Ultrasound-guided interventions for painful shoulder: from anatomy to evidence

Human shoulder anatomy: new ultrasound, anatomical, and microscopic perspectives

This study aimed to describe the shoulder anatomy, together with the anatomical relationships in adults and early stages of development. The shoulder muscles were studied from ultrasound, anatomical, and microscopic perspectives in a sample of 34 human shoulders. Thickness measurements were taken of the tendons and fasciae of the subscapularis, long head tendon of the biceps brachii, supraspinatus, infraspinatus, and teres minor. Ultrasound and dissection techniques are strongly correlated. However, the measurements obtained from the dissection technique were superior to those obtained from the ultrasound in all cases, except for the thickness of the long head tendon of the biceps brachii, the teres minor tendon, and the fascia thickness of the infraspinatus. In addition, the study of shoulder anatomy revealed no differences between females and males. Relevant findings from dissection included a clear overlap between the infraspinatus and supraspinatus, which shared tendon fibers, and a similar connection between the transverse ligament of the long head tendon of the biceps brachii and the subscapularis, which created a more interconnected shoulder function. The study of the anatomical measurements shows an underestimation of the shoulder measurements in the ultrasound compared with the dissection technique, but a high correlation between the measurements made by the two techniques. We present reference values for the tendon and fascia thicknesses of the rotator cuff, with no differences observed by gender. The relationships between shoulder structures described in the anatomical study imply as well that, in the event of an injury, adjacent tissues may be affected. This extended information may facilitate future optimal clinical explorations.

Neurovascular structures to avoid during musculoskeletal ultrasound-guided intervention in the extremities

Ultrasound is a useful modality for guiding injections and other procedures in the extremities. Its portability and the ability to adjust the probe and needle in real time, as well as lack of radiation exposure make it preferable for many routine procedures. However, ultrasound is highly operator dependent and a firm understanding of regional anatomy is important, including neurovascular structures that are in close proximity during many of these procedures. Knowledge of the characteristic location and appearance of neurovascular structures in the extremities allows safe needle advancement and prevention of iatrogenic complications.

Ultrasound-guided injection through the rotator cuff interval: a clinical perspective of one institution's results and description of technique

CONTEXT

Fluoroscopic injection through the rotator cuff interval (RCI) is a common technique for diagnostic arthrography and therapeutic intervention. Ultrasound approaches through the RCI have been less commonly studied, but there is a growing body of literature.

OBJECTIVES

The purpose of this study was to present a standardized technique of ultrasound-guided injection into the glenohumeral joint utilizing the RCI in magnetic resonance imaging (MRI) arthrography (MRA) and to report one medical group's experience with the technique.

METHODS

A retrospective chart review of all ultrasound-guided injections into the glenohumeral joint utilizing the RCI was performed from July 1, 2014 through June 1, 2021. Data were compiled for age, gender, body mass index (BMI), and prior surgery on the shoulder. The primary endpoint was successful administration of intra-articular dilute gadolinium contrast adequate for radiologic interpretation. A total of 487 injections into the glenohumeral joint via the RCI were performed. One hundred and fifty-five patients had previous shoulder surgery, with the remainder naive to intervention.

RESULTS

The success rate of injections into the glenohumeral joint was 99.4 %, with only three injections considered unsuccessful. The three unsuccessful injections did not succeed because of a lack of intra-articular contrast media present. This success rate is impressive and promising, particularly when considering that 155 of the patients had previous surgery, which could potentially cause complications, and because these injections were performed over a long period of 7 years.

CONCLUSIONS

Accessing the RCI under ultrasound guidance is a very successful technique for injection within the glenohumeral joint.

Intra-articular injections in the TMJ inferior joint space: A scoping review

OBJECTIVE

To perform a scoping review to identify the available evidence regarding intra-articular injections in the inferior joint space (IJS) of the temporomandibular joint (TMJ).

