Ultrasound-Guided Shoulder Injections in the Treatment of Subacromial Bursitis

Creating an Inexpensive PVC Shoulder Model for the Training of Ultrasound-Guided Posterior Glenohumeral Joint Injections

OBJECTIVES

Ultrasound-guided injections are used to treat common shoulder pathologies and have been shown to be more accurate and effective than traditional landmark-guided procedures. Currently, there exists no inexpensive shoulder model that accurately simulates the anatomical structures of the shoulder while also facilitating glenohumeral joint (GHJ) injection. Our model is an alternative to the traditional bedside training and provides a low-risk training environment.

METHODS

We created this model from easily accessible materials. Polyvinyl chloride pipe was used to create the skeletal infrastructure pectoral girdle. A detergent pod was used to represent the GHJ space. Steaks were used to simulate the infraspinatus and deltoid muscles, with meat glue as a fascial layer between the two simulated muscles. Total cost of materials for the model was $19.71.

RESULTS

Our model successfully replicates known anatomical features of the GHJ. Additionally, the model facilitates injection into a GHJ space, representing a GHJ injection. Our model was replicated to train medical student practitioners during five different educational sessions. The model was validated through comparison to standardized educational ultrasound training videos. It was further validated by ultrasound experts.

CONCLUSIONS

The shoulder model we created is effective in simulating GHJ injections under ultrasound guidance. It simulates realistic muscle and bony landmarks both for ultrasound imaging and injection feel. Importantly, it is inexpensive and easy to replicate allowing more access to medical practitioners and students to be educated on the procedure.

Systematic review and meta-analysis on the effectiveness of ultrasound-guided versus landmark corticosteroid injection in the treatment of shoulder pain: an update

BACKGROUND

Corticosteroid (CS) can be injected in a blind fashion (landmark-guided) or with ultrasound (US) guidance, and this may contribute to varying clinical results. We conducted this systematic review and meta-analysis to assess the effectiveness of US-guided versus landmark CS injections in the treatment of adult patients with shoulder pain.

METHODS

We searched MEDLINE (via PubMed), Scopus, Web of Science, EBSCO, and Cochrane Library for randomized controlled trials (RCTs) comparing US-guided versus landmark CS injection regarding visual analogue scale (VAS), functional scores, disability scores, abduction degree, and side effects. The data were pooled as mean difference (MD), standardized mean difference (SMD), or risk ratios (RRs), with 95% confidence intervals (CIs), using R software (meta package 4.9-0) for windows. Subgroup analysis and leave-one-out analysis were conducted.

RESULTS

Eighteen RCTs, with a total of 1010 patients, were included in this meta-analysis. The pooled estimate favored the US-guided over landmark CS injection in terms of the mean change of VAS between 6 weeks and baseline (SMD = - 0.48, 95% CI [- 0.79, - 0.17]), the shoulder functional scores (SMD = 0.35, 95% CI [0.05, 0.65]) and shoulder abduction degree (MD = 8.78, 95% CI [3.11, 14.46]). Whilst no significant difference was found between the compared group regarding the overall shoulder disability scores (SMD = - 0.51, 95% CI (- 1.25, 0.22]) and side effects (RR = 0.45, 95% CI [0.15, 1.34]). None of the eligible study analyzed the cost-effectiveness of the US-guided method compared with the landmark method for CS injection.

CONCLUSION

Our analysis showed that US-guided CS injection was effective in the treatment of various shoulder diseases. Further research on the cost-effectiveness of US-guided CS methods is needed.

Effectiveness of Ultrasound-Guided Versus Anatomic Landmark-Guided Corticosteroid Injection on Pain, Physical Function, and Safety in Patients With Subacromial Impingement Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study was to compare the efficacy and safety of ultrasound-guided versus anatomic landmark-guided corticosteroid injection for the treatment of subacromial impingement syndrome.

DESIGN

PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov , CBM, CNKI, and Wanfang databases were searched from inception to August 15, 2021, for randomized controlled trials comparing ultrasound-guided versus anatomic landmark-guided injections of corticosteroids for the treatment of subacromial impingement syndrome.

RESULTS

Twelve randomized controlled trials with 891 patients were included in this study; 454 patients received ultrasound-guided injections and 437 received anatomic landmark-guided injections. Pooled results showed that ultrasound-guided injection was more beneficial for pain relief (10 trials; mean difference = -0.58; 95% confidence interval = -1.05 to -0.10; P = 0.017) and functional improvement (11 trials; standard mean difference = -0.84; 95% confidence interval = -1.41 to -0.27; P = 0.004). There was no significant difference in shoulder range of motion. In the subgroup analysis, there was a significant difference in pain relief and functional improvement at 6-8 wks and with methylprednisolone.

CONCLUSIONS

Ultrasound-guided injection of corticosteroids is potentially superior to anatomic landmark-guided injection in improving the clinical symptoms of subacromial impingement syndrome; however, these findings should be interpreted with some caution as the quality of evidence was rated as moderate to very low.

