Acta Anaesthesiologica Taiwanica 52 (2014) 114e133
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Review Article
Chronic musculoskeletal pain: Ultrasound guided pain control Hong-Jen Chiou 1, 2, 3 *, Yi-Hong Chou 1, 2, Hsin-Kai Wang 1, 2, Yi-Chen Lai 1, 2 1
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC 3 National Defense Medical Center, Taipei, Taiwan, ROC 2
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 June 2014 Accepted 14 July 2014
The review demonstrates the unique advantages of ultrasonography in pain control. Several imaging modalities can be used to guide pain control, such as computed tomography, magnetic resonance imaging, and radiography. Ultrasonography has unique advantages over these other modalities in terms of its non-ionizing radiation, real-time imaging, portability, and cost-effectiveness. Ultrasonography with color Doppler and elastography can provide safer guidance to avoid blood vessels and the nerve trunk when using steroid or xylocaine infusions to encase the nerve trunk. This review focuses on the control of chronic pain in the upper limbs, lower limbs, and trunk.
Key words: musculoskeletal pain; ultrasonography
Copyright © 2014, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
1. Introduction According to international studies, the prevalence of chronic musculoskeletal pain varies from 11% to 50% in different populations.1e7 It may be related to age, sex, socioeconomic group, or ethnic background.8 The etiological factors behind non-malignant, but long-standing, pain in the musculoskeletal system are not yet fully understood or even identified. The causes of low back pain may include physical stress and previous back injury.9,10 Conservative management is the main method of relieving pain, but is not always successful. The local injection of a pain relief drug such as a steroid may be used for instant relief of the symptoms, but the effects are usually limited, possibly due to unguided injection. For those patients in whom the pain relief was unsuccessful, the failure could be due to the wrong area being injected because the image was not guided. There are several imaging modalities available to guide pain control, such as computed tomography, magnetic resonance imaging, and radiography. Ultrasonography (US), however, has unique advantages over the other modalities in terms of its non-ionizing radiation, real-time imaging, portability, and cost-effectiveness. US with color Doppler (CDUS) and elastography could provide
Conflicts of interest: All contributing authors declare no conflicts of interest. * Corresponding author. Department of Radiology, Taipei Veterans General Hospital, Number 201, Section 2, Shih-Pai Road, Taipei, Taiwan, ROC. E-mail address: [email protected] (H.-J. Chiou).
safer guidance to avoid blood vessels and the nerve trunk when injecting steroid drugs or xylocaine. US allows rapid and multiplanar approaches to lesions and CDUS allows the vascular structure to be detected. Gray-scale US and CDUS can be used to guide the needle precisely when injecting steroids into the target site, resulting in a reduction of the patient's discomfort and allowing further management. This review focuses on the control of chronic pain in the upper limbs, lower limbs, and trunk. Each patient was examined by US with compression to confirm the lesion. The injection of a mixture of 1 mL of shincort and 1 mL of 2% xylocaine to the most painful area was guided by US. A pain score (visual analog scale) was recorded at different times before and after injection.
2. Control of upper limb pain: Chronic shoulder, elbow, wrist, and hand pain Chronic shoulder pain is very common. Its causes are varied and include rotator cuff tears, calcific tendonitis, subdeltoid bursitis, and surrounding enthesopathies. A rotator cuff tear could be a fullthickness tear or a partial tear. The diagnosis of a rotator cuff tear can be made easily by ultrasonography; the diagnostic criteria include non-visualization, focal depression, focal cleft (Fig. 1), and focal thinning of the rotator cuff.11 The management of a fullthickness tear usually requires surgical intervention. A partial rotator cuff tear may present as a focal heterogeneous hypoechoic area in the rotator cuff with tenderness and thickening of the
http://dx.doi.org/10.1016/j.aat.2014.08.002 1875-4597/Copyright © 2014, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
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Fig. 1. A short-axis gray-scale ultrasound scan shows a focal hypoechoic cleft (arrowheads) that was confirmed as a full-thickness rotator cuff tear in the supraspinatus tendon.
subdeltoid bursa. Management includes physical therapy with or without the local injection of xylocaine and sodium hyaluronate.12 Subdeltoid bursitis (Fig. 2) usually presents as a thickening of the subdeltoid bursa with some fluid accumulation seen with US. Management may include the injection of a steroid mixed with
xylocaine to the subdeltoid bursa under US-guided control (Fig. 2).13 Calcific tendonitis in the rotator cuff can be easily diagnosed by plain film radiography and US14 with grading by CDUS (Fig. 3). Management may be different in the various stages; in the acute
Fig. 2. A 60-year-old man reported left shoulder pain. (A) Ultrasonography of the left subscapularis tendon shows thickening of the subdeltoid bursa (arrowheads). (B) Color Doppler ultrasonography shows hypervascularity in the left subdeltoid bursa. (C) Under guidance with ultrasonography (arrowhead), steroids were injected into the subdeltoid bursa. The patient's symptoms were relieved after treatment.
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Fig. 3. A 55-year-old woman reported severe left shoulder pain. (A) Gray-scale ultrasonography shows some echogenic nodules (arrowheads) in the left subscapularis tendon with thickening of the subdeltoid bursa. Nodular-type calcific tendonitis in the resorption stage was considered. (B) Color Doppler ultrasonography shows marked hypervascularity. (C) At the 6-month follow-up examination, gray-scale ultrasonography shows only tiny calcific spots remaining (arrowhead).
resorbed stage (Fig. 3) we recommend conservative treatment with or without the injection of a steroid mixed with xylocaine into subdeltoid bursa.14,15 In the cystic-type acute stage (Fig. 4), USguided aspiration with the injection of a steroid mixed with xylocaine is recommended. In the chronic formatted stage, several management methods may be used, including physical therapy, shock wave treatment, needle fragmentation to retrieve the calcified plaque, or repeated puncture with a fine needle with a steroid mixed with xylocaine injection (Fig. 5).14 In cases of a subdeltoid bursa ganglion, we recommend needle aspiration to decompress the pressure under US guidance (Fig. 6).16 The pain may sometimes be due to enthesopathy, such as in the insertion of the deltoid muscle into the acromial process. We recommend US-guided repeated puncture with a fine needle and the infusion of a mixed steroid and xylocaine injection into the surrounding enthesis region (Fig. 7). The US-guided injection of hyaluronate sodium into the shoulder joint was recommended for a patient with osteoarthritic changes in the shoulder joint. Chronic elbow pain may be due to tennis elbow, golfer's elbow, other enthesopathies or intra-articular arthritis. Tennis elbow usually presents on US as a heterogeneous hypoechogenicity in the
common extensor tendon insertion area with or without calcification spots; CDUS may show hypervascularity in the acute stage (Fig. 8). Management usually initially involves physical therapy, then US shock wave or fine needle repeated puncture over the area of tendonitis with or without infiltration of mixed steroid and xylocaine in the area surrounding the enthesis (Fig. 8).17 The injection of platelet-rich plasma into the region of tendonitis has recently been shown to solve the problem.17 In contrast with tennis elbow, golfer's elbow affects the medial side of the elbow and involves the common flexor tendon. US shows a heterogeneous hypoechogenicity in the common extensor tendon insertion area with or without calcification spots; CDUS shows hypervascularity in the acute stage (Fig. 9). Management is the same as for tennis elbow. Triceps tendon enthesopathy could present as decreased echogenicity in the tendon insertion region with increased vascularity. Physical therapy and repeated puncture with a fine needle with the infusion of a mixed steroid and xylocaine could be the treatment of choice. The same management can be applied in patients with collateral ligament enthesopathy. Intraarticular steroid injections to the elbow joint could be applied in patients with inflammatory arthritis, which is poorly controlled by systemic treatment.