METHODS

An electronic search of the PubMed, Web of Science and Scopus databases was performed using the following terms: "Arthrocentesis", "injection", "joint injection", "technique", "Temporomandibular joint", "Temporomandibular joint disorder". Full-text articles were obtained from the records after applying the inclusion/exclusion criteria. Only articles with full-text access were included.

RESULTS

Thirteen articles were included for analysis-one technical note, three cadavers studies, one animal study, two case reports, five randomised clinical trials and one retrospective study; studies were classified as 'patients-based studies' and 'non-patients-based studies'. Most 'patients-based studies' show moderate or high risk of bias. Techniques were categorised as 'anatomical technique' and 'image-guided technique'. Most 'patients-based studies' show favourable outcomes such as pain reduction, increase in maximum mouth opening, improvement in quality of life and improvement in TMJ dysfunction indexes for the treatment of arthrogenic TMDs. Comparisons between superior and IJS injections are scarce. On the other hand, 'non-patients-based' studies show that image-guided or ultrasound-checked injection techniques achieved a higher effectiveness for needle location than anatomical (or blind) techniques.

CONCLUSION

The amount of available evidence is scarce, heterogeneous in design, and most 'patients-based studies' show moderate or high risk of bias, which demands the generation of new research to obtain definitive conclusions. The tendency observed suggests that intra-articular injections for the IJS of the TMJ are able to relieve TMJ pain, increase mouth opening and improve TMJ dysfunction, and image-guided injection techniques seem to be more effective than anatomical techniques to locate the needle in the IJS.

Point-of-Care Ultrasound Unveiling Rotator Cuff Injuries in the Emergency Department: A Case Series

Acute shoulder pain is a common ED presentation with a wide range of pathologies that are often initially investigated with radiography. However, diagnosing rotator cuff injuries often requires further imaging for proper diagnosis and management. Bedside shoulder ultrasound is an application that allows for the evaluation of ligaments and tendons in addition to bony structures, all while utilizing direct patient feedback of focally tender areas, expediting diagnosis and therapeutic intervention. In this case series, we discuss our evaluation of patients with suspected rotator cuff pathology and the practice of using the stepwise shoulder ultrasound protocol. Four cases are presented that illustrate the use of shoulder ultrasound in diagnosing biceps tendon injury, supraspinatus tear, chronic supraspinatus tear with hemarthrosis, and subacromial-subdeltoid bursitis. This narrative highlights the valuable role of shoulder ultrasound for the expedited diagnosis and management of patients whose initial shoulder radiographs do not indicate any bony abnormalities.

High-Resolution Ultrasound Imaging of Axillary Nerve and Relevant Injury

OBJECTIVE

To evaluate the feasibility of axillary nerve (AN) visualization in healthy volunteers and the diagnostic value of AN injury via high-resolution ultrasonography (HRUS).

METHODS

AN was examined by HRUS on both sides of 48 healthy volunteers and oriented the transducer according to three anatomical landmarks: quadrilateral space, anterior to subscapular muscle, and posterior to axillary artery. The maximum short-axis diameter (SD) and cross-sectional area (CSA) of AN were measured at different levels, and AN visibility was graded by using a five-point scale. The patients suspected of having AN injury were assessed by HRUS, and the HRUS features of AN injury were observed.

RESULTS

AN can be visualized on both sides in all volunteers. There was no significant difference in SD and CSA of AN at the three levels between the left and right sides or in SD between males and females. However, the CSA of males at different levels was slightly larger than those of females (P < .05). In most volunteers, AN visibility at different levels was excellent or good, and AN was best displayed anterior to subscapular muscle. Rank correlation analysis revealed that the degree of AN visibility had correlation with height, weight, and BMI. A total of 15 patients diagnosed with AN injury, 12 patients showed diffuse swelling or focal thickening in AN, and 3 patients showed AN discontinuity.

CONCLUSION

HRUS is able to reliably visualize AN, and it could be considered as the first choice for diagnosing AN injury.

