Welcome to the Barnes ultrasound guided injection clinic

The Barnes Injection clinic provides a comprehensive clinical examination which is combined with a diagnostic ultrasound investigation as well as an injection under ultrasound guidance, this will all be provided within the one session.

The session has a clinical consultation included which incorporates a physical examination of the affected area. This will help the clinician to understand the nature of the problem. This is followed by a diagnostic ultrasound scan of the area which will provide additional information to help form a clinical diagnosis and to decide if injection therapy is the correct treatment for you. It will also help identify the structure to be injected.
Ultrasound guided injection therapy is highly accurate which in turn can also improve the effectiveness of the injection when it is compared with unguided or blind injections.
After the consultation the clinician will write a detailed report which will include the clinical diagnosis as well as the diagnostic findings from the ultrasound scan. It will also provide information about the injection procedure performed.

Expert clinical staff

The clinic is led by an expert clinician who has approximately 20 years of clinical experience managing complex musculoskeletal conditions in a leading London NHS Foundation Trust. Part of this role is diagnostic and - and Interventional musculoskeletal ultrasound. He also works in an NHS Radiology-department performing 1000s of diagnostic ultrasound scans each year as well as carrying out many ultrasound guided injection procedures every week.

High grade diagnostic ultrasound scanner
The clinic utilises a high-resolution ultrasound scanner which provides incredibly clear images which improves diagnostic accuracy as well as the accuracy of injections under ultrasound guidance.

What does the consultation consist of?

• Physical Examination (of the affected body part)
• Ultrasound scan (Diagnostic)
• Ultrasound guided injection

What is the benefit of having an ultrasound guided injection?

There is ample evidence that ultrasound guided steroid injections are a lot more accurate than unguided – or blind- steroid injections. Needle placement can be closely monitored whilst injecting under ultrasound guidance which reduces the risk of trauma to structures and this improves the safety of injections significantly.
Ultrasound guided injections are delivered by an expert Extended Scope Physiotherapist with extensive expertise in delivering ultrasound guided injections both in the clinical- as well as the Radiological setting delivering hundreds of ultrasound guided injections year in year out. The expert clinician performing the injection also has a wealth of knowledge and experience in managing complex musculoskeletal conditions.
You will receive a thorough clinical assessment followed by a diagnostic ultrasound scan to work out whether injection therapy is the correct treatment for you. This will help to evaluate the underlying source of your pain and to identify the correct area to inject.
If injection therapy is not thought to be appropriate for you will be given a full explanation of the assessment findings including advice regarding appropriate management. In that scenario you will only be charged a fee for the ultrasound scan but not for the injection.

Injections can be provided for the following areas:

Upper limb:
• Hand/wrist, elbow, shoulder, Hip, knee, ankle, foot.

Common conditions for which injection therapy is used:

Hand/wrist:
• Carpal Tunnel Syndrome
• Trigger finger,
• Tenosynovitis of the flexor tendons
• De Quervains tenosynovitis,
• Radio-carpal osteoarthritis
• 1st carpo-metacarpal joint osteoarthritis (1st CMC joint osteoarthritis)
• Osteoarthritis of the Meta-carpo-Phalangeal joints (MCP joints)
• Osteoarthritis of the Proximal Inter-phalangeal joints (PIP joints)
• Osteoarthritis of the distal interphalangeal joints (DIP joints)

Elbow
• Tennis elbow
• Golfers elbow
• Olecranon bursitis
• Elbow osteoarthritis

Shoulder
• Sub-acromial-subdeltoid bursitis
• Acromio-clavicular osteoarthritis
• Sterno-clavicular osteoarthritis
• Frozen shoulder
• Gleno-humeral joint osteoarthritis

Foot/Ankle
• Ankle osteoarthritis (Talo-crural-joint osteoarthritis)
• Subtalar joint osteoarthritis,
• mid-tarsal joint osteoarthritis
• Meta-tarso-phalangeal osteoarthritis
• Morton’s Neuroma, Plantar fasciitis
• Retro-calcaneal bursitis

Knee:
• Osteoarthritis knee
• Bakers cyst knee
• Pre patellar bursitis
• Infra-patellar bursitis
Hip:
• Osteoarthritis hip
• Trochanteric bursitis

Please note:
Injections are not given to any person of 16 years of age or younger. We are not able to provide injections for professional football players for reasons of insurance.

Informed consent:

Please read the relevant patient information leaflet (available from the Barnes clinic) on the relevant type of injection (steroid, hydrodistension or Hyaluronic acid) to ensure that injection therapy is appropriate for you. Please fill out and submit the online clinical information form, which will be emailed to you, this form has questions about your medical health and the information will be used to plan your assessment and check suitability for injection therapy. Your personal details will also be used to request any injectable prescription medicines.

STEROID INJECTIONS

What is a steroid injection?
A corticosteroid (also known as ‘cortisone’) is a medicine with anti-inflammatory properties, which can be injected directly into the tissues that are causing your pain symptoms. It is generally safer than being on long term steroid tablets which is more likely to lead to unwanted side effects. It is also safer than taking high dosages of non-steroidal anti-inflammatory tablets for longer periods of time. It acts directly in the area injected and is not the same as the steroids taken by bodybuilders or athletes.

