Comparing the accuracy and efficacy of ultrasound-guided versus blind injections of steroid in the glenohumeral joint in patients with shoulder adhesive capsulitis

British Elbow and Shoulder Society patient care pathway: Frozen shoulder

Background

Current guidelines from the British Elbow and Shoulder Society (BESS) were published in 2015 for managing frozen shoulders in the primary and secondary care setting. Updated guidelines have been developed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology.

Methods

A multi-disciplinary BESS Working Group defined key management questions based on agreed outcome measures and time points. A literature search, conducted up to March 2023 following PRISMA guidelines, identified randomised controlled trials, systematic reviews, and meta-analyses. Quality assessments were performed using the GRADE Decision Framework, considering bias, imprecision, indirectness, and inconsistency. Data were extracted for meta-analysis. In the absence of high-quality trials, narrative reviews were created.

Results

Consensus opinions produced statements based on the quality and volume of evidence and the magnitude of desirable and undesirable effects. These statements form a comprehensive framework for managing frozen shoulder.

Discussion

This updated guideline provides evidence-based guidance for managing frozen shoulder and identifies key areas for future research.

Ultrasound- Versus Landmark-Guided Corticosteroid Injections in Patients With Shoulder Pain: A Meta-Analysis and Systematic Review

This meta-analysis evaluated the effects of ultrasound-guided (USG) and landmark-guided (LMG) injections of corticosteroids into the shoulder joint cavity of patients with shoulder pain. The PubMed database was searched for articles (January 1, 2004-December 31, 2023) comparing USG and LMG injections of corticosteroids for the treatment of adult shoulder pain. Two authors independently performed data extraction and appraisal. The outcome measures collected were visual analogue scale (VAS) score and VAS score change at 1 and 6 weeks postinjection and range of motion (ROM) at 6 weeks postinjection. Thirteen studies including 656 patients were reviewed (USG and LMG groups, 328 patients each). The VAS score at 1 week postinjection and the ROM in abduction at 6 weeks postinjection were statistically different, but there were no statistically significant differences in other outcomes. This meta-analysis indicated that USG corticosteroid injection may have a better effect than LMG corticosteroid injection for early-stage shoulder pain and abduction in the mid- to long-term, but does not affect later shoulder pain or other ROMs.

Does the intervention for adhesive capsulitis in patients with diabetes differ from that for patients without diabetes?: A systematic review

BACKGROUND

Adhesive capsulitis (AC) is often accompanied by pain and restriction in range of movement, which long lasting symptoms often have negative impact on patients' work and lives. Since diabetes mellitus (DM) is an independent risk factor for developing AC, and AC with DM have more limitations of joint motion than general people.

AIMS

The aim of the present study is to evaluate the difference of clinical efficacy between diabetes and non-diabetes, and to explore whether AC with diabetes need special intervention compared to non-diabetes.

METHODS

Pubmed NCBI and Embase were searched for studies published in the last 30 years. We conducted a literature search for terms regarding AC and DM on Pubmed NCBI and Embase.

RESULTS

A total of 9 studies eligible for inclusion. The affected shoulders in these studies ranged from 26 to 135, 460 shoulders (551 participants) in total, including 166 shoulders in diabetic group and 394 shoulders in non-diabetic/idiopathic group. Interventions included shock wave therapy, hydrodilatation, arthroscopic capsular release, manipulation under cervical nerve root block. Evaluation indicators included pain, certain shoulder questionnaires, range of motion. Positive clinical efficacy were emerged after interventions between the 2 groups. The studies that better improvement of pain in non-diabetic/idiopathic group were 2 of 6, that of certain shoulder questionnaires were 4 of 8, that of range of motion were 3 of 6.

CONCLUSIONS

Whether AC combined with DM or not, the current treatment could achieve positive clinical effectiveness and there is some statistical evidence show that the curative effect of AC combined with DM is worse than non-diabetic. In other words, the available evidence suggests that patients with DM might require additional rehabilitation measures with routine glycemic control.

Comparison of ultrasound- vs. landmark-guided injections for musculoskeletal pain: an umbrella review

OBJECTIVE

This umbrella review synthesizes systematic reviews and meta-analyses to reach a conclusion concerning the overall effectiveness of ultrasound-guided vs landmark-guided injections for treating musculoskeletal pain.

DESIGN

Umbrella review.

METHODS

PubMed, EMBASE, MEDLINE, and Web of Science were searched for relevant systematic reviews and meta-analyses from inception to March 2024. Critical appraisal, data extraction, and synthesis were performed in accordance with the criteria for conducting an umbrella review.

RESULTS

Seventeen articles, comprising 4 systematic reviews and 13 meta-analyses, were included. Using the AMSTAR2 instrument for quality assessment, 3 articles were rated as high quality, 1 as moderate, 7 as low, and 6 as critically low. Generally, ultrasound-guided injections were found to be more accurate than landmark-guided injections, particularly in the shoulder joint, though the results for pain relief and functional outcomes varied. Ultrasound guidance was notably effective for injections into the bicipital groove, wrist, hip, and knee - yielding greater accuracy and improved pain management. Both ultrasound-guided and landmark-guided techniques showed low incidence of adverse effects.

CONCLUSION

This umbrella review offers an in-depth analysis of the comparative effectiveness of ultrasound-guided and landmark-guided injections across a range of musculoskeletal sites/conditions. The findings suggest that ultrasound-guided is a reliable method.

Is Ultrasound-guided or Landmark-guided Intra-articular Lidocaine Injection More Effective for Pain Control in Anterior Shoulder Dislocation Reduction? A Randomized Controlled Trial

BACKGROUND

Effective pain control during reduction of shoulder dislocation is essential for patient comfort. However, there is a lack of comprehensive research comparing the efficacy of different pain management techniques, specifically landmark-guided and ultrasound-guided intra-articular analgesic injections.