Recovery of brachial plexus injury after bronchopleural fistula closure surgery based on electrodiagnostic study: A case report and review of literature

BACKGROUND

Axillary thoracotomy and muscle flap are muscle- and nerve-sparing methods among the surgical approaches to bronchopleural fistula (BPF). However, in patients who are vulnerable to a nerve compression injury, nerve injury may occur. In this report, we present a unique case in which the brachial plexus (division level), suprascapular, and long thoracic nerve injury occurred after BPF closure surgery in a patient with ankylosing spondylitis and concomitant multiple joint contractures.

CASE SUMMARY

A 52-year-old man with a history of ankylosing spondylitis with shoulder joint contractures presented with right arm weakness and sensory impairment immediately after axillary thoracotomy and latissimus dorsi muscle flap surgery for BPF closure. During the surgery, the patient was positioned in a lateral decubitus position with the right arm hyper-abducted for approximately 6 h. Magnetic resonance imaging and ultrasound revealed subclavius muscle injury or myositis with brachial plexus (BP) compression and related neuropathy. An electrodiagnostic study confirmed the presence of BP injury involving the whole-division level, long thoracic, and suprascapular nerve injuries. He was treated with medication, physical therapy, and ultrasound-guided injections. Ultrasound-guided steroid injection at the BP, hydrodissection with 5% dextrose water at the BP and suprascapular nerve, and intra-articular steroid and hyaluronidase injection at the glenohumeral joint were performed. On postoperative day 194, the pain and arm weakness were resolved, and a follow-up electrodiagnostic study showed marked improvement.

CONCLUSION

Clinicians should consider the possibilities of multiple nerve injuries in patients with joint contracture, and treat each specific therapeutic target.

Assessing/Imaging the Subcoracoid Space: From Anatomy to Dynamic Sonography

In the pertinent literature, standardized sonographic protocols have been widely described to evaluate the different compartments of the shoulder. However, the subcoracoid space is a complex anatomical region-usually not included/described in basic ultrasound approaches. Accordingly, starting from its anatomy, we describe a two-phase dynamic ultrasound protocol to scan the subcoracoid space. This way, we aim to optimize the diagnosis and management of patients with anterior shoulder pain and subcoracoid effusion.

Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain

The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.

A Retrospective Case-Series of Patient-Reported Response to Ultrasound-Guided Corticosteroid Injection of the Long Head of Biceps Tendon in Orthopedic Surgery

Objective: Identify factors predictive of therapeutic success following ultrasound-guided sheath injection of the long head of the biceps tendon. Materials and Methods: A total of 162 cases were divided into three groups based on clinical responses: complete, partial, or no relief. The presence or absence of clinical symptoms, glenohumeral joint structural pathology, and treatment method was compared. Results: Of the 115 injections with follow-up, 19.1% reported no clinical response while 53.0% had a complete response. Patients with fibromyalgia or chronic spine pain were strongly associated with a poor outcome (odds ratio [OR] = 5.7, P < .001). Conclusion: Ultrasound-guided intra-sheath injection is an effective method of non-surgical management for biceps tendinopathy.

Clinical Tests of the Shoulder: Accuracy and Extension Using Dynamic Ultrasound

Shoulder pain is a common musculoskeletal disorder that has a significant impact on the patient's quality of life and functional health. Because the shoulder joint is a complex structure, the relevant symptoms of shoulder pain may not directly reflect the underlying pathology. Hence, several shoulder tests have been developed to examine shoulder problems, and their diagnostic accuracy varies. Familiarization with the performance of those physical tests and their strength and limitation are of utmost importance for physicians dealing with shoulder disorders. Therefore, the present narrative review focuses on summarizing the most commonly used tests in physical examination and their diagnostic performance on several shoulder pathologies. This article also discusses how ultrasound imaging can serve as an extension of those tests.

