Iliopsoas Tendon Sheath Injection

Hip
Equipment & Medications

Equipment

6–8 MHz Curved Probe 9–14 MHz Linear (slender habitus) 22g 3.5″ Spinal Needle 25g 1.5″ Needle 10 cc Syringe (lidocaine) 3 cc Syringe (steroid mix) Procedure Tray

Medications

Lidocaine 1% — 10 cc Kenalog 40 mg/cc — 1 cc Ropivacaine 0.5% — 1 cc
Procedure Steps
1

Standard pre-procedure workup: consent, indications, contraindications, allergies, and baseline pain level.

2

Position patient supine with leg in slight external rotation. A pillow under the ipsilateral knee promotes muscle relaxation.

3

Place the curved probe transversely over the anterior hip inferior to the inguinal ligament. Identify the iliopsoas tendon (oval, hyperechoic structure) and the adjacent iliopsoas bursa. Use color Doppler to identify the femoral vessels medially; confirm these are not in the needle path.

Iliopsoas tendon transverse
Click for annotated view
Iliopsoas bursa anatomy
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4

Mark the needle entry site and probe position on the skin.

5

Prep with betadine or chlorhexidine × 3 over a wide area.

6

Place sterile drape and sterile probe cover.

7

Under ultrasound guidance, inject 1% lidocaine superficially using the 25g needle. Anesthetize down toward the tendon sheath.

8

Exchange for the 22g spinal needle. Advance from lateral to medial under real-time guidance toward the iliopsoas tendon, targeting the peritendinous sheath. The approach is typically lateral to avoid the femoral neurovascular bundle.

Needle approach iliopsoas
Click for annotated view
9

Test-inject with 1% lidocaine. Confirm easy flow and sheath/bursal distention. The injectate should flow along and around the tendon. If resistance is felt, ensure the needle tip is not within the tendon itself — reposition.

Sheath distension
Click for annotated view
10

Once correct position is confirmed, exchange the syringe for the steroid/ropivacaine mixture and inject slowly.

11

Scan to document distribution of injectate along the tendon sheath.

12

Remove needle, clean skin with alcohol, and place bandage.

13

Reassess pain level and provide patient with a pain log.

References

  1. Lin JS, Gimarc DC, Adler RS, et al. Ultrasound-guided musculoskeletal injections. Semin Musculoskelet Radiol. 2021;25(6):769–784.
  2. Blankenbaker DG, De Smet AA, Keene JS, Fine JP. Classification and localization of acetabular labral tears. Skeletal Radiol. 2007;36(5):391–397.
  3. Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol. 2008;190(3):576–581.