Ultrasound-guided interventional procedures around the shoulder

Ultrasound-Guided Treatments for the Painful Shoulder

Shoulder pain is an extremely common condition. The painful shoulder may be the result of a wide spectrum of underlying pathological conditions, including calcific tendinopathy of the rotator cuff, subacromial-subdeltoid bursitis, acromioclavicular or glenohumeral arthritis, tenosynovitis of the long biceps tendon, rotator cuff lesions, and many other less common conditions. Ultrasound imaging is an effective tool for the diagnosis and also for the image guidance of treatment of the majority of these conditions. Several ultrasound-guided procedures are effective for pain relief, such as percutaneous irrigation, intra-bursal or intra-articular drugs injection, fluid aspiration, neural block. This review article aims to summarize and discuss the most common treatment possibilities with ultrasound guidance for the painful shoulder.

Infraspinatus atrophy due to Bennett lesion causing suprascapular nerve palsy

We report the case of a 19-year-old professional volleyball player who presented with right shoulder pain exacerbated during sports activity. On physical examination, infraspinatus atrophy was evident. As the clinical setting suggested suprascapular nerve entrapment syndrome, shoulder MR and later CT were performed. The results showed radiological signs of subacute-chronic infraspinatus muscle denervation and a Bennett lesion of the shoulder, presumably due to chronic repetitive trauma during the classical overhead swing in volleyball. The patient agreed to surgical treatment, and arthroscopic decompression was achieved. After months of rehabilitation, the pain gradually subsided, the infraspinatus muscle recovered its trophism, and the patient progressively returned to her regular sports activity.

Non-rotator cuff calcific tendinopathy: ultrasonographic diagnosis and treatment

Calcific tendinopathy is a condition that is related to the deposition of calcium, mostly hydroxyapatite crystals, within the tendons. The shoulder and the hip are commonly affected joints, but calcific tendinopathy may occur in any tendon of the body. While there is an extensive literature on the ultrasound diagnosis of calcific tendinopathy of the shoulder, there are only sporadic reports on other sites. This review combines the experience of our centers and a thorough analysis of the literature from the last 45 years (1972-2017) in order to highlight the localizations beyond the rotator cuff, their ultrasound characteristics and therapeutic possibilities.

Questioning the therapeutic value of corticosteroid bursal injection after ultrasound-guided irrigation and lavage for the treatment of shoulder calcific tendinosis

Objectives

The therapeutic value of corticosteroid bursal injection after ultrasound-guided irrigation and lavage for the treatment of shoulder calcific tendinosis has not been established yet in the long term.

Methods

41 patients suffering from chronic symptomatic rotator cuff calcific tendinopathy were recruited for this study. Group A (20 patients) received a double needle ultrasound-guided irrigation and lavage of the calcification with xylocaine injection, while group B (21 patients) underwent a double needle ultrasound-guided irrigation and lavage of the calcification with a xylocaine and betamethazone bursal injection.

Results

After twelve months, we documented full -or almost full- decline (VAS: 0-20/100) of the symptoms in 70% of the group A patients and in 61.9% of the group B patients. There was no statistical difference (chi square, p < 0.05) in group success ratio. We also did not find any statistical difference as for the mean Q-DASH difference between the two groups (t-test).

Conclusions

It was proven that the additional use of corticosteroid bursal injection did not provide with any additional short- to mid-term therapeutic benefit those patients with shoulder calcific tendinopathy who were treated with ultrasound-guided aspiration.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part I, shoulder

BACKGROUND

Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.

METHODS

Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.

RESULTS

A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).

CONCLUSIONS

Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

KEY POINTS

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

Ultrasound Appearance of the Migration of Tendon Calcifications

Calcific tendinopathy (CTe) is a frequent disorder related to the deposition of calcium hydroxyapatite crystals within tendons. Ultrasound has been shown to be an excellent imaging modality for the evaluation of CTe. During the resorptive phase of CTe, calcium deposits may migrate inside the tendons or in neighboring tissues and lead to local inflammation and severe pain. In this pictorial essay, we describe the ultrasound appearance of a spectrum of CTe migrations. Knowledge of the different migration patterns can help sonologists in their detection and in establishing the correct diagnosis.

Ultrasound-guided percutaneous irrigation of calcific tendinopathy: technical developments

Rotator cuff calcific tendinopathy (RCCT) is a common and painful shoulder disease characterised by deposition of calcium into the rotator cuff’s tendond. Different therapeutic options have been proposed, but the ultrasound-guided percutaneous irrigation (US-PICT) is been proved as an effective and safe first-line treatment. It can be performed with a single- of a double-needle tecnique, using warm saline solution to improve the dissolution of the calcific deposit. The procedure is ended with an intrabursal injection of local anaesthetics and slow-release steroids to improve the pain relief and to prevent complications. US-PICT leads to significative improvement in the shoulder funtion and pain relief in the short and long term, with a low complications rate. (www.actabiomedica.it)

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

Medial knee pain is common in clinical practice and can be caused by various conditions. In rare cases, it can even be by calcific bursitis of the medial collateral ligament (MCL). Treatment of calcific bursitis and/or calcification of the MCL classically includes observation, local injections, shockwave therapy and surgical resection. We report a case of nontraumatic medial knee pain poorly responsive to conservative treatments. Ultrasound (US) imaging revealed a massive lobed hyperechoic formation with partial acoustic shadow in the MCL context compatible with calcific bursitis, and magnetic resonance imaging (MRI) confirmed the presence of the bursa's calcific deposit surrounded by hyperintense signal compatible with pericalcific edema. We performed a double-needle ultrasound-guided percutaneous lavage (UGPL), which is today a fairly common treatment for many musculoskeletal disorders, such as rotator cuff calcific tendinopathy and elbow extensor tendons pathology, but regarding the knee, it is not part of ordinary care. This report shows the clinical and imaging presentation of calcific bursitis of the MCL and describes in detail the technique to perform the UGPL with a system of two needles, two syringes and a double connection to ensure a correct lavage of the calcium deposit without significant intrabursal pressure increase and consequently without pain during the procedure.