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Fig. 4. A 60-year-old man reported severe right shoulder pain. (A) Ultrasonography shows a cystic lesion with an echogenic rim (arrowheads); cyst-type calcific tendonitis in the right supraspinatus tendon was considered. (B) Under guidance with ultrasonography, aspiration (arrowhead) was performed with the dramatic relief of symptoms.
Chronic wrist pain may be due to enthesopathy, arthritis, nerve entrapment, or tenosynovitis. The US pattern of an enthesopathy will be heterogeneous hypoechogenicity, swelling, and increased vascularity in the region of enthesis. Repeated puncture with a fine needle with a steroid infusion could be applied for these lesions. The injection of mixed steroid and xylocaine to encase the nerve at the tunnel region could resolve the tunnel syndrome, but it is sometimes painful to relieve the retinaculum. De Quervain's syndrome presents as a focal thickening of the first compartment tendon sheath of the dorsal wrist. US shows hypoechogenicity in the tendon sheath with hypervascularity in the active state (Fig. 10).18 Management is conservative physical therapy, then repeated puncture over the tendon sheath with an injection of mixed steroid and xylocaine to the tendon sheath (Fig. 10). Tenosynovitis, especially in poorly controlled rheumatological disease, usually presents on US as a thickening of the tendon sheath with or without fluid accumulation and as hypervascularity in CDUS. Management may involve aspiration of the fluid first, then the injection of steroid into the tendon sheath (Fig. 11).
3. Control of lower limb pain: Hip, knee, ankle, and foot pain Chronic hip pain may be due to arthritis of the hip, an acetabulum labrum lesion, ganglion, bursitis, enthesopathy, or nerve entrapment syndrome such as the lateral femoral cutaneous nerve or the pudendal nerve. Arthritis of the hip could be due to degenerative change or inflammatory rheumatological changes. In poorly controlled rheumatological disease, injection of steroid to the hip joint under US guidance may relieve the symptoms (Fig. 12). Piriformis syndrome is an important cause of low back pain and accounts for 6e8% of low back pain.19 The diagnostic criteria include a gue sign at 45 , tenderness at the sciatic notch, positive Lase increased pain in the sciatic area with the thigh in the FAIR position, and electrodiagnostic studies that exclude myopathy or neuropathy.20,21 In our experience, the diagnosis should be confirmed by tenderness over the sciatic notch region (Fig. 13). The current treatment strategy incorporates rehabilitation, symptomatic relief, and, for more severe cases, local injections with either corticosteroids or botulinum.21 Under US guidance, local corticosteroid injections are a safe and effective treatment.
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Fig. 5. An adult patient reported right shoulder pain. (A) Ultrasonography shows an arc-shaped calcification (arrowheads). Under guidance with ultrasonography, repeated puncture was performed. (B) After the repeated puncture, ultrasonography shows that the arc calcification has changed into a nodular to cystic type of calcification (arrowheads). (C) Two months later, the calcification is visible as echogenic spots (arrowhead). The patient's symptoms were relieved.
Ischial tuberosity bursitis usually presents as heterogeneous hypoechogenicity with or without fluid accumulation over the ischial tuberosity region with tenderness (Fig. 14). CDUS shows hypervascularity in the acute stage. Management may be USguided aspiration of the fluid followed by a steroid injection or repeated fine needle puncture (especially in ischial tuberosity enthesopahy), then infusion with a steroid (Fig. 15). However, prior to steroid injection, infectious bursitis should be excluded, which may present as a weakly echogenic abscess. There are several muscles that insert in the buttock region, such as the gemellus muscle (Fig. 16), the quadratus femoris, and the sacralspinus ligament. Enthesopathy may occur in these muscles or in the tendon insertion region. This presents on US as decreased echogenicity with local tenderness. Under US guidance, repeated puncture then the infusion of steroid may resolve the patient's pain. The greater trochanter is an important anatomy inserted by several muscles, such as the gluteal medium, minimus, piriformis, and gemellus muscles. Therefore bursitis or enthesopathy is often seen in this location. US shows decreased echogenicity and tenderness over this area (Fig. 17). Under US guidance, repeated puncture and steroid infusion may resolve the symptoms and signs. Sometimes lateral hip snapping may occur due to calcification plaques over the gluteal medius. US shows echogenic calcification plaques with snapping during hip extension. US-guided repeated puncture over the calcified plaque and then infusion with steroids may resolve the symptoms. In the anterior aspect of the hip, inflammation of the adductor muscle insertion to the pubic bone may result in enthesopathy (Fig. 18). US shows decreased echogenicity and tenderness over the
insertion area. US-guided repeated puncture and the infusion of steroid may have a good effect. Enthesopathy may also occur on the edge of the iliac rim due to muscle insertion. US usually shows a relative decrease in echogenicity with tenderness. Under US guidance, repeated puncture and steroid injections give good results (Fig. 19). A ganglion may occur in the bursa, intramuscularly, or with joint fluid leakage. Management includes aspiration with an 18 gauge needle under US guidance, with or without the injection of steroid. If the ganglion comes from a labrum tear, repair of the labrum will be necessary to stop fluid leakage. US-guided aspiration can only relieve the symptoms temporarily as these will rapidly recur (Fig. 20). To make the diagnosis of nerve entrapment syndrome, the nerve trunk should be traced in its anatomical location. Comparison of the size of the nerve should be made both proximally and distally, and on the contralateral side. Entrapped nerves usually present as engorged on the proximal side and with local tenderness.22 Management includes the infusion of mixed steroid and lidocaine to encase the nerve. Lateral femoral cutaneous nerve entrapment usually occurs at the inguinal ligament and sartorius muscle level (Fig. 21) and is called meralgia paresthetica. Entrapment of the pudendal nerve may occur above the sacrospinous ligament region (Fig. 22). Chronic knee pain may be due to degenerative joint disease, a meniscus lesion, enthesopathy, nerve entrapment syndrome, or crystal deposition. US-guided injection of hyaluronate sodium to the knee joint may relieve pain due to degenerative joint disease. A meniscus tear could result in parameniscal ganglion and surgical
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Fig. 6. A 74-year-old man reported right shoulder pain in some positions. (A) Ultrasonography shows a small cystic lesion (arrowheads) in the right subdeltoid bursa that did not change morphologically after shoulder rotation. Subdeltoid ganglion was considered. (B) Under guidance with ultrasonography, aspiration was performed; the ganglion disappeared (arrowhead) and a minimal amount of jelly-like material was aspirated.
