Iliopsoas Bursa Injection

[knoxdoc]

Anyone have a good method to do these under fluoro (I'm not an US guru)? I have read that you can shoot an AP of the hip and aim for the superomedial aspect of the femoral head (11 o'clock on the left and 1 o'clock on the right), touch the overlying acetabulum, pull back 5mm, and shoot the dye.

Hopefully you don't skewer the fem nerve with this method. In the words of Ralph Wigham, that would make "two owwies."

---

Members don't see this ad.

 

[SSdoc33]

for iliiopsoas TENDON, i just go straight AP down to the lesser trochanter (its attachment), hit bone, contrast, then inject. never had a problem, N of about 40 or so. its always been significantly lateral to the femoral neurovascular bundle. as far as the bursa, im not sure. im also not sure how you could clinically tell the difference between an iliopsoas tendonitis and bursitis. ? MRI?

 

[knoxdoc]

for iliiopsoas TENDON, i just go straight AP down to the lesser trochanter (its attachment), hit bone, contrast, then inject. never had a problem, N of about 40 or so. its always been significantly lateral to the femoral neurovascular bundle. as far as the bursa, im not sure. im also not sure how you could clinically tell the difference between an iliopsoas tendonitis and bursitis. ? MRI?

You are right - you can't distinguish them clinically, but MRI can sometimes show inflammation in the bursa. I will try PT first for presumed tendinitis, and if she is not better I will try an injection. Going after the tendon insertion at the lesser troch seems like a good and safe first option to me - thanks.

 

[Mister Mxyzptlk]

I have read that you can shoot an AP of the hip and aim for the superomedial aspect of the femoral head (11 o'clock on the left and 1 o'clock on the right), touch the overlying acetabulum, pull back 5mm, and shoot the dye.

This is pretty much what I do.

In women, don't forget the possibility of femoral hernias as an etiology for groin pain.

 

[knoxdoc]

This is pretty much what I do.

In women, don't forget the possibility of femoral hernias as an etiology for groin pain.

Fortunately the GYN ruled that out first. Thanks for the confirmation on the approach.

 

[Tenesma]

i have gotten a few femoral blocks despite being "lateral" to the neurovascular bundle.... using the above technique... it also gets tricky in obese patients, cause you may end up going through bowel... if it is a tough patient, ill get a CT/MRI first to get a sense of what i am going through to get to the target

 

[drusso]

knox,

I've done a couple of these. Fenton describes a good technique in his "green" MSK injection book. Agree with the methods outlined by SSdoc and Mister M. I'll email you a pdf when I'm back in the office.

 

[SSdoc33]

i have gotten a few femoral blocks despite being "lateral" to the neurovascular bundle.... using the above technique... it also gets tricky in obese patients, cause you may end up going through bowel... if it is a tough patient, ill get a CT/MRI first to get a sense of what i am going through to get to the target

wow. if you have to worry about bowel, your patients have WAY more serious problems. you'll avoid the femoral block by only using a small amount of LA ( 1 mL). the cortisone is whats helping, anyway.

 

[Jcm800]

Anyone have a good method to do these under fluoro (I'm not an US guru)? I have read that you can shoot an AP of the hip and aim for the superomedial aspect of the femoral head (11 o'clock on the left and 1 o'clock on the right), touch the overlying acetabulum, pull back 5mm, and shoot the dye.

Hopefully you don't skewer the fem nerve with this method. In the words of Ralph Wigham, that would make "two owwies."

what symptoms and what exam/diagnostic criteria are u using to make the diagnosis of ilopsoas tendonitis?

 

[knoxdoc]

what symptoms and what exam/diagnostic criteria are u using to make the diagnosis of ilopsoas tendonitis?

26 y/o F kickboxer with focal R groin pain, non-radiating, exacerbated by climbing uphills or bouncing her child on her knee. No change with weight bearing on flat surface (walking). No radiation of the pain. No numbness/tingling. Neg xrays. Hip maneuvers negative except resisted hip flexion is painful. Thomas test reproduces pain. Tender in lateral aspect of femoral triangle, over iliopsoas. Neurologically intact. Neg reverse SLR.

Haven't gotten an MRI yet. No need at this point. If she doesn't get better with PT, inj, etc, then will need to rule out other stuff (femoral neck stress rxn/fx, labral tear, avulsion, etc).

 

[SSdoc33]

26 y/o F kickboxer with .....QUOTE]

i have seen similar symptoms in a 29 y/o trapeze artist, a 16 y/o mime, and a 42 y/o orangutan. who ARE these patients of yours? i think 90% of my patients are 60 y/o women.....

 

[drusso]

26 y/o F kickboxer with .....QUOTE]

i have seen similar symptoms in a 29 y/o trapeze artist, a 16 y/o mime, and a 42 y/o orangutan. who ARE these patients of yours? i think 90% of my patients are 60 y/o women.....

Last one I saw was in a 27 y/o rock-climber and paraglider instructor. I went straight to MRI with STIR. Symptoms in my case started suddenly after a "rough landing." I was concerned about stress fx or AVN, but it was just a soft tissue injury. Did the injxn, optimized PT, NSAIDs, etc.

I often think about this dx, but rarely make it. I love these kind of cases...

 

[Jcm800]

26 y/o F kickboxer with .....QUOTE]

i have seen similar symptoms in a 29 y/o trapeze artist, a 16 y/o mime, and a 42 y/o orangutan. who ARE these patients of yours? i think 90% of my patients are 60 y/o women.....

must be nice to have young patients like 60 year olds, hahah.

