 So, whenever orthopedic surgeons used to do blind procedures earlier, they always used to think that they were in the right place, but literature says that that's not correct. Almost 50% of the conventional joint injections are placed incorrectly and that's why we need an ultrasound guidance because we are giving smaller doses, we are giving at the precise location and it gives good relief to the patient. So, why use an ultrasound guidance? Basically to plan the correct approach because the injection has to be given at the right place. You have to avoid damage to vital structures like nerves, blood vessels and it basically saves time and mental torture to the patient. And last but not the least, you know when to aspirate, when to inject and when to stop injecting. So, the important thing is whenever a person comes to you with a lot of pain, it's basically caused because of altered biomechanics, because of overload, it causes tissue compromise which again leads to pain. So, this is like a vicious cycle. What we need to do is break the cycle at the point where the pain component goes away and then with a good rehab, a good physiotherapy, you can get the patient back to normal. Typically, we use the linear or the curvilinear probes for injections and it may be for any of these pathologies. We use any needles from 22 gauge needles, 18 gauge for giving injections or sometimes for giving local anesthesia, you can use even a 26 gauge needle. The anesthetic agents. Typically, we use lignocaine 2% or bupriacaine 0.5% either a mixture or either one so that the patient gets good pain relief immediately if the injection has gone at the right place. And then we have the steroids. So, the commonest used one where the patient has a decent amount of time to get relief and do a good rehab is Kennecott or the Triumph Synanone Acetonide. And then obviously, you have your PRPs which we sometimes give in muscle and tendon injuries and the synvisc for the knee joint arthritis cases. When you think of anesthetics, lignocaine 2% and bupriacaine 0.5% typically does the job well. Most of the times when steroid injections are given, these two are mixed with the steroid and given at that particular place. When you are injecting in a joint, some most of the times we use ropyvacaine or around the nerve. We can use either of them sometimes for getting pain relief, but lignocaine is the one which is commonly used. What are steroids? Locally acting steroids are nothing but pain modulating drugs and what they do is they give pain relief reduction of inflammation and because these two factors go down, the mobility is improved. And when the mobility is improved, the patient get to a good rehab and come back to normal fitness. Triumph Synanone Acetonide is used because it's long acting and you get preservative free Kennecott also, which is also called as Orochord. And otherwise, if you are interested in the short acting one, then typical beta methasone is used. So whenever you are injecting, you always either see the MRI, see the x-ray, do a scan of the patient and tell that yes, you will be injecting here, explain whatever complications may happen and then take the consent. Planning and point marking are very good, very important things. If you are not too sure where you are going, just take a marker and point exactly where the needle will be entering the patient's body. And most of the times when you are doing the injection, preferably do the injection in supine position because it avoids a vasovigal syncope. Then post procedure, you have to tell the patient that if there is a steroid, there is a chance of a flare up response. So you have to cover them with good anti-inflammatories to take good amount of rest, do icing regularly for a week and maybe give some antibiotics if you are given in a joint, but tendon sheets typically don't need any antibiotics to be given. And always tell the patient that maybe after three, four days, just drop in a message, how you feel. It always feels nice. Complications are all these and these one has to be beware. So when you are injecting steroids, you should not inject within the tendon substance, but you should inject it around the tendon. And in cases of uncontrolled diabetes and glaucoma, you should not inject. So first we come to the Bersal injections. Commonest Bersal injection in our day to day practice is for shoulder. On ultrasound or an MR, you will see a cuff tendonosis, partial cuff tear, impingement or a calcivic tendonitis. You keep the patient supine, you keep the probe over the subacromial bursa along its long axis. And this is how you position the needle so that you see the entire needle going under the footprint of the probe in this fashion. This is the supraspinitis. This is your subdeltoid bursa. That's your deltoid muscle, subcutaneous tissue plane. Your needle is coming from here and it will go into the subdeltoid bursa. So you have to reach the subdeltoid subacromial bursa. You have to go till the edge of the lateral tuberosity. Then you have to inject maybe a drop and see if you are within the bursa and then inject the whole thing. So typically what orthopedic surgeons do when they do blind injections is they hit the greater tuberosity here because the bursa almost extends all the way up till here. So now I've taken the needle up. I have seen and confirmed that I am in the bursa and then I've injected the whole dose. Then I come out and I give a small bandaid and tell the patient the necessary instructions. So in shoulder joint what you can do is you can give the joint injection either from medial to lateral that is here or you can give from lateral to medial that is here. When you do it either ways you have to try to be ambidextrous so so that you can do with the left hand and the right hand as well. And these are typically done in cases of adhesive capsulitis, labral tears or inflammatory arthropathies. In adhesive capsulitis typically what happens is the movements are restricted. The external rotation is restricted so that's why the sub scapularis does not come out. It comes out only till the one o'clock position whereas on the normal side you can see it is coming all the way out up to the three o'clock four o'clock position. You can almost see the muscle tendon junction of sub scapularis. So in such cases you this is a medial to lateral approach where you take the needle all the way under the probe through the infraspinatus into the posterior superior glenohumeral recess you hit the humeral head and then after you hitting you inject a little and see whether you are in the joint and then you can inject the whole dose. So before injecting the full dose what you can do is whatever local anesthesia given before the injection you can take that small one ml of dose and inject into the joint and confirm that you are in the joint. Then you go to the lateral part so what I've done here is I've used a spinal needle 18 gauge because you have to traverse a longer tissue. I've given little bit of local anesthesia then I have taken the same needle into the posterior superior glenohumeral recess. So this you are coming from lateral to medial you're traversing the deltoid you're traversing the infraspinatus and now my needle tip is in the glenohumeral recess. So once my needle tip is here which you can appreciate then I inject the whole dose and then what you're supposed to see is the capsule should distend freely your needle tip should not go within the labrum and you should not inject the labrum otherwise the labrum gets injured and then the dose does not have any effect because it you are injecting within the labrum. You're supposed to inject within the joint and when the capsule fills up like this and the joint distends then the patient really gets good relief over a period of time.