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Fig. 7. A 35-year-old male pilot reported left shoulder pain. (A) Ultrasonography shows deposits of calcific spots (arrowhead) in the deltoid muscle insertion into the acromion process region with tenderness. (B) Under guidance with ultrasonography, the patient was treated with repeated puncture (arrowhead) and infusion with steroids.
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Fig. 8. A 41-year-old man reported right elbow pain in the radial aspect. (A) Ultrasonography shows a heterogeneous echogenicity in the right common extensor tendon insertion to the radial epicondyle region with calcific plaques (arrowhead). (B) Color Doppler ultrasonography shows hypervascularity in the tendon insertion region. (C) Under guidance with ultrasonography, repeated puncture (arrowhead) and infusion with steroid was performed in the surrounding entheses region. The patient's symptoms were relieved.
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Fig. 9. A 51-year-old woman reported left medial elbow pain. (A) Ultrasonography shows decreased echogenicity in the common flexor tendon insertion to the medial epicondyle with the deposition of echogenic calcific spots (arrow). (b) Color Doppler ultrasonography shows increased vascularity (arrowhead). (C) Elastography shows that the entheses (arrowhead) had become softer than normal.
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Fig. 10. A 29-year-old woman reported severe right wrist pain in the radial aspect. (A) Transverse section ultrasonography of the wrist shows thickening of the tendon sheath over the first compartment region (arrowhead); De Quervain's syndrome was considered. (B) Color Doppler ultrasonography shows increased vascularity (arrowhead). (C) Under guidance with ultrasonography, repeated puncture over the thickened tendon sheath was performed and steroids were infused; the patient recovered after treatment.
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Fig. 11. A 73-year-old man with a history of rheumatoid arthritis reported painful swelling over his right hand. (A) Ultrasonography of the sagittal section of the right dorsal hand shows fluid accumulation and thickening of the tendon sheath (arrowheads) over the extensor tendon; tenosynovitis with pannus formation was considered. (B) Color Doppler ultrasonography shows increased vascularity (arrowheads) in the tendon sheath and pannus. (C) Under guidance with ultrasonography, aspiration and injection (arrowhead) of steroid to the tendon sheath were performed. (D) After the steroid injection, the patient's symptoms improved. At follow-up 2 months later, ultrasonography shows that the tendon sheath (arrowheads) had almost returned to normal.
Fig. 12. A 28-year-old man with ankylosing spondylitis reported left hip pain over a number of years. (A) Ultrasonography of his left hip shows minimal fluid (arrowhead) accumulation in the joint space. (B) Under guidance with ultrasonography (arrowhead), steroid was injected into left hip joint space. The patient's symptoms were relieved.
repair is recommended. There are many tendons and ligaments inserted into the knee joint and enthesopathy is very common. US can show swelling and decreased echogenicity in the enthesis region with tenderness; CDUS shows hypervascularity in the active or acute stage (Fig. 23). Under US guidance, repeated puncture with a fine needle and the infusion of mixed steroid and lidocaine is effective (Fig. 24). The main nerve trunks in the knee region are the posterior tibial nerve, the common peroneal nerve, and the nerve plexus. Any space occupied by a lesion within these nerve regions should be removed surgically. If the nerve entrapment was due to a fibrotic band, surgical release should be considered. However, if the nerve entrapment was due to mild external compression or focal mild swelling of the nerve due to neuritis (Fig. 25), US-guided injection of mixed steroid and lidocaine is the treatment of choice. Chronic ankle pain could be due to degenerative joint disease, enthesopathy, nerve entrapment syndrome, tenosynovitis, and ganglion. Ankle joint degenerative joint disease could present as spur formation on plain film radiographs, echogenic spur formation, or joint effusion in the acute exacerbation stage on US (Fig. 26). If conservative treatment and rest are ineffective, US-guided hyaluronate sodium injection may be effective for joint movement and pain relief. There are several tendons that pass through the ankle and tenosynovitis may affect these tendons. On US these present as thickening of the tendon sheath with or without fluid accumulation. The diagnosis and management of tenosynovitis or tendonitis are similar to those for the respective tendon in the wrist. Retrocalcaneal bursitis may result in heel pain. US shows increased fluid accumulation over the retrocalcaneal bursa with increased vascularity. US-guided aspiration with a steroid injection may resolve the symptoms.
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Fig. 13. A 68-year-old man reported right buttock pain over a period of 5 months. (A) A transverse section ultrasound scan shows swelling of the piriformis muscle (arrowheads) with severe tenderness; piriformis syndrome was considered. (B) The sagittal section at the sciatic notch region shows swelling of the piriformis muscle (arrowheads) with tenderness. (C) Under guidance with ultrasonography, a mixture of 1.5 cm3 shincort and 0.5 cm3 xylocaine was injected into the piriformis muscle. The patient's symptoms improved markedly after the injection.
Fig. 14. A 75-year-old man reported a painful mass in his right buttock; he could not even sit down. (A) Ultrasonography shows a cystic lesion (arrowhead) over the ischial tuberosity (arrow) region. (B) Color Doppler ultrasonography shows minimal vascularity in the wall of the cyst; ischial bursitis was considered. The fluid was aspirated and a mixture of steroid and xylocaine was injected into the space. This treatment cured the ischial bursitis.
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Fig. 15. An 82-year-old man reported right buttock pain. (A) Ultrasonography shows thickening of the entheses (arrowheads) over the ischial tuberosity region. (B) Elastography shows that the entheses region had become soft; enthesitis was considered. (C) Under guidance with ultrasonography, repeated puncture and infusion of steroid and lidocaine was performed. The patient's symptoms were relieved.
Fig. 16. A 55-year-old man reported right buttock pain and was referred for an ultrasound examination with an initial diagnosis of piriformis syndrome. (A) CDUS shows relatively decreased echogenicity in the superior gemellus muscle (arrowhead) insertion into the ischial spine region without vascularity; severe tenderness under ultrasonography-guided compression was noted and enthesopathy was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the enthesis region and infusion of mixed steroid and xylocaine in the region surrounding the enthesis was performed. The patient's symptoms improved after this procedure.
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Fig. 17. A 73-year-old woman reported right lateral hip pain lasting for more than 1 year. (A) An ultrasound scan over the right greater trochanter region shows an arc-shaped echogenic calcification (arrowhead) over the gluteal medius insertion region; enthesitis with calcification was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the calcific plaques and the infusion of a mixture of steroid and xylocaine in the surrounding enthesis were performed. The patient recovered after this procedure.
Fig. 18. A 50-year-old woman reported right inguinal pain over a period of several months. (A) An ultrasound scan of the pubic symphysis shows tiny echogenic spots (arrowhead) in the adductor longus tendon insertion region with severe tenderness; enthesopathy was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the calcific plaques and the infusion of a mixture of steroid and xylocaine into the surrounding enthesis was performed. The patient's symptoms improved after this procedure.
Fig. 19. A 34-year-old man reported right upper buttock pain over a period of several months. (A) An ultrasound scan shows a focal hypoechoic area (arrowhead) over the right posterior superior iliac spine (PSIS) with severe tenderness; enthesopathy was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the entheses and the infusion of a mixture of steroid and xylocaine in the region surrounding the enthesis was performed. The patient's symptoms improved after this procedure.