QUESTIONS/PURPOSES

Among patients undergoing closed reduction of a shoulder dislocation, were there differences between an intra-articular shoulder injection placed using anatomic landmarks and an ultrasound-guided intra-articular injection in terms of (1) pain before versus after the injection and pain before injection versus after the reduction, or (2) length of stay in the emergency department and complications of the procedure?

METHODS

Between August 2021 and March 2023, 28 patients with anterior shoulder dislocation were treated at the emergency department of a tertiary referral care center. They were randomly assigned to either the landmark-guided or ultrasound-guided intra-articular lidocaine injection group. Differences in pain levels between preinjection and postinjection, preinjection and postreduction, length of hospital stay, and complications were assessed and compared between the two groups. Patients were followed for 2 weeks.

RESULTS

There were no between-group differences in terms of age, gender, baseline pain score, and any other relevant factors. There were no differences between the groups in terms of pain reduction between preinjection and postinjection (landmark-guided: ΔVAS 2.8 ± 1.1, ultrasound-guided: ΔVAS 2.9 ± 1.0, mean difference -0.14 [95% confidence interval -0.97 to 0.68]; p = 0.72) or between preinjection and postreduction (landmark-guided: ΔVAS 6.6 ± 2.1, ultrasound-guided: ΔVAS 5.8 ± 1.8, mean difference 0.79 [95% CI -0.74 to 2.31]; p = 0.30). There were no differences in length of stay in the emergency department (landmark-guided: 162 ± 38 minutes, ultrasound-guided: 184 ± 73 minutes, mean difference 22 minutes [95% CI -67 to 24]; p = 0.33), and no complications were reported in either group during the 2-week follow-up period.

CONCLUSION

The results of the landmark-guided technique were not different from those of ultrasound-guided injection in terms of lower pain levels, length of stay, and complications. These findings provide valuable guidance for orthopaedic surgeons, enabling them to make informed decisions based on their expertise and available resources.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Efficacy of Combination Therapy (Hydrodilatation and Subdeltoid Bursa Injection With Corticosteroid, Mobilization, and Physical Therapy) vs Physical Therapy Alone for Treating Frozen Shoulder: A Randomized Single-Blind Controlled Trial, Phase I

OBJECTIVE

To compare the efficacy of combination therapy (hydrodilatation and subdeltoid bursa injection with corticosteroid, mobilization, and physical therapy [PT]) with that of PT alone for treating frozen shoulder.

DESIGN

A prospective, 2-arm parallel, single-blinded, randomized controlled trial.

SETTING

Rehabilitation clinic of a private academic hospital.

PARTICIPANTS

Patients (n=70) with frozen shoulder (freezing stage).

INTERVENTIONS

Participants (n=35) in the combination group underwent hydrodilatation and subdeltoid bursa injection with corticosteroid twice, mobilization, and usual-care PT for 8 weeks; participants (n=35) in the PT group received only the usual-care PT for 8 weeks.

MAIN OUTCOME MEASURES

The Shoulder Pain and Disability Index (SPADI) was the primary outcome measure. The secondary outcome measures were pain scores on a visual analog scale, range of motion (ROM), the Shoulder Disability Questionnaire (SDQ), quality of life (evaluated using the 36-item Short-Form Health Survey [SF-36]), and self-assessment of the treatment effect.

RESULTS

Compared with the PT group, the combination group had significantly better pain (during activity), SPADI, SDQ, active and passive ROM, and self-assessment scores (all P<.001) as well as scores on some parts of the SF-36 (physical function and bodily pain, P<.05). Between-group differences were significant at the 1-, 2-, 4-, and 6-month follow-ups.

CONCLUSIONS

A combination of hydrodilatation (with corticosteroid), bursal corticosteroid injection, and joint mobilization with PT was superior to PT alone for treating frozen shoulder, and the effects persisted for at least 6 months.

Corticosteroid Injection Methods for Frozen Shoulder: A Network Meta-analysis

OBJECTIVE

To investigate the efficacy of corticosteroid (CS) injection methods for frozen shoulder.

DATA SOURCES

PubMed, Embase, and Cochrane Library were searched up to May 6, 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) that investigated CS injection methods for frozen shoulder were included.

DATA EXTRACTION

Data were extracted independently by 2 authors. Risk of bias was assessed using the RoB 2 tool.

DATA SYNTHESIS

A random-effects network meta-analysis was performed within a frequentist framework. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. A total of 66 RCTs involving 4491 patients were included. For short-term outcomes, 4-site injection (vs placebo [PLA]: standardized mean difference [SMD]=-2.20, 95% confidence interval [CI], -2.81 to -1.59 in pain; SMD=2.02; 95% CI, 1.39-2.65 in global function) was the most effective (low certainty). Rotator interval injection was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.07, 95% CI, -1.51 to -0.64 in pain; SMD=0.94, 95% CI, 0.49-1.40 in global function). For midterm outcomes, 4-site injection was most effective (vs PLA: SMD=-1.71, 95% CI, -2.41 to -1.01 in pain; SMD=2.22, 95% CI, 1.34-3.09 in global function; low certainty). Distension via rotator interval (D-RI) was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.10, 95% CI, -1.69 to -0.51 in pain; SMD=1.46, 95% CI, 0.73-2.20 in global function). Distension and intra-articular injection via anterior or posterior approaches produced effects equivalent to those of rotator interval injection and D-RI.

CONCLUSIONS

Rotator interval injection, distension, and intra-articular injection had equivalent effects on symptom relief. More RCTs are required to validate the superiority of multisite injections.

Efficacy of combined ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy in patients with adhesive capsulitis: A randomised controlled trial

OBJECTIVE

To evaluate the therapeutic effect of combining ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy compared with physical therapy alone in patients with adhesive capsulitis.

DESIGN

A prospective, single-blinded, randomised controlled trial.

SETTING

Single medical centre.

PARTICIPANTS

Patients with adhesive capsulitis (N = 62) were divided into group A: ultrasound-guided hydrodilatation with hyaluronic acid + physical therapy (N = 31) and group B: physical therapy alone (N = 31).