Image-Guided Versus Blind Corticosteroid Injections in Adults With Shoulder Pain: A Systematic Review and Meta-Analysis

The present study aimed to compare the clinical effects of image-guided versus blind steroid injection to treat shoulder pain, which is always debatable. An electronic search of credible databases was conducted for randomized controlled trials (RCTs) comparing image-guided versus blind steroid injections. The continuous data were pooled as mean difference (MD) or standardized mean difference (SMD), and dichotomous data were grouped as odds ratio (OR) with 95% confidence interval (CI). Sensitivity analysis and leave-one-out analysis were performed. The meta-analysis of 20 RCTs comprising 1136 patients favored image-guided injection based on the MD of the visual analog score (VAS) and shoulder function scores, measured between six weeks follow-up and baseline (MD=0.63, 95% CI [0.13, 1.12], p=0.01 and SMD=0.35, 95% CI [0.05, 0.65], p=0.02, respectively). Meta-analysis did not favor either group regarding the shoulder disability scores or side effects (MD=-2.18, 95% CI [-12.19, 7.83], p=0.67, and OR=0.40, 95% CI [0.14, 1.15], p=0.09, respectively). The image-guided approach was associated with significant improvement in pain and shoulder functionality. However, no significant difference was observed between the two approaches in terms of disability scores and side effects.

Image-guided glucocorticoid injection versus injection without image guidance for shoulder pain

BACKGROUND

Despite widespread use, our 2012 Cochrane review did not confirm that use of imaging to guide glucocorticoid injection for people with shoulder pain improves its efficacy.

OBJECTIVES

To update our review and assess the benefits and harms of image-guided glucocorticoid injection compared to non-image-guided injection for patients with shoulder pain.

SEARCH METHODS

We updated the search of the Cochrane Central Register of Controlled Trials (CENTRAL, via Ovid), MEDLINE (Ovid), Embase (Ovid) and clinicaltrials.gov to 15 Feb 2021, and the World Health Organisation International Clinical Trials Registry Platform (http://www.who.int/trialsearch/Default.aspx) to 06 July 2020. We also screened reference lists of retrieved review articles and trials to identify potentially relevant studies.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that compared image-guided glucocorticoid injection to injection without image guidance (either landmark-guided or intramuscular) injection in patients with shoulder pain (rotator cuff disease, adhesive capsulitis or mixed or undefined shoulder pain). Major outcomes were pain, function, proportion of participants with treatment success, quality of life, adverse events, serious adverse events and withdrawals due to adverse events. Minor outcomes were shoulder range of motion and proportion of participants requiring surgery or additional injections. There were no restrictions on language or date of publication.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Nineteen trials were included (1035 participants). Fourteen trials included participants with rotator cuff disease, four with adhesive capsulitis, and one with mixed or undefined shoulder pain. Trial size varied from 28 to 256 participants, most participants were female, mean age ranged between 31 and 60 years, and mean symptom duration varied from 2 to 23 months. Two trials were at low risk of bias for all criteria. The most notable sources of bias in the remaining trials included performance bias and detection bias. Moderate-certainty evidence (downgraded for bias) indicates that ultrasound-guided injection probably provides little or no clinically important benefits compared with injection without guidance with respect to pain (15 trials) or function (14 trials) at three to six weeks follow-up. It may not improve quality of life (2 trials, low-certainty evidence, downgraded due to potential for bias and imprecision) and we are uncertain about the effect of ultrasound-guided injection on participant-rated treatment success due to very low-certainty evidence (downgraded for bias, inconsistency and imprecision). Mean pain (scale range 0 to 10, higher scores indicate more pain) was 3.1 points with injection without image guidance and 0.5 points better (0.2 points better to 0.8 points better; 1003 participants, 15 trials) with an ultrasound-guided injection. This represents a slight difference for pain (0.5 to 1.0 points on a 0 to 10 scale). Mean function (scale range 0 to 100, higher scores indicate better function) was 68 points with injection without image guidance and 2.4 points better (0.2 points worse to 5.1 points better; 895 participants, 14 trials) with an ultrasound-guided injection. Mean quality of life (scale range 0 to 100, higher scores indicate better quality of life) was 65 with injection without image guidance and 2.8 points better (0.7 worse to 6.4 better; 220 participants, 2 trials) with an ultrasound-guided injection. In five trials (350 participants), 101/175 (or 606 per 1000) people in the ultrasound-guided group reported treatment success compared with 68/175 (or 389 per 1000) people in the group injected without image guidance (RR 1.56 (95% CI 0.89 to 2.75)), an absolute difference of 22% more reported success (4% fewer to 62% more). Low-certainty evidence (downgraded for bias and imprecision) indicates that ultrasound-guided injections may not reduce the risk of adverse events compared to injections without image guidance. In five trials (402 participants), 38/200 (or 181 per 1000) people in the ultrasound-guided group reported adverse events compared with 51/202 (or 252 per 1000) in the non-image-guided injection group (RR 0.72 (95% CI 0.4 to 1.28)), an absolute difference of 7% fewer adverse events (15% fewer to 7% more). Five trials reported that there were no serious adverse events. The remaining trials did not report serious adverse events. One trial reported that 1/53 (or 19 per 1000) in the injection without image guidance group and 0/53 in the ultrasound-guided group withdrew due to adverse events. Sensitivity analyses indicate that the effects for pain and function may have been influenced by selection bias, and the effects for function may have been influenced by detection bias. The test for subgroup differences indicated there were unlikely to be differences in pain and function across different shoulder conditions.