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Fig. 20. A 60-year-old woman reported left anterior inguinal and hip pain. (A) Ultrasonography shows a hypoechoic cystic lesion (arrowhead) over the left inguinal region and a suspicious region connected to the acetabulum labrum (arrow); a labrum tear with a para-labral ganglion was considered. (B) Arthroscopy was suggested to repair the labrum, but the patient refused this treatment. Although it was explained that the cyst would rapidly recur after aspiration, the patient requested aspiration for instant relief of pain. Aspiration of the cyst was therefore carried out (arrowhead). The patient experienced a good improvement in her symptoms.
Fig. 21. A 62-year-old man reported right lateral thigh pain over a period of several months. (A) Ultrasonography shows swelling of the lateral femoral cutaneous nerve (LFCN) (arrowheads) over the anterior superior iliac spine and inguinal ligament region. Meralgia paraesthetica was considered. (B) Under guidance with ultrasonography, steroid was injected (arrow) to encase the nerve (arrrowhead). The patient's symptoms improved.
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Fig. 22. A young adult reported a painful sensation over the perianus and perineum region over several months. (A) Transverse ultrasonography shows the pudendal nerve (arrow) located above the sacrospinous ligament (arrowheads) and accompanying internal pudendal vessels (small arrow). (B) Under guidance with ultrasonography, steroid was injected, which encased the pudendal nerve (arrow). The patient's symptoms improved.
Fig. 23. A 49-year-old woman reported right medial knee pain. (A) Ultrasonography shows decreased echogenicity over the region of the medial collateral ligament insertion into the femur (arrowhead). (B) Color Doppler ultrasonography shows increased vascularity in the enthesitis region. (C) Under guidance with ultrasonography, repeated puncture over the entheses region and infusion of steroid surrounding the entheses region (arrowhead) were performed.
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Fig. 24. A 58-year-old woman reported right lateral knee pain. (A) Ultrasonography shows calcific spots (arrowhead) in the right biceps femoris tendon insertion into the fibula head region; enthesitis was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowhead) and infusion of steroid were performed. The patient's symptoms were relieved.
Fig. 25. A 60-year-old man, who had previously been involved in a traffic accident, reported right lower leg pain, lateral aspect. (A) Ultrasonography shows focal swelling of the sural nerve (arrowhead). (B) A sagittal scan shows fusiform swelling of the sural nerve (arrowhead). (C) Under guidance with ultrasonography, a steroid injection was used to encase the nerve (arrowhead). The patient recovered after the injection.
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Fig. 26. A 61-year-old woman with a history of rheumatoid arthritis reported severe left ankle pain. (A) Ultrasonography shows spur formation (arrowhead) in the left ankle joint with synovial proliferation. (B) Color Doppler ultrasonography shows increased vascularity. (C) Under guidance with ultrasonography, steroid was injected (arrowhead). The patient's symptoms were relieved.
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Fig. 27. A 57-year-old man reported left foot pain. (A) A transverse scan of his left ankle shows a cystic lesion (arrow) in close contact with the posterior tibial nerve (arrowhead). Ganglion compression to the posterior tibial nerve resulting in tarsal tunnel syndrome was considered. (B) Color Doppler ultrasonography shows no vascularity in the ganglion. (C) Under guidance with ultrasonography, aspiration was performed. (D) After aspiration, the ganglion is not visible on ultrasonography (arrow, posterior tibial nerve).
Plantar fasciitis is also an enthesopathy. It presents on US as thickening and decreased echogenicity in the plantar fascia insertion to the calcaneal bone region. Sometimes increased vascularity is noted on CDUS. US-guided repeated puncture in the fascia and enthesis region with infusion of steroid to the perifascia could resolve the symptom. Tarsal tunnel syndrome occurs in the medial aspect of the ankle. The etiology is due to compression of the posterior tibial nerve over the tarsal tunnel region by ganglion, fibrosis, degenerative joint disease or even a neurogenic tumor. More common findings are due to ganglion compression, which may be treated by surgical removal or under US-guided aspiration. (Fig. 27).22 4. Conclusion In patients with chronic musculoskeletal pain, we should first understand the etiology by tracing the patient's history. To avoid repeated recurrence of the symptoms, the patient should avoid the predisposing factor. The origin and location of the pain should be confirmed by physical examination assisted by imaging modalities, especially US, to make the correct diagnosis. The limitations of US are its operator dependence and its relatively long learning curve. Careful examination with an accurate scanning technique and good knowledge of anatomy may provide the correct diagnosis to aid in
selecting appropriate treatment. Finally, management could be conservative at first, but if there is no effect, image-guided puncture, aspiration or injection could be performed. However, the possibility of infection and neoplasms should be excluded prior to the injection of steroids. References 1. Crook J, Rideout E, Browne G. The prevalence of pain complaints in a general population. Pain 1984;18:299e314. 2. Lee P, Helewa A, Smythe HA, Bombardier C, Goldsmith CH. Epidemiology of musculoskeletal disorders (complaints) and related disability in Canada. J Rheumatol 1985;12:1169e73. 3. Laine VAI. Rheumatic complaints in an urban population in Finland. Acta Rheumatol Scand 1962;8:81e8. 4. Jacobsson L, Lindgarde F, Manthorpe R. The commonest rheumatic complaints of over six weeks' duration in a twelve-month period in a defined Swedish population. Prevalences and relationships. Scand J Rheumatol 1989;18:353e60. 5. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health 1984;74:574e9. 6. Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain 1989;37: 215e22. 7. Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization. Clin J Pain 1993;9:174e82. € m P, Ho € gstro €m K, Petersson IF, Svensson B, Jacobsson LT. 8. Bergman S, Herrstro Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study. J Rheumatol 2001;28:1369e77.
Ultrasound guided pain control 9. Heliovaara M, Makela M, Knekt P, Impivaara O, Aromaa A. Determinants of sciatica and low-back pain. Spine 1991;16:608e14. 10. Sobti A, Cooper C, Inskip H, Searle S, Coggon D. Occupational physical activity and long-term risk of musculoskeletal symptoms: a national survey of post office pensioners. Am J Ind Med 1997;32:76e83. 11. Yen CH, Chiou HJ, Chou YH, Hsu CC, Wu JJ, Ma HL, et al. Six surgery-correlated sonographic signs for rotator cuff tears: emphasis on partial-thickness tear. Clin Imaging 2004;28:69e76. 12. Blaine T, Moskowitz R, Udell J, et al. Treatment of persistent shoulder pain with sodium hyaluronate: a randomized, controlled trial. A multicenter study. J Bone Joint Surg Am 2008;90:970e9. 13. Molini L, Mariacher S, Bianchi S. US guided corticosteroid injection into the subacromial-subdeltoid bursa: technique and approach. J Ultrasound 2012;15: 61e8. 14. Chiou HJ, Chou YH, Wu JJ, Huang TF, Ma HL, Hsu CC, et al. The role of highresolution ultrasonography in management of calcific tendonitis of the rotator cuff. Ultrasound Med Biol 2001;27:735e43. 15. Chiou HJ, Hung SC, Lin SY, Wei YS, Li MJ. Correlations among mineral components, progressive calcification process and clinical symptoms of calcific tendonitis. Rheumatology 2010;49:548e55.
