Injecting Blindly Is Accepting Failure | The Pained Brain, Chapter 13

Blind injection accuracy · Failed shot

Blind Injection Accuracy: What a Failed Shot Does and Doesn’t Prove

Blind injection accuracy is lower than most patients assume: needles placed by feel reached the knee joint 72.8 percent of the time and the sacroiliac joint 22 percent. A shot that brought no relief may simply have missed its target, which proves neither that the treatment failed nor that you are a poor responder.

When a shot does nothing, the chart records a failed treatment, not a missed target. Before a bigger procedure gets booked, it is worth knowing which one happened and what else in your body was never measured.

You had the injection, felt little or nothing, and were told the shots do not work for you. Blind injection accuracy is the part of that story nobody wrote down: whether a needle placed by feel ever reached the structure it was aimed at. The video above, Injecting Blindly Is Accepting Failure, covers chapter 13 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD, and every study behind it is laid out in the book’s companion for chapter 13. The question here is narrower: what was measured before the needle went in, what was not, and which of those gaps you can ask someone to close.

How accurate are blind injections?

Surgeons scoped 162 knees immediately after a landmark-guided injection and checked where the needle tip sat. It was inside the joint 72.8 percent of the time, ranging from 53.2 percent for the least experienced injectors to 87.0 percent for the most experienced. The shoulder does worse. Pooled comparisons put the sheath around the biceps tendon, at the front of the shoulder, at 86.7 percent with ultrasound and 26.7 percent by feel. At the sacroiliac joint, low in the back, a blind needle landed inside the joint 22 percent of the time.

None of those figures describes a careless physician. They describe the ceiling on a hand working through skin it cannot see past.

Why didn’t my steroid shot work?

Among 106 consecutive blind shoulder injections, accuracy was 64.7 percent from the front and 45.7 percent from the back, and the physicians could not predict which of their own injections had landed. In people with inflamed joints, a trainee holding an ultrasound probe was accurate in 83 percent of joints, while senior rheumatologists relying on touch managed 66 percent, and only the probe users could judge their own accuracy.

That is a measurement problem in its purest form. One unrecorded variable, where the needle went, is quietly replaced by a recorded conclusion, that the treatment failed. The next rung of the ladder then gets built on that conclusion: a bigger procedure, a surgical consult, a note calling you a poor responder. A steroid blurs the picture further, because it spreads through tissue and can help from a near miss. A diagnostic block cannot hide that way. Its only job is to answer which structure hurts, and an answer from the wrong address is no answer.

Your body changes where the needle lands

A landmark is a map drawn on skin, and the map assumes an average body. In the scoped knee series, accuracy fell in patients with a body mass index of 30 or more. For needles in the lower spine, the line across the top of the hip bones that is supposed to mark the fourth lumbar space was correctly placed in 75.3 percent of people overall but in only 34 percent of people with obesity.

Body mass index is a blunt instrument for describing that body. It divides weight by height and cannot tell muscle from fat or say where the fat is stored. Bioimpedance body composition uses a small, painless electrical signal to estimate fat mass, lean mass and body water. It will not tell anyone where a needle should go; only imaging does that. What it does is replace one weight number with the compartments that number hides, which matters again after the procedure, when muscle has to carry the load. Why body composition tells you more than BMI is worth reading before any visit where your weight comes up.

What a standard pain visit measures, and what it leaves out

A typical referral for an injection carries a pain score, an exam and often a scan. Measura [Cardiometabolic and Autonomic Health Analysis] does not perform injections or imaging, and it does not treat anything. It measures the body a procedure lands in, and the findings go to your physician. That matters because an injection is only a bridge: whatever relief it gives is borrowed time and mobility, and what gets built in that window depends on terrain nobody put on the order form.

Three drivers sit under that terrain. The first is insulin resistance, the metabolic soil the book argues chronic pain grows in, with the low-grade, never-finished inflammation it calls metaflammation. The second is how fat and muscle are distributed, which decides how well a joint or tendon bears load once the pain quiets. The third is not biological. Referral pathways move a patient to the next procedure far more reliably than they move anyone to take a second look at the person, so the parts nobody measured stay unmeasured.

Measura’s laboratory panels put numbers on the metabolic side. If the pain is burning or tingling in the feet rather than a deep ache in one joint, sudomotor testing looks at sweat-gland function run by the small nerve fibers of the hands and feet, which is a different question from the one a joint injection asks. The page on numbness, burning and tingling explains when that question applies, and chronic pain and metabolic health explains why pain and metabolism belong in one conversation.

What should I ask my doctor after an injection fails?

Was my last injection done under imaging? If it was not, nobody knows whether it reached the target, and the failure may belong to the needle rather than to you.
If a diagnostic block is planned, will it be imaged, and will I be awake? Sedation inflates the rate of positive blocks, and the block depends on your honest report.
What is my body composition, not just my weight? Fat and lean mass are separate numbers, and they move separately.
What do my metabolic labs show as numbers? A result filed as normal is still a value that can be followed over time. What insulin resistance looks like before diabetes shows why the trend matters.
What is the plan for the weeks of relief? A bridge with nothing built on the far side is a pause, not a treatment.

Unmeasured is unmanaged

The honest complication cuts against a tidy story. Image guidance has not beaten blind injection in every steroid trial, because steroid still works from a near miss, and novices in one cadaver study needed about 28 supervised attempts before they could reliably see a needle with a probe. Precision is a learned skill, not a gadget you buy.

Measurement works the same way. A body composition reading, a lab panel or a nerve-function test fixes nothing by itself. What it does is stop a guess from being filed as a fact. A missed needle recorded as a failed patient is a guess in disguise, and so is a metabolic picture nobody ever drew. You are allowed to ask for both to be seen. Physicians weighing where this fits in a referral workflow can read the clinical version for practices.