INTERVENTIONS

Group A received three doses of ultrasound-guided hydrodilatation with hyaluronic acid-based injectates (20 mL in total). Both groups underwent structured physical therapy.

OUTCOME MEASURES

The primary outcome measure was Constant score, while secondary outcomes included Shoulder Pain and Disability Index score, numerical rating scale (at rest, night, and during motion), 36-item Short Form Health Survey, and range of motion of the shoulder. All measurements were collected at baseline, 6 weeks, and 12 weeks post-injection.

RESULTS

At week 12, the Constant scores were 68.29 ± 14.55 and 62.77 ± 14.44 for groups A and B, respectively. There was a greater reduction in the Constant score, Shoulder Pain and Disability Index, and numerical rating scale between the baseline and 6 weeks and between the baseline and 12 weeks in group A (Constant score: p < 0.05, Shoulder Pain and Disability Index: p < 0.01, and numerical rating scale: p < 0.05).

CONCLUSION

The combination of ultrasound-guided hydrodilatation with hyaluronic acid in conjunction with physical therapy provides additional benefits compared to physical therapy alone for the treatment of adhesive capsulitis at up to 12 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02708706.

Frozen Shoulder: Diagnosis and Management

ABSTRACT

Frozen shoulder is a common condition that causes pain and restriction of movement of the shoulder unrelated to secondary causes. It has three classic phases (freezing, frozen, and thawing), and is resolved in most cases within 1 to 2 years. Diagnosis is clinical based on global motion restriction and pain. Imaging plays an ancillary role to narrow the differential diagnosis. Physical therapy, nonsteroidal anti-inflammatories, and injection therapies are standard treatments, although none have been shown to alter the long-term course of the condition. Ultrasound guidance is recommended for injection-based therapy, although not required. Further study should focus on long-term outcomes and treatments that significantly alter the natural course of the disease.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Current evidence and practical knowledge for ultrasound-guided procedures in rheumatology: Joint aspiration, injection, and other applications

Ultrasound (US)-guided procedures have increasingly gained their role in the daily practice of rheumatology, owing to the growing evidence supporting their utility. The utilization of US guidance in procedures may enhance their accuracy, efficacy, and safety. This article presents a comprehensive review of the current evidence and practical knowledge pertaining to US-guided procedures in rheumatology, encompassing joint aspirations, injections, and other applications such as tendon sheath injections. We provide a detailed description of the US-guided procedure process and compare the in-plane and out-of-plane view methods, along with practical techniques based on existing evidence or our own expertise. For each joint, we summarize how to perform procedures with figures to facilitate a better understanding. Additionally, we introduce other applications of US-guided procedures for tendons, enthesis, bursae, and nerves as well as emerging therapies such as US-guided fascia hydrorelease. By utilizing these US techniques, rheumatologists can achieve the ability to manage a wider range of musculoskeletal conditions.

Adhesive Capsulitis

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

Ultrasound-Guided Injection of Dextrose Versus Corticosteroid in Chronic Plantar Fasciitis Management: A Randomized, Double-Blind Clinical Trial

DESIGN

Chronic plantar fasciitis (PF) is a common cause of chronic heel pain, with different conventional treatment options. In this randomized clinical trial, the effect of ultrasound-guided injection of dextrose versus corticosteroid in chronic PF was evaluated and compared.

METHODS

A total of 44 patients suffering from chronic PF who visited the physical medicine and rehabilitation clinic were enrolled in the study. Two table-randomized groups were formed. They received an ultrasonography-guided, single injection of either 40 mg methylprednisolone or 20% dextrose. Numeric Rating Scale (NRS), Foot and Ankle Ability Measure questionnaire with 2 subscales, Activities of Daily Living (FAAM-A) and Sports (FAAM-S), along with ultrasonographic parameters were evaluated before and at 2 and 12 weeks after the injection. Results. A total of 40 participants completed the study. Both interventions significantly improved pain and function at 2 and 12 weeks postinjection. After 2 weeks, compared with the dextrose prolotherapy, the corticosteroid group had significantly lower daytime and morning NRS scores (2.55 vs 4.1, P = .012, and 2.75 vs 4.65, P = .004), higher FAAM-S (66.84 vs 54.19; P = .047), and lower plantar fascia thickness at insertion and 1 cm distal to the insertion zone (3.89 vs 4.29 mm, P = .004, and 3.13 vs 3.48 mm, P = .002), whereas FAAM-A was similar in both groups (P = .219). After 12 weeks, all study variables were statistically similar between corticosteroid and dextrose prolotherapy groups. No injection-related side effects were recorded in either group.

CONCLUSION

Both methods are effective. Compared with dextrose prolotherapy, our results show that corticosteroid injection may have superior therapeutic effects early after injection, accompanied by a similar outcome at 12 weeks postinjection.

LEVELS OF EVIDENCE

Level II.

Squishing sound heard following an intra-articular shoulder injection with fluid and air is associated with higher efficacy: A retrospective analysis

BACKGROUND

Accuracy of blind intra-articular injections for the shoulder is rather low. It is unclear whether accurate injections for capsulitis of the shoulder are more effective than inaccurate injections.

OBJECTIVE

It has been hypothesized that a squishing sound following an intra-articular injection with a mixture of air and fluid means that the injection was accurately placed and that the efficacy of accurately placed injections is greater than that of inaccurate injections. The aim of the present study was to test the hypothesis that a squishing sound following an injection predicts a better clinical result.

METHODS

Files were selected of patients with capsulitis of the shoulder, who were treated with an intra-articular injection containing a mixture of triamcinolone, lidocaine, and air. After the injection, the shoulder was moved to determine whether a squishing sound could be produced. Efficacy was measured after two weeks according to the Patient Global Impression of Change scale. Differences in efficacy between injections with and without a squishing sound were expressed as an odds ratio.