133 16. Chiou HJ, Chou YH, Wu JJ, Hsu CC, Tiu CM, Chang CY, et al. Alternative and effective treatment of shoulder ganglion cyst: ultrasonographically guided aspiration. J Ultrasound Med 1999;18:531e5. 17. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1year follow-up. Am J Sports Med 2010;38:255e62. 18. Chiou HJ, Chou YH, Chang CY. Ultrasonography of the wrist. CARJ 2001;52: 302e11. 19. Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med J 1983;74: 69e72. 20. Robinson DR. Pyriformis syndrome in relation to sciatic pain. Am J Surg 1947;73:355e8. 21. Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch J, Rosner B, et al. Piriformis syndrome: diagnosis, treatment, and outcome e a 10-year study. Arch Phys Med Rehabil 2002;83:295e301. 22. Chiou HJ, Chou YH, Chiou SY, Liu JB, Chang CY. Peripheral nerve lesions: role of high-resolution US. Radiographics 2003;23:e15.
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Acta Anaesthesiologica Taiwanica journal homepage: www.e-aat.com
Review Article
Chronic musculoskeletal pain: Ultrasound guided pain control Hong-Jen Chiou 1, 2, 3 *, Yi-Hong Chou 1, 2, Hsin-Kai Wang 1, 2, Yi-Chen Lai 1, 2 1
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC School of Medicine, National Yang Ming University, Taipei, Taiwan, ROC 3 National Defense Medical Center, Taipei, Taiwan, ROC 2
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 June 2014 Accepted 14 July 2014
The review demonstrates the unique advantages of ultrasonography in pain control. Several imaging modalities can be used to guide pain control, such as computed tomography, magnetic resonance imaging, and radiography. Ultrasonography has unique advantages over these other modalities in terms of its non-ionizing radiation, real-time imaging, portability, and cost-effectiveness. Ultrasonography with color Doppler and elastography can provide safer guidance to avoid blood vessels and the nerve trunk when using steroid or xylocaine infusions to encase the nerve trunk. This review focuses on the control of chronic pain in the upper limbs, lower limbs, and trunk.
Key words: musculoskeletal pain; ultrasonography
Copyright © 2014, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
1. Introduction According to international studies, the prevalence of chronic musculoskeletal pain varies from 11% to 50% in different populations.1e7 It may be related to age, sex, socioeconomic group, or ethnic background.8 The etiological factors behind non-malignant, but long-standing, pain in the musculoskeletal system are not yet fully understood or even identified. The causes of low back pain may include physical stress and previous back injury.9,10 Conservative management is the main method of relieving pain, but is not always successful. The local injection of a pain relief drug such as a steroid may be used for instant relief of the symptoms, but the effects are usually limited, possibly due to unguided injection. For those patients in whom the pain relief was unsuccessful, the failure could be due to the wrong area being injected because the image was not guided. There are several imaging modalities available to guide pain control, such as computed tomography, magnetic resonance imaging, and radiography. Ultrasonography (US), however, has unique advantages over the other modalities in terms of its non-ionizing radiation, real-time imaging, portability, and cost-effectiveness. US with color Doppler (CDUS) and elastography could provide
Conflicts of interest: All contributing authors declare no conflicts of interest. * Corresponding author. Department of Radiology, Taipei Veterans General Hospital, Number 201, Section 2, Shih-Pai Road, Taipei, Taiwan, ROC. E-mail address: [email protected] (H.-J. Chiou).
safer guidance to avoid blood vessels and the nerve trunk when injecting steroid drugs or xylocaine. US allows rapid and multiplanar approaches to lesions and CDUS allows the vascular structure to be detected. Gray-scale US and CDUS can be used to guide the needle precisely when injecting steroids into the target site, resulting in a reduction of the patient's discomfort and allowing further management. This review focuses on the control of chronic pain in the upper limbs, lower limbs, and trunk. Each patient was examined by US with compression to confirm the lesion. The injection of a mixture of 1 mL of shincort and 1 mL of 2% xylocaine to the most painful area was guided by US. A pain score (visual analog scale) was recorded at different times before and after injection.
2. Control of upper limb pain: Chronic shoulder, elbow, wrist, and hand pain Chronic shoulder pain is very common. Its causes are varied and include rotator cuff tears, calcific tendonitis, subdeltoid bursitis, and surrounding enthesopathies. A rotator cuff tear could be a fullthickness tear or a partial tear. The diagnosis of a rotator cuff tear can be made easily by ultrasonography; the diagnostic criteria include non-visualization, focal depression, focal cleft (Fig. 1), and focal thinning of the rotator cuff.11 The management of a fullthickness tear usually requires surgical intervention. A partial rotator cuff tear may present as a focal heterogeneous hypoechoic area in the rotator cuff with tenderness and thickening of the
http://dx.doi.org/10.1016/j.aat.2014.08.002 1875-4597/Copyright © 2014, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
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Fig. 1. A short-axis gray-scale ultrasound scan shows a focal hypoechoic cleft (arrowheads) that was confirmed as a full-thickness rotator cuff tear in the supraspinatus tendon.
subdeltoid bursa. Management includes physical therapy with or without the local injection of xylocaine and sodium hyaluronate.12 Subdeltoid bursitis (Fig. 2) usually presents as a thickening of the subdeltoid bursa with some fluid accumulation seen with US. Management may include the injection of a steroid mixed with
xylocaine to the subdeltoid bursa under US-guided control (Fig. 2).13 Calcific tendonitis in the rotator cuff can be easily diagnosed by plain film radiography and US14 with grading by CDUS (Fig. 3). Management may be different in the various stages; in the acute
Fig. 2. A 60-year-old man reported left shoulder pain. (A) Ultrasonography of the left subscapularis tendon shows thickening of the subdeltoid bursa (arrowheads). (B) Color Doppler ultrasonography shows hypervascularity in the left subdeltoid bursa. (C) Under guidance with ultrasonography (arrowhead), steroids were injected into the subdeltoid bursa. The patient's symptoms were relieved after treatment.