AUTHORS' CONCLUSIONS

Our updated review does not support use of image guidance for injections in the shoulder. Moderate-certainty evidence indicates that ultrasound-guided injection in the treatment of shoulder pain probably provides little or no benefit over injection without imaging in terms of pain or function and low-certainty evidence indicates there may be no difference in quality of life. We are uncertain if ultrasound-guided injection improves participant-rated treatment success, due to very low-certainty evidence. Low-certainty evidence also suggests ultrasound-guided injection may not reduce the risk of adverse events compared with non-image-guided injection. No serious adverse events were reported in any trial. The lack of significant benefit of image guidance over injection without image guidance to improve patient-relevant outcomes or reduce harms, suggests that any added cost of image guidance appears unjustified.

Ultrasound Diagnosis Technology for Sports Injury Detection and Prevention: A Mini Review

Ultrasound as a medical diagnosis tool, comprising the strengths of noninvasive, portable and cost-saving, and it allows the evaluation of soft tissue pathology. In sports medicine field, sonography technology is used for the detection and prevention of injuries of upper and lower limbs, mainly including elbow, shoulder, knee and ankle joints. The implement of ultrasound diagnosis technology was discussed in this narrative literature review. Sonographic images of elbows could provide a dynamic assessment of medial joint laxity. Due to the importance of ultrasound assessment in lower-limb muscles, tendons, and ligaments, this technology has been applied extensively for many types of extra-articular injuries in the lower limb. Most muscle injuries can be assessed and graded using the ultrasound apparatus. Overall, sonographic image evaluation is a reliable and handy method for the initial examination of acute or chronic sports injuries.

The Future of Virtual Sports Ultrasound Education and Collaboration

ABSTRACT

Sports ultrasound (US) is a rapidly advancing and expanding field, where "hands-on" education and real-time instructor feedback are paramount in developing this skill. In light of a global pandemic and limited access to instructors and educational conferences, sports US education must adapt to continue to teach future ultrasonographers. Virtual US education, conducted using various virtual meeting platforms not only allows for continued didactic education but also can virtually recreate the "hands-on" training sessions with live, immediate instructor feedback that is necessary for acquiring competence. Additionally, using these methods, sports US conferences can continue in a virtual manner, sports US education can expand remote areas, and collaboration among distant experts may increase, all without the cost of travel and extended time away from work. While immediately relevant because of the COVID-19 pandemic, virtual US methods may continue to be beneficial as sports US education and collaboration continue to expand.

The effect of injection volume on long-term outcomes of US-guided subacromial bursa injections

PURPOSE

Limited data exist on the efficacy of high- compared to low-volume US-guided corticosteroid injections (CI) in the subacromial-subdeltoid (SA-SD) bursa. Our purpose was to compare the short- and long-term efficacy of low- and high-volume injections, by using a capacity reference of SA-SD bursa volume, as assessed on cadaveric specimens.

METHOD

Within two years, 136 patients (63 males, 73 females; mean age: 46.11 ± 10.28 years) who underwent SA-SD bursa US-guided CI for subacromial impingement, rotator cuff tendinopathy or shoulder overuse were prospectively included. Patients were randomly assigned to low-volume (1 mL triamcinolone acetonide/40 mg) or high-volume (1 mL triamcinolone acetonide/40 mg, 9 mL anaesthetic agents) groups (67 and 69 patients, respectively). Visual Analogue Scores (VAS) were recorded at baseline, 30 min, 3 weeks, 3 months, 6 months and 1 year post-treatment. Predictors of complete recovery (VAS ≤ 2) at 1 year were analysed with multivariate Cox regression analysis. SA-SD bursa cadaveric dissection in 10 specimens was performed for volume assessment.

RESULTS

Injection volume was the only predictor of complete pain resolution at 1 year. High-volume CI yielded higher chances of early pain recovery (2.837 HR, 95% CI 1.737-4.633, P < .001). Mean VAS scores at baseline and subsequent time-points were 6, 2.6, 2.2, 2, 1.6 and 1 for the high-volume and 7.8, 7.3, 4.7, 3.2, 2.5 and 1.8 for the low-volume group, respectively (P < .001, at all time-points). Cadaveric measurements showed a minimum SA-SD bursa volume of approximately 6.9 mL.

CONCLUSIONS

High-compared to low-volume US-guided CI are superior for achieving early pain recovery.

Ultrasound-Guided Versus Anatomic Landmark-Guided Steroid Injection of the Subacromial Bursa in the Management of Subacromial Impingement: A Systematic Review of Randomised Control Studies

This study is a systematic review of prospective randomised control studies comparing ultrasound-guided steroid injection of the subacromial space with anatomic landmark-guided injection in the treatment of subacromial impingement to determine if there is any difference in pain relief and functional outcome. Mesh terms and free-text words search of electronic databases, reference list of identified studies and grey literature was performed using the PICO format. All identified papers were sifted sequentially by title, abstract and review of full text articles. Four papers qualified and were included in the review and analysis. The total number of patients in the studies was 234 patients with 117 patients randomised to each of landmark-guided and ultrasound-guided injection groups. There was no statistically significant difference in VAS pain scores (P = 0.67), SDQ scores (P = 0.43), SPADI disability score (P = 0.17) and functional outcomes scores (P = 0.09) at 4 to 6 weeks when USS-guided subacromial steroid injection was compared with landmark-guided injection. SPADI pain scores (P = 0.02) demonstrates significant reduction in favour of landmark-guided injection. There was low to moderate risk of bias. In conclusion, ultrasound-guided subacromial steroid injection does not offer any statistically significant clinical improvement over landmark-guided injection in adults with subacromial impingement.