RESULTS

Sixty-one patients were selected. Squishing was heard after 47 injections (77%). Two weeks after the injection, a positive outcome was reported by 49 patients (80%). When squishing was heard, the effect was positive in 42 of the 47 patients (89%) and when no squishing was heard, the effect was positive in 7 of the 14 patients (50%). The odds ratio was 8.4 (95% CI 2.1-34.0; p= 0.003).

CONCLUSION

Efficacy of injections with a mixture of triamcinolone, lidocaine, and air for capsulitis of the shoulder is significantly greater when a squishing sound was heard after the injection. We hypothesize that squishing is related to accuracy and accuracy to efficacy. A future study with X-ray arthrography is needed to verify both hypotheses.

Usefulness of combined handheld ultrasound and fluoroscopy-guided injection in adhesive capsulitis of the shoulder: A prospective, randomized single blind-pilot study

BACKGROUND

Ultrasound is increasingly being utilized in the diagnosis and treatment of adhesive capsulitis.

OBJECTIVE

To compare the therapeutic effects and advantages of combined handheld ultrasound and fluoroscopy-guided intra-articular corticosteroid injection with those of conventional ultrasound-guided corticosteroid injection in adhesive capsulitis of the shoulder.

METHODS

A total of 39 patients diagnosed with adhesive capsulitis of the shoulder were randomly assigned into two groups. Group A patients (n= 19) underwent combined handheld ultrasound and fluoroscopy-guided corticosteroid injection and group B patients (n= 20) underwent conventional ultrasound-guided corticosteroid injection to the intra-articular space of the shoulder twice. Treatment efficacy was assessed at 2 and 6 weeks after the final injection, based on the verbal numeric pain scale, Shoulder Pain and Disability Index, and range of motion. Secondary outcome measures were the accuracy and procedure time.

RESULTS

Both injection methods were effective in the treatment of adhesive capsulitis. No significant differences in treatment efficacy and injection accuracy were observed between the two groups (p> 0.05).

CONCLUSIONS

This study showed no statistical differences in treatment efficacy between 2 groups. However, the combined use of ultrasound and fluoroscopy can increase the accuracy of injection compared with conventional ultrasound alone.

Ultrasound-Guided Suprascapular Nerve Block at Spinoglenoid Notch and Glenohumeral Joint Hydrodilation

Hydrodilation of the glenohumeral joint is commonly employed as a nonsurgical intervention for the frozen shoulder. Accuracy and pain during the procedure can be regarded as difficulties in performing this procedure. Ultrasonography (USG) guided injection and suprascapular nerve block can improve the accuracy and can decrease pain during the hydrodilation procedure. We present the step-by-step method for performing USG-guided injections for suprascapular nerve block and hydrodilation.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Complications in image-guided musculoskeletal injections

Complications in musculoskeletal interventions are rare and where they do occur tend to be minor, and often short-lived or self-limiting. Nonetheless, the potential for significant complications exists, and a thorough understanding of both the mechanisms which contribute and the manner in which they may clinically present is of critical importance for all musculoskeletal radiologists involved in performing procedures, both to mitigate against the occurrence of complications and to aid rapid recognition. The purpose of this review is to analyse the relevant literature to establish the frequency with which complications occur following musculoskeletal intervention. Furthermore, we highlight some of the more commonly discussed and feared complications in musculoskeletal intervention, such as the risk of infection, potential deleterious articular consequences including accelerated joint destruction and the poorly understood and often underestimated systemic effects of locally injected corticosteroids. We also consider both extremely rare but emergent scenarios such as anaphylactic reactions to medications, and much more common but less significant complications such as post-procedural pain. We suggest that meticulous attention to detail including strict adherence to aseptic technique and precise needle placement may reduce the frequency with which complications occur.

Value of imaging to guide interventional procedures in rheumatic and musculoskeletal diseases: a systematic literature review informing EULAR points to consider

OBJECTIVES

To summarise current data on the value of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal disease (RMDs) informing an European Alliance of Associations for Rheumatology taskforce.

METHODS

A systematic literature review was conducted to retrieve prospective and retrospective studies published in English and comparing different (imaging) techniques, different settings and procedural protocols to guide interventions in patients with RMDs. MEDLINE, EMBASE, the Cochrane Library and Epistemonikos databases were searched through October 2021. Risk of bias (RoB) was assessed using the Cochrane RoB tool for randomised trials V.2 (ROB2), the RoB tool for Non-Randomised Studies of Interventions and the appraisal tool for cross-sectional studies.

RESULTS

Sixty-six studies were included (most with moderate/high RoB); 49 were randomised controlled trials, three prospective cohort studies and 14 retrospective studies. Fifty-one studies compared either one imaging technique with another imaging technique, or with palpation-guided interventions. Ultrasound (US) was most frequently studied (49/51), followed by fluoroscopy (10/51). Higher accuracy was found for US or fluoroscopy compared with palpation-guided interventions. Studies comparing different imaging techniques (12/51) did not endorse one specific method. Different settings/equipment for imaging-guided procedures (eg, automatic vs manual syringes) were investigated in three studies, reporting heterogeneous results. Fifteen studies compared different imaging-guided procedures (eg, intra-articular vs periarticular injections).

CONCLUSION

Higher accuracy of needle positioning at joints and periarticular structures was seen in most studies when using imaging (especially US) guidance as compared with palpation-guided interventions with the limitation of heterogeneity of data and considerable RoB.

Is the Anterior Injection Approach Without Ultrasound Guidance Superior to the Posterior Approach for Adhesive Capsulitis of the Shoulder? A Sequential, Prospective Trial

BACKGROUND

Shoulder injections for conditions such as adhesive capsulitis are commonly performed and can be administered through image-based or landmark-based injection approaches. Ultrasound-guided injections are widely used and accurate because ultrasound allows real-time visualization of the needle and injected contrast. Landmark-based injections would be advantageous, if they were accurate, because they would save the time and expense associated with ultrasound. However, few prospective studies have compared well-described landmark-based shoulder injection techniques without ultrasound.