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Fig. 3. A 55-year-old woman reported severe left shoulder pain. (A) Gray-scale ultrasonography shows some echogenic nodules (arrowheads) in the left subscapularis tendon with thickening of the subdeltoid bursa. Nodular-type calcific tendonitis in the resorption stage was considered. (B) Color Doppler ultrasonography shows marked hypervascularity. (C) At the 6-month follow-up examination, gray-scale ultrasonography shows only tiny calcific spots remaining (arrowhead).
resorbed stage (Fig. 3) we recommend conservative treatment with or without the injection of a steroid mixed with xylocaine into subdeltoid bursa.14,15 In the cystic-type acute stage (Fig. 4), USguided aspiration with the injection of a steroid mixed with xylocaine is recommended. In the chronic formatted stage, several management methods may be used, including physical therapy, shock wave treatment, needle fragmentation to retrieve the calcified plaque, or repeated puncture with a fine needle with a steroid mixed with xylocaine injection (Fig. 5).14 In cases of a subdeltoid bursa ganglion, we recommend needle aspiration to decompress the pressure under US guidance (Fig. 6).16 The pain may sometimes be due to enthesopathy, such as in the insertion of the deltoid muscle into the acromial process. We recommend US-guided repeated puncture with a fine needle and the infusion of a mixed steroid and xylocaine injection into the surrounding enthesis region (Fig. 7). The US-guided injection of hyaluronate sodium into the shoulder joint was recommended for a patient with osteoarthritic changes in the shoulder joint. Chronic elbow pain may be due to tennis elbow, golfer's elbow, other enthesopathies or intra-articular arthritis. Tennis elbow usually presents on US as a heterogeneous hypoechogenicity in the
common extensor tendon insertion area with or without calcification spots; CDUS may show hypervascularity in the acute stage (Fig. 8). Management usually initially involves physical therapy, then US shock wave or fine needle repeated puncture over the area of tendonitis with or without infiltration of mixed steroid and xylocaine in the area surrounding the enthesis (Fig. 8).17 The injection of platelet-rich plasma into the region of tendonitis has recently been shown to solve the problem.17 In contrast with tennis elbow, golfer's elbow affects the medial side of the elbow and involves the common flexor tendon. US shows a heterogeneous hypoechogenicity in the common extensor tendon insertion area with or without calcification spots; CDUS shows hypervascularity in the acute stage (Fig. 9). Management is the same as for tennis elbow. Triceps tendon enthesopathy could present as decreased echogenicity in the tendon insertion region with increased vascularity. Physical therapy and repeated puncture with a fine needle with the infusion of a mixed steroid and xylocaine could be the treatment of choice. The same management can be applied in patients with collateral ligament enthesopathy. Intraarticular steroid injections to the elbow joint could be applied in patients with inflammatory arthritis, which is poorly controlled by systemic treatment.
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Fig. 4. A 60-year-old man reported severe right shoulder pain. (A) Ultrasonography shows a cystic lesion with an echogenic rim (arrowheads); cyst-type calcific tendonitis in the right supraspinatus tendon was considered. (B) Under guidance with ultrasonography, aspiration (arrowhead) was performed with the dramatic relief of symptoms.
Chronic wrist pain may be due to enthesopathy, arthritis, nerve entrapment, or tenosynovitis. The US pattern of an enthesopathy will be heterogeneous hypoechogenicity, swelling, and increased vascularity in the region of enthesis. Repeated puncture with a fine needle with a steroid infusion could be applied for these lesions. The injection of mixed steroid and xylocaine to encase the nerve at the tunnel region could resolve the tunnel syndrome, but it is sometimes painful to relieve the retinaculum. De Quervain's syndrome presents as a focal thickening of the first compartment tendon sheath of the dorsal wrist. US shows hypoechogenicity in the tendon sheath with hypervascularity in the active state (Fig. 10).18 Management is conservative physical therapy, then repeated puncture over the tendon sheath with an injection of mixed steroid and xylocaine to the tendon sheath (Fig. 10). Tenosynovitis, especially in poorly controlled rheumatological disease, usually presents on US as a thickening of the tendon sheath with or without fluid accumulation and as hypervascularity in CDUS. Management may involve aspiration of the fluid first, then the injection of steroid into the tendon sheath (Fig. 11).
3. Control of lower limb pain: Hip, knee, ankle, and foot pain Chronic hip pain may be due to arthritis of the hip, an acetabulum labrum lesion, ganglion, bursitis, enthesopathy, or nerve entrapment syndrome such as the lateral femoral cutaneous nerve or the pudendal nerve. Arthritis of the hip could be due to degenerative change or inflammatory rheumatological changes. In poorly controlled rheumatological disease, injection of steroid to the hip joint under US guidance may relieve the symptoms (Fig. 12). Piriformis syndrome is an important cause of low back pain and accounts for 6e8% of low back pain.19 The diagnostic criteria include a gue sign at 45 , tenderness at the sciatic notch, positive Lase increased pain in the sciatic area with the thigh in the FAIR position, and electrodiagnostic studies that exclude myopathy or neuropathy.20,21 In our experience, the diagnosis should be confirmed by tenderness over the sciatic notch region (Fig. 13). The current treatment strategy incorporates rehabilitation, symptomatic relief, and, for more severe cases, local injections with either corticosteroids or botulinum.21 Under US guidance, local corticosteroid injections are a safe and effective treatment.
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Fig. 5. An adult patient reported right shoulder pain. (A) Ultrasonography shows an arc-shaped calcification (arrowheads). Under guidance with ultrasonography, repeated puncture was performed. (B) After the repeated puncture, ultrasonography shows that the arc calcification has changed into a nodular to cystic type of calcification (arrowheads). (C) Two months later, the calcification is visible as echogenic spots (arrowhead). The patient's symptoms were relieved.
Ischial tuberosity bursitis usually presents as heterogeneous hypoechogenicity with or without fluid accumulation over the ischial tuberosity region with tenderness (Fig. 14). CDUS shows hypervascularity in the acute stage. Management may be USguided aspiration of the fluid followed by a steroid injection or repeated fine needle puncture (especially in ischial tuberosity enthesopahy), then infusion with a steroid (Fig. 15). However, prior to steroid injection, infectious bursitis should be excluded, which may present as a weakly echogenic abscess. There are several muscles that insert in the buttock region, such as the gemellus muscle (Fig. 16), the quadratus femoris, and the sacralspinus ligament. Enthesopathy may occur in these muscles or in the tendon insertion region. This presents on US as decreased echogenicity with local tenderness. Under US guidance, repeated puncture then the infusion of steroid may resolve the patient's pain. The greater trochanter is an important anatomy inserted by several muscles, such as the gluteal medium, minimus, piriformis, and gemellus muscles. Therefore bursitis or enthesopathy is often seen in this location. US shows decreased echogenicity and tenderness over this area (Fig. 17). Under US guidance, repeated puncture and steroid infusion may resolve the symptoms and signs. Sometimes lateral hip snapping may occur due to calcification plaques over the gluteal medius. US shows echogenic calcification plaques with snapping during hip extension. US-guided repeated puncture over the calcified plaque and then infusion with steroids may resolve the symptoms. In the anterior aspect of the hip, inflammation of the adductor muscle insertion to the pubic bone may result in enthesopathy (Fig. 18). US shows decreased echogenicity and tenderness over the
insertion area. US-guided repeated puncture and the infusion of steroid may have a good effect. Enthesopathy may also occur on the edge of the iliac rim due to muscle insertion. US usually shows a relative decrease in echogenicity with tenderness. Under US guidance, repeated puncture and steroid injections give good results (Fig. 19). A ganglion may occur in the bursa, intramuscularly, or with joint fluid leakage. Management includes aspiration with an 18 gauge needle under US guidance, with or without the injection of steroid. If the ganglion comes from a labrum tear, repair of the labrum will be necessary to stop fluid leakage. US-guided aspiration can only relieve the symptoms temporarily as these will rapidly recur (Fig. 20). To make the diagnosis of nerve entrapment syndrome, the nerve trunk should be traced in its anatomical location. Comparison of the size of the nerve should be made both proximally and distally, and on the contralateral side. Entrapped nerves usually present as engorged on the proximal side and with local tenderness.22 Management includes the infusion of mixed steroid and lidocaine to encase the nerve. Lateral femoral cutaneous nerve entrapment usually occurs at the inguinal ligament and sartorius muscle level (Fig. 21) and is called meralgia paresthetica. Entrapment of the pudendal nerve may occur above the sacrospinous ligament region (Fig. 22). Chronic knee pain may be due to degenerative joint disease, a meniscus lesion, enthesopathy, nerve entrapment syndrome, or crystal deposition. US-guided injection of hyaluronate sodium to the knee joint may relieve pain due to degenerative joint disease. A meniscus tear could result in parameniscal ganglion and surgical
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Fig. 6. A 74-year-old man reported right shoulder pain in some positions. (A) Ultrasonography shows a small cystic lesion (arrowheads) in the right subdeltoid bursa that did not change morphologically after shoulder rotation. Subdeltoid ganglion was considered. (B) Under guidance with ultrasonography, aspiration was performed; the ganglion disappeared (arrowhead) and a minimal amount of jelly-like material was aspirated.