Frequently asked questions

How often does a blind injection miss its target?

It depends on the joint and on the hands. Knee injections placed by feel were inside the joint 72.8 percent of the time in one scoped series, the biceps tendon sheath was reached 26.7 percent of the time, and the sacroiliac joint 22 percent. The larger problem is that the injector usually cannot tell which ones missed. Bring that history to your next appointment along with these questions worth asking your doctor.

Does body weight affect where an injection lands?

It can. Knee injection accuracy fell in patients with a body mass index of 30 or more, and the hip-bone landmark used for lower-spine needles was in the right place for 34 percent of people with obesity. Weight is still a blunt number. Body composition is not the same as weight, and separating fat mass from lean mass describes the body far better than a scale.

Does Measura perform injections or imaging?

No. Measura is a testing service. It measures vascular, autonomic, nerve, metabolic, body composition and cognitive function, and it sends the findings to your physician, who makes any treatment decision. Imaging and injections happen in a procedure setting elsewhere. The testing describes the body that a procedure will land in. For the full list, see what Measura actually measures.

If my injection did not work, was the diagnosis wrong?

Not necessarily. A missed needle, a steroid that helped briefly from a near miss, or pain coming from a neighboring structure can each look like a failed diagnosis. An imaged diagnostic block, with you awake, is how a pain source is proven. What happens once the damaged tissue is found, and why the metabolic terrain decides the recovery, is covered in tendon pain and your metabolic numbers.

How do I prepare for metabolic and body composition testing?

Instructions vary with the tests your physician orders, and the testing team gives you the specifics ahead of time. Bring a current medication list and any records of earlier injections, including whether imaging was used, so the whole history sits in one place. The practical steps are laid out on the how to prepare page.

What is the next step if a steroid injection does not work?

Before a bigger procedure gets booked, find out whether the last injection was done under imaging. If it was not, nobody knows whether it reached the target. If a diagnostic block is planned, ask for imaging and to stay awake, since sedation inflates the rate of positive blocks. Then ask for your body composition and metabolic labs as numbers, and for a plan for the weeks of relief.

Is an image-guided injection more accurate than a blind one?

For placement, yes. At the biceps tendon sheath, pooled comparisons found 86.7 percent accuracy with ultrasound against 26.7 percent by feel, and a trainee holding a probe was accurate in 83 percent of joints against 66 percent for senior rheumatologists working by touch. Image guidance has not beaten blind injection in every steroid trial, because steroid can still help from a near miss.

Measure the body before the next procedure

Ask your physician about body composition, metabolic labs and nerve-function testing so the next decision rests on numbers. Measura sends every finding to your physician.

Send a message

4477 Woodson Rd, Suite 201, St. Louis, MO 63134. Monday to Friday, 9:00 a.m. to 5:00 p.m. Please do not send symptoms, diagnoses or images through a web form — a website form is not a secure medical channel. Send your name and number and we will call you back.

References

Altuntas, Y., Ipek, E., Balkanlı, B., Alibakan, G., & Eren, O. T. (2026). Arthroscopic Assessment of Landmark-Guided Knee Injection Accuracy: A Prospective Observational Study. American Journal of Physical Medicine & Rehabilitation. Epub ahead of print, 2026-06-05. https://doi.org/10.1097/PHM.0000000000003057
Aly, A.-R., Rajasekaran, S., & Ashworth, N. (2015). Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British Journal of Sports Medicine, 49(16), 1042–1049. https://doi.org/10.1136/bjsports-2014-093573
Tobola, A., Cook, C., Cassas, K. J., Hawkins, R. J., Wienke, J. R., Tolan, S., & Kissenberth, M. J. (2011). Accuracy of glenohumeral joint injections: comparing approach and experience of provider. Journal of Shoulder and Elbow Surgery, 20(7), 1147–1154. https://doi.org/10.1016/j.jse.2010.12.021
Cunnington, J., Marshall, N., Hide, G., Bracewell, C., Isaacs, J., Platt, P., & Kane, D. (2010). A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis and Rheumatism, 62(7), 1862–1869. https://doi.org/10.1002/art.27448
Malik, M., & Ismail, S. (2019). Accuracy of Tuffier’s Line Identification by Palpation Method: Cross-Sectional Comparative Study Among Obese, Pregnant and Control Groups. Turkish Journal of Anaesthesiology and Reanimation, 48(2), 108–114. https://doi.org/10.5152/TJAR.2019.82346
Rosenberg, J. M., Quint, T. J., & de Rosayro, A. M. (2000). Computerized tomographic localization of clinically-guided sacroiliac joint injections. The Clinical Journal of Pain, 16(1), 18–21. https://doi.org/10.1097/00002508-200003000-00004
Barrington, M. J., Wong, D. M., Slater, B., Ivanusic, J. J., & Ovens, M. (2012). Ultrasound-guided regional anesthesia: how much practice do novices require before achieving competency in ultrasound needle visualization using a cadaver model. Regional Anesthesia and Pain Medicine, 37(3), 334–339. https://doi.org/10.1097/AAP.0b013e3182475fba
Hurley, R. W., Adams, M. C. B., Barad, M., Bhaskar, A., Bhatia, A., Chadwick, A., Deer, T. R., Hah, J., Hooten, W. M., Kissoon, N. R., Lee, D. W., Mccormick, Z., Moon, J. Y., Narouze, S., Provenzano, D. A., Schneider, B. J., van Eerd, M., Van Zundert, J., Wallace, M. S., … Cohen, S. P. (2022). Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Regional Anesthesia and Pain Medicine, 47(1), 3–59. https://doi.org/10.1136/rapm-2021-103031