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Ultrasound Guided Treatment at EOSM

Role of Ultrasound-Guided Injections in Orthopaedic Sports Medicine: Upper Extremity

At EOSM Dr.Alleyne will office utilize ultrasound to help diagnose injuries and to assist with the accurate placement of injections in the office. Ultrasound is not necessary 100% of the time to receive an injection or to diagnose a problem but it can help to insure greater accuracy and early diagnosis. Feel free to discuss with Dr.Alleyne the role of ultrasound at EOSM.

From the American Academy of Orthopedic Surgery

By: Yashika Patel, MDAnthony J. Scillia, MDAnthony Festa, MDVincent K. McInerney, MDStuart Hirsch, MD

The use of ultrasound to evaluate musculoskeletal structures was first reported in 1958. Since then, its use has grown exponentially, particularly in the office setting. Ultrasound enables physicians to reliably visualize soft-tissue structures including muscle bellies, tendons, ligaments, arteries, and nerves, as well as identify any pathologic changes within these structures.

The use of ultrasound has several advantages, including the relatively lower cost compared to other imaging methods and the absence of ionizing radiation. It is a repeatable, noninvasive imaging modality that is capable of providing real-time dynamic tissue assessment. In addition, ultrasound can be used to quickly compare the affected and contralateral sides when necessary.

Ultrasound has also been used as an imaging guide for intra-articular or soft-tissue injections to help improve accuracy. Using ultrasound guidance, a physician can directly visualize an injection needle’s path and the immediate structures around it, thereby minimizing risk of injury to adjacent nerves or blood vessels.

This review discusses the clinical accuracy of ultrasound-guided injections and techniques in current literature in the following five areas of the shoulder and elbow:

  • the acromioclavicular (AC) joint
  • the long head of the biceps tendon
  • the glenohumeral joint
  • the ulnar collateral ligament (UCL)
  • the lateral epicondyle (tennis elbow)

Administering injections Corticosteroid injections can be administered using either palpation of bony landmarks or imaging as a guide. Differences in injection technique may contribute to the variability in reported clinical outcomes; current studies quote variable accuracy rates of blind (landmark-guided) and imaging-guided injections.

Injection accuracy depends on many variables, including the site of injection, the approach taken to deliver the injection, and the physician’s technical skill. When considering glenohumeral injections for example, one clinical study reported accurate injection location in 10 of 24 attempts (42 percent), while a separate study reported successful injection in only 2 of 20 attempts (10 percent).

The approach (anterior or posterior) can affect the accuracy of glenohumeral injections in particular. A cadaveric study assessing the difference in these two approaches reported 80 percent accuracy anteriorly and 50 percent accuracy posteriorly.

Image guidance during injection has shown favorable accuracy rates compared to blind injection. Cadaveric studies in which the exact injection site was confirmed by dissection found that the landmark-based method was accurate 40 percent to 66 percent of the time, while fluoroscopic guidance yielded accuracy rates of 100 percent. Other cadaveric studies have reported similarly high accuracies (95 percent to 100 percent) when imaging guidance was used.

Outcome comparisons Few randomized controlled trials compare image-guided and landmark-guided injections, and most of these studies pertain only to shoulder joint injections. Based on outcomes in two moderate-sized shoulder injection studies, researchers concluded that patients who had undergone ultrasound-guided injections demonstrated greater improvement in both pain and shoulder function at 6 weeks than those who received landmark-guided injections.

Another shoulder injection study found that the group receiving an ultrasound-guided subacromial injection showed significantly greater improvement than the group with a blind injection. Patients in the ultrasound group demonstrated a mean visual analog scale (VAS) score improvement of 34.9, compared to just 7.1 for the blind group (P < 0.001). Likewise, the change in mean shoulder function assessment score was also greater for the ultrasound group (15 v 5.6, P = 0.012). Based on these findings the researchers concluded that image-guided corticosteroid injections should be the method of choice, especially in patients who previously received a blind injection that failed.

Similar results were demonstrated in a separate study of 60 patients randomly assigned to receive either landmark-guided (n = 30) or ultrasound-guided (n = 30) triamcinolone injections for shoulder pain. The ultrasound group showed a vast improvement in VAS pain and Constant scores at 6 weeks compared with the landmark-guided group. The mean VAS pain score decrease was 4.0 ± 1.7 for the ultrasound group compared to 2.2 ± 0.9 for the landmark-guided group (P < 0.05); the mean Constant score change was 32.2 for the ultrasound group compared to 12.2 for the landmark-guided group (P < 0.05).