Image guidance used for large joint and bursa injections; a survey study

Objectives: To determine the current rates of use of available image guidance modalities for large joint and bursal injections, in addition to their relationships to physician demographics.Methods: An electronic survey was sent to 3,400 members of the American Medical Society for Sports Medicine (AMSSM), examining types of guidance used for each large joint and bursal injection.Results: A total of 674 sports medicine physicians responded to the survey. Intra-articular hip and glenohumeral joint injections were more commonly performed with ultrasound guidance, while palpation-guidance was more common with all other injections. Physicians who specialized in Physical Medicine & Rehabilitation (PM&R) were more likely to use ultrasound for trochanteric bursa (p = 0.007, OR = 4.16 [1.46-11.8]), while internal medicine-, pediatrics-, and family medicine-trained physicians were more likely to use palpation guidance for at least one joint (p < 0.05). Physicians with fewer years of experience were more likely to use ultrasound for glenohumeral joint injections (p ≤ 0.002 for all age groups with less than 20 years of experience, ORs ranging from 6.3 to 9.2).Conclusion: Palpation-guidance is the most common technique used for large joint and bursal injections, other than for glenohumeral and hip joint injections. PM&R-trained physicians and those with less experience tend to use ultrasound more frequently.

Changes in Blood Glucose Level After Steroid Injection for Musculoskeletal Pain in Patients With Diabetes

Objective

To investigate changes in blood glucose level after steroid injection in patients with type 2 diabetes mellitus (DM) and factors affecting those changes.

Methods

We retrospectively studied 51 patients with type 2 DM who underwent steroid injection for shoulder and back pain. Mean fasting blood sugar (FBS) levels for 7 days before steroid injection was used as the baseline blood glucose level, which was compared with FBS levels for 14 days after steroid injection. We compared the differences in blood glucose changes between HbA1c >7% and HbA1c ≤7% groups and those between insulin and non-insulin treated groups. Demographic data, injection site, and steroid dose were analyzed.

Results

Compared to baseline, blood glucose significantly (p=0.012) elevated 1 day after steroid injection but not 2 days after injection. In the HbA1c >7% and insulin groups, blood glucose was significantly increased 1 day after injection compared to that in the HbA1c ≤7% (p=0.011) and non-insulin (p=0.024) groups, respectively. Higher HbA1c level before injection was significantly (p=0.003) associated with the degree of blood glucose increase 1 day after injection. No significant differences were noted in the degree of blood glucose increase according to injection site or steroid dose.

Conclusion

Higher HbA1c level was associated with greater elevation in blood glucose 1 day after steroid injection. Careful monitoring of blood glucose is required on the first day after steroid injection in patients with poorly controlled DM.

Ultrasound-guided versus palpation-guided corticosteroid injections for tendinosis of the long head of the biceps: A randomized comparative study

PURPOSE

To compare accuracy, patient discomfort, and clinical outcome of ultrasound-guided versus palpation-guided corticosteroid injections to the bicipital groove in patients with long head of biceps (LHB) tendinosis.

MATERIALS AND METHODS

Forty-four patients with primary LHB tendinosis were randomized into two groups (group A, n = 22; group B, n = 22). All patients underwent treatment with a single corticosteroid injection to the bicipital groove. Injections in group A were performed under ultrasound-guidance, while in group B using a palpation-guided technique. The duration of each procedure was recorded. To assess accuracy, ultrasound examination was performed in both groups after injection. Patient discomfort was evaluated with visual analogue scale (VAS) for pain. The clinical outcome was assessed comparing the VAS, the Single Assessment Numeric Evaluation (SANE) score and the QuickDASH score before treatment and after 4 weeks and 6 months.

RESULTS

The mean duration of the procedure was 64 ± 6.87 s in group A and 81.91 ± 8.42 s in group B (p < 0.001). Injection accuracy in group A was 100% and in group B 68.18%. Discomfort was lower in group A, as compared to group B (22.10 vs. 35.50; p < 0.001). Symptoms, as measured by VAS, SANE and QuickDASH scores, improved in both groups at 4 weeks and 6 months (p < 0.05). Superior clinical improvement was recorded in group A in both time points (p < 0.05).

CONCLUSIONS

Corticosteroid injections are an effective treatment for primary LHB tendinosis. Under ultrasound guidance, injections to the bicipital groove are faster and produce lower discomfort. Superior accuracy and clinical outcomes can be achieved using the ultrasound-guided technique.

LEVEL OF EVIDENCE

Level II; Prospective Randomized Comparative Study.

