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