Effects of Ultrasound-Guided Peritendinous and Intrabursal Corticosteroid Injections on Shoulder Tendon Elasticity: A Post Hoc Analysis of a Randomized Controlled Trial

OBJECTIVES

The study aimed to investigate whether the shoulder tendons changed their elasticity after ultrasound-guided peritendinous or intrabursal corticosteroid injections.

DESIGN

Post hoc secondary analysis of a double-blinded, randomized controlled study with 3 months of follow-up.

SETTING

Outpatient rehabilitation clinic.

PARTICIPANTS

Patients with subacromial impingement syndrome (N=60).

INTERVENTIONS

Patients with unilateral shoulder pain were randomly assigned to receive standard ultrasound-guided subacromial or dual-target corticosteroid injections. The supraspinatus tendons were exposed to 40 mg triamcinolone acetonide in the formal group, whereas the long head of the biceps brachii tendons (LHBT) and supraspinatus tendons were individually infiltrated by 20 mg triamcinolone acetonide in the latter group. Patients' bilateral shoulders were divided into group 1 (n=30, receiving standard subacromial injections), group 2 (n=30, receiving dual-target injections), and group 3 (n=60, without injections).

MAIN OUTCOME MEASURES

Strain ratio of LHBT and supraspinatus tendons using ultrasound elastography.

RESULTS

The repeated-measures analysis of variance revealed no intragroup difference of the strain ratio of the LHBT (P=.412 for group 1, P=.936 for group 2, P=.131 for group 3) and supraspinatus tendon (P=.309 for group 1, P=.067 for group 2, P=.860 for group 3) across the 3 time points. Treating group 3 as the reference, the linear mixed model revealed no significant changes in tendon elasticity after either the standard subacromial injection (P=.205 for the LHBT and P=.529 for the supraspinatus tendon) or the dual-target injection (P=.961 for the LHBT and P=.831 for the supraspinatus tendon).

CONCLUSIONS

Elasticity of the LHBT and supraspinatus tendons is unlikely to change after a single dose of peritendinous or intrabursal corticosteroid injections. Future studies with a shorter follow-up interval are needed to validate whether corticosteroid injections can cause transient changes of the tendon's elasticity.

The Correlation of Quantitative Ultrasound Measures and Supraspinatus Tendon Quality: A Pilot Study

Background:

The objective of this study was to determine the feasibility of assessing tendon quality as quantified by histology through changes in quantitative ultrasound measures.

Methods:

Eight cadaveric shoulders (four with a small supraspinatus tendon tear) were examined using conventional B-mode ultrasound in the transverse plane by internally rotating and hyperextending the humerus. Quantitative ultrasound measures (skewness, kurtosis, variance, and echogenicity) were calculated based on the grayscale distribution of the ultrasound image taken of the supraspinatus tendon near the insertion site. The specimens were then dissected to the supraspinatus tendon where tendon biopsies were taken near the insertion site, mid-substance, and myotendinous junction. Through histology, tendon quality was evaluated based on collagen fiber organization, fatty infiltration, nuclei shape, and cellularity. Correlations between quantitative ultrasound measures and histological grades of tendon quality were determined through Pearson or Spearman's rho correlations.

Results:

A total of three significant correlations between quantitative ultrasound measures and histological parameters of tendon quality were found. Significant correlations between kurtosis and cellularity at the insertion site (r = 0.724) (P < 0.05) as well as variance and fatty infiltration at the myotendinous junction (ρ = −0.843) (P < 0.05) and for the whole tendon (ρ = −0.826) (P < 0.05) were found.

Conclusion:

The results show the potential for quantitative ultrasound measures to assess factors of tendon quality that can only be determined through histology. With further development of the methodology that utilizes quantitative ultrasound measures, clinicians might be able to evaluate the tendon quality noninvasively in future.