A Prospective Randomized Study Comparing the Effectiveness of Midlateral and Posterior Subacromial Steroid Injections

The authors sought to compare the accuracy and effectiveness of the mid-lateral and posterior routes of subacromial injection. They conducted a prospective randomized study involving 50 shoulders scheduled to receive subacromial injection via the midlateral or posterior route. After injection, a blinded musculoskeletal radiologist interpreted the radiographs. Age, sex, body mass index, side of shoulder involved, circumference of the proximal humerus, and acromial type were assessed. The accuracy rates of the injections, modified University of California Los Angeles shoulder scores, and visual analog scale pain scores were compared. The accuracy rate of the midlateral route was significantly higher than that of the posterior route (92% vs 68%; P<.034). Although there were significantly improved modified University of California Los Angeles shoulder and visual analog scale pain scores in both groups after injection, differences in functional outcomes were not statistically significant (P>.05). Univariate analysis showed no correlation between accuracy and age, sex, body mass index, or circumference of the proximal humerus. However, injection route had some influence on accuracy, with a crude odds ratio of 5.41 (95% confidence interval, 1.017-28.791; P=.048) for the midlateral route. Midlateral was the preferred route for subacromial injection. [Orthopedics. 2019; 42(1):e44-e50.].

Ultrasound-guided subacromial-subdeltoid bursa corticosteroid injections: a study of short- and long-term outcomes

AIM

To assess shoulder pain and disability in patients undergoing corticosteroid injection into the subacromial-subdeltoid (SA-SD) bursa under ultrasound guidance, evaluating both short and long-term outcomes.

MATERIALS AND METHODS

In this prospective, longitudinal, analytical study 376 patients referred for SA-SD bursa injection during a 6 month period were asked to complete a questionnaire assessing shoulder pain and disability in the form of the Shoulder Pain and Disability Index (SPADI). Patients were reassessed at 6 weeks and 12 months post-injection. Data were collated and analysed based on the diagnosis made at ultrasound.

RESULTS

Almost two-thirds (63.6%) of patients irrespective of the underlying diagnosis showed improvement in pain and disability 6 weeks after injection, but this figure decreased significantly after 12 months to 27.3%. There was no significant difference in outcome between patients with a rotator cuff tendon tear and without a tear at 6 weeks; however, there was a difference between these two groups at 12 months with significantly fewer patients with a tear receiving benefit.

CONCLUSION

The pattern of good short-term, but poorer long-term outcomes from SA-SD bursa injection is in line with previous studies; however, this study provides additional information on the effect of the underlying diagnosis on the potential outcome, specifically the presence or absence of a rotator cuff tendon tear.

Existing Evidence on Ultrasound-Guided Injections in Sports Medicine

Office-based ultrasonography has become increasingly available in many settings, and its use to guide joint and soft tissue injections has increased. Numerous studies have been conducted to evaluate the use of ultrasound-guided injections over traditional landmark-guided injections, with a rapid growth in the literature over the past few years. A comprehensive review of the literature was conducted to demonstrate increased accuracy of ultrasound-guided injections regardless of anatomic location. In the upper extremity, ultrasound-guided injections have been shown to provide superior benefit to landmark-guided injections at the glenohumeral joint, the subacromial space, the biceps tendon sheath, and the joints of the hand and wrist. Ultrasound-guided injections of the acromioclavicular and the elbow joints have not been shown to be more efficacious. In the lower extremity, ultrasound-guided injections at the knee, ankle, and foot have superior efficacy to landmark-guided injections. Conclusive evidence is not available regarding improved efficacy of ultrasound-guided injections of the hip, although landmark-guided injection is performed less commonly at the hip joint. Ultrasound-guided injections are overall more accurate than landmark-guided injections. While current studies indicate that ultrasound guidance improves efficacy and cost-effectiveness of many injections, these studies are limited and more research is needed.

Ultrasound-Guided Steroid Injection of the Pisotriquetral Joint: A Multidisciplinary Effort

From the perspective of a multidisciplinary team, the authors describe the first reported use of ultrasound guidance for steroid injection into the pisotriquetral joint to relieve wrist pain of a person with spinal cord injury undergoing acute inpatient rehabilitation. Musculoskeletal ultrasound guidance was used to improve the accuracy of a corticosteroid injection of the pisotriquetral joint and the basal thumb in a 70-year-old man with paraplegia experiencing multifocal degenerative wrist pain. There was no bleeding or bruising after the injections, and the patient reported complete pain resolution 1 wk after the injections, which continued for over 1 yr. A multidisciplinary team was key in diagnosis, selection of treatment, and evaluation of treatment effect. Corticosteroid injection of the pisotriquetral joint under ultrasound guidance can be used as a treatment modality for managing wrist pain stemming from that joint. Further investigation and studies evaluating the use of ultrasound versus other imaging modalities for injection of the wrist are indicated.

Relation Between Subacromial Bursitis on Ultrasonography and Efficacy of Subacromial Corticosteroid Injection in Rotator Cuff Disease: A Prospective Comparison Study

OBJECTIVE

To evaluate the correlations between subacromial bursitis (bursal thickening and effusion) on ultrasonography and its response to subacromial corticosteroid injection in patients with rotator cuff disease.

DESIGN

Prospective, longitudinal comparison study.