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Fig. 7. A 35-year-old male pilot reported left shoulder pain. (A) Ultrasonography shows deposits of calcific spots (arrowhead) in the deltoid muscle insertion into the acromion process region with tenderness. (B) Under guidance with ultrasonography, the patient was treated with repeated puncture (arrowhead) and infusion with steroids.
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Fig. 8. A 41-year-old man reported right elbow pain in the radial aspect. (A) Ultrasonography shows a heterogeneous echogenicity in the right common extensor tendon insertion to the radial epicondyle region with calcific plaques (arrowhead). (B) Color Doppler ultrasonography shows hypervascularity in the tendon insertion region. (C) Under guidance with ultrasonography, repeated puncture (arrowhead) and infusion with steroid was performed in the surrounding entheses region. The patient's symptoms were relieved.
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Fig. 9. A 51-year-old woman reported left medial elbow pain. (A) Ultrasonography shows decreased echogenicity in the common flexor tendon insertion to the medial epicondyle with the deposition of echogenic calcific spots (arrow). (b) Color Doppler ultrasonography shows increased vascularity (arrowhead). (C) Elastography shows that the entheses (arrowhead) had become softer than normal.
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Fig. 10. A 29-year-old woman reported severe right wrist pain in the radial aspect. (A) Transverse section ultrasonography of the wrist shows thickening of the tendon sheath over the first compartment region (arrowhead); De Quervain's syndrome was considered. (B) Color Doppler ultrasonography shows increased vascularity (arrowhead). (C) Under guidance with ultrasonography, repeated puncture over the thickened tendon sheath was performed and steroids were infused; the patient recovered after treatment.
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Fig. 11. A 73-year-old man with a history of rheumatoid arthritis reported painful swelling over his right hand. (A) Ultrasonography of the sagittal section of the right dorsal hand shows fluid accumulation and thickening of the tendon sheath (arrowheads) over the extensor tendon; tenosynovitis with pannus formation was considered. (B) Color Doppler ultrasonography shows increased vascularity (arrowheads) in the tendon sheath and pannus. (C) Under guidance with ultrasonography, aspiration and injection (arrowhead) of steroid to the tendon sheath were performed. (D) After the steroid injection, the patient's symptoms improved. At follow-up 2 months later, ultrasonography shows that the tendon sheath (arrowheads) had almost returned to normal.
Fig. 12. A 28-year-old man with ankylosing spondylitis reported left hip pain over a number of years. (A) Ultrasonography of his left hip shows minimal fluid (arrowhead) accumulation in the joint space. (B) Under guidance with ultrasonography (arrowhead), steroid was injected into left hip joint space. The patient's symptoms were relieved.
repair is recommended. There are many tendons and ligaments inserted into the knee joint and enthesopathy is very common. US can show swelling and decreased echogenicity in the enthesis region with tenderness; CDUS shows hypervascularity in the active or acute stage (Fig. 23). Under US guidance, repeated puncture with a fine needle and the infusion of mixed steroid and lidocaine is effective (Fig. 24). The main nerve trunks in the knee region are the posterior tibial nerve, the common peroneal nerve, and the nerve plexus. Any space occupied by a lesion within these nerve regions should be removed surgically. If the nerve entrapment was due to a fibrotic band, surgical release should be considered. However, if the nerve entrapment was due to mild external compression or focal mild swelling of the nerve due to neuritis (Fig. 25), US-guided injection of mixed steroid and lidocaine is the treatment of choice. Chronic ankle pain could be due to degenerative joint disease, enthesopathy, nerve entrapment syndrome, tenosynovitis, and ganglion. Ankle joint degenerative joint disease could present as spur formation on plain film radiographs, echogenic spur formation, or joint effusion in the acute exacerbation stage on US (Fig. 26). If conservative treatment and rest are ineffective, US-guided hyaluronate sodium injection may be effective for joint movement and pain relief. There are several tendons that pass through the ankle and tenosynovitis may affect these tendons. On US these present as thickening of the tendon sheath with or without fluid accumulation. The diagnosis and management of tenosynovitis or tendonitis are similar to those for the respective tendon in the wrist. Retrocalcaneal bursitis may result in heel pain. US shows increased fluid accumulation over the retrocalcaneal bursa with increased vascularity. US-guided aspiration with a steroid injection may resolve the symptoms.
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Fig. 13. A 68-year-old man reported right buttock pain over a period of 5 months. (A) A transverse section ultrasound scan shows swelling of the piriformis muscle (arrowheads) with severe tenderness; piriformis syndrome was considered. (B) The sagittal section at the sciatic notch region shows swelling of the piriformis muscle (arrowheads) with tenderness. (C) Under guidance with ultrasonography, a mixture of 1.5 cm3 shincort and 0.5 cm3 xylocaine was injected into the piriformis muscle. The patient's symptoms improved markedly after the injection.
Fig. 14. A 75-year-old man reported a painful mass in his right buttock; he could not even sit down. (A) Ultrasonography shows a cystic lesion (arrowhead) over the ischial tuberosity (arrow) region. (B) Color Doppler ultrasonography shows minimal vascularity in the wall of the cyst; ischial bursitis was considered. The fluid was aspirated and a mixture of steroid and xylocaine was injected into the space. This treatment cured the ischial bursitis.
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Fig. 15. An 82-year-old man reported right buttock pain. (A) Ultrasonography shows thickening of the entheses (arrowheads) over the ischial tuberosity region. (B) Elastography shows that the entheses region had become soft; enthesitis was considered. (C) Under guidance with ultrasonography, repeated puncture and infusion of steroid and lidocaine was performed. The patient's symptoms were relieved.
Fig. 16. A 55-year-old man reported right buttock pain and was referred for an ultrasound examination with an initial diagnosis of piriformis syndrome. (A) CDUS shows relatively decreased echogenicity in the superior gemellus muscle (arrowhead) insertion into the ischial spine region without vascularity; severe tenderness under ultrasonography-guided compression was noted and enthesopathy was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the enthesis region and infusion of mixed steroid and xylocaine in the region surrounding the enthesis was performed. The patient's symptoms improved after this procedure.
