirin or an NSAID;
• inflammatory bowel disease, ulcerative colitis, or Crohn’s disease;
• if surgery is scheduled (especially bypass surgery); or
• if you are in late pregnancy or you are breast-feeding a baby
• if you have any risk or history of heart disease or high blood pressure.

If you have any of these please inform the radiologist or a member of Imaging staff. The radiologist will go through the risks and side effects in more detail before your procedure and you will be able to ask any questions you may have then.

If you are or if you think you could be pregnant, if you have had any allergic reaction to NSAID, Aspirin or local anaesthetic in the past, you must tell your referring doctor and the Imaging team.

Are there any side-effects with the NSAID injection?

As with any drug, Ketorolac can have some common side effects of Ketorolac, these include:

• nausea, stomach pain, indigestion, diarrhoea;
• dizziness, drowsiness;
• Headache
• Increased risk of a heart attack or stroke
• Increased blood pressure

If you experience any of these after the procedure please don’t hesitate to contact the imaging department or your GP.

Are there any medications that can affect the NSAID injection?

Please inform a member of staff if you are taking the following medications:

• pentoxifylline;
• probenecid; or
• aspirin or other NSAIDs

Are there any alternatives?

This is the alternative that is being offered instead of a steroid injection at this current time.

Consent – asking for your consent

The radiologist will ask you if you are happy for the injection to go ahead. This is called ‘verbal consent’ and you will be asked to sign a consent form which states you agree to have the injection and understand what it involves. If you do not wish to have the injection or are undecided, please tell the radiographer/ radiologist.

It is your decision and you can change your mind at any time. Please remember that you can ask the radiographer any questions you have at any time before, during or after your procedure.

What do I need to do in preparation for the scan?

In many cases you do not need to do anything to prepare for the scan. If you are taking any of the medications mentioned above, please inform a member of staff when making the appointment/ on the day. Please have your travel home planned.

What do I need to wear?

Please wear clothes that are easy to remove, as you will be required to change into a hospital gown before you have your injection. This is to ensure a sterile procedure.

What happens during the procedure?

Before the injection takes place, you will be given the opportunity to ask the radiographer any questions you have. You will be asked to get changed into a hospital gown and remove any clothing around the site being injected. The radiologist will go through a consent form, check any allergies and explain the procedure and answer any questions you may have.

You will then sit or lie down on the bed and the radiologist will do an ultrasound of the area of interest. The radiologist will clean the injection site and then may inject a small amount of local anaesthetic to numb the area which may sting for a few seconds. Once this has taken effect, a needle will be placed into the site and while checking under ultrasound. Once the radiologist is happy that the tip of the needle is in the correct place, the injection will be given.

How long will the procedure take?

The procedure usually takes about 30 minutes, however it is patient dependant. You can leave the department after the injection as long as you feel comfortable enough.

Will there be anyone with me during the scan?

The healthcare assistant and radiologist will talk to you through what’s going on during the procedure. A relative can be in the room for the injection if necessary.

Can I bring my children?

Unfortunately we are not able to offer childcare facilities and your children cannot go into the scan room with you. If you need to bring your children with you, please bring along an adult who can look after them while you are having the examination.

What happens afterwards?

Immediately after the injection, you may feel that your pain has gone or is significantly reduced. This is due to the local anaesthetic and will last for a few hours.

The benefits of the injection may last for a few weeks or even months.  You may need more than one injection to settle the symptoms. Please speak to your referring doctor if you have any queries after your injection.

Please try and fill in the pain chart if you are given one at the end of the procedure.