 

[Mister Mxyzptlk]

it also gets tricky in obese patients, cause you may end up going through bowel

Try lifting up the panniculus before you insert the needle.

 

[Tenesma]

most of my iliopsoas tendinitis patients are older (>50) who are 6-12 months out from a hip replacement.... usually because the acetabular cup is too big and the tendon is catching/rubbing against it.... usually what they need is the cup re-sized but you all know how much orthopods love doing that... so instead they get shipped to me for these injections with the hope that the patient gets used to the sensation... surprisingly most do...

 

[knoxdoc]

26 y/o F kickboxer with .....QUOTE]

who ARE these patients of yours? i think 90% of my patients are 60 y/o women.....

That's exactly why she earns a post. Wanted to hug her just because she wasn't a 45 y/o narc seeker or an 85 y/o .... but then I figured I'd get sued, so I backed off. I didn't want to ruin a good day.

And she wasn't even one of those "fix me now, dammit" athletes.

 

[glacier azul]

In residency- have seen this done blind. No flouro. Landmarks, obviously lateral to neurovasc bundle, palpable pulse is obvious.

That's exactly why she earns a post. Wanted to hug her just because she wasn't a 45 y/o narc seeker or an 85 y/o .... but then I figured I'd get sued, so I backed off. I didn't want to ruin a good day.

And she wasn't even one of those "fix me now, dammit" athletes.

 

[knoxdoc]

In residency- have seen this done blind. No flouro. Landmarks, obviously lateral to neurovasc bundle, palpable pulse is obvious.

That makes sense - I have needled the iliopsoas plenty of times for EMG and got right in 1" lateral to the femoral artery. Then its just a matter a going through the muscle to the bursa.

 

[Pain Applicant1]

Anyone mind revisiting this? Does anyone use this technique?


www.painphysicianjournal.com/2007/july/2007;10;565-571.pdf

 

[PinchandBurn]

how is this billed? Trigger Point/Bursa Injection. If TPI, then cant bill for fluro....

 

[bedrock]

how is this billed? Trigger Point/Bursa Injection. If TPI, then cant bill for fluro....

You can't bill flouro guidance for a trigger point? I've never done that anyway, but I believe that powermd bills ultrasound guidance for his trigger points and gets paid.


You can use similar codes for joint/bursa injections. It's a large bursa, so I'd bill it as 20610(major joint/bursa) + 77002(flouro) or 76942 (US).

 

[PinchandBurn]

You can't bill flouro guidance for a trigger point? I've never done that anyway, but I believe that powermd bills ultrasound guidance for his trigger points and gets paid.


You can use similar codes for joint/bursa injections. It's a large bursa, so I'd bill it as 20610(major joint/bursa) + 77002(flouro) or 76942 (US).

You can bill for Ultrasound for TPI, but from what I gather you can not bill a TPI with fluro.

 

[powermd]

You can't bill flouro guidance for a trigger point? I've never done that anyway, but I believe that powermd bills ultrasound guidance for his trigger points and gets paid.


You can use similar codes for joint/bursa injections. It's a large bursa, so I'd bill it as 20610(major joint/bursa) + 77002(flouro) or 76942 (US).

Yup. Sure is easier to see that neurovascular bundle too!

I hate not being able to bill fluoro for TPs because there are many times I want to inject the origins of the lumbar erector spinaes along the sacrum (or PSIS) in fat people. Can't see well beyond 4-5 cm with my US.

 

[pmrmd]

Yup. Sure is easier to see that neurovascular bundle too!

I hate not being able to bill fluoro for TPs because there are many times I want to inject the origins of the lumbar erector spinaes along the sacrum (or PSIS) in fat people. Can't see well beyond 4-5 cm with my US.

An origin isn't a TP though. Its more like 20551, fluoro-billable, than 20552.

 

[specepic]

I find it interesting how many folks on here advocate (or at least do not object to) fluoro guidance for IP bursa injection who have previously derided the idea of SIJ or ESIs with US. Lets apply the same appropriate standards. US is so clearly superior for an injection like this that fluoro has no real role in 2012 (almost wrote 2011 ).

No, I cannot cite a DBRCT but you can see my needle tip in the bursa with US, not imply its location based on bony landmarks. Also, esp for this inj, you can be quite close to NVB, which you can SEE with US. In a forum that emphasizes quality and safety...

High horse over

 

[epidural man]

I find it interesting how many folks on here advocate (or at least do not object to) fluoro guidance for IP bursa injection who have previously derided the idea of SIJ or ESIs with US. Lets apply the same appropriate standards. US is so clearly superior for an injection like this that fluoro has no real role in 2012 (almost wrote 2011 ).

No, I cannot cite a DBRCT but you can see my needle tip in the bursa with US, not imply its location based on bony landmarks. Also, esp for this inj, you can be quite close to NVB, which you can SEE with US. In a forum that emphasizes quality and safety...

High horse over

 

[drf]

I find it interesting how many folks on here advocate (or at least do not object to) fluoro guidance for IP bursa injection who have previously derided the idea of SIJ or ESIs with US. Lets apply the same appropriate standards. US is so clearly superior for an injection like this that fluoro has no real role in 2012 (almost wrote 2011 ).

No, I cannot cite a DBRCT but you can see my needle tip in the bursa with US, not imply its location based on bony landmarks. Also, esp for this inj, you can be quite close to NVB, which you can SEE with US. In a forum that emphasizes quality and safety...

High horse over

Ya. These are fairly straight forward with US. Hip IA. Trochanteric bursa. Iliopsoas tendon. Iliopsoas bursa. Lat fem cutaneous nerve. hip is one of my favorite targets!