QUESTION/PURPOSE

Using anatomic landmarks, and without using ultrasound, is the accuracy of glenohumeral injection for adhesive capsulitis greater via the posterior approach or via a new anterior approach?

METHODS

Between 2018 and 2020, we treated 108 patients potentially eligible for adhesive capsulitis treatment. These patients had clinical symptoms of aggravating shoulder pain with a duration of less than 4 months and passively impaired, painful glenohumeral ROM. Due to the exclusion of patients with other shoulder conditions (full-thickness rotator cuff ruptures and posttraumatic stiffness), 95 patients received an injection in this sequential, prospective, comparative study. Between 2018 and 2019, 41 patients (17 males and 24 females; mean age 52 ± 5 years; mean BMI 24 ± 3 kg/m2) were injected through the posterior approach, with the acromion as the anatomical landmark, during the first part of the study period. After that, between 2019 and 2020, 54 patients (20 males and 34 females; mean age 54 ± 4 years; mean BMI 23 ± 3 kg/m2) received an injection through a new anterior approach, with the acromioclavicular joint as the anatomic landmark, during the second part of the study period. Injections via both approaches were administered by two experienced shoulder specialists (both with more than 10 years of experience). Both specialists had experience with the posterior approach before this study, and neither had previous training with the new anterior approach. Injections contained a corticosteroid, local anaesthetic, and contrast medium. Radiographs were taken within 20 minutes after the injection, and a radiologist blinded to the technique determined accuracy. Accurate injections were defined as having contrast fluid limited to the glenohumeral joint, while inaccurate injections displayed leakage of contrast fluid into the soft tissue or subacromial space. All of the enrolled patients were analyzed.

RESULTS

In the group with the posterior approach, the accuracy was 78% (32 of 41) in contrast to 94% (51 of 54, odds ratio 0.21 [95% CI 0.05 to 0.83]; p = 0.03) in patients with the new anterior approach.

CONCLUSION

The new anterior approach without the use of ultrasound was more accurate than the posterior approach. In fact, it was nearly as accurate as previously published ultrasound-guided approaches. We recommend using the new anterior approach for intraarticular glenohumeral injections instead of ultrasound-guided injections because it will save time and costs associated with ultrasound. Still, the clinical effects (anxiety, pain, functional outcome, and adverse events) of the new anterior approach should be compared with ultrasound-guided injections in a randomized study.

LEVEL OF EVIDENCE

Level II, therapeutic study.

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.

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials.

METHODS

A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model.

RESULTS

Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy.

CONCLUSIONS

No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone.

LEVEL OF EVIDENCE

II, systematic review and network meta-analysis of level I and II studies.

Treatment of Primary Shoulder Stiffness: Results of a Survey on Surgeon Practice Patterns in Italy

Objectives  Shoulder stiffness is a condition of restricted glenohumeral range of motion (ROM), which can arise spontaneously or as consequence of a known cause. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. The aim of this study was to investigate surgeon practice patterns in Italy regarding treatment of primary shoulder stiffness.

Methods  A literature review was performed to identify randomized controlled trials reporting results of shoulder stiffness treatment. The following controversial or critical points in the treatment of primary shoulder stiffness were identified: modalities of physical therapy; indication for oral corticosteroid; indication and frequency for injective corticosteroid; technique and site of injection; and indication, timing, and technique for surgery. A survey composed by 14 questions was created and administrated to the members of a national association specialized in orthopaedics and sports traumatology (SIGASCOT at the time of survey completion, recently renamed SIAGASCOT after the fusion of the societies SIGASCOT and SIA).

Results  A total of 204 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 51%, and injections of corticosteroids by 72%. The posterior injection approach was the one preferred and a number of three was considered the upper limit for repeated injections. Injective therapy with local anesthetics and hyaluronic acid was considered by more than 20% of the interviewed. Thirty percent of the interviewed did not treat shoulder stiffness surgically.

Conclusion  Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. Several controversial points emerged both from a literature review and from this national survey. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology and should aim at pain reduction, ROM restoration, functional regain, and shortening of symptoms duration, with conservative therapy remaining the mainstay of treatment.

Analysis of Three-Dimensional Ultrasound in Diagnosis of Shoulder and Neck Inflammation and Surrounding Tissue Lesions

Ultrasound imaging technology can not only show neck tear the degree and extent of disease, to help make the correct diagnosis, can also be used to assess shoulder neck inflammation after surgery to repair a shoulder muscle neck tissue integrity and healing. Ultrasound imaging with high-resolution, real-time operation, low cost, etc. gradually become shoulder neck inflammatory disease preferred imaging modality. The sensitivity and specificity for three-dimensional ultrasound imaging of shoulder neck inflammation were 78% and 93% in this study. The full-thickness inflammation sensitivity and specificity were 50% and 95%. The sensitivity and specificity of inflammation were 57% and 87%, respectively. This study shows that the diagnostic accuracy of 3D ultrasound imaging in shoulder and neck inflammation and surrounding tissue lesions is close to that of MRI. Three-dimensional appearance of new technologies such as ultrasound imaging will further improve ultrasound imaging techniques in shoulder neck inflammation application in the diagnosis and treatment assessment.

A prospective double-blind randomized trial on ultrasound-guided versus blind intra-articular corticosteroid injections for primary frozen shoulder

AIMS

Ultrasound (US)-guided injections are widely used in patients with conditions of the shoulder in order to improve their accuracy. However, the clinical efficacy of US-guided injections compared with blind injections remains controversial. The aim of this study was to compare the accuracy and efficacy of US-guided compared with blind corticosteroid injections into the glenohumeral joint in patients with primary frozen shoulder (FS).

