Choosing Wisely: Ultrasound for Lateral Hip Pain?

Last post, I wrote about the EVOLVE initiative, based on the international ‘Choosing Wisely’ campaign, which seeks to get us doctors to consider which investigations, procedures, or interventions  are overused, inappropriate, not based in evidence or just outdated. 

Time to consider ultrasound use. Specifically for lateral hip pain.

There is lack of evidence to show that ultrasound for the investigation of lateral hip pain changes management or improves outcomes. 

In 2015, more than 262,000 ultrasounds of the buttock, thigh and hips were funded by MBS (medicare benefits scheme) at a cost of more than A$26 million in 2015 with an annual growth rate of around 16% over the last decade. it is uncertain how many of these were done for lateral hip pain (but it's likely to be quite  few).

The EVOLVE initiative also put forward this suggestion:

Do not use ultrasound guidance to perform injections into the trochanteric bursa as it provides no additional benefit in comparison to non-image guided injection.

A review of the literature revealed that there was not clear high quality evidence available that supports the belief that ultrasound-guided injection into the trochanteric bursa for lateral hip pain is more effective than a blind injection (i.e. an injection without any imaging guidance).

Worse still, around my location of practice, we have noted radiology practices requesting an ultrasound of the area before agreeing to perform the guided-cortisone injection to the trochanteric bursal region. So, 2 imaging sessions for lateral hip pain, extra time and costs for potentially little additional benefit.

Now, for some disclosure. 

Some of you already know that rheumatologists are increasingly using ultrasound as part of their clinical bedside examinations. I have trained in ultrasound and I do work with an ultrasonographer (for those interested, this is our machine).

This is quite different from the status quo of referring patients elsewhere for their ultrasound investigations. You can read some reasons why rheumatologists feel this is useful at this link.

I do perform injections to the trochanteric bursa and the associated gluteal tendons “blind” without using ultrasound-guidance but there are definite circumstances where I would use ultrasound guidance.

These include:

• If the blind injection did not seem to work well and there is worry that placement was not correct.
• If the person has larger hips with an increased amount of padding. In this case, I do want to be able to guide a special, longer needle to the appropriate site.

I do occasionally also ultrasound the area to help manage lateral hip pain. 

• When the diagnosis is unclear in some way.
• When the patient would be helped by being able to see/understand the problem better with the help of imaging.

So, given the proposed recommendations, will I stop using the ultrasound for lateral hip pain?

Mmm...probably not. I'll likely consider my modus operandi and will likely be even more selective of who and which hips I ultrasound.

Any thoughts?