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Ultrasound · Hip

Proximal Hamstring (Ischial Tuberosity) Injection

hiphamstringischial tuberositytendinopathy

Treats

  • Proximal hamstring tendinopathy
  • Ischiogluteal bursitis

Contraindications

  • Active local skin infection at entry site (absolute)
  • Suspected septic bursa (absolute)
  • Known allergy to local anesthetic, steroid, or antiseptic prep
  • Therapeutic anticoagulation — review case-by-case
  • Uncontrolled diabetes (relative)
  • High-grade hamstring tendon tear (relative — favor regenerative injectate)

Pre-procedure checklist

  • Confirm patient identity (two identifiers)
  • Confirm procedure, side, and site — mark with patient awake
  • Review allergies and anticoagulation
  • Confirm informed consent
  • Pre-scan: identify ischial tuberosity facets (conjoined tendon on inferomedial; semimembranosus on superolateral); locate sciatic nerve lateral to the tendon; Doppler inferior gluteal artery
  • Time-out immediately before needle entry

Positioning

  • Prone; leg slightly abducted and neutral
Positioning

Probe

  • Curvilinear probe (2-5 MHz) for depth
Probe

Landmarking — find the view

  • Transverse over the gluteal fold to identify the bright curved ischial tuberosity.
  • Identify the conjoined tendon (biceps femoris long head + semitendinosus) originating from the INFEROMEDIAL FACET of the ischial tuberosity, and the semimembranosus originating from the SUPEROLATERAL FACET as a separate tendon. Confirm which tendon is being targeted before injection.
  • Locate the Sciatic Nerve lateral and posterior to the hamstring origin.

The correct ultrasound view

  • Hyperechoic bony tuberosity with thick fibrillar tendon origin; Sciatic nerve clear laterally.
The correct ultrasound view

Needle corridor

  • In-plane medial-to-lateral OR caudal-to-cranial approach, keeping the sciatic nerve in view at all times and the needle tip MEDIAL to the nerve.
Needle corridor

Avoid

  • Sciatic nerve (lateral — always identify first and keep needle MEDIAL to it throughout)
  • Inferior gluteal artery (Doppler survey)
  • Inferior gluteal nerve (L5, S1, S2 — courses from the greater sciatic foramen to gluteus maximus; injury causes gluteus maximus weakness)
  • Posterior femoral cutaneous nerve (S1-S3 — runs medial to the sciatic nerve at the ischial tuberosity level; injury causes posterior thigh numbness)

Steps

  1. 1Identify the sciatic nerve first and stay medial to it.
  2. 2Advance to the tendon origin or the bursa superficial to it.
  3. 3Inject 4-6 mL; confirm spread at the bone-tendon interface.
  4. 4STOP IMMEDIATELY if the patient reports electric, shooting, or paresthetic sensations down the leg.

Tips

  • A longer spinal needle (22G 3.5") is often required for the gluteal depth.
  • For true proximal hamstring TENDINOPATHY (not bursitis), corticosteroid is generally NOT recommended as first-line — PRP or hyperosmolar dextrose are preferred. Corticosteroid at a load-bearing tendon origin carries risk of further tendon degeneration and potential partial or complete rupture. If steroid is used, single low dose only (≤ 3 per year) and counsel the patient accordingly.
  • If color Doppler shows the inferior gluteal artery in the planned path, abandon and re-plan.

Resident pearls

  • The Sciatic Nerve is your 'No-Fly Zone' — always keep it in view and stay MEDIAL.
  • The ischial tuberosity shadows heavily; use this shadow to orient your depth.
  • Differentiating between tendinopathy and ischiogluteal bursitis is key for therapeutic effect.
  • Conjoined tendon = inferomedial facet; semimembranosus = superolateral facet (separate tendon).

Supplies

  • 10 mL Syringe
  • 22G 3.5" Spinal Needle
  • 18G Drawing Needle
  • 1% Lidocaine (3-5 mL)
  • Triamcinolone 40 mg OR Dexamethasone 4-10 mg
  • Alcohol Swabs (vial tops)
  • Betadine/Chloraprep
  • Sterile Gloves
  • Sterile 4x4 Gauze Pads
  • Sterile Towels & Drapes
  • Adhesive Bandage (Band-Aid)
  • Washcloth/Towel (gel cleanup)
  • Needle Disposal Safety Cap
  • Sterile probe cover & gel

Post-procedure

  • Apply a clean dressing; remove after 24 hours.
  • Local anesthetic relief for 1-4 hours; steroid begins 24-72 hours.
  • Steroid 'flare' in 2–10% — manage with ice and acetaminophen.
  • Rest 24-48 hours; avoid prolonged sitting and heavy hamstring loading for 1 week.
  • Return immediately for: spreading redness, swelling, fever, disproportionate pain, OR new leg weakness, foot drop, or sciatica.
  • Diabetics: expect 50-100 mg/dL glucose rise for 3-5 days.
  • Maximum 3 injections per site per year.