METHODS

Intra-articular corticosteroid injections were administered to 90 patients primary FS, who were randomly assigned to either an US-guided (n = 45) or a blind technique (n = 45), by a shoulder specialist. Immediately after injection, fluoroscopic images were obtained to assess the accuracy of the injection. The outcome was assessed using a visual analogue scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the subjective shoulder value (SSV) and range of movement (ROM) for all patients at the time of presentation and at three, six, and 12 weeks after injection.

RESULTS

The accuracy of injection in the US and blind groups was 100% (45/45) and 71.1% (32/45), respectively; this difference was significant (p < 0.001). Both groups had significant improvements in VAS pain score, ASES score, SSV, forward flexion, abduction, external rotation, and internal rotation throughout follow-up until 12 weeks after injection (all p < 0.001). There were no significant differences between the VAS pain scores, the ASES score, the SSV and all ROMs between the two groups at the time points assessed (all p > 0.05). No injection-related adverse effects were noted in either group.

CONCLUSION

We found no significant differences in pain and functional outcomes between the two groups, although an US-guided injection was associated with greater accuracy. Considering that it is both costly and time-consuming, an US-guided intra-articular injection of corticosteroid seems not always to be necessary in the treatment of FS as it gives similar outcomes as a blind injection. Cite this article: Bone Joint J 2021;103-B(2):353-359.

Efficacy of platelet-rich plasma injections in patients with adhesive capsulitis of the shoulder

PURPOSE

The goal of this study is to investigate whether platelet-rich plasma (PRP) injections are effective in the management of adhesive capsulitis of the shoulder (AC). A triple-blind, randomized controlled trial was designed and conducted in a medical school hospital.

METHODS

32 adult patients with adhesive capsulitis (21 female, 11 male with a mean age of 57, ranging from 23 to 70) were included in this study. Patients had to have shoulder pain and restrictions in movements (at least 25% when compared to the other side, and at least in two directions) for three months minimum and nine months maximum. Patients were randomized to two groups, and one group took PRP injections for three times every two weeks, while the other group took saline injections in same frequency and volume. A standardized exercise program was also applied to all patients. Patients were evaluated with Shoulder Pain and Disability Index (SPADI), Visual Analogue Scales for pain and disability, ranges of movements, and use of analgesics in before, after, and third month after the initiation of the therapy.

RESULTS

Baseline comparisons between groups showed no differences. SPADI and ranges of motion in all directions showed significant improvements with therapy, and the group which took PRP injections showed better improvements when compared to the control group (p < 0.05). Visual Analogue Scale was found to be better for the PRP group after therapy and third month, and not for the control group (0.4 ± 1.06 and 0.17 ± 0.72 vs. 2.5 ± 2.6 and 2 ± 2.2, respectively, p < 0.05). Use of analgesics was not found to be significant for both groups (p > 0.05).

CONCLUSION

PRP injections were found to be effective in both pain and disability, and showed improvements in a restricted shoulder due to adhesive capsulitis. These findings might point out PRP as a therapeutic option in the management of adhesive capsulitis.

Beliefs, attitude, and knowledge of the Iranian physiatrists towards neuromusculoskeletal ultrasound and common barriers in its application

Background

Regarding the increasing application of neuromusculoskeletal sonography among medical specialties, specifically physiatrists, this study aims to assess the knowledge and skill level of these specialists in neuromusculoskeletal sonography in Iran.

Methods

This descriptive, cross-sectional study was performed in 2018. The utilized questionnaire developed based on previous studies in collaboration with 6 university lecturers of Shaheed Beheshti, Iran, and Tabriz medical universities and a physiatrist from Hacettepe University (Turkey); it included questions entailing demographic data, knowledge, and performance levels. Its validity and reliability were evaluated through face validation, pilot study, and the Cronbach α calculated via SPSS. Data extraction and analysis were also performed by SPSS-25.

Results

Of 364 questionnaires distributed, 300 were properly filled and entered into the study, of which, 38% were filled by clinical residents, 10% university lecturers, and 52% other categories (e.g. private sector).

The average number of musculoskeletal patient visits was 140.6 ± 119 and the mean number of musculoskeletal sonographies requested was 8.2 ± 5.2 per month (the three most common indications reported as the shoulder, carpal tunnel syndrome, and tendon injuries).

95% of the participants considered the importance of sonography for physiatrists to be “very high” or “high”; with the most valuable applications “as a guide for procedures (90%), its diagnostic utility (68%), and follow up/evaluating the response to treatment (45%). 86% of physiatrists reported they had participated in musculoskeletal sonography courses, 60% during residency, and the rest through workshops.

Also, the participants mentioned safety (83%), the possibility of performing simultaneous diagnosis and intervention procedures (70%), repeatability (58%), and dynamic imagery (52%) as the major advantages of musculoskeletal ultrasound.

Conclusion

a large number of doctors consider musculoskeletal sonography to be essential for physiatrists, though insufficient education on the subject and the low number of ultrasound devices are some of the obstacles in enhancing the use of this technology in PM&R setting. Presenting certified specific training courses during residency, provision of necessary rotations, using the capacities of the PM&R scientific committee, and the private sector for running workshops and professional training courses are suggested for enhancing the knowledge and skills of neuromusculoskeletal sonography.

Shoulder MR Arthrography: Comparative Evaluation of Three Different Contrast Injection Techniques Using an Anterior Approach

BACKGROUND

MR arthrography (MRA) is commonly used in the assessment of shoulder internal derangements. Correct intra-articular contrast injection is required for this modality. Anterior injections under fluoroscopic, ultrasound-guidance, or without image-guidance have been described in the literature. However, no simultaneous comparison has been performed between the three techniques.

PURPOSE

To compare the accuracy and performance of fluoroscopy (FL)-guided, ultrasound (US)-guided and non-image-guided intra-articular contrast injection via an anterior approach for performing shoulder MRA.

STUDY TYPE

Prospective.

SUBJECTS

Two-hundred and ten patients (180 men and 30 women; mean age, 33 ± 12 years; range 20-60 years) with clinically suspected shoulder pathology.