SETTING

University-affiliated tertiary care hospital.

PARTICIPANTS

Patients with rotator cuff disease (N=69) were classified into 3 groups based on ultrasonographic findings; (1) normative bursa group (group 1, n=23): bursa and effusion thickness <1mm; (2) bursa thickening group (group 2, n=22): bursa thickness >2mm and effusion thickness <1mm; and (3) bursa effusion group (group 3, n=24): bursa thickness <1mm and effusion thickness >2mm.

INTERVENTION

A single subacromial injection with 20mg of triamcinolone acetonide.

MAIN OUTCOME MEASURES

Visual analog scale (VAS) of shoulder pain, Shoulder Disability Questionnaire (SDQ), angles of active shoulder range of motion (flexion, abduction, external rotation, and internal rotation), and bursa and effusion thickness at pre- and posttreatment at week 8.

RESULTS

There were no significant differences between the 3 groups in demographic characteristics pretreatment. Groups 2 and 3 showed a significant difference compared with group 1 in changes on the VAS and abduction; group 3 showed a significant difference compared with group 1 in changes of the SDQ, internal rotation, and external rotation; and all groups showed significant differences when compared with each other (groups 1 and 3, 2 and 3, and 1 and 2) in changes of thickness.

CONCLUSIONS

A patient with ultrasonographic observation of subacromial bursitis, instead of normative bursa, can expect better outcome with subacromial corticosteroid injection. Therefore, we recommend a careful selection of patients using ultrasonography prior to injection.

Musculoskeletal interventional procedures: With or without imaging guidance?

Aspiration and injection of joints and soft tissues is an indispensable skill used in everyday practice by the clinical rheumatologist. Most rheumatologists recognise that performing these procedures using anatomical landmarks is not always successful, particularly in the case of small or infrequently injected joints, bursae or tendon sheaths. Musculoskeletal ultrasound confirms the local pathological-anatomical diagnosis and is the most applicable and feasible imaging method that can be applied in clinical practice in guiding musculoskeletal interventional procedures. From 1993, there has been substantial examination of the accuracy of landmark- and imaging-guided procedures. We have searched the literature and ascertained whether imaging techniques improve the accuracy of musculoskeletal procedures and whether the accuracy of needle placement can be translated into improved clinical outcome (efficacy).

Exercise therapy after ultrasound-guided corticosteroid injections in patients with subacromial pain syndrome: a randomized controlled trial

Background

Subacromial pain syndrome (SAPS) accounts for around 50 % of all cases of shoulder pain. The most commonly used treatments are glucocorticosteroid (steroid) injections and exercise therapy; however, despite treatment SAPS patients often experience relapse of their symptoms. Therefore the clinical effect of combining steroid and exercise therapy is highly relevant to clarify. The aim of this randomized controlled trial was to investigate if exercise therapy added to steroid injection in patients with SAPS will improve the effect of the injection therapy on shoulder pain.

Methods

In this two-arm randomized trial running over 26 weeks, patients with unilateral shoulder pain (> 4 weeks) and thickened subacromial bursa (> 2 mm on US) were included. At baseline all participants received two steroid injections into the painful shoulder with an interval of one week. Subsequently they were randomized (1:1) to either 10 weeks exercise of the involved shoulder (intervention group) or exercise of the uninvolved shoulder (control group). The patients were re-examined after the exercise program (at week 13) and again at week 26. The primary outcome assessed after 26 weeks was change in shoulder pain analyzed using the intention-to-treat principle (non-responder imputation).

Results

Ninety-nine SAPS patients (58 female) participated (49 intervention/50 control). At both follow up visits (week 13 and 26) no statistically significant between-group differences in pain changes on a visual analog scale (mm) were seen (13 weeks: pain at rest 1.7 (95 % CI –3.6 to 7.0; P = 0.53); pain in activity 2.2 (95 % CI –6.5 to 10.9; P = 0.61), 26 weeks: rest 5.6 (95 % CI –0.9 to 12.1; P = 0.09); activity 2.2 (95 % CI –6.8 to 11.2; P = 0.62). The reduction in pain was most evident in the control group at all four pain measurements. The only difference between groups was seen by US examination at week 13, where fewer participants with impingement were observed in the intervention group compared with the controls (9 vs. 19 participants; P = 0.03).

Conclusion

Exercise therapy in the painful shoulder in SAPS patients did not improve the effectiveness of steroid injections for shoulder pain in patients with unilateral SAPS and enlarged subacromial bursa on US examination.

Trial registration

ClinicalTrials.gov (NCT01506804). Registration date 5 May 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1002-5) contains supplementary material, which is available to authorized users.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based upon the evidence, the official AMSSM position relevant to each subject is made.

Ultrasound monitoring of fracture healing: is this the end of radiography in fracture follow-ups?

OBJECTIVE

To compare the efficacy of ultrasonography (US) versus radiography (XR) in monitoring fracture healing.

DESIGN

Prospective diagnostic follow-up study.

SETTING

Department of Orthopaedics, Level II trauma center.

PATIENTS

Forty-eight acute closed tibial mid diaphysis fracture (OTA 42-A and B) treated by closed reduction and internal fixation with a reamed statically locked tibial interlocking nail between October 2011 and October 2012.