[Usefulness and reliabitlity of musculoskeletal point of care ultrasound in family practice (2): Muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures]

This article is a continuation of the review initiated in the previous issue about the usefulness of musculoskeletal point of care ultrasound in Primary Care, completing the scenarios of muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures.

Migration of calcium deposit over the biceps brachii muscle, a rare complication of calcific tendinopathy: Ultrasound image and treatment

Calcific tendinopathy is characterized by the deposition of calcium, mostly hydroxyapatite crystals, in tendons. Women are more frequently affected than men, with prevalence in the fourth and fifth decades of life. This condition has been reported between 2.5 and 7.5% of healthy shoulders in adults, but other tendons may also be affected. A complication of this condition is the migration of calcium deposits from tendons, usually the supraspinatus, into the subacromial-subdeltoid bursa. We reported a rare complication of calcific tendinopathy, that is, calcium deposits migrated from the long head of the biceps tendon over the proximal tract of the biceps brachii muscle.

Interventional therapeutic procedures in the musculoskeletal system: an Italian Survey by the Italian College of Musculoskeletal Radiology

PURPOSE

To perform an online survey among all members of the Italian College of Musculoskeletal Radiology to understand how therapeutic musculoskeletal procedures are performed in daily practice in Italy.

METHODS

We administered an online survey to all 2405 members about the use of therapeutic musculoskeletal procedures in their institutions asking 16 different questions. Subgroup analysis was performed between general and orthopaedic hospitals with Mann-Whitney U and χ ² statistics.

RESULTS

A total of 129/2405 answers (5.4% of members) were included in our analysis. A median of 142.5 (25th-75th percentiles: 50-535.5; range 10-5000) therapeutic musculoskeletal procedures per single institution was performed in 2016. Arthropathic pain was the main indication. The most common procedures were joint injection, bursal/tendon injection, and irrigation of calcific tendinopathy. Ultrasound-guided procedures were mainly performed in ultrasonography rooms (77.4%) rather than in dedicated interventional rooms (22.6%). Conversely, fluoroscopic procedures were performed almost with the same frequency in interventional radiology suites (52.4%) and in general radiology rooms (47.6%). In most institutions (72%), autologous blood or components were not used. The median number of therapeutic musculoskeletal procedures performed in orthopaedic hospitals was significantly higher than in general hospitals (P = 0.002), as well as for the use of autologous preparations (P = 0.004).

CONCLUSION

Joint injection, bursal/tendon injection, and irrigation of calcific tendinopathy were the most common therapeutic musculoskeletal procedures, being arthropathic pain the main indication. The percentage of procedures and the use of autologous preparations were significantly higher in orthopaedic hospitals than in general hospitals.

Intramuscular migration of calcific tendinopathy in the rotator cuff: ultrasound appearance and a review of the literature

Calcific tendinopathy of the shoulder is a common condition caused by calcium hydroxyapatite crystals, affecting the tendons of the rotator cuff. Among uncommon complication, one is the migration of the calcium in the subacromion-subdeltoid bursa. More rare is the intraosseous migration. We present four cases of an even more rare condition, not well described in literature yet, the intramuscular migration of calcium.

Ultrasound-guided interventional procedures around the shoulder

Ultrasound is an established modality for shoulder evaluation, being accurate, low cost and radiation free. Different pathological conditions can be diagnosed using ultrasound and can be treated using ultrasound guidance, such as degenerative, traumatic or inflammatory diseases. Subacromial-subdeltoid bursitis is the most common finding on ultrasound evaluation for painful shoulder. Therapeutic injections of corticosteroids are helpful to reduce inflammation and pain. Calcific tendinopathy of rotator cuff affects up to 20% of painful shoulders. Ultrasound-guided treatment may be performed with both single- and double-needle approach. Calcific enthesopathy, a peculiar form of degenerative tendinopathy, is a common and mostly asymptomatic ultrasound finding; dry needling has been proposed in symptomatic patients. An alternative is represented by autologous platelet-rich plasma injections. Intra-articular injections of the shoulder can be performed in the treatment of a variety of inflammatory and degenerative diseases with corticosteroids or hyaluronic acid respectively. Steroid injections around the long head of the biceps brachii tendon are indicated in patients with biceps tendinopathy, reducing pain and humeral tenderness. The most common indication for acromion-clavicular joint injection is degenerative osteoarthritis, with ultrasound representing a useful tool in localizing the joint space and properly injecting various types of drugs (steroids, lidocaine or hyaluronic acid). Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy. This review provides an overview of these different ultrasonography-guided procedures that can be performed around the shoulder.

Migration of calcium deposits into subacromial-subdeltoid bursa and into humeral head as a rare complication of calcifying tendinitis: sonography and imaging

Calcifying tendinitis of the shoulder is a common condition characterized by the deposition of calcium, predominantly hydroxyapatite crystals, in the rotator cuff. A rare complication of this condition is the migration of calcium deposits from tendons, usually the supraspinatus, into the subacromial-subdeltoid bursa or into the humeral greater tuberosity. These complications are responsible for intense acute shoulder pain and functional disability. Patient anamnesis and clinical symptoms must be considered to make the diagnosis, but imaging, particularly sonography, is often necessary, showing a typical presentation related to the locations of calcium deposits. We present sonographic and other imaging features of subacromial-subdeltoid bursitis and humeral osteitis related to the migration of calcium.