FIELD STRENGTH/SEQUENCE

1.5T/fat-suppressed T₁ -weighted, T₂ -weighted, and 3D-gradient-echo images.

ASSESSMENT

Patients underwent shoulder MRA after anterior intra-articular contrast injection under FL- or US-guidance or without image-guidance. Patients were randomized among the three techniques with each group comprising 70. The techniques were compared according to the accuracy of intra-articular needle placement, attempts success rate, pain during and 24 hours after injection, procedure times, contrast extravasation rate, joint distension, and MRA diagnostic efficacy. Pain was assessed by the visual analog scale (VAS) pain-score.

STATISTICAL TESTS

Pearson's chi-squared and Kruskal-Wallis tests.

RESULTS

FL- and US-guided injections (100% accuracy) were significantly more accurate than non-image-guided (85.7% accuracy) (P < 0.05). US-guidance was the least painful, with statistical differences between image-guided and non-image-guided techniques regarding the first attempt success rate (95.7% and 92.8% for FL- and US-guided vs. 78.6% for blinded), VAS-score 24 hours-post-procedure (1.7 ± 1.7, and 1.5 ± 1.4 vs. 2.2 ± 1.4), procedure time (11.9 ± 1.6, and 7.4 ± 1.7 vs. 4.3 ± 0.76 minutes), and contrast extravasation rate (5.7%, and 8.6% vs. 30%) (all P < 0.05). Procedure time was also significantly different between FL and US-guidance (P < 0.05).

DATA CONCLUSION

Imaging-guided injections are more accurate and tolerable than non-image-guided and should be considered to confirm intra-articular needle position, hence adequate capsular distension and good diagnostic quality of shoulder MRA. US guidance is a less painful, rapid, and safe alternative to the FL approach. Evidence Level: 2 Technical Efficacy Stage: 5. J. MAGN. RESON. IMAGING 2021;53:481-490.

Real-Time Impedance Detection of Intra-Articular Space in a Porcine Model Using a Monopolar Injection Needle

Rheumatoid arthritis and osteoarthritis can be treated through specific drug injection into the intra-articular space. Several failures during drug injection attempts with conventional fluoroscopy and ultrasonography in a small area of the intra-articular space have been reported. In this work we present an innovative impedance measurement-based method/algorithm for needle tip positioning to enhance image-guided intra-articular vaccination treatment. A novel algorithm for detecting the intra-articular space in the elbow and knee joints of a live porcine model is reported. An impedance measurement system was developed for biological tissue measurement. The electrical impedance in the intra-articular space was monitored and the needle tip was examined by ultrasonography. The contrast dye was vaccinated and checked using fluoroscopy to confirm that the dye was properly inoculated in the cavity. The electrical impedance was estimated for various needle inclusion profundity levels in saline solution, which were broadly used to evaluate the proposed device for in vivo examinations. Good efficiency was observed in the impedance-based measurements using a monopolar injection needle for intra-articular therapy. To enhance the needle tip positioning for intra-articular therapy, the intended impedance measurement device with a monopolar injection needle can be used as a complement to existing modalities.

Needle Length Requirement for Glenohumeral Joint Injection Using the Neviaser Approach

Intra-articular glenohumeral joint injections are commonly performed in the clinical setting for diagnostic and therapeutic purposes. Multiple approaches are described, including the anterior and posterior approaches and the less studied superomedial (Neviaser) approach. The purpose of this study was to determine the length of needle required to enter the shoulder joint via the Neviaser approach by radiography and magnetic resonance imaging (MRI) measurements. Additionally, the authors sought to identify any correlation between needle length and body mass index (BMI). They performed a retrospective review of 101 consecutive patients evaluated by one faculty member at their institution. Inclusion criteria were age older than 50 years, no previous shoulder surgery, no history of acromioclavicular joint injury, and having a true anteroposterior radiograph and MRI within 1 year of each other. Using a digital imaging system, the Neviaser approach needle path was drawn for both images, and the lengths were measured. Correlation coefficients for needle length and BMI were calculated. The images of 58 (57.4%) male patients and 43 (42.6%) female patients were evaluated (average BMI, 31.2 kg/m²). The average needle length measurement was 4.27 cm on radiograph and 3.9 cm on MRI. Correlation coefficients were r=0.36 (P=.0002) using radiographs and r=0.53 (P<.0001) using MRIs. When using the Neviaser approach, there is a moderate positive correlation between BMI and the measured distance between skin and the glenohumeral joint when assessed on MRI, and a weak positive correlation on radiographs. The authors conclude that an injection needle of 2 inches or greater is required to reliably access the shoulder joint, and this length may increase with increasing BMI. [Orthopedics. 2020;43(4):e215-e218.].

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.

Accuracy of unguided and ultrasound guided Coracohumeral ligament infiltrations - a feasibility cadaveric case series

BACKGROUND

Coracohumeral ligament (CHL) thickening, contracture, and fibroplasia have been identified in glenohumeral idiopathic adhesive capsulitis (GHIAC). The CHL is the main structure responsible for the range of motion limitations. Favorable outcomes have been reported with CHL surgical release. Intra-articular glenohumeral joint corticosteroid infiltrations are utilized to disrupt the inflammatory process and reduce pain in GHIAC. The aim of this study was to investigate whether the CHL could be accurately targeted with a periligamentous infiltration.

METHODS

A convenience sample of 12 unembalmed cadaver shoulders (mean age: 74.5 years, range 66-87 years) without evidence of previous injury or surgery were utilized in this exploratory double factor feasibility cadaveric (unguided and ultrasound (US) guided) case series. Two clinicians trained in musculoskeletal infiltration techniques carried out the infiltrations on each shoulder with colored latex. One clinician infiltrated without guidance, the other with US-guidance. The injecting clinicians were blinded to the others infiltration procedure and the order was randomized. An anatomist blinded to the infiltration order performed a shoulder dissection and recorded the infiltrate location. Percentage calculation for accuracy of infiltration and a chi-square evaluation of the difference between unguided and US-guided infiltrations was applied.