The benefits of steroid injections
A steroid injection can help to reduce swelling, pain and stiffness caused by inflammation. This can speed up your rehabilitation and return to normal activities sooner by ‘breaking the cycle’ of pain and inflammation. It can also be helpful to aid in the diagnosis of your condition if it is not clear which structures are responsible for your pain. You may also have a local anaesthetic injected at the same time, which allows for temporary pain relief.

What are the risks?
Generally speaking, ultrasound guided steroid injections are low risk. There are however a number of potential side-effects and risks that you should be aware of prior to the injection. Please refer to our patient information leaflet which explains the potential risks and side-effects associated with steroid injections.

Which Medicines can interfere with steroid injections?
Certain medications might interfere with steroids. When you are taking medications for conditions such as diabetes, cancer, or HIV please check with your specialist whether a steroid injection is appropriate. Blood thinning medications such as warfarin may require a blood test and a temporary adjustment/change of your medication to make sure the blood is not too thin which might cause bleeding in the joint. If you are on blood thinning medication such as warfarin you should consult your specialist first to obtain his/ her advice before having an injection.
Please include any information regarding your health and or medication that you are taking to your appointment.

The injection procedure:

You will be placed in a comfortable position. The skin is cleaned with antiseptic. A needle is positioned into the affected area whilst the procedure is monitored by means of ultrasound guidance. The steroid (plus possibly a local anaesthetic) is injected through the needle. A plaster will be placed over the site to keep it clean.

Is the injection painful?
The injection is generally not very painful and is usually well tolerated. Sometimes it can be sore for a few hours after the procedure.

HYALURONIC ACID INJECTIONS

Hyaluronic acid is a natural part of the fluid that lubricates and has been shown to improve shock absorption in your joints and it keeps them working smoothly.
When you have osteoarthritis (OA), the hyaluronic acid in the affected joint becomes thinner. Hyaluronic acid injections add to your body's natural supply. They can reduce joint pain and improve nutrition to the joint surfaces. When effective the benefit can last for many months sometimes more than 6 months and the benefit in some cases can last for up to a year.

Why are Hyaluronic Acid Injections offered to patients?
Health professionals can’t predict who will benefit from hyaluronic acid injections. But many doctors and qualified allied health professionals give hyaluronic acid injections to people with osteoarthritic joints who are active and want to continue to maintain an active lifestyle and whose symptoms have not responded to non-drug treatments such as exercise heat or ice, and who have not been getting better with painkillers such as Paracetamol, Ibuprofen, Naproxen or other non-steroidal anti-inflammatories.
Hyaluronic acid injections are often tried by people who can't take painkillers. It is also useful in for those who don’t want or can't have invasive surgery.

How Effective are Hyaluronic Acid Injections for Osteoarthritis?
Studies show that hyaluronic acid injections may work better than painkillers for some people with OA. Other studies have shown they also may work as well as corticosteroid knee injections.
Hyaluronic acid injections seem to work better for some people than others. From my extensive experience in using hyaluronic acid injections for osteoarthritis joint conditions patients who have pain induced by loadbearing or activity tend to respond more favourably than those who have very high levels of pain even during rest (i.e non-mechanical pain). In the second group steroid injections (if appropriate) are more likely to lead to pain reduction.

What happens during the injection?
You will be placed in a comfortable position. The skin is cleaned with antiseptic. A needle is positioned into the affected area whilst the procedure is monitored by means of ultrasound guidance. The hyaluronic acid is injected through the needle. A plaster will be placed over the site to keep it clean.

Is the injection painful?
The injection is not particularly painful although due to the higher volume injected and the gel like consistency it can be slightly more uncomfortable than a steroid injection. The clinician is thoroughly trained in this procedure. Sometimes there could be several days of pain following the procedure.

Further information on hyaluronic acid injections
Before your appointment you will receive an information leaflet on hyaluronic acid injections. Please read this carefully. Also please fill out and return the questionnaire we will provide on your general health so that we can be sure this treatment is right for you.

HYDRODISTENSION INJECTIONS

What is a hydrodistension/hydrodilation injection?

Hydrodistension or high volume injections are performed under ultrasound guidance with the aim of precisely depositing anti-inflammatory steroid, local anaesthetic and saline to give pain relief whilst also deliberately stretching the lining of the joint (joint capsule). This procedure is increasingly used in the treatment of ‘frozen shoulder’ (adhesive capsulitis) and has been shown to be effective in the majority of patients by giving pain relief and also helping them to regain movement. These injections can give rapid and effective reduction in pain and inflammation; however, improvements are usually temporary. As with all medicines, some people may experience side effects.

How successful is it?
Several studies have shown that ultrasound guided shoulder joint hydrodilatation can help reduce patients’ pain and improve their range of motion. This technique is performed under aseptic conditions and a local anaesthetic is injected into the shoulder joint usually combined with a steroid joint and the needle is guided by the ultrasound images.

Will it be painful?
You may feel mild discomfort during the procedure and a fullness or heaviness as the joint is filled. After the examination, you may experience swelling and discomfort. These symptoms usually disappear after 48 hours and, if necessary, you may take your usual painkillers.

What are the risks and benefits of this procedure?
The benefit of this treatment is that it should reduce the pain and discomfort in your shoulder and help with movements. There is a small risk of infection when a needle is placed in a joint but we minimise the risk by using an aseptic technique. However, if you experience redness, persistent pain or swelling after the procedure, you should contact your GP or go to your nearest accident and emergency department.

Everything you need to know about Hydrodistension injections is in the information leaflet that you will be sent prior to your appointment.

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