Not every injection needs ultrasound, and some targets are better defined or more reliably confirmed using fluoroscopy or computed tomography, so the sport and exercise medicine (SEM) clinician needs to know when a landmark technique is sufficient and when fluoroscopy or another imaging method is required. Landmark injection uses palpable surface anatomy to place a needle and remains entirely appropriate for many accessible targets, while fluoroscopy uses real-time X-ray, usually with radiographic contrast, to reach deep or bony targets such as spinal facet joints, and it brings the legal and practical obligations that come with ionising radiation. Those obligations apply across Great Britain under the relevant regulations, with corresponding separate regulations in Northern Ireland. This page covers when landmark technique is adequate, how fluoroscopy is used and regulated in the UK, and how to choose between the available forms of guidance.
When is landmark guidance appropriate?
Landmark technique means identifying the target from palpable surface anatomy and injecting without imaging, and it remains a legitimate and often preferable choice. It is appropriate where the target is large, superficial and reliably palpable, where the clinician performs the injection regularly and reliably, and where a small placement error would not change the result. A knee with a palpable effusion, an olecranon bursa, a subacromial injection in a patient with normal anatomy, and a trigger point in an accessible muscle are all reasonable landmark targets. The advantages are real: no imaging equipment is needed, the procedure is quick and there is no ionising radiation, although it should still be performed in an appropriately equipped clinical environment.
Landmark technique suits large accessible targets, ultrasound suits soft tissue and most peripheral joints, and fluoroscopy suits deep bony and spinal targets where contrast can confirm needle position. Each carries different advantages and limitations.
The limitation is accuracy, which varies considerably by target. Studies comparing needle position after landmark injection show that placement is frequently accurate at large superficial joints but much less reliable at deeper, smaller or anatomically complex targets, and clinicians tend to overestimate their own accuracy. Body habitus matters, since palpable landmarks become unreliable where soft tissue is thick, and altered anatomy from previous surgery or deformity further reduces reliability. The practical conclusion is not that landmark technique is obsolete but that it should be chosen deliberately: if the diagnosis depends on the injection being accurate, if the target is deep or small, or if a previous landmark injection has failed without an obvious explanation, imaging should be used instead.
How is fluoroscopy used and regulated?
Fluoroscopy uses real-time X-ray imaging, typically with a mobile C-arm, to guide a needle to a target defined by bony anatomy. It is commonly used for spinal targets such as facet joint and medial branch blocks, epidural and nerve root injections, and for some sacroiliac joint and deep joint injections, although fluoroscopy or computed tomography is selected according to the target, the procedure, local expertise, availability and radiation exposure. Its strength is precisely where ultrasound is weakest: bone is seen clearly rather than blocking the view, and radiographic contrast can be injected to confirm that the needle is in the intended compartment and to help detect an intravascular position, which is a meaningful safety step for spinal procedures, although it reduces rather than abolishes that risk. Its weakness is that soft tissue detail is poor, so tendons, bursae and nerves are not directly visualised, and it requires a radiography suite, trained staff and equipment that a clinic room does not have. In UK practice these procedures are generally performed by radiologists or pain specialists rather than in a routine sport and exercise medicine clinic, and the sport and exercise medicine clinician's role is usually to refer appropriately and to interpret the result.
Justification means sufficient net benefit before authorising an exposure, and optimisation means dose kept as low as reasonably practicable. The employer sets the written procedures and entitles duty holders; the referrer supplies clinical information, the practitioner justifies the exposure, and the operator carries out the practical aspects. Authorisation is separate from justification.
The use of ionising radiation is governed in the UK by the Ionising Radiation (Medical Exposure) Regulations 2017, and the framework is examinable. Two principles underpin it. Justification means that every individual exposure must show sufficient net benefit before it is authorised, weighing the diagnostic or therapeutic benefit against the detriment of the radiation. Optimisation means that once justified, the dose must be kept as low as reasonably practicable (ALARP), consistent with the intended purpose. The regulations place overarching duties on the employer, who establishes the written procedures, entitles individuals as duty holders and defines their scope of practice. Within that framework, the referrer supplies the clinical information needed for justification, the practitioner is the registered healthcare professional entitled to take responsibility for justifying the individual exposure, and the operator is responsible for each practical aspect they carry out, which includes anyone pressing the exposure control. Authorisation is a separate process from justification: it is the means of demonstrating that justification has been carried out, it must occur before the exposure, and in permitted circumstances an appropriately entitled operator may authorise under guidelines issued by the practitioner. One person may hold more than one role, which is common where a clinician performs their own image-guided procedure, and all duty holders must be adequately trained and work within the employer's written procedures. Practical dose reduction follows familiar principles: use pulsed rather than continuous screening, keep screening time short, collimate to the area of interest, use last-image-hold rather than re-screening, keep the image receptor close to the patient, and use personal protective equipment and distance for staff, since scatter is greatest close to the patient.
Exam Tips
•Landmark technique is appropriate for large, superficial, reliably palpable targets and where a small placement error would not change the result; accuracy falls at deep, small or anatomically complex targets.
•Body habitus, previous surgery, deformity and large effusions all reduce landmark reliability, and clinicians tend to overestimate their own accuracy.
•Fluoroscopy suits deep bony and spinal targets, shows bone clearly and allows contrast to confirm needle position and help detect intravascular placement, but shows soft tissue poorly; fluoroscopy or computed tomography is chosen by target, procedure, expertise and availability.
•In UK practice, spinal image-guided injections are generally performed by radiologists or pain specialists rather than in a routine sport and exercise medicine clinic.
•Use of ionising radiation is governed by justification, meaning sufficient net benefit before the exposure, and optimisation, meaning dose kept as low as reasonably practicable (ALARP); the regulations apply across Great Britain, with corresponding separate regulations in Northern Ireland.
•Know the duty holders: the employer sets procedures and entitles individuals; the referrer provides clinical information; the practitioner justifies the exposure; and the operator carries out practical aspects, including pressing the exposure control. Authorisation is a separate process from justification.