RESULTS

An accuracy of 75% was achieved for unguided infiltration and 80% for US-guided infiltration techniques. Chi-squared indicated there was no significant difference (p = 0.82) between the unguided and US-guided techniques.

CONCLUSION

US-guided and unguided infiltrations achieved good accuracy targeting the CHL, suggesting infiltrations can specifically and accurately target the CHL. In vivo investigation using such infiltration techniques are warranted.

The effectiveness of hydrodistension and physiotherapy following previously failed conservative management of frozen shoulder in a UK primary care centre

BACKGROUND

There is a lack of evidence on the clinical effectiveness of hydrodistension for frozen shoulder following failed conservative management.

METHODS

A total of 90 patients opted for hydrodistension following failed initial treatment which included physiotherapy and at least one corticosteroid injection. Shoulder pain and function were assessed at baseline, and 6, 12 and 24 weeks using the Shoulder Pain Disability Index (SPADI), The Upper Extremity Functional Index (UEFI) and a visual analogue scale (VAS) for pain. Active ranges of motion were assessed at baseline, post-24 hr and discharge.

RESULTS

We observed clinically important improvements in pain (VAS -5.5; 90% confidence interval [CI] -6.0 to -5.0; SPADI pain, -20; 90% CI-23 to -17) and function (UEFI 23; 90% CI 19 to 26; SPADI disability, -32; 90% CI -36 to -28) at 6 weeks. These improvements remained clearly substantial at 24 weeks. Active range of motion improved substantially post-24 hr (flexion 20, 90% CI 18 to 23; lateral rotation 14, 90% CI 12 to 16; abduction 22, 90% CI 19 to 25) and at discharge (flexion 37, 90% CI 33 to 41; lateral rotation 24, 90% CI 21 to 27; abduction 44, 90% CI 38 to 50).

DISCUSSION

This single-arm observational study suggests that hydrodistension is an effective treatment of frozen shoulder within a UK primary care setting when standard treatment has failed.

Comparing The Efficacy Of Local Triamcinolone Injection In Carpal Tunnel Syndrome Using Three Different Approaches with or without Ultrasound Guidance

Purpose

The present article has investigated the added value of ultrasound (US) guidance on improving the efficacy of local triamcinolone injection via comparing two US-guided methods versus a conventional landmark-guided approach.

Methods

Eighty-one subjects with mild or moderate CTS were included and randomly assigned into three categories including landmark-guided, conventional US-guided midline approach and US-guided ulnar in-plane method. Primarily, participants in the three groups were relatively similar in terms of demographics and their clinical variables comprising visual analog scale (VAS) for pain, pain-free grip strength (PFGS), Boston CTS questionnaire (BCTQ), EDX parameters, and cross-sectional area (CSA) of median nerve measured by ultrasonography. Ten weeks after injection, the changes of clinical and para-clinical outcomes were reassessed for 76 patients who finished the study.

Results

Our findings showed that all three injection methods were associated with a significant and relatively similar improvement in clinical and electrodiagnostic parameters. The post-injection evaluation showed a statistically significant change in all variables except for symptom severity score (SSS) of BCTQ. The best effect-size values were observed for VAS [56%] and functional severity scale (FSS) of BCTQ [42%], both reported in the US-guided midline group. However, no significant difference was found between the groups regarding their improvement in any of the outcome variables (P value >0.05).

Conclusion

Based on the current data, all three injection methods were effective in improving electrodiagnostic findings and clinical symptoms of CTS. Although all approaches were relatively similar, US-guided midline approach was associated with slightly better outcomes.

Treatment of Adhesive Capsulitis of the Shoulder

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

Diagnostic value of ultrasonography versus electrodiagnosis in ulnar neuropathy

Purpose

Ulnar neuropathy at elbow is the second-most common compression neuropathy. The main aim of this study was to assess the diagnostic value of ultrasonography (US) as an alternative method to electrodiagnosis (EDX), which had traditionally been used as the method of choice.

Methods

This diagnostic study was conducted on 66 participants (32 patients` elbows and 34 normal elbows) referred for EDX. Both groups were reassessed by US to evaluate the consistency of the two tests. The quantitative parameters of US, such as cross-sectional area (CSA) of the ulnar nerve at three different levels around the medial epicondyle (ME) were compared between groups.

Results

Our findings demonstrated that CSA at the ME and 2 cm distal to the ME were significantly larger in the patient group than normal participants. This higher nerve size was more prominent among those who had predominant axonal loss rather than demyelinating lesions (P<0.01). Finally, we evaluated US diagnostic value with the best singular feature (2 cm distal to ME) at a cutoff of 9 mm², which revealed specificity of 80% and sensitivity 84%.

Conclusion

Based on these results we can conclude that US is a sensitive and specific method in diagnosing ulnar neuropathy at the elbow and can be used as an acceptable complementary method, in particular when EDX is not available.

Editorial Commentary: Unguided Glenohumeral Injections-Do We Achieve Sufficient Accuracy?

Image-guided (fluoroscopy, ultrasound, computed tomography, magnetic resonance imaging) and unguided glenohumeral injection techniques are frequently used for different diagnostic and therapeutic purposes in clinical practice. Guided injections are highly accurate, reproducible, and more often performed in routine practice. Nevertheless, these techniques are more cost intensive and time consuming, and require special imaging devices. In case of fluoroscopic- or computed tomography-guided injections, radiation exposure of the patient is a disadvantage. In contrast, unguided glenohumeral injection techniques do not have these drawbacks, but rather are based on the precise identification of anatomic landmarks and depend on the experience of the provider. That is the reason they are supposed to be less accurate and less reproducible than guided techniques. But recent studies showed comparable accuracy; therefore, the use of unguided glenohumeral injection techniques should be considered in daily clinical practice in the hands of experienced shoulder arthroscopists.