Ultrasound Guided Shoulder Injections
• Lisa Pomranky, MD
• Marie Barton, 4th year OHSU Medical Student
Disclosure
• I have no financial disclosures
Objectives
• Review:
− Common guided injections in and around the shoulder
− Accuracy and Efficacy
− Indications
First…
• Let’s go on a tour of the shoulder!
Bicep
Subscapularis
Supraspinatus
Glenohumeral
AC Joint
Glenohumeral Joint
Glenohumeral Joint – approach
Glenohumeral Joint
● LMGI vs USGI accuracy
○ Patel: Cadaveric study in 2012 using posterior approach, 40 US, 40 landmark guided by 2 surgeons. Ultrasound-guided was more accurate (92.5% vs 72.5% with p= 0.02)
Glenohumeral Joint● LMGI vs USGI efficacy
○ Raeissadat: RCT of 41 patients with adhesive capsulitis saw improvements in pain, ROM, and functional score after 1 and 4 weeks that were more prominent in the US-guided group, but the differences were not statistically significant, except for the changes in extension where the improvements were significantly higher in the US-guided group (11 vs 2 degrees at 1 wk and 12 vs 3 degrees at 4 wk, p = 0.01)
○ Lee: In 2009 RCT of 43 patients with adhesive capsulitis, greater improvement in function and pain in first 2-3 weeks in US guided, but no difference after 4 weeks. (Figure at right)
● Greater benefits from US-guided in the short-term but equivalent after 1 month
Glenohumeral Joint
● Indications:○ GH arthritis
○ Frozen shoulder
○ Diagnostic purposes
● Cost Effectiveness
○ A 2017 cost-effectiveness study provided simulation models where
ultrasound-guided injections in adhesive capsulitis showed to be the
cheapest in 44% of cases compared to palpation- (34%) and
fluoroscopy-guided (22%) injections
Bicep Sheath – approach
Bicep Sheath – approach
With US probe anterior, biceps in short axis
● Humeral head = blue line
● Biceps tendon = green arrow
● Needle = pink arrows
Bicep Sheath
● LMGI vs USGI accuracy
○ Hashiuchi: 30 patients with tendinitis or tenosynovitis, higher accuracy in USG vs LMG (86.7% vs 26.7%, p<0.05)
○ Gazzillo: A study performed at Mayo Clinic demonstrated the difficulty of palpating biceps brachii tendon by assessing accuracy with ultrasound. Sports medicine fellow correctly identified the tendon in 12% of cases, and PMR resident correctly identified 0%.
● USGI vs Fluoroscopy-guided accuracy
○ Pestcavage-Thomas: Compared to fluoroscopy-guided biceps tendon sheath injection, ultrasound had higher (90.6% vs 74.0%) success rates, with similar pain relief and complication rates
Bicep Sheath
● LMGI vs USGI efficacy
○ Zhang: 98 patients with tendinitis, greater reductions in pain and increases in quality of function in USG vs LMG using VAS score (-4.8 vs -2.9, p<0.01) and Constant-Murley score (53 vs 42.1, p<0.05)
● Indications:
○ Alternative for intra-articular
○ Isolated bicep tenosynovitis
Acromioclavicular Joint – approach
Acromioclavicular Joint
● LMGI vs USGI accuracy○ Aly: Meta-analysis of three trials revealed
USG to be more accurate vs landmark-guided (93.6% vs 68.2%, p<0.0001, I =0%)
● LMGI vs USGI efficacy ○ Park et al: Among 100 patients with AC
osteoarthritis, USGI showed significantly greater improvements in pain and function at 3 and 6 months. Significant outcome predictor was injection accuracy.
Acromioclavicular Joint
● Indications: ○ Arthritis○ Distal Clavicle Osteolysis
Subacromial Space – approach
Subacromial Space● LMGI vs USGI accuracy
○ Dogu: In a study of 46 patients with rotator cuff pathology, accuracy of US guided was higher but not significant (70 vs 65%, p>0.05)
● LMGI vs USGI efficacy
○ Aly: Meta-analysis of 3 studies showed significantly greater reduction in pain (MD 1.47) and improvement in function (SMD 0.70) in US group at 6 weeks. Figures at right
○ Cole et al: No difference in pain or function at 6 weeks between LMG and USG groups, in a study of 56 patients with impingement syndrome,*but accuracy was not assessed
Pain reduction
Functional improvementAly et al 2015
Subacromial Space
● Indications: ○ Isolated bursitis○ Impingement○ Hydroxyapatite deposition○ Diagnostic purposes
Calcific Tendinopathy/Hydroxyapatite Deposition Disease
Zhang 2019: Meta-analysis comparing ultrasound-guided percutaneous lavage (UGPL,“control”) with other “experimental” treatments (NSAID, rest, PT, extracorporeal shock-wave therapy, subacromial corticosteroid injections)
Calcification disappearance rate RR 1.73 [1.44, 2.07]
Constant shoulder score MD 10.49 [6.99, 13.98]
Need for surgery MD 10.49 [6.99, 13.98]
Fenestration/Barbotage
Pre and Post Barbotage