INTERVENTION

Evaluation of fracture healing using both US and XR at 2 week intervals.

MAIN OUTCOME MEASUREMENTS

Ultrasonographic criterion for fracture healing was set as progressive appearance of periosteal callus along with progressive decrease in visibility of nail. Radiographic criterion for fracture union was set as the appearance of bridging callus across all 4 cortices.

RESULTS

Thirty-eight of 48 fractures achieved union, 6 developed a delayed union, whereas 4 went onto nonunion. It was observed that using the above-stated criteria, fracture union was diagnosed at an average of 2 weeks earlier with US as compared with XR. Four of the 6 delayed unions and all nonunions declared themselves much earlier on US versus XR.

CONCLUSIONS

Ultrasonography can provide valuable early information about union and predict delayed and nonunions at an earlier time interval than standard plain radiographs.

LEVEL OF EVIDENCE

Diagnostic level II. See Instructions for authors for a complete description of levels of evidence.

Effects of repeated steroid injection at subacromial bursa with different interval

Objective

To evaluate the effects of repeated steroid injection at subacromial bursa with different interval for patient with periarticular shoulder disorder.

Methods

Group A (n=10) received subacromial bursa injection only on their first visit, group C (n=10) received the injection on their first visit and one week later, and group B (n=10) received the injection on their first visit and two weeks later. All injections were done with a combination of 40 mg (1.0 mL) of triamcinolone and 5.0 mL 0.5% lidocaine (6 mL total). We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at baseline at 1, 2, and 4 weeks after the initial injection.

Results

In VAS, comparing the changes in VAS between groups, group B showed significant improvements compared with group A or C at 4 weeks after the initial injection (p<0.05). In SDQ, comparing the changes in SDQ between the groups, group B and C showed more improvement than group A at 4 weeks after the initial injection, but these results were not statistically significant (p>0.05). In AROM, comparing the changes in AROM of external rotation between groups, group B and C showed significant improvement compared with group A at 4 weeks after the initial injection (p<0.05).

Conclusion

It may be more effective in pain relief for patients with periarticular disorder to receive subacromial bursa injections twice with 2-week interval, as opposed to once.

American Medical Society for Sports Medicine position statement: interventional musculoskeletal ultrasound in sports medicine

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based on the evidence, the official AMSSM position relevant to each subject is made.

Do subacromial ultrasonography findings predict efficacy of intra-bursal injection? Prospective study in 39 patients

BACKGROUND

Ultrasonography has become an investigation of choice in the management of shoulder pain. The objective of this study was to determine whether the efficacy of subacromial-subdeltoid bursa injection correlated with the ultrasound findings.

MATERIAL AND METHODS

We prospectively recruited patients who were seen between November 2012 and November 2013 for subacromial pain and whose rotator cuff was either intact or showed a full-thickness tear less than 1cm in length. A standardised physical examination of the shoulder was followed immediately by static and dynamic ultrasonography, intra-bursal injection of lidocaine, and a repetition of the same physical examination. Recorded ultrasonography features were the appearance of the bursa, shape of the coraco-acromial ligament, and bursal deformation induced by passage under the coraco-acromial ligament during dynamic imaging. A response to the injection was defined as greater than 75% improvements in at least three of the physical examination parameters.

RESULTS

We included 39 patients with a mean age of 56.7 years. Ultrasonography showed abnormalities of the bursa in 30 patients, including 1 with an intra-bursal effusion, 10 with thickening, and 19 with both. Deformation of the bursa under the coraco-acromial ligament was noted in 26 patients. The proportions of patients with bursal effusion and with bursal thickening were similar in the 20 responders and 19 non-responders. Neither were any significant differences found for coraco-acromial ligament shape or bursal deformation under the ligament.

CONCLUSIONS

No correlation was found between ultrasonography findings and the efficacy of a local anaesthetic injection into the subacromial bursa. These findings suggest that ultrasound abnormalities may constitute mere physiological changes, in keeping with earlier studies in asymptomatic individuals. Thus, subacromial impingement may be currently overdiagnosed.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

BACKGROUND

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections.

OBJECTIVE

Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues.

DESIGN

Systematic review of the literature.

RESULTS

USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C).

CONCLUSIONS

The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.

Subacromial impingement syndrome and pain: protocol for a randomised controlled trial of exercise and corticosteroid injection (the SUPPORT trial)

BACKGROUND

Subacromial impingement syndrome is the most frequent cause of shoulder problems which themselves affect 1 in 3 adults. Management commonly includes exercise and corticosteroid injection. However, the few existing trials of exercise or corticosteroid injection for subacromial impingement syndrome are mostly small, of poor quality, and focus only on short-term results. Exercise packages tend to be standardised rather than individualised and progressed. There has been much recent interest in improving outcome from corticosteroid injections by using musculoskeletal ultrasound to guide injections. However, there are no high-quality trials comparing ultrasound-guided and blind corticosteroid injection in subacromial impingement syndrome. This trial will investigate how to optimise the outcome of subacromial impingement syndrome from exercise (standardised advice and information leaflet versus physiotherapist-led exercise) and from subacromial corticosteroid injection (blind versus ultrasound-guided), and provide long-term follow-up data on clinical and cost-effectiveness.

