Procedural guidance with ultrasound is challenging traditional medicine. And for good reasonprecision is an ally whenever you are inserting a needle into a human body. With some imagination, I am able to conjure up a gruesome Hollywood-esque image of someone gripping a syringe in a gloved fist and thrusting it towards a body with the intention of hitting a target under the skin. In my mind, there is an element of chance as to whether the needle hits the intended anatomical target. It's a stab in the dark. In a more nuanced and stable clinical scenario, the insertion point is carefully considered and the odds of missing may be relatively low. But no matter how low, it seems intuitively sensible to use any imaging guidance available. And increasingly, that guidance is provided by ultrasound. Ultrasound has been established as a helpful addition to inserting intravenous lines, taking biopsies and draining free fluid, to name but a few.If one assumes that the person inserting a needle has absolutely no knowledge of underlying anatomy and is simply taking a stab whilst hoping it will hit its spot then it is easy to perceive the massive benefit of ultrasound-guided procedures. But that simply isn't true. Medical students spend many hours learning about surface anatomy and how it relates to the underlying layers of tissue, muscle and bone below the skin. Doctors have a great understanding of anatomy and use their hands to palpate for certain underlying structures such as bony processes, tendons and veins, in order to piece together an image in their mind about the underlying anatomy. Anyone who has had blood taken knows that those technicians who do this are adept at feeling the anatomy on the inside of the elbow to find a vein to puncture and drain blood from no matter how deep it is. It is a well-honed skill.But taking blood is one thing, injecting substances is quite another. Intra-articular injections for the treatment of joint osteoarthritis have been popular for some time and are safely performed using anatomical landmarks only. But increasingly, practitioners are using ultrasound to guide needle placement. In this issue of AJUM, Oo et al. 1 have performed a systematic review of ultrasound-guided injections and concluded that clinical outcomes are superior compared with landmark-guided