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Fig. 17. A 73-year-old woman reported right lateral hip pain lasting for more than 1 year. (A) An ultrasound scan over the right greater trochanter region shows an arc-shaped echogenic calcification (arrowhead) over the gluteal medius insertion region; enthesitis with calcification was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the calcific plaques and the infusion of a mixture of steroid and xylocaine in the surrounding enthesis were performed. The patient recovered after this procedure.
Fig. 18. A 50-year-old woman reported right inguinal pain over a period of several months. (A) An ultrasound scan of the pubic symphysis shows tiny echogenic spots (arrowhead) in the adductor longus tendon insertion region with severe tenderness; enthesopathy was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the calcific plaques and the infusion of a mixture of steroid and xylocaine into the surrounding enthesis was performed. The patient's symptoms improved after this procedure.
Fig. 19. A 34-year-old man reported right upper buttock pain over a period of several months. (A) An ultrasound scan shows a focal hypoechoic area (arrowhead) over the right posterior superior iliac spine (PSIS) with severe tenderness; enthesopathy was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowheads) over the entheses and the infusion of a mixture of steroid and xylocaine in the region surrounding the enthesis was performed. The patient's symptoms improved after this procedure.
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Fig. 20. A 60-year-old woman reported left anterior inguinal and hip pain. (A) Ultrasonography shows a hypoechoic cystic lesion (arrowhead) over the left inguinal region and a suspicious region connected to the acetabulum labrum (arrow); a labrum tear with a para-labral ganglion was considered. (B) Arthroscopy was suggested to repair the labrum, but the patient refused this treatment. Although it was explained that the cyst would rapidly recur after aspiration, the patient requested aspiration for instant relief of pain. Aspiration of the cyst was therefore carried out (arrowhead). The patient experienced a good improvement in her symptoms.
Fig. 21. A 62-year-old man reported right lateral thigh pain over a period of several months. (A) Ultrasonography shows swelling of the lateral femoral cutaneous nerve (LFCN) (arrowheads) over the anterior superior iliac spine and inguinal ligament region. Meralgia paraesthetica was considered. (B) Under guidance with ultrasonography, steroid was injected (arrow) to encase the nerve (arrrowhead). The patient's symptoms improved.
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Fig. 22. A young adult reported a painful sensation over the perianus and perineum region over several months. (A) Transverse ultrasonography shows the pudendal nerve (arrow) located above the sacrospinous ligament (arrowheads) and accompanying internal pudendal vessels (small arrow). (B) Under guidance with ultrasonography, steroid was injected, which encased the pudendal nerve (arrow). The patient's symptoms improved.
Fig. 23. A 49-year-old woman reported right medial knee pain. (A) Ultrasonography shows decreased echogenicity over the region of the medial collateral ligament insertion into the femur (arrowhead). (B) Color Doppler ultrasonography shows increased vascularity in the enthesitis region. (C) Under guidance with ultrasonography, repeated puncture over the entheses region and infusion of steroid surrounding the entheses region (arrowhead) were performed.
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Fig. 24. A 58-year-old woman reported right lateral knee pain. (A) Ultrasonography shows calcific spots (arrowhead) in the right biceps femoris tendon insertion into the fibula head region; enthesitis was considered. (B) Under guidance with ultrasonography, repeated puncture (arrowhead) and infusion of steroid were performed. The patient's symptoms were relieved.
Fig. 25. A 60-year-old man, who had previously been involved in a traffic accident, reported right lower leg pain, lateral aspect. (A) Ultrasonography shows focal swelling of the sural nerve (arrowhead). (B) A sagittal scan shows fusiform swelling of the sural nerve (arrowhead). (C) Under guidance with ultrasonography, a steroid injection was used to encase the nerve (arrowhead). The patient recovered after the injection.
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Fig. 26. A 61-year-old woman with a history of rheumatoid arthritis reported severe left ankle pain. (A) Ultrasonography shows spur formation (arrowhead) in the left ankle joint with synovial proliferation. (B) Color Doppler ultrasonography shows increased vascularity. (C) Under guidance with ultrasonography, steroid was injected (arrowhead). The patient's symptoms were relieved.
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Fig. 27. A 57-year-old man reported left foot pain. (A) A transverse scan of his left ankle shows a cystic lesion (arrow) in close contact with the posterior tibial nerve (arrowhead). Ganglion compression to the posterior tibial nerve resulting in tarsal tunnel syndrome was considered. (B) Color Doppler ultrasonography shows no vascularity in the ganglion. (C) Under guidance with ultrasonography, aspiration was performed. (D) After aspiration, the ganglion is not visible on ultrasonography (arrow, posterior tibial nerve).
Plantar fasciitis is also an enthesopathy. It presents on US as thickening and decreased echogenicity in the plantar fascia insertion to the calcaneal bone region. Sometimes increased vascularity is noted on CDUS. US-guided repeated puncture in the fascia and enthesis region with infusion of steroid to the perifascia could resolve the symptom. Tarsal tunnel syndrome occurs in the medial aspect of the ankle. The etiology is due to compression of the posterior tibial nerve over the tarsal tunnel region by ganglion, fibrosis, degenerative joint disease or even a neurogenic tumor. More common findings are due to ganglion compression, which may be treated by surgical removal or under US-guided aspiration. (Fig. 27).22 4. Conclusion In patients with chronic musculoskeletal pain, we should first understand the etiology by tracing the patient's history. To avoid repeated recurrence of the symptoms, the patient should avoid the predisposing factor. The origin and location of the pain should be confirmed by physical examination assisted by imaging modalities, especially US, to make the correct diagnosis. The limitations of US are its operator dependence and its relatively long learning curve. Careful examination with an accurate scanning technique and good knowledge of anatomy may provide the correct diagnosis to aid in
selecting appropriate treatment. Finally, management could be conservative at first, but if there is no effect, image-guided puncture, aspiration or injection could be performed. However, the possibility of infection and neoplasms should be excluded prior to the injection of steroids. References 1. Crook J, Rideout E, Browne G. The prevalence of pain complaints in a general population. Pain 1984;18:299e314. 2. Lee P, Helewa A, Smythe HA, Bombardier C, Goldsmith CH. Epidemiology of musculoskeletal disorders (complaints) and related disability in Canada. J Rheumatol 1985;12:1169e73. 3. Laine VAI. Rheumatic complaints in an urban population in Finland. Acta Rheumatol Scand 1962;8:81e8. 4. Jacobsson L, Lindgarde F, Manthorpe R. The commonest rheumatic complaints of over six weeks' duration in a twelve-month period in a defined Swedish population. Prevalences and relationships. Scand J Rheumatol 1989;18:353e60. 5. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health 1984;74:574e9. 6. Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain 1989;37: 215e22. 7. Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization. Clin J Pain 1993;9:174e82. € m P, Ho € gstro €m K, Petersson IF, Svensson B, Jacobsson LT. 8. Bergman S, Herrstro Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study. J Rheumatol 2001;28:1369e77.
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