METHODS/DESIGN

The study design is a 2x2 factorial randomised controlled trial. 252 adults with subacromial impingement syndrome will be recruited from two musculoskeletal Clinical Assessment and Treatment Services at the primary-secondary care interface in Staffordshire, UK. Participants will be randomised on a 1:1:1:1 basis to one of four treatment groups: (1) ultrasound-guided subacromial corticosteroid injection and a physiotherapist-led exercise programme, (2) ultrasound-guided subacromial corticosteroid injection and an advice and exercise leaflet, (3) blind subacromial corticosteroid injection and a physiotherapist-led exercise programme, or (4) blind subacromial corticosteroid injection and an advice and exercise leaflet. The primary intention-to-treat analysis will be the mean differences in Shoulder Pain and Disability Index (SPADI) scores at 6 weeks for the comparison between injection interventions and at 6 months for the comparison between exercise interventions. Although independence of treatment effects is assumed, the magnitude of any interaction effect will be examined (but is not intended for the main analyses). Secondary outcomes will include comparison of long-term outcomes (12 months) and cost-effectiveness. A secondary per protocol analysis will also be performed.

DISCUSSION

This protocol paper presents detail of the rationale, design, methods and operational aspects of the SUPPORT trial.

TRIAL REGISTRATION

Current controlled trials ISRCTN42399123.

Effects of subacromial bursa injection with corticosteroid and hyaluronidase according to dosage

Objective

To evaluate effects of subacromial bursa injection with steroid according to dosage and to investigate whether hyaluronidase can reduce steroid dosage.

Methods

Thirty patients with periarticular shoulder disorder were assigned to receive subacromial bursa injection once a week for two consecutive weeks. Ten patients (group A) underwent subacromial bursa injection with triamcinolone 20 mg; another group of ten patients (group B) with hyaluronidase 1,500 IU and triamcinolone 20 mg; and the other ten patients (group C) with triamcinolone 40 mg. We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at study entry and every week until 1 week after the 2nd injection.

Results

All groups showed statistically significant improvements in VAS after 1st and 2nd injections. When comparing the degree of improvement in VAS, there were statistically significant differences between groups C and A or B, but not between groups A and B. SDQ was statistically significantly improved only in groups B and C, as compared to pre-injection. There were statistically significant differences in improvement of SDQ after the 2nd injection between groups C and A or B. Statistically significant improvements in AROM were shown in abduction (groups B and C) and in flexion (group C only).

Conclusion

Repeated high-dose (40 mg) steroid injection was more effective in terms of pain relief and functional improvements of shoulder joint than medium-dose (20 mg) steroid injection in periarticular disorder. Hyaluronidase seems to have little additive effect on subacromial bursa injection for reducing the dosage of steroid.

Effect of Subacromial Injections of Hyaluronan on Different Grades of Rotator Cuff Lesion: A Prospective Study

Rotator cuff lesions are quite common and in some cases Hyaluronic Acid (HA) can play a role in pain relief and in restoring functions. The aim of the study was to point out the correct indications for HA injection therapy through a prospective study: firstly defining the safety and efficacy of HA in the different grades of cuff tears, then evaluating the maintenance at 90 days, as secondary endpoint. A prospective, open-label uncontrolled study was developed. One hundred patients diagnosed with different rotator cuff lesions were divided into 4 grade-related groups based on a modified Neer's classification. A cycle of 3 US-guided injections of medium-low weight HA was performed through the anterolateral way, one every two weeks. Follow-up was at 0, 15, 30, 45 and 90 days. VAS, Oxford-Shoulder-Score (OSS) and Constant-Murley were used for evaluations. In grade I and II, at day 45, a significant reduction of VAS and increase of Constant-Murley and OSS resulted. In grade IV VAS slowly decreased in the first 45 days, while OSS and Constant did not improve significantly. In grade III patients had no benefit from a clinical and subjective point of view. At ninety days the beneficial effect was still maintained in grades I, II and IV. Overall, the treatment showed a high tolerability profile. In conclusion, patients affected by bursitis or partial cuff tears benefit from HA, while in cuff arthropathy HA might only delay surgery or represent a palliative. In complete tears HA was not effective in pain relief or functional recovery.

How to perform local soft-tissue glucocorticoid injections?

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae is the hallmark of many inflammatory rheumatic diseases, but inflammation or rather irritation of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in the literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

Interventional musculoskeletal US: an update on materials and methods

Pain is one of the most common causes of reduced productivity. The annual cost of health-related reductions in productivity has been estimated at approximately 225 billion dollars in the United States alone. Ultrasound-guided locoregional infiltration procedures have frequently been shown to offer economical, effective, lasting relief of pain. In-depth familiarity with the equipment (probes and needles) and techniques used to perform these procedures are fundamental for safe, effective treatment. In fact, depending on the characteristics of the patient and the clinical problem, the approach and technique may have to be modified to simplify the procedure and ensure better results. Up-to-date knowledge of the drugs used for these infiltrations (indications, how they are used) is equally important. Our aim is to provide an update on the techniques and materials used in interventional musculoskeletal ultrasonography based on a review of the most recent literature as well as on our personal experience.