Ultrasound-Guided Hydrodilatation of the Shoulder Capsule at the Rotator Interval: Technical Tips and Tricks

Adhesive capsulitis and disorders of the intra-articular portion of the long head of the biceps brachii tendon are common causes of shoulder pain. Sonographic findings, coupled with clinical evaluation and medical history, are paramount for prompt diagnosis. Herewith, either to precisely confirm the pain generator(s) or to appropriately treat relevant cases, ultrasound-guided interventions are often required in daily clinical practice. Targeting the anatomical structures involved in the aforementioned pathological conditions, we briefly describe some technical tips and tricks as regards ultrasound-guided hydrodilatation of the shoulder capsule at the rotator interval.

Sonographic Pearls for Imaging the Brachial Plexus and Its Pathologies

The brachial plexus (BP) is a complicated neural network, which may be affected by trauma, irradiation, neoplasm, infection, and autoimmune inflammatory diseases. Magnetic Resonance Imaging is the preferred diagnostic modality; however, it has the limitations of high cost and lack of portability. High-resolution ultrasound has recently emerged as an unparalleled diagnostic tool for diagnosing postganglionic lesions of the BP. Existing literature describes the technical skills needed for prompt ultrasound imaging and guided injections for the BP. However, it remains particularly challenging for beginners to navigate easily while scanning its different parts. To address this, we share several “clinical pearls” for the sonographic examination of the BP as well as its common pathologies.

Comparison of glenohumeral joint rotation between asymptomatic subjects and patients with subacromial impingement syndrome using cine-magnetic resonance imaging: a cross-sectional study

Background

The purpose of this study to compare glenohumeral joint motion during active shoulder axial rotation between subacromial impingement syndrome (SIS) shoulders and asymptomatic shoulders using cine-magnetic resonance imaging (cine-MRI). Measurement of glenohumeral joint motion via manual intervention does not assess the usual glenohumeral joint motion, and the glenoid surface cannot be confirmed manually. However, cine-MRI can produce clear images of glenohumeral joint rotation. Therefore, we sought to measure the active ROM of the glenohumeral rotation using cine-MRI.

Methods

Seventy-three shoulders in 42 asymptomatic volunteers and 110 SIS shoulders in 103 consecutive patients were included in this study. We evaluated 36 matched pairs (72 shoulders in total) adjusting for baseline characteristics with propensity score matching method. The patients underwent cine-MRI during axial rotation of the adducted arm. During imaging, participants rotated their shoulder from the maximum internal rotation to the maximum external rotation over the first 10 s and then back to the maximum internal rotation over the subsequent 10 s. We assessed internal/external rotation, and compared the asymptomatic and SIS shoulders in this regard. Evaluation of rotation angles was performed on a series of axial images through the humeral head center.

Results

The mean internal rotation angles of the asymptomatic and patient groups were 55° ± 10° and 41° ± 23°, respectively, (P = .002; 95% Confidence Interval [CI], 51–58 vs 33–49); the mean external rotation angles were 47° ± 15° and 21° ± 25°, respectively, (P < .001; CI, 42–52 vs 13–29).

Conclusions

Compared to asymptomatic shoulders, SIS shoulders showed significantly restricted glenohumeral rotation as determined by cine-MRI. Our results suggested that the significant limitation of active glenohumeral rotation might be associated with rotator cuff dysfunction.

Novel Regional Anesthesia for Outpatient Surgery

PURPOSE OF REVIEW

Peripheral nerve blocks are effective and safe modalities for perioperative analgesia. But it remains unclear what blocks are adequate for ambulatory surgeries, as well as the proper patient management before and after discharge.

RECENT FINDINGS

Emerging nerve blocks have sparked interests due to ease to perform under ultrasound guidance and lower risks of adverse events. Some of these novel blocks are particularly suitable for ambulatory procedures, including but not limited to motor-sparing lower extremity nerve blocks and phrenic-sparing nerve blocks for shoulder surgeries. The adoption of peripheral nerve block into outpatient surgery is a multidisciplinary effort that encompasses appropriate patient choice, careful selection of nerve blocks that minimize potential adverse events after discharge, and proper patient follow-up until block effects resolve.

Accuracy of shoulder ultrasound examination for diagnosis of rotator cuff pathologies: a single-center retrospective study

BACKGROUND

Shoulder pathologies need accurate diagnosis for best management and treatment provided to patients.

OBJECTIVE

Determine the diagnostic sensitivity, specificity and accuracy of shoulder ultrasonography (US).

DESIGN

Retrospective, analytical.

SETTING

Tertiary care center in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

We included all shoulder exams performed between January 2010 and December 2016 that met the inclusion criteria. Data was collected retrospectively from the a picture archiving and communication system and patient records. The patients were evaluated using US for the presence of rotator cuff tears and classified into intact, full-thickness tear, partial-thickness tear, tendinosis, subacromial/subdeltoid bursitis and acromioclavicular joint degenerative changes. The US findings were correlated with the shoulder MRI study findings. The time interval between the US examination and MRI ranged from 0 to 180 days (6 months).

MAIN OUTCOME MEASURES

To compare the sensitivity, specificity and accuracy of shoulder US studies in the detection of rotator cuff pathologies in comparison to MRI findings.

SAMPLE SIZE AND CHARACTERISTICS

86 (60 females, 26 male), mean age 53.7 years (range, 19-85).

RESULTS

The sensitivity, specificity and accuracy of US for the detection of full-thickness supraspinatus tears compared with those of MRI were 86%, 82% and 83%, respectively. The sensitivity, specificity and accuracy of US for the detection of partial-thickness supraspinatus tears compared with those of MRI were 38%, 70% and 58%, respectively. Overall PPV, NPV, sensitivity, specificity and accuracy of US for the detection of full-thickness tears compared with those of MRI were 35%, 97%, 78%, 83% and 83%, respectively. For partial-thickness tears, the overall PPV, NPV, sensitivity, specificity and accuracy of US compared with those of MRI were 51%, 60%, 51%, 60% and 56%, respectively.

CONCLUSION

Overall, US has high sensitivity, specificity and accuracy for the detection of full-thickness tears compared with the detection of partial-thickness tears.

LIMITATIONS

Small sample size and retrospective.

CONFLICT OF INTEREST

None.

Effects of Adding Interferential Therapy Electro-Massage to Usual Care after Surgery in Subacromial Pain Syndrome: A Randomized Clinical Trial

Subacromial pain syndrome (SAPS) is a prevalent condition that results in loss of function. Surgery is indicated when pain and functional limitations persist after conservative measures, with scarce evidence about the most-appropriate post-operative approach. Interferential therapy (IFT), as a supplement to other interventions, has shown to relieve musculoskeletal pain. The study aim was to investigate the effects of adding IFT electro-massage to usual care after surgery in adults with SAPS. A randomized, single-blinded, controlled trial was carried out. Fifty-six adults with SAPS, who underwent acromioplasty in the previous 12 weeks, were equally distributed into an IFT electro-massage group or a control group. All participants underwent a two-week intervention (three times per week). The control group received usual care (thermotherapy, therapeutic exercise, manual therapy, and ultrasound). For participants in the IFT electro-massage group, a 15-min IFT electro-massage was added to usual care in every session. Shoulder pain intensity was assessed with a 100-mm visual analogue scale. Secondary measures included upper limb functionality (Constant-Murley score), and pain-free passive range of movement. A blinded evaluator collected outcomes at baseline and after the last treatment session. The ANOVA revealed a significant group effect, for those who received IFT electro-massage, for improvements in pain intensity, upper limb function, and shoulder flexion, abduction, internal and external rotation (all, p < 0.01). There were no between-group differences for shoulder extension (p = 0.531) and adduction (p = 0.340). Adding IFT electro-massage to usual care, including manual therapy and exercises, revealed greater positive effects on pain, upper limb function, and mobility in adults with SAPS after acromioplasty.